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Treatment in the Community – A New Option
There have been many attempts to change law and policy in the field of mental health over the last 20 years or more, to address the problem of people who are sometimes referred to as ‘revolving door patients’. It’s not a particular helpful description, but it’s one of those shorthand terms that people in the mental health field often come up with. Here we are describing a group of people with probably quite severe and long lasting mental health problems, coming into hospital, getting treatment, leaving hospital and stopping treatment, becoming unwell again and then getting admitted back into hospital. At the very severest end some might go onto commit violence to others or harm themselves, and will often feature in inquiry reports. These are people who make newspaper headlines, concern politicians and policy makers, with a cry of ‘something must be done’ and often the response is to bring in a new policy or new law. So we’ve had the Care Programme Approach, we’ve had supervision registers, we’ve had Supervised Discharge Orders – now abolished - and most recently in the Mental Health Act for England and Wales, Supervised Community Treatment (SCT), or Community Treatment Orders (CTO). These are two official terms for the same thing – I’ll try and explain that later.
What is involved in a Community Treatment Order?
Essentially what is involved is a requirement on a certain group of patients, meeting certain criteria to remain on treatment whilst living out in the community following discharge from hospital. If the patient stops accepting treatment they could be recalled to hospital. The National Institute for Mental health England describes the orders like this ‘SCT gives the opportunity for patients to continue with their daily lives in the community while having treatment, thus giving the stability they need for their improved mental health. It also provides the back-up of speedy recall, leading to earlier treatment, if required, which in turn is likely to contribute to a faster recovery.’ Sounds wonderful if you put it like that, but the introduction of these orders has not been without controversy. For those who remember the long debates in parliament about changes to mental health law leading up to the Mental Health Amendment Act of 2007, you will recall heated arguments about the idea of compulsory treatment in the community. In an attempt to manage people with severe mental health problems who were posing risk to themselves or others, politicians and policy makers were trying to ensure that medical treatment that was being administered in hospital (if necessary by force) did not end the moment the unwilling patient left hospital. However the prospect of what compulsory treatment in the community would look like led to outcries of protest from service user groups, with the spectre being raised of people being forcibly injected on their kitchen table. However, SCTs and CTOs are nothing like that. As I said before the only power or sanction that can accompany a treatment order, is that if things are going wrong for the person in the community, they can be recalled back to hospital by the person in charge of their care (the Responsible Clinician).
Seeing Community Treatment in action
Let’s describe a case scenario. John has been detained in hospital under section 3 of the Mental Health Act (CTOs can only be applied to people who have been on section 3, and some sections of the act concerned with criminal patients). He has a severe mental health problem characterised by paranoid ideas that his family are conspiring to hurt him. He receives treatment in hospital including medication, and some social skills training to allow to him live more independently. He is ready to be discharged home, but there are concerns about what will happen next:
- He will stop taking medication and will soon relapse and be back into hospital if he stops taking medication (which is what has happened in the past)
- He will mix with some young people in his neighbourhood who exploit him financially
- He will stop letting his parents help him clean his flat.
The care team agree that a CTO could work. It imposes certain conditions, these include mandatory conditions about being willing to be medically examined and other discretionary conditions. In John’s case these might include attending his surgery for medication by injection, and keeping away from those who have been exploiting him. If the care team find John not complying with these conditions that might start to trigger alarm bells, and if John starts to relapse and once again meets the criteria for admission to hospital, they could require him to be recalled. This decisions would be taken if there are risk factors present that say that John should be back in hospital. All of this can be achieved without going through the whole sectioning process again. A letter from the Responsible Clinician will be enough. Once recalled to hospital John can be assessed and a decision made as to whether he can be sent home again, or revoke or cancel the CTO so he becomes a detained patient once again.
Controversy in the Act
The orders are still proving controversial, mainly because of their widespread use. The government estimated around 500 people would be put on CTOs in the first year of their operation. The actual figure has been about 4,000. (Source: Health and Social Care information Centre).
You may well have Service Users in your care who are subject to CTOs or the mental health care team might be suggesting their use for someone you are supporting. In which case I hope this description has been useful. Now there are other frameworks for the care and treatment of people outside hospital, such as Guardianship, which I’ve described in an earlier article, and leave of absence from hospital, which in many ways has similarities to a CTO, in that it is relatively easy to order someone back to hospital. In fact CTOs are part of section 17 of the Mental Health Act which is concerned with leave from hospital. I’ll write about that in a future article. If you wish to look up more of the requirements of a CTO the QCS management system describes the law in policy CR12 Mental Health Regulations 1983 Policy and Procedure.
Finally, is there a difference between an SCT (Supervised Community Treatment) and a CTO (Community Treatment Order)? Supervised Community Treatment is essentially the concept of this new treatment framework, whilst the Community Treatment Order is the legal means by which someone can receive Supervised Community Treatment.
Everything I’ve described here concerns mental health law in England and Wales. There are Community Treatment Orders covered by Scottish mental health law which operate somewhat differently than the English version. I’ll cover that in a future article but meanwhile there’s a useful guide produced by the Mental Welfare Commission for Scotland which can be downloaded from http://www.mwcscot.org.uk/media/73253/a_guide_to_compulsary_treatment_orders.pdf
David Beckingham – QCS Expert Mental Health Contributor