Tuesday, 11 January 2011

Community Treatment Orders and the Role of the AMHP

After the frippery of the last two posts, here is a hefty New Year analysis of Community Treatment Orders, complete with references and tasty statistics. (Don’t forget to put me in your references, AMHP trainees!)

The 2007 Mental Health Act introduced a new role for AMHP’s: functions relating to the new powers of Community Treatment Orders. These functions were “to agree (or not) to the making of a Community Treatment Order (CTO) (s.17A); the extension of a CTO (s20A); conditions to be included in a CTO (s17B); and revocation of a CTO(s17F)” (Mental Health Act 2007 New Roles, NIMHE, October 2008).

Previously, the nearest equivalent had been Sec.25A, relating to Aftercare under Supervision. Sec.25A, inserted into the MHA in 1996, had been intended to provide a legal framework to ensure that patients who had been detained under Sec.3 could be treated in the community. However, Sec.25A never really had any legal teeth to enforce this. Essentially, the patient had to agree to the imposition of aftercare under supervision. If they disagreed, then no order could be made, and they would just have to be discharged anyway when they were well enough. Even if they did agree, they could change their mind at any time, and not much could practically be done about it.

I was only ever involved in one discharge under Sec.25A. The patient, who had been in hospital under Sec.3 for several years, willingly agreed to a comprehensive plan for aftercare in the predischarge meetings. However, the instant he had been formally discharged from Sec.3, he changed his mind about it all. Within a fortnight, he had stopped his medication and began to hide from his care coordinator, and two weeks later he turned up at his parents’ house in the middle of the night, beside himself with fear because everyone in Charwood was listening to his thoughts on their TV’s and the CIA had tracker drones scanning his every move. Within a month of being on Sec.25A he was back in hospital under Sec.3. Sec.25A never really caught on.

Community Treatment Orders, however, are something different. They were also quite controversial, since various Human Rights organisations had concerns about the proposed powers, which could compel patients to have treatment in the community on pain of being recalled to hospital if they refused.

There are certainly ethical issues with CTO’s. Can it ever be right to force people who are not detained in hospital to take medication against their will? But then what is the alternative? The stated purpose of CTO’s 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.” (25.2 MHA Code of Practice) That sounds pretty good, doesn’t it?

In addition, the power is designed only to be used with severely mentally disordered people who are at high risk of relapse, often referred to as “revolving door” patients – people like Jenny, about whom I wrote in July 2009 (“God told me not to answer the door!”), who are having to be repeatedly admitted to hospital, often under the MHA. Those frequent relapses and admissions, when the person may take many months in hospital to recover, are likely to be far more harmful to their quality of life than the imposition of controls that may actually allow them to function normally and live a fulfilled life in their own homes.

There is an odd thing, though, about CTO’s. This is the role of the AMHP in the whole process. ASW’s, AMHP’s predecessors, had specific and extensive powers in relation to the detention of patients under the 1983 MHA. As I have often described on this blog, the ASW/AMHP has the power, and the responsibility, to arrange for the detention and admission of a mentally disordered patient. Doctors can recommend, but it is the ASW/AMHP who makes the final decision – and who takes the consequences for that decision. The ASW/AMHP is acting independently of the local authority that approves them. Despite the opinions of some patients that AMHP’s enjoy exerting their power, the reality is that it is an onerous and stressful task that is never taken lightly.

But CTO’s put the AMHP in the position of merely recommending and endorsing the decision of the Responsible Clinician (RC), the psychiatrist in charge of the patient. Their role, although essential to the legal process, is comparatively minor. In practice, it consists of little more than signing a brief, preprinted statement on a piece of paper.

The AMHP becomes involved in the CTO process in three ways. In the case of the making of the CTO in the first place, the AMHP is presented with a form (CTO1) already largely filled out by the RC. The AMHP then has to sign that he or she agrees that the patient meets the legal criteria, that the CTO is appropriate, and that any conditions that the RC has made are necessary or appropriate. In the case of the extension of a CTO beyond the initial 6 months (CTO7) the AMHP again has to agree that the patient meets the criteria and that extension is appropriate.

