1. The Nearest Relative Joan Rapaport PhD Tutors Professor Shula Ramon ARU Professor William Bingley UCLAN

2. Overview Provide brief background history Describe its shaping up Explain some recent history & current developments

3. What is the Nearest Relative? Can influence a relative’s hospital detention Identified under legal hierarchy Principal early origins: Madhouse Law

4. Brief historical background Statute de Prerogative Regis (medieval - ‘Chancery Lunatics’) Madhouses Act 1774 Madhouses Act 1828 Lunacy & Lunatics Asylum & Paupers Act 1845 Lunacy Act 1990

5. Gestation & birth Royal (Percy) Commission 1954 - 1957 Relatives: different definitions & roles Tensions - disaffected relationships Standing Committee E - hierarchy & procedures Mental Health Act 1959 NR powers includes application for admission (also MWO) Court procedure re admission abolished

6. Dr Edith Summerskill ‘There is another point I want to make about the nearest relative. It is easy to dismiss this, but it is quite conceivable that the nearest relative is not necessarily the person most concerned to promote the welfare of the patient … At the moment we are discussing imponderables, but I confess that I find it difficult to suggest an alternative. No doubt we are all thinking of our nearest relatives and that “but by the grace of God there goes …” some of us. We should be quite content that our relatives should be there to look after our welfare, but can that be said of all people?’ HC 598 736

7. Hierarchy & Rules Husband or wife Son or daughter Father or mother Brother or sister Grandparent Grandchild Uncle or aunt Nephew or niece Highest on the list Age of majority 21 (18) Eldest at each level Father before mother Divorce, separation & partnerships Full blood over half UK Sexual Offences Act (removed by 1983 Act)

8. NR powers To make the application To object to a treatment section (civil cases) To seek discharge To delegate role (under memorandum)

9. ‘What do you want, Mam?’ To be hung. You won’t send me away, will you?’ ‘No.’ But as Laing and Co. might smugly note, ‘No’ meant ‘Yes’ and in due course she was back in hospital. … I was always nervous of discussing anything but the matter in hand with my mother’s various psychotherapists for fear they were taking notes on me too, and whatever I said, however lightly, would be taken down in evidence against me; I was part of the equation’. Alan Bennett - Untold Stories p 107 THEORETICAL IMPACTS

10. Mental Health Act 1983 New power to ask SSD to send an ASW to assess a close relative with a view to hospital admission (S13(4)) Hierarchy modified: priority to relative who cared for the pt; person living with the pt 5 yrs included; mother and father equally eligible

11. NR problems MHAC 1991 - ASW reports - abuser NRs - MHAC recommendations re displacement ignored! NRs involved in sexual abuse Pt challenges where wrong NR had been identified in the admission process NRs blocking treatment sections

12. Rise of carer - NR demise? Carer movement Community care policy - carer shortages Carers Act 1995 - carer right to own assessment of need Psychiatric homicides & media response 1995 MHA amended - supervised discharge - NR loss of applicant role (also ASW)

13. Late 1990s - MHA reform Proposals to replace NR with NP & carer NP appointed by the pt NP - rights to be involved in care plans, make an application of pt’s behalf to MHRT Carer - rights to be involved if pt agreed Assumed/hoped that NP and carer would be the same person

14. Proposed MHA reform - professional discretion to exclude carers from consultations about care planning Where ‘consultation will be inappropriate or counter- productive, for example where there is conflict of interest between the patient and carer’. DH MH Bill 2002 Notes ‘It is very dubious whether it is ever possible to divorce the interests of the individual entirely from the interests of the carer.’ Brazier (1992).

15. NR research: main findings NR role little known by service users & carers Powers seldom used Potential for ASW/NR reciprocation for pt benefit Role’s positive potential overlooked Major problem with the ID process

16. From reform to amendment MHA 2007 NR survival - intact Remedies to displace inappropriate relatives Same sex relationships recognition (formalises case law)

17. Practice concerns - comparisons Professional prejudices Assessment of care and social context Carer information and risk assessment Interpretations of person-centred care Case law (Bristol case) - interpretations The case for psychodynamic approaches?

18. NR story Evolution Birth Existence Near demise and resurrection Research and Ethics - do-able now?