What now for deprivations of liberty?
What will the effect of the postponement of the Liberty Protections Safeguards be on local authorities? Local Government Lawyer asked 50 adult social care lawyers for their views on the potential consequences.
SPOTLIGHT |
Arianna Kelly looks at a new case with significant implications for local authorities using the Care Act ‘easements’.
The Care Act ‘easements’ were brought into force on 31 March 2020. Per the statutory guidance, local authorities may take a decision to apply the new and much higher threshold for receiving care. That threshold states that a person is not entitled to receive care and support from a local authority as a matter of right unless it is necessary to prevent a breach of the person’s human rights – most likely to be Articles 2, 3 or 8 of the European Convention.
A new judgment from Mr Justice Chamberlain, University College London Hospitals NHS Foundation Trust v MB (Rev 1) [2020] EWHC 882 (QB) (09 April 2020), considers when a refusal to provide hospital care may breach a person’s Article 3 rights. While the judgment makes broad statements about the inapplicability of Article 3 in relation to the allocation of scarce resources, it also highlights the importance of effective provision of community care for those who do not receive hospital care. This case has important implications for local authorities, which will likely bear the responsibility for avoiding breaches of human rights in cases of this nature.
The facts
The case involved an application by the Trust for possession of the room of a patient, MB, in anticipation that the room would be needed for COVID-19 patients. MB had been in the hospital for over a year as a neuropsychiatric inpatient. She had multiple mental health diagnoses and a functional neurological disorder. Hospital staff had found MB extremely difficult to care for due to her behaviour. The hospital had been attempting to discharge MB since August 2019, but she had refused to leave.
MB had care needs, and a 24-hour care package was to be made available to her by the local authority upon her discharge, with a review of this provision after three months. MB considered that the proposed care package was inadequate, and sought a guarantee that she would receive 24-hour care in the community for at least a year.
The arguments
MB opposed the Trust’s application on the basis that it would breach her Article 3, 8 and 14 rights, and would be contrary to ss. 29 and 149 of the Equality Act 2010. She submitted that if her discharge proceeded as planned, she would be at risk of suicide, self-harm or suffering extreme distress.
The Trust argued that the discharge was appropriate notwithstanding MB’s concerns, that the care package was appropriate, and that in any event, the Trust did not have control over the nature of the care package offered by the local authority. In evidence from a treating doctor, it was stated that "there are no mental health reasons…to keep her in this hospital".
The court made the following findings on the evidence:
The judgment
The court granted the Trust’s application. MB did not argue that the decision to seek possession of her room was irrational, and the court found that such an argument would have been unsustainable. Mr Justice Chamberlain considered whether MB had a public law defence to the hospital’s application under Articles 3, 8 or 14:
Article 3:
Article 8:
Article 14 and s.149 Equality Act 2010:
Discussion and application for local authorities
If there is scarcity of resources in the health and social care sectors as a result of the pandemic, difficult decisions will need to be made as to which individuals receive care and which do not. In this judgment, the court appeared to find that that Article 3 was not (or was extremely unlikely to) be engaged by a decision to refuse care to a person on the basis of scarcity, so long as the care was denied for the purpose of providing care to others – even where such a decision caused the person who was denied care to experience serious suffering.
I do not believe that this is an accurate statement of what is required of the state under Article 3, and that the finding in MB was strongly influenced by two factors:
My view is that the ratio in this case was overbroad in its statements on the inapplicability of Article 3 in cases of allocation of scarce resources, and that the key finding was actually that MB was not at any meaningful risk of experiencing Article 3 suffering because she would always have support available to her. If upon discharge, MB would have been likely to experience suffering of a level as to engage Article 3, the court would have had to grapple with the far more difficult question of whether the hospital was permitted to inflict this fate upon her in order to free up resources for as-yet-unidentified others.
In support of its ratio, the court in MB looked to two cases, Pretty v DPP and R v North West Lancashire Health Authority, both of which present different and more complicated pictures of what is required by Article 3:
The negative prohibition in the article is absolute and unqualified but the positive obligations which flow from it are not absolute: see Osman v United Kingdom, above; Rees v United Kingdom (1986) 9 EHRR 56…states…may not take direct action in relation to an individual which would inevitably involve the inflicting of proscribed treatment upon him (D v United Kingdom (1997) 24 EHRR 423)’.
o The ‘treatment’ prohibited by Article 3 refers to ‘“ill-treatment” that attains a minimum level of severity and involves actual bodily injury or intense physical or mental suffering… The suffering which flows from naturally occurring illness, physical or mental, may be covered by Article 3, where it is, or risks being, exacerbated by treatment, whether flowing from conditions of detention, expulsion or other measures, for which the authorities can be held responsible.’
o Looking primarily to D v United Kingdom, the Strasbourg court considered that a state’s responsibility may be engaged by removing a person who was very unwell to a place where ‘no effective medical or palliative treatment’ was available.
The threshold for the suffering required to engage Article 3 is high, but my view is that where such suffering arises, the obligations of the state to prevent it are significantly less flexible than is suggested in MB. I would note the following passage from D v United Kingdom:
“49. The Court must reserve to itself sufficient flexibility to address the application of that Article in other contexts which might arise. It is not therefore prevented from scrutinising an applicant’s claim under Article 3 where the source of the risk of proscribed treatment in the receiving country stems from factors which cannot engage either directly or indirectly the responsibility of the public authorities of that country, or which, taken alone, do not in themselves infringe the standards of that Article. To limit the application of Article 3 in this manner would be to undermine the absolute character of its protection.
In D v United Kingdom, N v United Kingdom and De Almeida v Kensington and Chelsea, courts were called upon to consider whether an Article 3 breach would occur if either a local authority refused to provide support for the person, or the person was removed from the UK to a country where no (or grossly inadequate) social support was available to the person. Where the prospect of grotesque suffering of such a level as to make an Article 3 breach a serious prospect was present, the courts did take into account the finite nature of finances for either health or social care – in stark contrast to arguments under Article 8, where these arguments were often central.
Conclusion
In short, I would advise local authorities considering their obligations under Article 3 to treat the judgment in MB with caution. Per the statutory guidance, the Care Act ‘easements’ should not be exercised until a depletion of the workforce or a surge in demand for care is so great that local authorities are unable to comply with their Care Act duties. Thus, local authorities should only be making determinations of eligibility on the basis of avoiding breaches of Article 3 if they are in a position of allocating scarce resources.
While the threshold for engaging Article 3 is very high, my view is that cases will exist which oblige local authorities to provide care to avoid breaching it – and the potential breach would not fall away simply because the budget for social care has been spent in other ways. The facts of what level of suffering the person would be likely to experience in the absence of care will be key, particularly in cases where an affirmative act is taken to withdraw care and support which a person relies upon. Further, social care resources are typically more flexible than health resources, (particularly where direct payments may be appropriate for meeting needs), and are less likely to run up against the hard limitations of resources which may be seen in health settings.
Where brutal decisions may need to be taken on an urgent basis in relation to access to health care, the existence of an effective provision of social care for people who are not afforded hospital care will be vital to ensuring that their Article 3 rights are upheld.
Arianna Kelly is a barrister at Kings Chambers.