When a patient has been recalled to hospital by the RC under the powers of the CTO and it appears they will need to remain in hospital for more than 72 hours, the RC will then reinvoke the original Sec.3 by revoking the CTO. Then the AMHP simply has to agree on form CTO5 that the patient meets the criteria for detention in hospital, and that it is appropriate to revoke the CTO.

However, a funny thing about CTO’s is the remarkable lack of rules or guidance relating to the discharge of the AMHP’s role. AMHP’s are subject to all sorts of requirements relating to the detention of patients, laid down either in the Act itself, or in guidance in the form of the Reference Guide and the Code of Practice. These include having to interview the patient “in a suitable manner” before making a decision, the correct identification of the Nearest Relative, notifying the patient and their nearest relative of their rights under the Act, having to write a detailed report explaining and justifying their decisions, and ensuring that all other the legal requirements have been met. Failure to do any of these things may lead to accusations that the AMHP has acted in bad faith or even illegally.

But when it comes to CTO’s, there is no requirement to write a report (unless you disagree with the psychiatrist). Department of Health guidance published in 2008 states only: “In making these judgements, the AMHP is expected to bring knowledge of the patient’s social situation into the discussion. This may require discussion with the patient’s care co-ordinator or key worker so that information about the patient’s home, family, informal support networks, cultural background, and so on can all form part of the decisions which are taken about SCT.” (Supervised Community Treatment: A Guide for Practitioners, DH, Sep 2008) There is no actual requirement even to interview the patient or consult with the nearest relative. There also seems to be no guidance as to what would constitute grounds to disagree with the consultant’s view. Somehow, that doesn’t feel right.

Although CTO’s have been in force since the end of 2008, it wasn’t until a few months ago that I was actually called upon to discharge my AMHP functions. I have now signed a CTO1 (making a CTO) and a CTO5 (revoking a CTO). (So that now makes me an expert, of course.)

Although I am sure that many AMHP’s, after two years of the new powers, will have been involved in plenty of CTO’s, especially if they are hospital based, and can therefore easily pop down the corridor to fill in a form, it came as something of a surprise to me to suddenly be exercising a new function. So I consulted with other colleagues as to how to go about making the assessment and the decision. That was when I fully realised the lack of guidance and procedural protocols. The other AMHP’s, even those who had been involved in many CTO’s, all seemed somehow uncomfortable with the whole process, all approaching the task in their own ways, and as much in the dark about it all as I was.

The first request I received was for a CTO on a 14 year old girl who had been in hospital for over a year under Sec.3. That in itself put me outside my comfort zone – in my day to day work I only work with adults. She had a diagnosis of bipolar affective disorder. This made me even more uncomfortable – it had always been my belief that the usual age of onset for bipolar affective disorder was somewhere in the mid 20’s to mid 30’s. Could a child therefore even receive this diagnosis? Child and Adolescent Psychiatry was even more mysterious than I had thought.

However, it was not my role as AMHP to question a diagnosis. I simply had to “decide whether to agree with the patient’s responsible clinician that the patient meets the criteria for SCT, and (if so) whether SCT is appropriate.” (25.24, MHA Code of Practice). I also had to “consider the wider social context for the patient. Relevant factors may include any support networks the patient may have, the potential impact on the rest of the patient’s family, and employment issues. The AMHP should consider how the patient’s social and cultural background may influence the family environment in which they will be living and the support structures potentially available.” (25.24,25.25 Code of Practice)

So I consulted with the hospital RC (who was actually making the CTO), as well as the community RC (who would be managing the CTO). I spoke to the Care Coordinator. I interviewed the patient, who was on S.117 home leave in Charwood, and her mother. I read the girl’s psychiatric notes. Then I wrote a report, simply using as headings the factors to be taken into account. Then the hospital RC posted the CTO1 to me (I wasn’t going to drive 120 miles to fill in a form). When I received it, I filled in my part, then posted it back. And when he received it a couple of days later, it was completed and she became subject to Supervised Community Treatment. And that was the end of my involvement, although I suppose I may be called on to be involved in any renewal process after the first 6 months.

