Community Treatment Orders fail to cut mental health hospital readmissions, major study finds

Community Treatment Orders do not cut hospital readmission rates in mental health despite ‘curtailing’ patients’ liberty, a study has found. The findings have prompted social workers to question the ethics and effectiveness of CTO use.

The first UK-based randomised controlled trial to test CTOs – powers granted to doctors and approved mental health professionals to impose strict supervised community treatment on mental health patients – found that their use “does not reduce the rate” of people being readmitted to hospital.

The study compared the outcomes of patients discharged under CTOs with patients discharged under section 17 leave – an older and “less restrictive” form of supervised community treatment.

 “We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty [brought by CTOs],” the study findings – published in The Lancet journal – concluded.

The latest figures show that 4,200 patients were discharged on CTOs in 2011-12, an increase of 10% on the previous year. 

Decisions to discharge patients from hospital under CTOs require the agreement of a responsible clinician (usually a psychiatrist) and an approved mental health professional (AMHP – usually a social worker). Section 17 leave does not require AMHP sign-off.

Social workers said that the findings from the Lancet study raise fresh question marks over the ethics and effectiveness of the use of CTOs, particularly as the primary driver behind the Department of Health’s decision to introduce the powers in 2008 was to cut hospital readmission rates among so-called ‘revolving door’ patients.

Martin Webber, a social work academic at York University, said that the Lancet study “raises further issues about the ethics of CTOs”.

“If CTOs do not improve outcomes should they be avoided? Studies have indicated that psychiatrists prefer CTOs as they provide a means to recall people to hospital quickly whose mental health is deteriorating,” said Webber.

“It is another way of controlling people with mental health problems in the community and perhaps the only thing it reduces is the concern of the psychiatrist that they will be sued if an adverse event were to occur. However, it appears that this type of coercion does not work.”

Steve Chamberlain, chair of The College of Social Work’s AMHP leads network, said that some AMHPs feel it can be “very difficult” to challenge psychiatrists’ on their decisions to discharge patients on CTOs.

“We are responsible for agreeing, or not agreeing, to CTOs and we do sometimes feel uncomfortable with the amount of compulsion that’s there,” he said. “But we cannot, as AMHPs, wash our hands of the figures because the fact is if we said no they wouldn’t be as high.”

Chamberlain said that the Lancet study added to previous evidence from the USA and Australia that CTOs do not cut hospital admission rates.

“A concern is that, as the Care Quality Commission has noted, there is an over-representation of patients from black, Asian and minority ethnic groups on CTOs,” he said.

“If this study is replicated elsewhere you need to question whether CTOs are the wisest thing to do? Is the best thing really to keep people under compulsion when they’re no longer in hospital?”

The Department of Health said it originally hoped that CTOs would help reduce hospital admissions of “revolving door” patients but insisted this was not the “sole aim” of the policy. CTOs were also intended to benefit those with a chronic mental disorder that had stabilized following treatment in hospital, the department said.

A Department of Health spokesperson said: “Every decision to place someone on supervised community treatment is a clinical decision. There is no right or wrong number of people who should be on a community treatment order at any one time. Similarly, decisions about when to take someone off supervised community treatment are a matter for clinical judgement.”

“We will, nonetheless, consider the implications of this report carefully.”