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Community Treatment Orders: Where are they from and where are they going to?

Community Treatment Orders: Where are they from and where are they going to?. Simon Lawton Smith Head of Policy, Mental Health Foundation AMHP AGM, Manchester, 20 March 2012. The evolution of CTOs.

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Community Treatment Orders: Where are they from and where are they going to?

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  1. Community Treatment Orders:Where are they from and where are they going to? Simon Lawton Smith Head of Policy, Mental Health Foundation AMHP AGM, Manchester, 20 March 2012

  2. The evolution of CTOs • a natural result of care in the community, with the closure of large psychiatric institutions; improved medication; “least restrictive alternative” • an evolution (and formalisation) of long-term hospital leave arrangements (New Zealand and Australia; Scotland) • a reaction to incidents of violence such as a high-profile homicide (USA and Canada, eg Laura’s Law in California, Brian’s Law in Ontario, Kendra’s Law in New York)

  3. How far have we progressed? “The important classification to be made among the insane so far as society is concerned, is a division into dangerous and non-dangerous insane. The principle of conditional liberation… is practiced at Broadmoor, England, with excellent results. A person who, after being carefully observed for a sufficient length of time, seems to be cured, is committed to relatives who undertake to guard him, but the state reserves the right to effective control. The patient is subjected to frequent visits and in case of the violation of the rules imposed, whether on the part of the patient or his guardian, is recommitted to Broadmoor. The method seems to offer all the necessary guarantees for the protection of society.” American Journal of Insanity, April 1899, p.744

  4. The use of CTOs internationally • Despite limited evidence base of effectiveness compared to good community services, CTOs have been introduced widely in last 20 years • Compulsory community treatment is not new - in some states of the US powers have existed for around 25 years, in Israel, Australia and New Zealand around 20 years, in Canada 10 or 11, in Scotland 5 years, in England and Wales 3 years • Systems and legislation varies. But commonly a) aimed at patients who tend to be non-compliant with medication and frequently relapse b) ensure a patient complies with a set of conditions – most importantly that they take their medication

  5. CTOs: International variations Lawton-Smith S: A Question of Numbers (King’s Fund, 2005, updated 2012)

  6. International CTOs: reasons for variationsLawton-Smith S: A Question of Numbers (King’s Fund, 2005) Variations occur because of differences in: • the scope of the powers in each piece of legislation • the attitude of mental health professionals towards CTOs and their understanding of their powers • the bureaucracy involved in making CTOs • the availability (or otherwise) of good community services to support people on CTOs • the number of available in-patient beds

  7. Scotland: the evidence Scottish law on CCTOs (Community Compulsory Treatment Orders) differs from England and Wales Act, eg • requires impaired decision-making • all applications for compulsion (whether for a hospital or community CTO) have to be authorised by a three-person Mental Health Tribunal. • CCTOs authorised either directly on someone living in the community or as a variation to a hospital CTO

  8. Scotland: CCTOs grantedMental Welfare Commission (MWC), Scotland (2008)

  9. Scotland: people under CCTOsMental Welfare Commission Scotland – 2011 provisional data

  10. Scotland: people under CCTOs by Health BoardMental Welfare Commission data, as at March 2011

  11. Scotland: CCTOs a good thing? • “The number of people subject to long-term community orders continues to rise while the number of orders for treatment in hospital continues to fall. We think this is a good thing, although we have found that more people have been readmitted to hospital from community orders this year.” • “We found that 85% of people thought that compulsory community treatment had been of at least some benefit to them.” Mental Welfare Commission for Scotland: Our Annual report 2010-11

  12. England: new CTOs madeNHSIC data, October 2011

  13. England: people under CTOsNHSIC data, October 2011 (as at 31 March each year)

  14. The initial impact in England Briefing Paper 2: Supervised Community Treatment (Mental Health Alliance, 2010) • in Year 1 (Nov 08 – Oct 09) use of SCT (over 4,000 uses) was much higher than anticipated by the Government (400-600) • most psychiatrists think it a useful option (325 v 74 in a survey) • little information about the impact of SCT on people’s treatment and people’s quality of life – some positive stories from clinicians, some negative reactions from patients • the rate of CTO use in England has flattened out (300-350 a month), but, as fewer people are being discharged from CTOs than are being placed under CTOs, the overall number of people under a CTO rising.

  15. London variationsCQC email to SL-S,3 August 2010 NHS Trust Nos. on SCT CTOs /100,000 pop • Barnet, Enfield and Haringey 124 15.5 • Camden and Islington 90 21.4 • Central and North West London 176 9.8 • East London 124 17.5 • North East London 74 7.4 • Oxleas 71 9.5 • South London and Maudsley 155 14.1 • South West London and St George’s 108 10.8 • West London 50 7.1

  16. Care Quality Commission / NHSIC findings1. Monitoring the use of the Mental Health Act in England 2009/10, CQC Oct 20102. In-patients formally detained in hospitals under the Mental Health Act, 1983 - andpatients subject to supervised community treatment, Annual figures, England2010/11, NHSIC Oct 2011 An average of 367 CTOs made each month in England from November 2008 to March 2010 – dropped to 320 per month in 2010/11 From CQC sample of 208 SOAD reports • Proportion of BME patients on CTO “larger than might be expected” • 81% had schizophrenia or other psychotic disorder, 12% had mood disorder • 98% prescribed some form of antipsychotic medication, 65% receiving depot injections • 35% prescribed above British National Formulary limits • 30% do not have a reported history of non-compliance (ie not just revolving door patients, as DoH suggested) • Some problems with continuity of care for patients, poor inpatient to community handovers, delays in AMHP approval, difficulties over recalling patients to hospital (often bed availability), some clinicians not clear that patient’s refusal to consent cannot be overridden unless recall to hospital

  17. From the North-West Taylor J A (2011) “A study of Supervised Community treatment in a North West local Social Services Authority” 21 CTO applications, 27 CTO renewals and 8 CTO revocations between January and December 2010 in one LSSA. AMHP questionnaire (9 respondents): • general agreement that CTOs enhance earlier identification of relapse; improve access to housing; reduce risk of self-harm • but they do not help improve access to education, employment, voluntary work or recreational activity, or reduce stigma and discrimination. SCT conditions (25 patients in December 2010): • Take antipsychotic medication : 90% • Monitored by community team: 80% • Compliance with psychological interventions: 4.7% A number of groups disproportionally under SCT – single, unemployed, members of BME communities

  18. The unanswered questions • How long are people staying on CTOs? • What are the reasons for discharge (expiry of CTO; revocation; clinician discharge; death)? • What is in people’s care plans and do they get it? • What is the impact on contact with the criminal justice system? • What is the impact on staff time and resources? • What do service users and family carers think of them? • What benefits are coming in terms of improved quality of life?

  19. England, Scotland and New Zealand

  20. Suggested further reading • Lawton-Smith S (2005) A Question of Numbers: The potential impact of community-based treatment orders in England and Wales. King’s Fund, London • Churchill, R et al (2007) Cochrane Review: International experiences of using community treatment orders. Department of Health, London • Lawton-Smith S, Dawson J and Burns T (2008) Community Treatment Orders are not a good thing. British Journal of Psychiatry 193, 96-100 • NIMHE (2008) Supervised Community Treatment: A Guide for Practitioners. Department of Health, London • Mental Health Alliance (2010) Briefing Paper 2: Supervised Community Treatment. Mental Health Alliance, London • Care Quality Commission (2010) Monitoring the use of the Mental Health Act in 2009/10. CQC, London

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