The other piece of work I have so far done was a revocation of a CTO following a recall to hospital. This related to Leroy, who I wrote about in this blog in May 2009. Leroy had been on a CTO for over a year, but on Christmas Day he was found naked by police in Charwood town centre, stopping cars and kissing the windows. Ill advised use of amphetamine was believed to be implicated. He had been informally admitted to Bluebell Ward, but it was clear, despite the amphetamine wearing off, that he was unwell and would need to remain in hospital for more than 72 hours.

I felt more comfortable with this. I knew Leroy well, I knew his relapse signature, and it seemed likely that it would be appropriate for him to remain in hospital for treatment. It also seemed that the CTO seemed to be having some positive effect, as in the 18 months since he had been subject to Supervised Community Treatment, acute admissions to hospital had gone down. A bit. And the length of time he then spent in hospital had also reduced. So I interviewed him, wrote a report, and signed my bit of the CTO5.

There’s one other thing that leaves me feeling a little uncomfortable about CTO’s. That is, that they are very popular.

Often, it takes quite a while for mental health professionals get used to legal changes like this. Not so with CTO’s.

In a document published in October 2010 (In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment, Annual figures, England 2009/10) the total number of patients placed on CTO’s in 2008-9 was 2,109. In 2009-10 it had virtually doubled to 4,020. Over the same period, the number of patients detained under Sec.3 (only people detained under Sec.3 and some forensic sections can be placed on a CTO) was completely static, at 21,538 for 2008-9 and 21,332 in 2009-10.

This means that within two years of the introduction of CTO’s nearly 19% of patients detained in hospital under Sec.3 were discharged on a CTO. And since CTO’s are often being kept in place for a year or more, this could mean a growing accumulation of patient in the community on CTO’s.

It may take some convincing that this constitutes the “least restrictive” option.


  1. Ironically, I read this post after completing my first CTO application yesterday and I was fussing around for ages trying to ask various people about 'what to do' and reading back through the CoP and the little blue book - so it seems I had something of a parallel experience.
    I have done a revocation though..
    My understanding is that some of the predominance depends on particular consultants and their preferences (and perhaps risk aversion.. ). I wish I'd been able to read this before I'd done the CTO though. I was a difficult decision for me.

  2. done a few CTO's including first one in our patch consultants often seemed unaware of grounds and needed to be guided through formsbut so far a positive experience have also challenged the need for them at times and managed to disuade them

  3. i have recalled someone to hospital who was on a cto,horrible business - any member of the community team can do so if they have the right document, i was 2 months out of my social work degree i questioned it as i felt out of my depth.
    i also had a service user on a cto who booked himself informally into hospital whilst unwell and his cto was not revoked the managers just changed the address of his cto to the PICU i questioned this also as how could he be treated in the community when he was actually in a PICU psychotic my question went to the CQC but they said it was okay todo that funny how this scenario is not mentioned in the CoP.
    for what its worth i think the CTO is used too much by consultants and there is not enough debate amongst the community team about the purpose,
    we have people that are still getting ill just as much and still being recalled to hospital as much as if they were not on a CTO which makes me wonder if the CTO is the right thing to use for these people.

  4. Hi

    I'm doing a study on the impact of CTOs on services and service users and have found it interesting to read on it from the perspective of an AMHP, as most of the commentary comes from a psychitry perspective. I just wanted to make a couple of clarifying points. CTOs do not technically include powers which force service users to take medication in the community, or to be recalled if they refuse. The principle that medication cannot be given forcibly in the community still stands. The only way a CTO can be revoked is if the service user does not meet the two mandatory criteria - namely that they must make themselves available to the RC for CTO renewal and to the SOAD for oversight of the proposed medication. Otherwise they can only be recalled to hospital if they require treatment in hospital and if they do not receive that treatment they would be a risk to themselves or others. Therefore a service user who refuses to take their medication but remians sufficiently stable should not be recalled - lack of compliance in itself is not enough for a CTO to be recalled. This is the theory - what happens in practice is another matter.

