The Nearest Relative
Joan Rapaport PhD
Tutors
Professor Shula Ramon ARU
Professor William Bingley UCLAN
Overview
• Provide brief background history
• Describe its shaping up
• Explain some recent history & current
developments
What is the Nearest Relative?
• Can influence a relative’s hospital detention
• Identified under legal hierarchy
• Principal early origins: Madhouse Law
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
Gestation & birth
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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
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
Hierarchy & Rules
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Husband or wife
Son or daughter
Father or mother
Brother or sister
Grandparent
Grandchild
Uncle or aunt
Nephew or niece
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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)
NR powers
• To make the application
• To object to a treatment section (civil cases)
• To seek discharge
• To delegate role (under memorandum)
THEORETICAL IMPACTS
‘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
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
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
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)
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
Proposed MHA reform - professional discretion
to exclude carers from consultations about care
planning
Where ‘consultation will be inappropriate or counterproductive, 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).
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
From reform to amendment
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MHA 2007
NR survival - intact
Remedies to displace inappropriate relatives
Same sex relationships recognition
(formalises case law)
Practice concerns - comparisons
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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?
NR story
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Evolution
Birth
Existence
Near demise and resurrection
• Research and Ethics - do-able now?