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.
VARIATION IN THE USE OF CTOS
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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