The PACT advance decision-making template - preparing for Mental Health Act reforms with co-production, focus groups and consultation

Sep 11, 2026

Advance decision making (ADM) in mental health receives broad stakeholder support but remains difficult to implement, creating a gap between aspirations and everyday practice. The study aims to address barriers ahead of proposed statutory ADM reforms in England and Wales by developing feasible co-produced ADM resources. Focus groups and consultation elicited stakeholder experience and views, including iterative feedback on a prototype ADM template and guidance. A co-produced PACT (Preferences and Advance decisions for Crisis and Treatment) template was universally supported and designed to facilitate person-centred assessments amid fluctuating capacity.

LanguageEnglish

CategoryPresentations

FormatPDF

Pages13

Reading Time5 min

AccessFree to download

Highlights

Stakeholder support and implementation challenges

Government commitment to reform

Co-production of the PACT template

Abstract

Background

Aims

Methods

Results

Conclusion

Introduction

Existing ADM evidence and limitations

Reform of the Mental Health Act 1983 for statutory ADM

Human rights rationale for statutory ADM

International Journal of Law and Psychiatry 71 (2020) 101563 Contents lists available at ScienceDirect International Journal of Law and Psychiatry journal [homepage:](homepage: www.elsevier.com/locate/ijlawpsy)[ www.elsevier.com/locate/ijlawpsy](homepage: www.elsevier.com/locate/ijlawpsy) | The PACT advance decision-making template: preparing for Mental Health Act reforms with co-production, focus groups and consultation
Lucy A. Stephensona,⁎,1, Tania Gergela,1, Alex Ruck Keeneb, Larry Rifkinc, Gareth Owenaa Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
b Institute of Psychiatry, Psychology and Neuroscience, King's College London, 39 Essex Chambers, United Kingdom c South London and Maudsley NHS Foundation Trust, United Kingdom | | | | --- | --- | --- | | H I G H L I G H T S | | | | • Mental health advance decision-making is widely approved but difficult to implement.
• UK government has committed to legal reform supporting advance decision-making.
• To prepare, stakeholder concerns need to be understood and addressed.
• Stakeholders were invited to co-produce the PACT advance decision-making template.
• PACTs facilitate collaborative, personalised advance decision making. | | | | A R T I C L E I N F O
Keywords:
Advance directive Severe mental illness Bipolar
Mental capacity
Mental health law | A B S T R A C T
Background: Advance decision making (ADM) in mental health is supported by stakeholders but faces significant barriers. These must be overcome, not least to support the UK government's commitment to introduce statutory mental health ADM in England and Wales.
Aims: To build understanding and address the gap between aspirations for ADM and actuality, with feasible coproduced ADM resources.
Methods: We used focus groups and consultation to explore experience and views of stakeholders on ADM processes and materials. Discussions included feedback on an ADM template which was adapted accordingly throughout the research process.
Results: Between September 2017 and December 2019, 94 individuals, representing stakeholders advised on design and process of ADM, alongside wider discussion at stakeholder events. Collaborative ADM was universally supported. Valued outcomes were diverse and combining aspirations with practicality required resolving dilemmas. A prototype template and guidance, the PACT (Preferences and Advance decisions for Crisis and Treatment) was co-produced, designed to help manage fluctuating mental capacity through collaborative decision making. The PACT enables direct engagement with medico-legal frameworks, with provision to facilitate person-centred assessments, treatment refusals and requests. Resources including supported engagement and cross-agency awareness and accessibility were seen as essential.
Conclusion: Our research confirms high stakeholder motivation to engage in ADM is hampered by multiple barriers. We identified enabling conditions for ADM and co-produced an ADM template and guidance which supports achievement of a range of valued outcomes. Further developments to support and evaluate the process of implementation are now needed to prepare for statutory change. | | ⁎ Corresponding author. E-mail address: [Lucy.a.stephenson@kcl.ac.uk](Lucy.a.stephenson@kcl.ac.uk) (L.A. Stephenson). 1 Joint first authors. [https://doi.org/10.1016/j.ijlp.2020.101563](https://doi.org/10.1016/j.ijlp.2020.101563) Received 11 March 2020; Received in revised form 17 April 2020 Available online 21 July 2020 0160-2527/ © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license ([http://creativecommons.org/licenses/BY/4.0/](http://creativecommons.org/licenses/BY/4.0/)). L.A. Stephenson, et al. 1. Introduction Advance decision making (ADM) for mental health crises is widely approved, but under-used and under-resourced, particularly when compared to ADM in physi

FAQs

Why is advance decision making (ADM) in mental health still difficult to implement?

The study reports that ADM is widely approved but faces significant practical and legal implementation barriers, leading to an “aspirations vs actuality” gap.

What was the purpose of using focus groups and consultation in this research?

Focus groups and consultation were used to explore stakeholder experiences and views on ADM processes and materials, including feedback used to adapt an ADM template during the research.

What is the PACT template and what does it help with?

The PACT (Preferences and Advance decisions for Crisis and Treatment) template and guidance were co-produced to support collaborative, person-centred decision making, including managing fluctuating mental capacity and facilitating engagement with medico-legal frameworks.

Sep 11, 2026

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