Memorandum submitted by King's Fund (MH 52)
Community-based Compulsory Treatment Orders (CCTOs) in Scotland
Powers to impose CCTOs in Scotland came into effect on 5 October 2005, via the Mental Health (Care and Treatment) (Scotland) Act 2003. CCTOs may be imposed either directly on a patient living in the community (which is not a power the Government seeks for England and Wales) or on discharge from compulsory detention in hospital. A CCTO may last for six months, then if considered necessary it may be renewed for another 6 months, after which it may be renewed annually.
The King's Fund published a paper in November 2006 on the first six months' use of CCTOs (Community-based Compulsory Treatment Orders in Scotland: the early evidence, www.kingsfund.org). To update these findings, we have recently visited Scotland where we have spoken about CCTOs to the Mental Welfare Commission, the Mental Health Tribunal, the Scottish Executive, mental health charities and a small number of front-line mental health staff.
This note sets out a summary of the findings from both the original paper and updated data.
While we believe there are some important messages for England and Wales in respect of the experience to date of CCTOs in Scotland, it is important to remember that
a) the Scottish Act includes criteria for compulsion both that medical treatment is available that would be likely to prevent the mental disorder worsening or alleviate any of its symptoms or effects, and that the patient's ability to make decisions about the provision of medical treatment is significantly impaired. The Government's proposals for SCT in England and Wales do not contain these criteria;
b) in Scotland, all compulsory treatment (whether in hospital or the community) is authorised by an independent Tribunal, with a legal chair and a general (lay) member. In England and Wales it will be authorised, as now, by doctors and an Approved Mental Health Professional (currently ASW).
As a result, it is generally accepted that the threshold for compulsion is higher in Scotland than that proposed by the Government for England and Wales.
NB: data on numbers of CCTOs authorised and people subject to CCTOs are sourced from the Mental Health Tribunal and Mental Welfare Commission and are considered provisional.
(1) There is widespread agreement in Scotland that the driving force behind the Act is the desire to provide a system of compulsory treatment, backed by key principles, that is fairer for the patient and helps to ensure they get the care and treatment they need - and that this has, by and large, been achieved. In particular, patients' participation both in the process of compulsion and the drawing up of their care plans is considered significantly better than under previous legislation. It is considered helpful that the debate in Scotland has not focussed on issues of public safety, or been driven by any specific incidents involving a person with a mental disorder.
(2) Between around 30-40 CCTOs are being authorised each month - this number has remained broadly stable for the past year. Approximately one-third of these CCTOs are imposed on a person living in the community, with two-thirds being imposed on discharge from hospital (as a variation to a hospital-based CTO).
(3) Before the Act was passed, it was estimated that around 200 people at any one time might be on a CCTO. As at October 2006 (ie after one year) there were 245 people subject to CCTOs in Scotland. This is a rate of around 5 per 100,000 population. If that rate was applied to Supervised Community Treatment (SCT) in England and Wales, then some 2,500 people would be under SCT after 12 months of new SCT legislation coming into effect.
(4) The numbers of people subject to CCTOs appear still to be rising. We estimate that the figure will have risen by now to something over 300 people. No data has yet been collected on when people are being taken off orders, but is clear that at the moment more people are being placed on them than are coming off them.
(5) To date there appears to be no increase in the total numbers of people under (hospital and community) compulsion, which suggests that CCTOs are genuinely being used as a less restrictive alternative to hospital detention (or in place of long-term leave from hospital), and not as a preventative measure against patients who would previously not have been subject to compulsory powers.
(6) Each quarter between 10 and 20 people under a CCTO need to be rehospitalised. No research has yet been conducted into whether in general there are fewer readmissions among CCTO patients, but this does suggest that CCTOs will not always be successful in keeping people well in the community, whether or not they comply with their treatment plan.
(7) No-one to whom we spoke felt that the lack of a power to impose, as part of a CCTO, a condition "that the patient abstain from a particular conduct" (as the Government proposes in England and Wales ) was a problem in managing CCTO patients in the community.
(8) There is anecdotal evidence that the extra pressures imposed on mental health professionals in processing applications for CTOs and Tribunal hearings, and on Mental Health Officers providing support to people on a CCTO, means staff have less time available for other, voluntary, patients.
(9) It has not yet been possible to ascertain whether extra money added to allocations to help implement CCTOs has been used for that purpose by Health Boards and local authorities.
(10) The Scottish Act is generally considered to be fair and balanced in respect of its powers to impose CCTOs, and the process of introducing CCTOs into Scotland has by and large been successful. Although the numbers of people subject to CCTOs are already higher than expected, it is not felt that this has to date led to an increase in the use of compulsion. Initial findings suggest CCTOs are being applied appropriately and are ensuring greater patient participation in their care planning. Whether they are bringing clinical and social benefits to patients or improving patient and public safety - which are key issues - is not yet known.
(11) Lessons that might be learnt for England and Wales need to take into account the different legislative criteria for compulsion between the Scottish Act and the Mental Health Bill for England and Wales, and the extra Scottish safeguard of the authorisation of all compulsory treatment by independent Tribunals.