Of CTOs


Community Treatment Orders – Supervised Community Treatment – however it is termed it is one of the aspects of the amended Mental Health Act that I thought I would likely not have significant contact with on a day to day basis. I was right. But my experience might be far from typical as the take-up of these Community Treatment Orders has been much higher than was estimated by the government.

As Community Care reported a couple of weeks back

The statistics revealed that 2,134 community treatment orders were issued in England from November 2008, when they came into force, to March 2009. The government expected there to be 450 CTOs in England and Wales in the first year.

That figure of about 2000 is only until March – currently the whispers (from various training courses) say that the figure is nearer 4000.

So what are they for?

And who do they affect?

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This was one of the more controversial parts of the amended Mental Health legislation in England because it allowed for conditions relating to treatment to be placed on patients in their own homes. It allows for a process of ‘recall’ to hospital is the conditions relating to treatment are not met.

We, in our training and discussions, are often signposted to people who may have a very clear history of ‘revolving door’ admissions with similar sets of circumstances and the CTO provides a means of enforcing treatment with the threat of recall to hospital in the background and a legal framework being provided in order to do so.

The general discussions that I’ve been party to in my local trust area seems to revolve around a few consultants being very much in favour of using them and others not using them at all so the national figures are high. It is another way of managing risk through compulsion and in an increasingly risk averse culture, it can be seen as an additional safeguard.

I have been involved in a couple of CTO-related decisions in my role as an AMHP (Approved Mental Health Professional). Generally the RC (Responsible Clinician) will be the one to arrange the CTO however before it is valid, the forms have to be signed by an AMHP in order to serve as one-man check and balance system to ensure that the conditions set are fair and appropriate and that the least restrictive path is met.

The other role of the AMHP is in the revocation of a CTO. If, when a patient is recalled to hospital by their Responsible Clinician it is seen fit that they need to revert to the section that they were detained under prior to the CTO, a signature of an AMHP is required on the paperwork in order to validate it.

The only CTO-related issues that I have been involved in so far have been to revoke a CTO – in the situation, the patient was not someone I knew very well but I had been involved in the initial community assessment and bringing her into hospital as a result. I was asked to consider the revocation of the CTO and saw that she was extremely unwell – at least as unwell as the point of the initial assessment considered that it was far more appropriate at that time that she was in hospital for a while longer.

The other decision is more recent so will probably come back to it at a later date and is, as of now, unresolved which is more reason for me not to dwell on details but it has raised interesting dilemmas about how much influence can be placed to sign some of the pink forms (all Mental Health Act forms are pink – for the record) if it will ‘make life easier’. As I said, it’s probably something I will return to at some point.

I was involved in some in-house training about the new Mental Health Act legislation and to be honest, because of the time involved, we skimmed very briefly over CTOs – thinking that they wouldn’t necessarily be relevant within over 65s services however, we are considering a few refresher sessions because, as Pope wisely said ‘A little knowledge is a dangerous thing’..

One thought on “Of CTOs

  1. We have the same thing here, although we’ve had it for a few years already. It’s called “provisional order” here, because the person can be int he community provided they adhere to the treatment plan. They are wanting to change the mental health act to include more possibilities for involuntary community treatment, but I’m not sure what more they can actually do.

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