There are many mental health workers who attitudinally consider ‘treatment’ and related concepts to gravitate around medication. They are wrong. This article will explore the concept of treatment the Mental Health Act 1983 (as amended 2007) for England & Wales. The law and its application are inescapable when treating or caring for people with mental disorders. In Treatment – what it means, there was an overview of treatment for the purposes of the MHA. This article drills deeper into the intricacies by reference to recent case law.
But first, in the context of medical treatment within the NHS in the UK, several pieces of statute law govern the rights and treatment of patients, whether they are inpatients or outpatients. This means there is no point trying to ‘escape law’. This needs to be said because most people who work in health services, never read much of the law, do not know it and are therefore incapable of apply it with direct knowledge. Caution: This does not mean that they may not have attended a course on legal requirements.
The following list is not exhaustive, but often appied when interpreting issues in the MHA 1983:
- Mental Health Act 1983 – This Act provides the legislative framework for the treatment, control, and care of mentally disordered persons within England and Wales. It sets out when a person can be admitted, detained, and treated in hospital without their consent, either for their own health and safety or for the protection of other people.
- Mental Capacity Act 2005 – This Act provides a framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves. The Act’s key principle is to ensure that those who lack capacity are involved in decisions affecting them as much as possible.
- Health Act 2009 – This Act legally established the NHS Constitution, giving it a basis in statute. The Act requires that the NHS pay regard to the Constitution in its decisions and actions. It also mandates that the Constitution be reviewed and refreshed every 10 years to ensure it remains relevant and up-to-date.
- Health and Social Care Act 2012 – This Act provides significant changes in the way that healthcare services are organised, delivered, and regulated within England. It affects how NHS services are commissioned and the responsibilities of healthcare professionals. It further reinforces the significance of the NHS Constitution by requiring that all providers of NHS services in England adhere to the Constitution as part of their contractual obligations.
- Care Act 2014 – This Act sets out how adult social care in England should be provided. This includes the assessment and provision of care and support, the care and support provided directly by local authorities, and the interaction between social care and other services like healthcare and housing.
- Human Rights Act 1998 – This Act incorporates the rights contained in the European Convention on Human Rights (ECHR) into domestic British law. The Act plays an important role in the contexts of healthcare and social care, especially concerning issues of privacy, dignity, and freedom from inhumane treatment.
- Equality Act 2010 – This Act consolidates anti-discrimination laws in the UK. It ensures equality of treatment and non-discrimination in the provision of services, including healthcare.
Clarification from case law.
SF v Avon and Wiltshire Mental Health Partnership NHS Trust and RB [2023] UKUT 205 (AAC) is most informative. The Upper Tribunal in SF v Avon and Wiltshire Mental Health Partnership NHS Trust grappled with the nuanced interpretation of ‘treatment‘ and ‘appropriate treatment‘ within the context of the Mental Health Act 1983. It underscored that the determination of ‘appropriate medical treatment’ necessitates a patient-centric approach, acknowledging the distinctive circumstances and needs of each individual. It also highlighted that while the MHA offers an inclusive definition of ‘medical treatment‘, encompassing nursing, psychological intervention, and specialist mental health habilitation, rehabilitation, and care, the central issue lies in the treatment’s purpose – to alleviate or prevent the worsening of the mental disorder or its manifestations.
In essence, the Upper Tribunal stressed that the mere availability of generic medical treatment does not suffice; it must be ‘appropriate’ to the patient’s specific diagnosis and needs. It further clarified that interventions aimed solely at containing the risk of physical harm, without addressing the underlying mental disorder, do not qualify as ‘medical treatment’ in the context of the MHA. It drew upon the European Court of Human Rights’ stance in Rooman v Belgium [2019] ECHR 105, emphasising the necessity of ‘real therapeutic measures‘ and an ‘individualised programme‘ that facilitates the patient’s potential reintegration into society.
In conclusion, the Upper Tribunal’s ruling in this case provides a significant precedent in interpreting ‘treatment’ and ‘appropriate treatment’ under the MHA. It establishes that treatment must be genuinely therapeutic, tailored to the patient’s specific needs, and aimed at alleviating the mental disorder or its manifestations, rather than merely containing associated risks.
