Community Treatment Orders were introduced by the 2007
changes to the Mental Health Act 1983, and came into force in 2008.
The New Code of Practice states that the purpose of a CTO
“is to allow suitable patients to be safely treated in the community rather
than under detention in hospital, and to provide a way to help prevent relapse
and any harm – to the patient or to others – that this might cause. It is
intended to help patients to maintain stable mental health outside hospital and
to promote recovery.” (Para.29.5)
It goes on to suggest that CTO’s could be regarded as
fulfilling the principles oftreating
patients using the least restrictive option and maximising their independence.
CTO’s have been very popular since their inception in
2008. This could be at least partly due to the process being initiated and
managed by psychiatrists rather than AMHP’s, unlike with admission to hospital
under Sec.2, 3, or 4, where an AMHP, as a non-medical professional, leads the
process and makes the final decision.
But CTO’s have also been very contentious. Critics regard
them as being excessively controlling and interfering with patients’ human
rights, while supporters regard them as a way of enabling patients with severe
and enduring mental disorder to live as normal and fulfilled a life as possible
Both views have their merits. It is one thing to argue
that it is unreasonable to enforce treatment on a person who is not in a
hospital, but there is also a point in arguing that it has to be better that
someone remains out of hospital as long as there is a framework to ensure
treatment for their mental disorder.
For compulsory treatment in the community to be
justifiable, it has to be shown not only that it results in fewer admissions to
hospital, but that is can also demonstrate a better quality of life for the
So has there been a reduction in the numbers of
admissions since 2008? It appears not. The Health and Social Care Information
Centre (HSCIC) publish annual statistics for patients formally detained under
the MHA, and for people subject to CTO’s. The figures for 2013-14 came out at
the end of October 2014.
The Report states that since 2008 the number of people
subject to CTO’s as of 31st March 2014 has more than doubled, an increase of
206% or 3,610. Over the same period there has indeed been a reduction in the
number of people detained under Sec.3 for treatment, which must be linked to
the increase in CTO’s, as patients can be recalled to hospital and their CTO’s
revoked without the need for a fresh assessment under the MHA.
However, over the same period, overall detentions in
hospital under the MHA have increased by a third, so that in the period 2013-14
“the Act was used 53,176 times to detain patients in hospital for longer than
72 hours” (ie. Under Sec.2 or Sec.3).
So, while there has been a reduction of people detained
in hospital under Sec.3, mainly as a result of the introduction of CTO’s,
overall detentions have increased to record levels.
While it may be tempting to reach the conclusion that
CTO’s have not fulfilled their function of reducing admissions to hospital, the
reality is far more complex, as it is likely that the nationwide cutbacks in
services for people with mental health problems over the same period have
contributed to this rise in acute admissions.
The only significant research into the link between CTO’s
and hospital admissions is the OCTET Trial, published in 2013.
The object of this research was to see if CTO’s reduced
readmission. They monitored the samples (a total of 333, of whom 166 were
discharged on CTO’s and the rest on extended Sec.17 leave) for 12 months. Their
conclusion was that “the imposition of compulsory supervision does not reduce
the rate of readmission of psychotic patients. We found no support in terms of
any reduction in overall hospital admission to justify the significant
curtailment of patients' personal liberty.”
While the conclusion seemed unequivocal, I had some
considerable misgivings about the usefulness of this piece of research, not
least because of the miniscule size of the sample, which I wrote about on this blog back in April 2013. It is clear that much more research needs to be done
in this area.
So what about the effectiveness of CTO’s in improving the
quality of life of patients?
The research looked at three trials consisting of a total
of 752 people. The report concluded: “Results from the trials showed overall [compulsory
community treatment] was no more likely to result in better service use, social
functioning, mental state or quality of life compared with standard 'voluntary'
It did note that “people receiving CCT were less likely
to be victims of violent or non-violent crime.”
There are some provisos to these findings. For a start,
the authors considered that the quality of evidence for the main outcomes was
low to medium grade. They also noted that “other than feelings of coercion or
being controlled, there were no other negative outcomes”
None of the available research satisfactorily provides
evidence one way or another for the efficacy or otherwise of compulsory
community treatment. All that is certain is that there should be much more
research if such a potentially contentious form of intervention is to continue
to be used at the current levels.