healthcare update - issue five
Supervised community treatment - then and now
CTOs – What are they and why do we have
them?
Supervised Community Treatment, in the form of Community
Treatment Orders (CTOs), was introduced in November 2008 by the
Mental Health Act 2007. The purpose of a CTO is to allow service
users to be treated safely in the community, rather than under
detention in hospital.
A CTO is only available to the responsible clinician treating a
service user already detained under section 3. Two conditions must
be attached (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) and other “necessary or
appropriate” conditions may be imposed.
At any time whilst on a CTO, the responsible clinician can
recall the service user for a period up to 72 hours, if in his
opinion, the patient needs treatment in hospital and there is a
risk of harm to the patient or others. Beyond that, the responsible
clinician should consider revoking the CTO altogether, resulting in
the service user reverting to detained status under the Act.
The purpose of CTOs was ostensibly to help in particular the
“revolving door” patients and “to provide a way to help prevent
relapse and harm – to the patient or to others – that this might
cause” (Code of Practice, Chapter 25.2).
CTOs – the evidence
The government recognised CTOs were controversial, not least
because many practitioners and stakeholders saw them as further
evidence of the need to exercise social control over those with
mental illnesses.
Concerns were raised further when it became clear that the
evidence-based support for the effectiveness of CTOs was thin. A
2005 Cochrane review (Kisley et al) found evidence that compulsory
community treatment may not be an effective alternative to standard
forms of care. On the numbers alone, it found that it would take 85
CTOs to prevent one readmission, 27 to prevent one episode of
homelessness and 238 to prevent one arrest.
An Institute of Psychiatry literature review (Churchill et al)
of CTOs internationally was similarly inconclusive when it came to
the evidence of the effectiveness of this type of treatment. They
found stakeholder perception of CTOs was mixed and indeed, any
improvements in clinical outcomes and patient care tended not to be
attributed to the CTO. They also found no evidence that CTOs in
fact kept people out of hospital, nor any evidence of increased
contact with services.
CTOs – the numbers
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. The government
estimated the numbers subject to a CTO would be low, only around
200 initially, increasing to about 2,200 by 2013.
The government estimates that the cost to the NHS and local
authorities of introducing CTOs (estimated at £3.4 million in the
first year) will be outweighed by the savings in terms of hospital
bed days (£8.7 million in the first year).
It may well be the case that the government’s estimates are low.
The suggestion is that CTOs are being more widely used than had
been anticipated.
It therefore remains to be seen whether these estimates are
accurate but at the end of the day, these are simply numbers. The
real proof of the pudding will be in whether CTOs will help service
users maintain stable mental health outside hospital and prevent
readmission or relapse. It is far too early to say with any degree
of certainty whether this will happen.
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aspects of the subject matter and does not provide comprehensive
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