As MPs discuss the Mental Health Bill, Mark Hunter considers the implications of introducing compulsory community treatment orders
As the tortuous process of reforming the Mental Health Act 1983 looks to be finally nearing its conclusion, mental health professionals and service users remain unclear on how, when and for whom the envisaged powers of compulsory treatment will be used.
Compulsory community treatment orders (CTOs) have been at the heart of the debate that has dragged on since the government first announced it wanted to overhaul the act.
The new powers appeared in 2002 as one of the more controversial proposals in the first draft Mental Health Bill. The intention was to allow patients who had been detained under section three of the Mental Health Act 1983 to receive compulsory treatment in the community. The government claimed this would address so-called “revolving door” patients, who, on leaving hospital, discontinue treatment, relapse and then require detention again.
However, critics pointed out that the broad criteria under which the new powers could be used meant that anybody who was sectioned could be forced to receive treatment in the community. This could result in thousands of mentally ill people receiving treatment against their will.
The government claimed that CTOs would affect only a few hundred patients each year. However, a report from the King’s Fund in 2005 estimated that within 15 years the net could widen to affect up to 13,000 patients. There was also concern that CTOs could disproportionately target some ethnic minority groups.
After an unprecedented outcry – there were more than 2,000 responses during the 10-week consultation – the bill was hastily sidelined while a joint scrutiny committee was set up to consider its proposals. Two years later, the bill resurfaced as a second draft that provoked its own hail of protest when it emerged that the government had rejected the committee’s key evidence.
Plans for a whole new Mental Health Act were abandoned in favour of simply amending the 1983 legislation. However, when the amended bill was published in November last year, it became clear that the government was still attempting to sneak through many of the original draft’s more controversial proposals, including the plans for CTOs.
Fast forward to the House of Lords in February this year, when a key amendment to the bill placed far greater restriction on the circumstances in which a CTO could be used. But the government refused to take this setback lying down. Health minister Rosie Winterton immediately made it clear that the government would seek to overturn the Lords’ amendment which, she said, had “seriously weakened our plans for better protection for patients and the public”.
“This means that patients will have to stay in hospital longer or be discharged without proper supervision, leaving patients untreated and families in distress,” Winterton told a Local Government Association conference in London.
“These are people with profound mental health needs, who, at times, will pose a serious risk. For the sake of mental health patients, their families and the safety of the public, these changes must be overturned.”
After the Lords’ debate, the government chose to publish a review of CTOs, which it sponsored, showing that in six countries where CTOs are currently used there is little evidence that they actually work.
Author Rachel Churchill from the Institute of Psychiatry at King’s College, London, said that the review had found little evidence of positive effects of CTOs. “None of the nine experimental studies we looked at found evidence suggesting that CTOs reduce either hospital readmission or length of stay, or that they improve compliance,” she said.
The government has responded to Churchill’s study by promising £500,000 to fund further research on supervised community treatment over the next two and a half years. Experience from Scotland, which introduced CTOs in October 2005, suggests that while the measure undoubtedly increases bureaucracy, it can be successful if it is limited to a small number of clearly defined, vulnerable patients.
“The acceptance of CTOs in Scotland is the result of the orders being seen as fairer for the patient and applying only to a very specific population of revolving door patients,” concluded a recent report from the King’s Fund.
Views on CTOs from mental health service user groups range from “only under very strict criteria and with set time limits” to “not for anyone, ever”.
Paul Farmer (pictured left), chief executive of Mind, believes that CTOs have no place in the care of people with mental illness.
“Community treatment orders won’t help people at all,” he says. “They do not improve compliance with medication. They do not lower incidents of violence or arrest. They do not reduce length of stays in hospital. They do not prevent re-admissions. But they will scare vulnerable people away from seeking help when they need it.”
According to Andy Bell, chair of the Mental Health Alliance, there may be cases where a CTO becomes necessary. However, he believes that under most circumstances, the provision of high quality, supportive community care can obviate the need for compulsion. Services such as the Antenna assertive outreach team in Haringey, (see panel, below left) offer far more than simple medication.
“I wouldn’t go so far as to say ‘No CTOs, ever’,” says Bell, “although the jury is out on whether it works at all. But medication is only a small part of people’s lives. Sure it may be an important part, but we need approaches where people have all their other needs looked after as well, such as housing, education and so on.”
Indeed, one of the conclusions of Rachel Churchill’s report on CTOs was to urge the government to “consider whether any potential therapeutic gains might be better delivered by enhancing the quality and assertiveness of community treatment for high risk patients”.
Bell points out that the amount of supervision a mental health patient receives on discharge from hospital is a lottery and that investing in approaches such as assertive outreach might be far more effective than simply compelling people to take their medication. If every patient who was sectioned received that kind of support on discharge, there may be no need for CTOs at all.
Alternatives to treatment orders
As team leader of the Antenna assertive outreach service in Haringey, Michelle Simmons works with some of the most difficult to engage users of mental health services. It is significant, therefore, that she says she has never encountered circumstances under which she believes compulsory treatment would have been helpful.
“I’m not saying compulsory treatment should never be used, but we have never come across a situation where it would be necessary,” she says.
Antenna is a multidisciplinary assertive outreach service aimed at young, black people aged between 16 and 25 who are suffering problems with their mental health. Most are suffering psychosis, depression or early onset schizophrenia.
The service is provided by three outreach workers, a consultant psychiatrist, an occupational therapist, a family liaison officer and administrative support. The service, which currently has 52 clients drawn from the London borough, aims to offer not only psychiatric support but also help with other areas of the young people’s lives, such as education, employment, housing, legal problems and family breakdown.
“The aim of the service is to reintroduce these young people into mainstream society,” says Simmons.
“So while we do monitor medication, it’s not done in isolation. We also work with their school, with the colleges, with the church. We go into their houses and work with their families. We’ve got a lot of different programmes to help people learn new skills and a young people’s group to ensure we keep our finger on the pulse of what is relevant to them.
“The approach has been extremely successful – we’ve had people go on to university, set up businesses, get married. I’m not saying it’s been easy. It requires a lot of commitment and dedication, but at the end of the day, it works.”
This article appeared in the 26 April issue under the headline “The net widens”