Friday, 5 December 2008

Nearest, dearest

The new Mental Health Act will change the way we see the nearest relative.

Now the Mental Health Act has been amended, it will provide new systems for the selection – and most importantly, the removal – of a patient’s nearest relative.

Where a person has mental disorder, her nearest relative (NR) has firm powers and entitlements: to apply for her to be detained under the Mental Health Act 1983 (MHA) or discharged, for example, and to be informed about an admission under section 2 or object to a proposed admission under section 3. The fact that a patient could not choose her NR was therefore a matter of great concern.

Some people even claim to have been abused by their NR, and the prospect of that person being involved in her life can prove detrimental to a patient’s mental health. Almost a decade ago, the Government acknowledged that this state-of-affairs might breach human rights, and it promised the European Court of Human Rights(ECtHR) that it would give patients more of a say in the selection of their NR. (FC v United Kingdom, Application no 37344/97, Decision of 7 September 1999; JT v United Kingdom, Application no 26494/95, Decision of 30 March 2000) The recent changes are an attempt to fulfil that promise.

Because the changes were so long in coming, practitioners began to devise ad hoc solutions of their own. Some, for example, argued that where abuse was alleged, it was “not reasonably practicable” to consult a NR about a patient’s proposed admission under section 3. (MHA, s 11(4)) Though this approach was considered dubious, it has been approved by the High Court. (E v Bristol City Council, [2005] EWHC (Admin) 74) But it is only a partial solution to the problem: even if he need no longer be consulted, a NR will continue to enjoy all the other powers and entitlements of the role. A more comprehensive solution was clearly required.

The changes
The amendments to MHA 1983 were made by the Mental Health Act 2007. The first one had little to do with the Government’s promise to the ECtHR. Since 1 December 2007, where two people are in a civil partnership, one has been the NR of the other. (MHA 1983, s 26(1)(a)) Most of the other changes, however, deal with the removal of the NR.

A patient can now apply to remove her NR (a right she shares with any relative of hers, any other person with whom she resides and an Approved Mental Health Professional). (MHA 1983, s 29(2)(a)-(c) & (za)) And there will be a new ground for displacement, which any applicant might use: the NR is “not a suitable person to act as such”. (MHA 1983, s 29(3)(e)) The amended Act does not say what this means.

That is not to say that ‘suitability’ has gone unmentioned. During the Parliamentary debates that produced the 2007 Act, the minister, Rosie Winterton, said, “we intend the idea of unsuitability to cover situations in which there is no effective relationship between the patient and the nearest relative, or where the relationship has broken down irretrievably.” (Hansard, 18 June 2007, col 1099) So, the circumstances in which a NR might be unsuitable will not be limited to abuse. In fact, the revised MHA 1983 Code of Practice says that an application might be appropriate if there is: "any reason to think that the patient has suffered, or is suspected to have suffered, abuse at the hands of the nearest relative (or someone with whom the nearest relative is in a relationship), or is at risk of suffering such abuse"; "any evidence that the patient is afraid of the nearest relative or seriously distressed by the possibility of the nearest relative being involved in their life or their care"; or "a situation where the patient and nearest relative are unknown to each other, there is only a distant relationship between them, or their relationship has broken down irretrievably." (Para 8.13)

Furthermore, the procedure by which a NR might delegate his functions to someone else is now contained in regulation 24 of The Mental Health (Hospital, Guardianship and Treatment) (England) Regulations 2008. (The old regulations have been repealed.) And there is new official guidance, which includes “Seven steps to identify the nearest relative”. (Department of Health, 2008, Reference guide to the Mental Health Act 1983, ch 33)

Patients now have some control over their nearest relatives and, in the most flagrant cases, can have them removed. But much of the law that pre-dated the recent changes remains in force. Though we might, for a while, become pre-occupied with the notion of ‘unsuitability’, we certainly haven’t seen the last of the question of ‘practicability’.

These changes are discussed in more detail in the second edition of my book, The Nearest Relative Handbook, which will be published by Jessica Kingsley Publishers in January 2009. More details may be found here.