Supervised Community Treatment

1. Supervised Community Treatment • Sue Browning • Social work team manager

2. What are the criteria? • the patient is suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment (b) it is necessary for his health or safety or for the protection of other persons that he should receive such treatment; (c) subject to his being liable to be recalled as mentioned in paragraph (d) below, such treatment can be provided without his continuing to be detained in a hospital; (d) it is necessary that the responsible clinician should be able to exercise the power under section 17E(1) below to recall the patient to hospital; and (e) appropriate medical treatment is available for him. There is no lower age limit

3. a. the patient is suffering from a mental disorder of a nature or degree’ • With SCT the nature of a person’s mental disorder is likely to be of more important than the degree of their disorder

4. b. it is necessary for the patient’s health, or safety or the safety of others.’ • Risk needs to be considered within the context of the patient’s history of mental disorder (the ‘nature’) • The risk of deterioration and the possible risks associated with that

5. c. Consenting or agreeing to cooperate? COP: 25.14 ‘Patients do not have to consent formally to SCT. But in practice, patients will need to be involved in decisions about the treatment to be provided in the community and how and where it is to be given, and be prepared to co-operate with the proposed treatment.’

6. d. Recall? ‘….. The key factor in the decision is whether the patient can safely be treated for mental disorder in the community only if the responsible clinician can exercise the power to recall the patient to hospital for treatment if that becomes necessary’ • COP 25.7

7. What a CTO does • Only for inpatients subject to section 3 or 37 • Order for discharge subject to recall • Suspends s3 or 37 • Treatment against will only in hospital under recall

8. Mandatory conditions The following two conditions must be applied (under s17b of the MHA): • that the patient must make himself available for examination of whether his CTO should be extended under s20A • that if a SOAD doctor needs to see him/her, he must also make himself available

9. Other conditions • Must be necessary or appropriate • Ensure that the patient receives medical treatment and/or • Prevent risk of harm to patient’s health or safety and/or • It is necessary to protect other people • AMHP agrees necessary and appropriate

10. Conditions? • COP 25.33 “ be kept to minimum consistent with achieving purpose” • restrict liberty as little as possible • have a clear rational in line with purposes • cultural needs and background of patient

11. COP 25.34 • “the nature of the conditions will depend on patient’s individual circumstances. They may cover matters such as where and when the patient is to receive treatment in the community; where the patient is to live; and avoidance of known factors or high-risk situations relevant to patient’s mental disorder’’

12. Victims • S 37 now included in DVCV 2004 • Check with MAPPA if have committed sexual/violent offence • Victim will have been consulted by Victim Liaison Service • May have made representations re SCT or conditions • COP 30.29-30.31,25.37

13. The Application Process An RC and an AMHP must: • Agree that the criteria are met The AMHP must also • Agree that it is appropriateto make the order

14. Recommendations from the MHRT • The MHRT can recommend that the RC considers the use of SCT • It is up to the RC whether or not they agree to the use of the order

15. CPA & the SCT process • The use of SCT sits within the CPA process as a whole • Any SCT application needs to be supported by a comprehensive care plan • Any care plan must be informed by the guiding principles of the Act • It is important that patient and carers are fully involved in the planning and application process • Clearly, in this context, an RC would also need to be satisfied that the use of SCT is appropriate

16. Guardianship S17 leave or SCT? COP Ch.28

17. S17 leave or SCT? If the RC wishes to send someone on s17 leave for more than 7 days, the law now says that they must consider whether SCT would be a better option

18. So which one? • Guardianship – welfare • Leave of Absence- break in hospital treatment • SCT- prevention of harm and revolving door- “no reason to think that the patient needs further treatment as detained inpatient …. But the RC needs to be able to recall” COP May 2008 28.5

19. SCT – the protections • The person isn’t subject to Part 4 so cannot be forced to accept medication in the community • They can be recalled to hospital to prevent an acute crisis • The person gains a further right of appeal to the MHRT when they start on SCT • Again, if their order is revoked, the hospital managers have a duty to refer them to the MHRT straight away (the patient also has the option to withdraw if they wish to appeal at a later stage within the 6 month period.) • An AMHP can prevent the use of SCT, it’s conditions, extension and revocation • They are entitled to an IMHA • The Nearest Relative has a similar right of discharge to section 3

