The Mental Health Act has changed. The hard part starts now

I have a soft spot for the unglamorous end of policymaking. Not the set-piece speeches, or the moment a Bill becomes an Act and the cameras move on. I mean the work that happens behind the scenes: the drafting that runs late into the evening, the careful gathering and weighing of evidence, the compromises revisited again and again, and the persistence required to keep a reform alive while political attention drifts elsewhere. 

I saw that up close during my time in the Department of Health and Social Care. Mental health policy attracts people who care deeply, often for personal reasons. That matters, because reforms of this scale do not survive without officials who are prepared to keep making the case through changing ministers, competing priorities and years of procedural grind. 

So, it was a significant moment when the amended Mental Health Act finally received Royal Assent at the end of 2025. Years of work, scrutiny and debate came together in law and that deserves recognition. 

Legislation never whole answer

However, the Care Quality Commission’s latest annual report, Monitoring the Mental Health Act in 2024/25, underscores a more complex truth. Many of the challenges it describes do not hinge on legislative change, but on delivery, culture and capacity, at the same time as the system is asked to implement significant new statutory requirements. 

The Act was reformed because the old system was failing too many people: poor experiences of detention, deep racial inequalities in how powers are used, and autistic people and people with a learning disability being detained in environments that do them harm. These were not abstract policy concerns, but profoundly human ones. 

The CQC’s report shows that those underlying pressures have not eased. In many respects, they have intensified. Demand for mental health services continues to rise. People are often more unwell by the time they reach assessment or admission. Services are operating with little spare capacity, and staff are stretched thin. (A full summary of the report’s findings can be found here.) 

This context matters, because the success or failure of the amended Act will not be decided by the elegance of its clauses. It will be decided by whether the system can actually deliver what the law now expects of it. 

Rights and safeguards do not implement themselves. While the Act rightly strengthens choice, autonomy and legal protections for people subject to detention, those safeguards only matter if they can be delivered reliably in practice. 

If staffing shortages mean a ward cannot facilitate leave, activities or even consistent access to basic spaces, then “least restriction” becomes harder to achieve in practice. If people are held for too long in unsuitable settings because beds are unavailable, then the legal framework can start to feel theoretical rather than real. 

The CQC’s findings repeatedly link the quality of care under the Act to practical realities: bed availability, workforce gaps, ward environments, and how well services coordinate care and discharge. These are not peripheral operational issues. They are the conditions under which the Act is applied day to day.   

The same is true of dignity and trust. The CQC’s report reflects both the best of mental health services, where patients describe staff as compassionate and committed, and the worst, where people feel their rights were poorly explained or staff attitudes were dismissive.   

Reform cannot rely on goodwill alone. It has to be supported by the conditions that make good care possible. 

Inequality is where this becomes most stark. Year after year, the CQC has highlighted deep and persistent racial disparities in the use of the Mental Health Act. Those disparities remain. Black people are still far more likely to be detained or subject to coercive powers. Deprivation continues to shape who is most likely to enter the system under compulsion. 

This is not a side issue, but a question of legitimacy. A legal framework that is experienced as unfair by particular communities will struggle to command trust, however carefully it is drafted. 

From societal causes to local action

These inequalities are shaped by factors far beyond the acute mental health system, from housing and education to employment and community support, but that does not make them intractable. Local, place-based leadership still has practical levers to reduce risk and prevent crisis before detention becomes the outcome. 

The Patient and Carer Race Equality Framework was designed as a practical tool to drive change, not a statement of intent. But the CQC’s findings on awareness should give everyone pause. If staff do not know what PCREF is, it cannot shape practice.   

Reducing inequality requires more than commitment at board level. It requires operational discipline, data literacy and the willingness to change how decisions are made on the ground. 

So, what should the next phase of reform focus on? 

First, the Code of Practice. This is not a technical afterthought. It is the bridge between legislation and reality. It will shape how new rights and duties are interpreted, how far discretion stretches, and what “good” looks like in practice. It needs time, expertise and genuine engagement across the system. If it is rushed or under-resourced, uncertainty will be baked into implementation from the start. 

Second, the things that can be done now, without waiting for every provision of the Act to be formally commenced. Advance Choice Documents are an obvious example. Supporting people to express preferences, values and wishes should not be treated as something that only becomes important once the law demands it. It is a practical expression of dignity and autonomy that services, of which many are, can prioritise today. 

The same applies to the everyday basics of good care: explaining rights clearly, involving people in decisions, tailoring care plans to individual needs, and reducing restrictive practices through better staffing, skills and environments. None of these require new legislation to start happening more consistently, but they do need resourcing sufficiently. 

Third, inequality must move from aspiration to action. Frameworks and strategies matter, but what matters more is whether services understand their own data, interrogate patterns of detention and coercion, and act on what they find. Leaders should be able to answer simple questions: do staff understand PCREF, are they trained to use it, and is it shaping decisions about care and risk? 

Fourth, we need to be honest about resourcing. The CQC’s report makes clear that high bed occupancy, out-of-area placements, workforce shortages and poor estates are not background noise. They directly affect whether care under the Act is lawful, therapeutic and safe.   

If we want detention to be less common, we need credible community alternatives. If we want safeguards to function, we need the people and infrastructure to deliver them. Reform without investment is not reform. It is expectation without means. 

Finally, we should be more ambitious about evidence and learning. Mental health research remains underfunded relative to the scale of need. Some promising work is underway, such as Mental Health Research Groups, but whole-system backing is needed for it to have the desired impact. Implementation will raise hard questions about what works, for whom, and in what contexts. We should be designing this next phase to generate answers, not relying on anecdote or isolated examples of good practice. 

Reform is measured in experience, not statute

I am proud of the colleagues, past and present, who carried this reform to Royal Assent. They will not need to be named to know who they are. They also know, better than anyone, that passing a law is not the same as changing reality. 

People subject to the Mental Health Act do not experience legislation. They experience waiting, environments, staffing, restrictions, explanations, and whether anyone listens. 

The success of this reform will be measured there. 

For readers who want to explore the evidence underpinning these challenges, a companion analysis examines CQC’s Monitoring the Mental Health Act 2024/25 report in depth.