article
CTOs – benefit or burden?
01 October 2008
The introduction of Community Treatment Orders will pose
significant challenges to local service providers. Mark Barnett
explains.
On 3 November 2008 the Mental Health Act 2007
comes into force. It introduces Supervised Community Treatment in
the form of “Community Treatment Orders” (CTOs). Patients subject
to a CTO can be treated in the community for their mental disorder
without their consent.
Only patients detained under section 3 or
unrestricted Part 3 patients are eligible for Supervised Community
Treatment. The patient’s Responsible Clinician can place the
patient on a CTO, with the written agreement of the Approved Mental
Health Professional (AMHP), provided the following criteria are
met:
- The patient is suffering from a mental disorder of a nature or
degree which makes it appropriate for him to receive medical
treatment;
- That treatment is necessary for his health or safety or for the
protection of others;
- Such treatment can be provided without the patient’s continuing
detention in hospital;
- The Responsible Clinician must be able to exercise his power to
recall the patient; and
- Appropriate medical treatment is available to the patient.
The Responsible Clinician will need to
properly assess the risk of the patient’s condition deteriorating
once he is discharged to the community. In doing so, he should be
mindful of the patient’s history of compliance with medication,
attitude to treatment (and indeed, the CTO itself) and external
factors such as the conditions into which the patient will be
discharged. The Act’s Code of Practice emphasises the importance of
good care planning and support in the community. Also, adequate
consultation with the patient will be essential – whilst a patient
does not have to consent to Supervised Community Treatment, clearly
if he does not, the likelihood of its success will be reduced.
The Responsible Clinician and AMHP will also
have to carefully consider what conditions to attach to the CTO.
There are two mandatory conditions, these being that the patient
must make themselves available for assessment either when needed
for consideration of extension of the CTO, or to enable a Second
Opinion Appointed Doctor to provide authorisation for compulsory
treatment. There is otherwise no prescriptive list of what such
conditions might be, but they should only be attached if they are
“necessary or appropriate” to ensure the patient receives medical
treatment, prevent the risk of harm to the patient’s health and
safety, or to protect other persons.
The teeth of the CTO takes the form of the
threat of recall or revocation. At any time whilst the patient is
on a CTO, the Responsible Clinician can recall him for a period up
to 72 hours. He can do this if in his opinion the patient needs
treatment in hospital and there is a risk of harm to the patient or
others, notwithstanding compliance with any conditions. Beyond
that, the Responsible Clinician should consider revoking the CTO
altogether, meaning that the patient would revert to detained
status under the Act. Clearly this has implications insofar as the
availability of beds for patients who are recalled from their CTO
is concerned.
In introducing CTOs, the Act appears to make
some radical changes. However, whether patients on CTOs will see
the benefit and achieve earlier discharge remains to be seen. A
Department of Health report in 2007 decided that due to a lack of
reliable evidence it was still not possible to conclude whether
CTOs would be beneficial or harmful.
There seems little doubt however, that CTOs
will present significant challenges to mental health service
providers in monitoring and managing their service users on CTOs,
placing yet more pressure on community resources. A King’s
Fund Report in September 2005 estimated that over a period of 10 to
15 years, the number of patients subject to a CTO could be anything
between 7,800 and 13,000.
Detailed care planning will be necessary and
any conditions attached to the CTO will need to be kept under
regular review, in particular if the patient’s circumstances
change. Improvements in the patient’s mental health should arguably
lead to the suspension of one or more of the conditions, in
particular if the Trust is to avoid accusations that it is
inappropriately restricting the patient’s liberty.
Whilst the threat of recall or revocation of
the CTO in many cases will ensure compliance, there will inevitably
be patients who will be recalled to hospital. In practice, a
patient should not be recalled unless it is known that there is a
bed available, although they can be recalled for out patient
treatment. The suitability of this will of course depend on the
reason for recall, as it is questionable whether recalling for out
patient treatment would be appropriate where the patient
represented a risk to himself or others.
Whilst patients can be recalled to any
hospital and not just the hospital to which they were originally
detained, this is bound to place additional pressures on bed
management issues.
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