Opt-out in mental health advocacy is coming. But what kind of advocacy do people really need?

The Mental Health Act 2025 brings some pretty significant changes for advocacy.

IMHA will be extended to informal patients. For compulsory patients, advocacy will move towards an opt-out model.

These are changes I have wanted to see for a long time. But there is a question that I think we need to start asking now:

What kind of advocacy are we actually going to deliver?

There is a risk that we congratulate ourselves on extending access to IMHA, change a few referral processes and carry on delivering advocacy in fundamentally the same way. And that would be a huge missed opportunity.

Opt-out has to mean more than automatic referral

The current system is largely built around people asking for advocacy, or someone referring them. Usually there is an issue. Someone wants help with their medication. Their leave has been refused. They want support at a ward round. They want to complain.

The advocate comes in, supports with the issue and, often, closes the case.

There is nothing inherently wrong with that. Sometimes people want exactly this kind of focused, transactional advocacy. But it doesn't work for everyone.

Think about somebody who has been in hospital for ten years. Someone who doesn't trust professionals. Someone who communicates differently. Someone who doesn’t understand advocacy. They have experienced repeated restraint. They have become so used to restrictions that they no longer question them.

Asking them "do you want an advocate?" may get us absolutely nowhere. For these people, advocacy may start with a cup of tea and a conversation. And then another conversation. And another. It may take weeks or months before the person decides that this advocate is safe enough to trust.

That is advocacy too.

So if opt-out simply becomes: automatic referral → identify an issue → provide advocacy → close we will have changed the mechanism without really changing the model.

Some advocacy needs a relationship

I would like the new Code of Practice to explicitly recognise relational advocacy.

Some people want an advocate to sort something out and disappear again. Great. This will work when things are simple and focused - a transactional approach is perfect.

But how many times do you see people where its messy? It's intense and outcomes are uncertain. There isn't a clear single advocacy 'issue' with an obvious resolution. Yet advocacy could make a difference. What is needed is continuity and an advocate who is around long enough to get to know the person. Somebody who notices when things change. Somebody who understands how the person communicates and what matters to them. Somebody who has the time and presence to understand family dynamics and appreciate who matters to the person.

And if this idea makes you spit your tea out in horror because you have been told IMHA is issue based, please read chapter 6 of the Code of Practice. This is nothing in the current code that says IMHA has to be issue based. It simply says who can have an IMHA.

Relational advocacy must be available. It becomes even more important when someone cannot clearly instruct their advocate.

Non-instructed advocacy is barely visible in the current Code. That needs to change.

A person who cannot tell an advocate, "I want you to challenge this" should not receive less advocacy. In fact, I would argue that they may need independent scrutiny more than anyone.

Advocates need to know how to use observation, previous wishes and feelings, Advance Choice Documents, communication preferences, family knowledge and rights-based approaches to understand someone's experience and represent them.

We need advocates who are curious enough to ask:

• What is happening to this person?

• What would they tell me if they could?

• What rights are at stake here?

And culture matters too.  The new Code has an opportunity to say something much stronger about culturally appropriate advocacy.  CAA cannot simply mean finding an advocate from the same ethnic background or translating an advocacy leaflet.

It is much deeper than that. It means cultural humility. It means being curious about someone's identity, culture, faith, family, community and traditions without assuming that we understand them. It also means advocates understanding racism.

We need advocates who are confident enough to notice when race, culture or stereotypes may be influencing how someone's distress is interpreted, how risk is assessed, how restrictions are imposed or how force is used.

And we need advocacy services to contribute what they learn to the Patient and Carer Race Equality Framework.

Advocates hear things that services don't always hear. That intelligence matters. There is another thing I would like the Code to say much more clearly.

Good advocacy will sometimes make services uncomfortable.

Advocates question things. Why can't she have that? Where is the evidence for this restriction? When was it last reviewed? Why is he still in long-term segregation? Why hasn't anyone responded to this request? Why is this person still in hospital?