    The other point is that although CTOs are supposed to be for 'revolving door' patients, there is evidence to suggest they are being used preventatively - the recent CQC report on the use of CTOs states that a third of their sample did not have a reported history of non-compliance or disengagement. This could go some way to explaining the higher than expected numbers, and as the CQC add is a worrying development if CTOs start to become the 'normal' route for civil detainees.

  5. One reason for the popularity of CTOs may be that unlike detention, which is limited by the number of beds in hospitals, and criteria for detention can be adjusted up and down to keep the hospitals full and trusts and private providers profitable; there is no upper limit to the number of people they may be applied to. Why would you ever release someone from a CTO when for no cost you can keep them living in
    fear that one step out of line could lead to them being recalled to indefinite imprisonment?

    However, from your victims point of view a CTO has to be better than being imprisoned in hospital, and there's always the opportunity to disappear, although to be safe this tends to require fleeing the country which makes it difficult to maintain employment and housing in the UK.

  6. Hi MB
    any thoughts on CTOs and people on the autism spectrum? Chris

  7. I have recently used a CTO for someone with Asperger's, which I briefly mentioned in my recent post "Are Community Treatment Orders taking over the MHA?" However, his was an unusual case, as he had a significant forensic history and was on a Court section. It was always envisaged, from when the 1983 MHA was first made law, that it should be exceptional for the Act to be used for people with learning difficulties, and I think the same applies to CTO's. You would need to be very clear about what you were intending to achieve by using a CTO, and what the purpose of a hospital recall might be.

  8. I've had similar problems coming to terms with 'what the CTO intends to achieve' and the lack of a transparent process by which AMHPs can can add anything meaningful to the process. A request to attend CTO discharge meetings (two things combined) arrive on the desk a few days before the meeting takes place. AMHPs are on a daily rota, so the case isn't properly thought about until a few hours beforehand, unless you have extremely conscientious colleagues willing to do the groundwork and hand it over.
    So, what taking into acount context and alternatives? Where is the precedence and framework for disagreement with the RC? I'm finding CTOs a pernicious form of bed management, unfortunately.

  9. on a similar note as a trainee AMHP with no shortage of CTO requests i am concerned that the role of the AMHP is merely an opportunity to practice ones signature. With little evidence of the service user.

  10. This is a very interesting article...I suffer from fasting hypoglycaemia 1-2 times yearly and end up being confused as a result of it. Normally I am in my right mind in between episodes. However, I have been misdiagnosed and am being treated as a mentally ill patient under a CTO just because I don't take my meds. Why, it causes horrendous eczema flare ups and photosensitivity to sunlight resulting in severe peeling skin on a red face.
    Why is there no clause for people allergic to the meds?

  11. My son suffers from severe ocd, intrusive thoughts of harming others, including loved one's for the last eight years of his life This is confirmed by three assesments,and yet he has not been fully treated. Expert opinion on the subject says that you will need to get a balance of the right and appropriate medication including SSRI and antipsychotic with exposure therapy. The recommendation from The Maudsley was that he should be taperd off the antipsychotic and should be vigilantly observed for any signs of withdrawal or relapsed. This failed completely as staff were unable to recognise that he was getting unwell.He was admitted in hospital in March 2014 under section 2 then section 3. Eight months went by without addressing the severe ocd. He was put back on Repiridone 4gm which exacerbate the ocd symptoms. He was put on a CTO ON THE BASIS THAT HE WAS A DANGER TO HIMSELF AND OTHERS. Expert opinion on the subject says that they are least ikely to act on their thoughts. The CTO was renewed again in May. Fortunately his new RC started him on a new SSRI and the improvement has been remarkable. He is able to travel, going to cinema ,concerts, going for meals, playing his music and doing other things that he could not do before. Mentally there has been a 70-80 improvement and I believe he can move to his flat with some support.His Cto is due for renewal again and this time I believe it will last for another year and the criteria for detaining has shifted to him not complying fully to the rules and regulation set out, This includes cooking, washing etc. The criteria for his detention has shifted to be able to cook as Jamie Oliver perhaps This is very concerning to me and I would like what a social worker would say to this?

  12. anyone ever refused to sign a CTO?