Why has the number of community treatment orders issued far outstripped forecasts?

Why has the number of community treatment orders issued far outstripped forecasts? Jeremy Dunning asks the experts. Case studies by Sally Gillen

The high number of community treatment orders (CTOs) being issued is causing concern among mental health charities and professionals.

The rates have far exceeded government expectations. Official figures show 2,134 CTOs were issued in England from November 2008, when they came into force, to March 2009.The government expected 350-450 to be issued in England and Wales in the first year.

At the same time, the number of people detained in hospital under the Mental Health Act 2007 increased by 100 to 47,700 in 2008-9. This is contrary to the government’s stated intention to reduce the number of patients in hospital through the use of CTOs.

“There have been significantly more CTOs than forecasted but we cannot ­automatically assume that this is a bad thing,” says Anthony Deery, head of mental health operations at the Care Quality Commission. “CTOs allow for people to receive specialist supervised treatment in the community, which is a less restrictive option and often more preferable for the patient.

“CTOs are still very new. We need to look at evidence across a greater period of time in order to draw conclusions about whether they are being used appropriately and effectively. To date, we don’t have evidence that CTOs are being used inappropriately.”

Ruth Cartwright (pictured), professional officer at the British Association of Social Workers, is less sure. “There is a little suspicion that doctors may have seized so enthusiastically upon CTOs to free up beds,” she says. “That could mean some patients are set up, released before they are ready and when they are likely to fail.”

A mental health social worker has joined the debate on CareSpace, Community Care’s online discussion forum. “I see CTOs used frequently because there aren’t enough beds on wards to keep clients safe. A discharge from the ward and subsequent CTO for a lower-risk client is the answer when a patient of greater need comes along,” he says.

Cartwright is also concerned that CTOs are issued to cover professionals’ backs in case something goes wrong. “There is a risk-aversion component to CTO use, which means people are under legal restrictions who perhaps don’t need to be,” she explains.

Consultant psychiatrist Dr Tony Zigmond, of the Newsam Centre at Seacroft Hospital, Leeds, agrees. He says the high number of CTOs could be due in part to the “blame culture and fear of criticism”.

The increased workload from the rise in CTOs is also creating extra pressures for community mental health teams which are crucial in supervising and monitoring people on CTOs.

But Peter Corser, a mental health social worker, says: “My impression is that there has been a degree of restraint in using CTOs because they fit only a narrow band of people who tend to have a long history of involvement with mental health services and are quite chaotic.

“The high numbers reported could well be that this group of clients is being placed on orders. I would be surprised if those high numbers persist.”

For Simon Lawton-Smith, head of policy at the Mental Health Foundation, the key issue is whether CTOs bring benefits to patients.

“Are they helping people recover better than being detained longer in hospital or receiving good care in the community on a voluntary basis?” he asks.

“Are they reducing risk in terms of both patient and public safety?

“At the moment we simply don’t know. In the longer term we’re going to need to monitor their impact carefully to see whether the evidence justifies their use.”

What is a CTO?

Community treatment orders were introduced as part of the Mental Health Act 2007 to allow compulsory treatment of people with a range of psychiatric disorders in the community.

They allow doctors to place conditions on the treatment of detained patients who are discharged from hospital. CTOs must be agreed with an approved mental health professional – typically a social worker. Under a CTO, patients must take their medication or face being returned to a psychiatric unit.

CTOs have always been controversial, with an Institute of Psychiatry review in 2007 finding no evidence from other countries of their worth.

The report, which examined 72 studies into the use of CTOs in six countries, found it was not possible to state whether they were beneficial or harmful to patients.

Case Study 1

‘Visits should be unannounced so they can see him as he is’

When Mary’s 34-year-old son was put on a community treatment order soon after they were introduced, she supported the move. Diagnosed with paranoid schizophrenia at age 19, Patrick had been a revolving-door patient, and Mary believed a CTO would be a good alternative to the repeated hospital admissions that had marked his life for so long.

Now Mary says the CTO simply does not work for her son. Under the conditions of the CTO, Patrick is not allowed to drink alcohol, take recreational drugs or move out of the area. But, because he lives alone, there is nobody to monitor what he does on a day-to-day basis, or to ensure he keeps to the conditions. The result is that he does not.

Since he has been on a CTO Patrick has been picked up by police several times and the housing association wants to evict him because of antisocial behaviour. Patrick regularly turns up at his mother’s home, threatening to kill her. If he drinks or takes drugs in her presence, Mary has a responsibility to notify the authorities. She hasn’t had to do this so far and, fearing her son, she worries about having to report him in future. His social worker visits fortnightly to give him injections but sometimes he doesn’t answer the door or he goes out.

“They shouldn’t say when they’re coming because he fixes himself up,” Mary says. “The visits should be unannounced so they can see him as he is. At the time I thought it was a good idea but now I would rather he was back in hospital for a long time.

“He takes drugs, which stop his medication to control his schizophrenia working. He then becomes very poorly before anything is done. There is no early intervention.”

Patrick’s elder brother, Mary’s first child, was also a paranoid schizophrenic. He died from an overdose after being released from hospital against his and Mary’s wishes. She now worries that her son is vulnerable and should not be living in the community.

Case study 2

‘CTO has kept my father steady’

Emma’s experience (not her real name) has been more positive. As a carer for her father, she has repeatedly experienced the trauma of having him detained in hospital.

“It was section after section every year before he was put on a community treatment order and it was awful to have to keep going back to hospital, really traumatic,” she says.

“It doesn’t give him the chance to slip through the net. He can’t just lock his door and become ill again. If they see him wavering they react. They have been fantastic and the CTO has kept him steady. He must keep hospital appointments and has fortnightly visits from a social worker and befrienders.

“The umbrella provided by the CTO has protected him. If you asked him he may see it as a restriction but it’s a safety buffer really.

“I feel positive about it even though I was sceptical in the beginning. When you have a family member who is ill you are sceptical because so many things come and go and the mental health services have not always been so good. My father now has a relatively normal life in the community – where he should be.”

‘I wish my son was back in hospital’

Published in Community Care 12 November under the heading CTO Outlook Uncertain