That isn't an advocate being difficult. That is the job. Of course, challenge should be thoughtful, evidence-based and respectful. But independence means very little if an advocate feels unable to disagree with the organisation caring for the person.

And challenge needs follow-through. There is little value in supporting someone to say "I want my leave reviewed" if that request then disappears into the system.

Advocacy isn't simply about giving someone the opportunity to express a view. It is about helping them have influence. That requires the people around them to listen and respond.

Extension to informal patients

Extending IMHA to informal patients also opens an entirely new area of advocacy. I think one of the most important questions advocates can ask informal patients is: "You are here voluntarily. What does that actually mean in practice?"

Can you leave?

Do you know you can leave?

What happens if you walk towards the door?

Have you been told that you will be detained if you try to leave?

Have you genuinely consented to being here?

What restrictions are you living under?

An informal legal status does not necessarily mean someone experiences themselves as free. IMHA could become an incredibly important safeguard against de facto detention.

And then there is the biggest question of all

Why is this person still here?

I think discharge is one of the biggest omissions from the current advocacy chapter.

Advocacy should not suddenly become interested in discharge when somebody is six weeks away from leaving hospital. Creating a route out should begin much earlier.

What does this person want their life to look like? Where do they want to live? What support do they want? What is currently preventing discharge? Who is responsible for sorting it out? And when are they going to do it?

For people who have spent years in hospital, there is a subtle but important danger. The question can gradually change from: "Why does this person need to remain in hospital?" to: "Can we prove it is safe for this person to leave?"

Those are not the same question.

Advocacy has an important role in keeping the first one alive. And advocacy shouldn't simply help someone get out of hospital. It should help them have a say over the life they are being discharged to.

One person. One advocate.

There is another change I would love us to think about. We have created a complicated statutory advocacy landscape. IMHA. IMCA. Care Act advocacy. NHS complaints advocacy. Relevant Person's Representatives.

Each makes perfect sense when viewed through the legislation that created it. But imagine experiencing it as the person. You have spent six months getting to know Frank, your IMHA. Now you want to make a complaint.

"Ah. That's complaints advocacy. We'll refer you to Brian."

Then there is a safeguarding enquiry.

"That's Care Act advocacy. Meet Susan."

Then you lack capacity around a significant medical decision.

"You need an IMCA. Here's Ahmad."

We have designed advocacy around legal frameworks rather than human beings. Wherever possible, why can't the appropriately trained advocate who already knows and is trusted by the person simply continue?

One person. One advocate.

The system should fit around the person rather than expecting the person to fit around the system.

Advocates see things

Finally, there is something else that I think we underestimate. Advocates see patterns. One unanswered request may mean very little. Twenty unanswered requests tell us something. One strange restriction may be an individual decision. The same restriction appearing across a ward tells us something else. Advocates notice when people stop asking. We notice when restrictions gradually become normal. We notice when everybody's language starts sounding institutional. We notice when discharge never quite gets any closer.

This is systemic advocacy.

It doesn't mean turning advocates into inspectors. Our allegiance remains with the people we support. But advocacy services hold an extraordinary amount of intelligence about what life actually feels like inside mental health services.

We should use it.

This is bigger than extending eligibility

Mental health hospitals contain enormous imbalances of power. People can make decisions about where another person lives, whether they can leave, what treatment they receive and, in some circumstances, whether force can be used against them.

Advocacy cannot remove that power. But it can provide a counterweight. So as we write the new Code of Practice, I hope we are ambitious. I don't want opt-out advocacy simply to mean that more people appear on an advocacy referral spreadsheet.

I want advocacy that is visible. Relational. Culturally humble. Rights-focused. Persistent. Prepared to challenge. Interested in people's lives, not simply their legal status. And there when somebody cannot easily speak for themselves.

The Mental Health Act 2025 gives us an opportunity to position independent advocacy not simply as a service people access when they have a problem, but as part of the safeguarding and rights infrastructure of mental health care.

If we get this right, the expansion of IMHA could achieve something much more important than increasing the number of people technically entitled to an advocate.

It could change who gets heard.