CTOs and nearest relative role could be overhauled in MHA review

Independent review of the Mental Health Act publishes interim report outlining its purpose to give people greater autonomy over care services

mental health act
Photo: Gary Brigden

Community treatment orders (CTOs) could be reformed after the interim report on the independent review of the Mental Health Act (MHA) found they are failing to reduce re-admissions.

The nearest relative role also faces an uncertain future with the report declaring the role is “no longer fit for purpose”.

Chaired by former president of the Royal College of Psychiatrists Professor Simon Wessely, the interim review, published today, identified several priorities that would be examined further before formal recommendations to the government later this year.

One of the key findings highlighted was that CTOs had failed to achieve their primary role of reducing re-assessments, with the review suggesting that they “should not remain in their current form”.

CTOs were introduced in the 2007 amendments to the MHA as a form of supervised community treatment for people who have been detained under section 3 and certain other sections of the MHA in order to allow suitable service users to be safely treated in the community rather than in hospital.

Yet almost 5,000 people were found to be currently on a CTO at any time, considerably more than the number estimated by the government prior to their induction.

‘Coercive and restrictive’

Qualitative evidence considered by the review also displayed that CTOs had been regularly experienced as “coercive and restrictive” by people who were subject to them.

Another problem CTOs black or black British’ people are nine times more likely to be given a CTO than white people.

In response to these findings, the review said it would investigate the implications of either reforming or replacing CTOs before the final review is published.

It also said it would consider further the disparity of views about the effectiveness of CTOs and how experiences varied between different service users.

Speaking about the publication of the interim report, Wessely stressed the importance of the review’s work.

“People with the most severe forms of mental illness have the greatest needs and continue to be the most neglected and discriminated against. They are also the group who are the most likely to be subject to the influence and powers of the Mental Health Act.

“We have an opportunity to replicate the advances made for people with common mental illness for those with more serious conditions,” he added.

‘No longer fit for purpose’

In addition to looking at the value of CTOs, the report identified issues surrounding the current nearest relative role and how it could be made more straightforward for approved mental health practitioners (AMHPs).

Created to safeguard people who are detained and ensure their family has a statutory role in their care, the review declared the nearest relative role was “no longer fit for purpose” as family and friends who are not eligible to fulfil the role “struggle to engage in the care of the person they support”.

In particular, the report highlighted how the statutory order of preference of the nearest relative has led to inappropriate people being selected for the role.

In some cases, the report heard how the displacement process for unsuitable relatives was causing some extensions to some forms of detention, especially for services users with non-traditional family structures. AMHPs involved in the review said they had experienced difficulty identifying the correct nearest relative.

The report concluded that a future model would have to take into consideration how disagreements can be resolved in the service user’s best interests without significant delays in treatment.

Reforming the nearest relative provision to allow individuals to nominate a person of their choice was one of the suggestions put forward by the report. It proposed that the nominated person is granted a statutory role in treatment decisions; a move which could mirror the principles of the power of attorney in the Mental Care Act.

Service users to have a say

The decision to give service users greater autonomy over their care was a common theme through the interim report.

The review said it would further consider whether service users “have enough of a say” in MHA decisions, and explore whether a person’s mental capacity should play a role in detention and treatment under the MHA.

Decisions to detain under the Act and renewals were discussed as it investigated whether current risk thresholds were correct.

Shorter detention periods

Similar questions were discussed at last week’s Community Care Live Manchester, as some delegates asked whether detention times were too long with service users having to wait up to six months before their situation was reviewed.

The interim review suggested that combining section 2 and 3 of the MHA into a single section would allow a “shorter maximum period of detention for all service users”.

It was predicted that a single section might allow “more appropriate and robust safeguards” to be in place for renewals.

“Most of the matters raised in our interim report are still very much open for discussion. We want to express our thanks to the extraordinary number of people who have already contributed their experiences and knowledge to our work so far, and we will be calling on you again before our task is complete,” said Wessely.

4 Responses to CTOs and nearest relative role could be overhauled in MHA review

  1. keithbc6472 May 2, 2018 at 1:25 pm #

    CTOs were seen as an alternative to being treated in hospital. However, they have been used only at the point of discharge (anyway) and seen as a safeguarding process to provide a framework for closer monitoring/engagement.

    If a patient was not deemed to fulfil the criteria, they tend to be discharged anyway!

  2. Bob136 May 3, 2018 at 7:07 pm #

    Sorry this feels a bit like complaining about the wallpaper when the roof is leaking! Chronic lack of health and social care funding in mental health is causing most of the problems in the city I work in. In my experience the act is sometimes used unnecessarily as it is the only way to secure a bed for someone. Lack of good quality crisis/home treatment is reducing the availability of less restrictive options. Expanding caseloads and targets mean that care coordinators are unable to be as supportive as they would like to be when trying to prevent a crisis. Lack of social care provision, especially accommodation means that people are having to stay in hospital longer if they don’t want to be discharged to the street. Oh and lets not forget the chronic lack of amhp’s resulting in people waiting 4 weeks for an assessment under the act. Personalty I think that efforts should be focused elsewhere at this time.

  3. Andrew Clayton May 4, 2018 at 11:20 am #

    I have been involved in may CTOs since their inception around 10 years ago. For the greater part I see their benefit. I have always maintained that when used properly they are a useful tool to enable those who present certain risks to move forward to embrace a less structured life in the community with some safeguards.
    I have never been shy in refusing to authorise a CTO or never so precious to accept a challenge if a colleague feels there is a less restrictive alternative. I agree with the other post here…there are far wider and deeper issues with our mental health system, namely the systematic starvation of funding and destruction of not statutory services which supported front line work so well.

  4. Santino May 12, 2018 at 9:26 pm #

    In agreement with s2 & s3 having shorter detention time/review as this will hopefully then ensure that the Nearest Relative should be consulted rather than just informed as then if the NR does not agree to detention the AMHP would then need to apply to the court to remove the NR. Who best knows the patient who would be subject to detention under s3 So what would be interesting to find out is how many AMHP’s have had to apply to the courts to remove the NR of BAME patients given that they were are consulted. Given that BAME males are up to 4 times more likely to be sectioned, given that hardly any applications to the courts are made then it would appear that the NR are in agreement, or is there other reasons?

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