The decision drew on other relevant case law:
- R (on the application of O’Reilly) v Blenheim Healthcare Ltd [2005] EWHC 241 (Admin): Distinguished between acts carried out for the purpose of treatment and treatment itself, highlighting that monitoring alone may not constitute ‘medical treatment’.
- DL-H v Devon Partnership NHS Trust [2010] UKUT 102 (AAC): This case likely provided guidance on the interpretation of ‘appropriate medical treatment’.
- 6.8 This medical treatment must be appropriate, taking into account the nature and degree of the person’s mental disorder and all their particular circumstances, including cultural, ethnic and religious considerations. By definition, it must be treatment which is for the purpose of alleviating or preventing a worsening of the patient’s mental disorder or its symptoms or manifestations.
- 6.9 The appropriate medical treatment test requires a judgement about whether an appropriate package of treatment for mental disorder is available for the individual in question. Where the appropriate medical treatment test forms part of the criteria for detention, the medical treatment in question is treatment for mental disorder in the hospital in which the patient is to be detained. Where it is part of the criteria for SCT it refers to the treatment for mental disorder that the person will be offered while on SCT.
- 6.10 The test requires a judgement about whether, when looked at in the round, appropriate medical treatment is available to the patient, given:
- the nature and degree of the patient’s mental disorder; and
- all the other circumstances of the patient’s case.
- In other words, both the clinical appropriateness of the treatment and its appropriateness more generally must be considered.
- DL-H v Partnerships in Care & SoSJ [2014] AACR 16: Similar to the previous case, this likely offered interpretative guidance on ‘appropriate medical treatment’.
- SLL v (1) Priory Health Care and (2) Secretary of State for Justice (Mental Health) [2019] UKUT 323 (AAC): Established that medical treatment with no prospect of therapeutic benefit cannot be considered ‘appropriate’, even if it technically falls within the MHA definition.
- PM v Midlands Partnership NHS Foundation Trust [2020] UKUT 69 (AAC); [2020] AACR 23: Determined that monitoring, without intervention, does not inherently qualify as ‘medical treatment’ under the MHA.
- Rooman v Belgium [2019] ECHR 105: Emphasised the dual function of detention under Article 5(1)(e) of the ECHR, requiring both social protection and a therapeutic purpose with ‘real therapeutic measures’.
Summary and takeaway points.
SF v Avon and Wiltshire Mental Health Partnership NHS Trust case and related jurisprudence went deep into the concept of treatment and ‘appropriate treatment’. The key points to extract are as follows:
- Patient-centric approach: The determination of ‘appropriate medical treatment‘ necessitates a patient-centric approach, considering the individual’s specific needs, circumstances, and diagnosis.
- Therapeutic purpose: Treatment must be genuinely therapeutic, aiming to alleviate or prevent the worsening of the mental disorder or its manifestations. Interventions solely focused on containment or risk management do not qualify as ‘medical treatment’.
- Individualised treatment plans: Treatment plans should be tailored to the individual’s specific needs and circumstances, considering factors such as cultural, ethnic, and religious considerations.
- Holistic assessment: The assessment of ‘appropriateness’ involves a comprehensive evaluation of the treatment’s clinical relevance, potential benefits, and broader suitability for the patient, balancing restrictiveness against therapeutic value.
- Contextual application: The appropriateness of treatment is assessed within the specific context of detention or Supervised Community Treatment, focusing on the treatment available in the hospital or under SCT, respectively.
- Dynamic interpretation: The concept of ‘appropriate treatment’ is subject to evolving jurisprudence, reflecting advancements in mental healthcare practices and a growing emphasis on patient autonomy and dignity.
These takeaways underscore the importance of a nuanced and holistic approach to assessing the appropriateness of medical treatment under the MHA. It is not merely about providing any treatment but ensuring it is the right treatment for the individual, fostering their recovery and well-being while respecting their rights and autonomy.