Post-legislative scrutiny of the Mental Health Act 2007 - Health Committee Contents

5  Supervised Community Treatment

71.  Supervised Community Treatment (SCT) was introduced as part of the 2007 Act to enable some patients with mental disorder to live and be treated in the community whilst still being subject to recall to detention. SCT is only considered for those patients detained for treatment and must be agreed by an Approved Mental Health Professional (AMHP) for the purpose of delivering "appropriate medical treatment which is necessary for their health or safety or for the protection of others."[92]

72.  The conditions imposed are dependent on the specific circumstances of each case and they form part of the Community Treatment Order which is made by the clinician responsible. CTO conditions "cannot compel treatment or authorise deprivation of liberty".[93]

Purpose of the legislation

73.   As of 31 March 2012 4,764 people were subject to CTOs in England.[94] As discussed in Chapter 2, evidence presented to the Committee has argued that CTOs have not reduced the number of people detained in psychiatric units. Simon Lawton-Smith argued that there was not the physical capacity to accommodate another 5,000 detained patients and that the provisions had added significantly to the total number of people subject to the Mental Health Act.[95]

74.  Nevertheless Simon Lawton-Smith told us that supervised community treatment was in some cases "helping people to stay well in the community"[96] and that AMHPs had found that they were "useful to a degree".[97] Naomi James argued that there was stigma attached to patients subject to CTOs associated with an emphasis placed on risk rather than development of a care-plan based around a broader concept of recovery.[98] Mr Lawton-Smith and Ms James both said that CTOs had tended to diminish the concept of treatment to involve simply medicating patients within the community.[99]

75.  The impact assessment for the 2007 Act indicated that the introduction of CTOs would save the NHS approximately £34 million per year by 2014-15. As outlined in Chapter 2 this figure was calculated on the assumption that 10% of section 3 admissions would instead be placed under supervised community treatment.

76.  The Department of Health's supplementary evidence informs us that:

at the time of the Act it was expected that the use of community treatment orders (CTOs) would build up gradually over five years, so that by 2013 around 3,000-4,000 people would be on CTOs at any one time. The Health and Social Care Information Centre reported 4,764 patients on CTOs in England on 31 March 2012.[100]

The Department of Health's memorandum explains that "the greater than expected numbers of patients on CTOs will have an impact on the true costs and benefits of CTOs"[101] but officials could not tell us if the projected saving is likely to be met.

77.  Debate continues about the value of CTOs, but no evidence was presented to the Committee which suggested that any short-term revision of the legislation is necessary. The Committee recommends that the Ministers keep this aspect of the legislation under review.

'Revolving door' patients

78.  In oral evidence the MHA argued that CTOs were being applied beyond the original intention of the legislation. They said that the purpose of the provisions in the 2007 Act was to address the 'revolving door syndrome' whereby patients left hospital, disengaged from treatment, deteriorated and were eventually readmitted to a psychiatric ward. On this basis, placing patients without a history of disengagement from treatment on CTOs is inappropriate in the view of the MHA. The MHA's written evidence outlines the extent to which CTOs have been used for patients who have no history of refusing to engage with treatment:

Care Quality Commission data (2009/10 Annual Report on the use of the Mental Health Act) suggests some 30% of people placed on a CTO have no history of non-compliance with treatment (so are not 'revolving door' patients).[102]

79.  Simon Lawton-Smith outlined the nature of the MHA's concern:

I think there is an issue if someone enters hospital for the first time as a young man with, say, psychosis, and is immediately discharged under a community treatment order, without any evidence that they will necessarily not take their medication, relapse and have to go back into hospital. [...] During the House of Lords Committee stage, Lord Warner stated, 'One thing that has not changed as much as we would like, however, is the continuing number of revolving-door patients,'[103] so he specifically mentioned CTOs in terms of revolving-door patients. We are worried that they are being used perhaps inappropriately [...] for patients who do not have a history of continuing non-compliance.[104]

80.  The Department of Health contests this interpretation of the legislation and said that the purpose of supervised community treatment had been misunderstood. Anne McDonald told the Committee that:

when the 2007 Act was originally debated there was an amendment that tried to restrict it to people who had been detained more than once. That amendment was not made, so Parliament's intention was not to restrict it to just that group but to put it to the clinical decision about the risk in the community rather than that group of patients.

This builds on the evidence in the Department of Health's memorandum to the Committee which acknowledged the fact that there was some dispute over the interpretation of the 2007 Act. The memorandum noted that:

Some commentators have asked why SCT is being used for people "it was not intended for", for example CQC's 2009/10 annual report questioned the number of SCT patients who do not have a history of non-compliance and this concern has been repeated in the Mental Health Alliance's recent report. These comments may be a misunderstanding of the original intention of the 2007 Act which was that SCT should be available to support "modern provision of mental health services, where treatment is based in the community rather than in hospital".[105]

Dr Griffiths admitted that "clearly the intention was to try and help support people who were in and out of hospital to remain better and more stable for longer."[106] He argued, however, that there are cases where CTOs could be useful for patients who did not meet these criteria, and said that he could envisage such circumstances.

81.  During the passage of the 2007 Act, Parliament considered and rejected the proposal that CTOs should be limited to those with a history of non-compliance. The Committee does not therefore believe that the current application of CTOs is incompatible with the 2007 Act.

82.  Although the Committee is satisfied that the operation of CTOs does reflect the intention of the legislation, it is right that this intention is kept under review. Compulsory medical treatment, whether in the community or in hospital, raises serious civil rights issues and needs to be supported by evidence of its need and its effectiveness.