20. Time limits A CTO has the same time limits as section 3 i.e. 6 months, 6 months, 12 months

21. Review at the end of the period • At the end of the period of compulsion, both the Responsible Clinician and the AMHP have to reassess, and agree that the criteria are met, prior to the order being extended further • The AMHP must also agree that the use of the power continues to be ‘appropriate’

22. A decision against extension • If the AMHP does not agree to the extension of the order, it cannot be extended • A decision NOT to agree to extension does not mean the patient will be instantly discharged in law, but the RC should consider reviewing the order, none the less

23. Recall and Revocation • If the compulsory conditions are breached, the RC can recall the patient • If other conditions set are breached, recall can only happen if the criteria on the following slide are met, however • If the following criteria are met, the person can be recalled whether or not they have breached their conditions.

24. The RC can recall the patient subject to the following criteria: • the patient needs to receive treatment for mental disorder in hospital; and • there would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled.

25. What this means…. • It is possible to recall the patient at an earlier stage, if it is considered that non- compliance with medication would lead to further deterioration in their mental health • This will usually relate to the nature of their mental disorder, rather than it’s degree • The advantage of this is not just for the patient’s mental health but also avoids the potentially stigmatising effects (such as police involvement) often associated with later intervention

26. The effect of recall section 17e • Once recalled, the patient becomes subject to Part 62A of the Mental Health Act. This means the person can be forced to take medication • The recall may last for up to 72hrs

27. The effect of Revocation 17f • If the order is revoked, the CTO reverts to its previous status (i.e. s3, s37 etc). • The Section starts again, 6 months, 6 months and a year for extension. The patient is subject to Part 4 and is treated on the basis of the CTO11 completed by the SOAD whilst on SCT

28. How someone is recalled • The Act says that a patient will become subject to recall once they have received the notice to recall in writing • Received means either physically being given the order or it being sent to the last known address of the patient

29. Recall cont’d • In practice, the Code (25.57) suggests that in most cases the recall notice should be given directly to the patient. In this case the power to recall is effective immediately • Where the recall notice needs to be posted, the notice is deemed to be served on the 2nd working day after posting • If the recall notice is hand delivered, it will take the following day • In either case, if the patient does not comply, they would be deemed to be AWOL

30. Recall cont’d • The liability to be detained therefore comes back into effect • The 72 hrs only begins once they have returned to hospital • ‘hospital’ has a wider meaning to include community treatment centres, where this is deemed to be a more appropriate place for recall • The power to enforce treatment starts when the patient arrives at the hospital (as above) • The patient does not have to be returned to their ‘responsible’ hospital

31. How the order is revoked The CTO may be revoked if • The RC considers that the patient again needs to be admitted to hospital for medical treatment under the Act; and • An AMHP agrees with that assessment and also believes that it is appropriate to revoke the CTO

32. Other outcomes to recall • The RC may discharge the recall order at any time during the 72 hr period, allowing the person to return to the community under SCT • The hospital managers must ensure that eitherthe person has been discharged back to the community or that the RC has an AMHP’s agreement to revoke the order • Of course, the RC is free to discharge the patient from the CTO whenever he or she feels the criteria are no longer met

33. Amending or suspending conditions • The Responsible Clinician may amend or suspend conditions imposed on the service user, but it would not be good practice to make changes soon after imposing the order, unless there were a change in circumstances • Any changes must be sent in writing to the service user

34. People currently on section 25A • Anyone currently on section 25A (Supervised Discharge) must be reviewed and may be considered for SCT as part of that review • Transitional arrangements will apply and these give 6 months for the review to take place, after the 3rd November, i.e. before the 2nd May 2009

35. References • CSIP training package • SCT A guide for practitioners October 2008 NIMHE • Code of practice DH May 2008 • Oxleas SCT Local Policy