Effectiveness of community treatment orders

83.  The results of the Oxford Community Treatment Order Evaluation Trial (OCTET) undertaken in 2012 and led by Professor Tom Burns at the University of Oxford tell us that CTOs have not succeeded in reducing the readmission to hospital as compared with section 17 leave. Section 17 leave is "a well established rehabilitation practice used for brief periods to assess the stability of a patient's recovery after or during a period of involuntary treatment".[107]

84.  The Committee has been advised that this randomised control trial represents the most rigorous analysis yet of CTOs in England. Professor Burns and his team found no "support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty".[108] In light of the OCTET research findings the Committee recommends that Ministers should review the current operation of CTOs.

85.  The Committee does not object to the principle of supervised community treatment in defined circumstances and agrees with Dr Griffiths that it is possible to envisage justifying a CTO on grounds other than a previous record of non-compliance with a treatment regime after discharge from hospital. The Committee is, however, struck that the evidence base for this policy remains sparse, with the result that the argument has not developed far since the passage of the legislation. The Committee recommends that the Department should commission a fuller analysis of the value of a CTO in different clinical situations.


86.  Across England there have also been substantial variations in the use of CTOs. The CQC found that the "lowest reported 'discharge rate' onto a CTO was 4% and the highest 45.5%."[109] These figures are a proportion of the total number of admissions under the Mental Health Act for each health care organisation. The CQC also found that "a number of NHS organisations with considerable rates of detention under the Act provided nil returns for the use of CTO."[110]

87.  Dr Griffiths explained to the Committee that variation was to be expected because differing demographics in local areas required diverse service configurations.[111] He also said that although he was not comfortable with the degree of variation, the use of a CTO was a clinical decision.[112]

88.  The role of mental health tribunals was called in to question by the Mental Health Alliance. Dr Chalmers told us in oral evidence that:

There was quite a push from the tribunal service for us to consider placing people on CTOs. If we did not, they would adjourn and come back and ask us what our decision making was around that.[113]

Dr Griffiths acknowledged concern in this area, but argued that this was more as a result of confusion around the wishes of tribunals than a specific push towards CTOs. Dr Griffiths said that tribunals asked the question:

"Have you considered a CTO?", because they are anxious that people should consider the least restrictive option at all times. It seems to me that what some clinicians may do is interpret that as meaning the tribunals expect them to be put on a CTO. The tribunals say that is not what they are saying but that they are merely asking whether they have considered it. To what extent that may be driving behaviour is unclear.[114]

Clinical debate

89.  The oral evidence presented by the MHA demonstrated that there was division within the psychiatric community regarding the use of CTOs. Simon Lawton-Smith highlighted a survey of over 500 psychiatrists, the results of which had found that 325 respondents thought CTOs were useful and 74 did not.[115] He added that some psychiatrists believed CTOs to be unethical. The MHA acknowledge that some variation would be driven by demographics but Dr Chalmers conceded that:

CTOs split the profession initially. Some felt that they were overly paternalistic [...] Others were quite keen.[116]

90.  The CQC has criticised the inclusion of vague conditions within CTOs, highlighting requirements such as 'not abusing alcohol' as being meaningless without a definition of what constitutes abuse.[117] Naomi James explained to the Committee that the loss of choice and control had a negative impact on patients and the stigma attached to CTOs existed as a result of being subject to conditions "without choice".[118]

91.  Dr Chalmers said:

This is a good practice issue [...] I certainly do not think we should tell people how to live their lives, but some doctors have felt that they have the power to put in place a lot of unreasonable conditions.[...] It is something about which the college has concerns, and on which we want to issue good practice guidelines.[119]

92.  Although the Committee accepts that use of a CTO in an individual case is a clinical decision, we are surprised by the extent of variation between clinicians. The Committee recommends that the Royal College of Psychiatrists should engage with the evidence review recommended at Paragraph 85 and draw its conclusions to the attention of its members. The Committee does not believe that wide variations of clinical practice should be permitted to continue without serious professional challenge.

Effect of financial pressures on clinical decisions

93.  Whatever the outcome of the clinical debate, there is no justification for clinical decisions, in particular about the civil rights of vulnerable patients, being distorted by financial pressures. In this context the Committee is concerned that the pressure on beds in psychiatric wards outlined in Chapter 1 may also be driving the inappropriate use of CTOs. Simon Lawton-Smith told the Committee that 25% of all CTOs were revoked with the patient readmitted to hospital. He said:

It is possible that people were discharged from hospital earlier than they should have been, maybe to free up a bed. There is no firm evidence on that, but it is obviously a danger when there is such pressure on beds.[120]

94.  The absence of clear clinical guidelines supported by robust analysis of the evidence increases the risk that individual decisions will be distorted by financial considerations. This consideration reinforces the need for the review of the evidence recommended in Paragraph 85, supported by the engagement of the Royal College of Psychiatrists recommended in Paragraph 92.

92   Department of Health, July 2012, p 11 Back

93   Care Quality Commission, January 2013, p 77 Back

94   Ev 41 Back

95   Q 33 Back

96   Ibid Back

97   Ibid Back

98   Q 45 Back

99   Qq 33, 45 Back

100   Ev 41 Back

101   Ibid Back

102   Ev 36 Back

103   HL Deb, 17 January 2007, c701 Back

104   Q 45 Back

105   Department of Health, July 2012, p 12-13 Back

106   Q 126 Back

107   Professor Tom Burns, Community Treatment Orders for patients with psychosis (OCTET): a randomised control trial, The Lancet, Vol 381(2013), p 3 Back

108   Ibid, p 1 Back

109   CQC, January 2013, p 77 Back

110   Ibid p 80 Back

111   Q 127 Back

112   Ibid Back

113   Q 43 Back

114   Q 131 Back

115   Q 40 Back

116   Q 43 Back

117   CQC, January 2013, p 81 Back

118   Q 45 Back

119   Q 42 Back

120   Q 33 Back

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Prepared 14 August 2013