Community Treatment Orders
| Author | Michael Butler |
| Pages | 197-210 |
Chapter 20
Community Treatment Orders
20.1 INTRODUCTION
CTOs were, perhaps, the most significant change in mental health law brought about by the MHA 2007, and were intended as a solution to the longstanding problem of providing effective community-based treatment for certain patients with chronic, relapsing mental disorders who were reluctant to accept help. The widespread perception was that many such patients (colloquially known as ‘revolving door patients’) faced a destructive pattern of repeated admissions to hospital caused by non-compliance with community treatment plans, in particular an unwillingness or inability to take prescribed medication. Something, it was felt, needed to change.
In order to prevent such non-compliance therefore and, hopefully, repeated admissions to hospital, the MHA 2007 amendments to the MHA 1983 effected changes which mean that certain patients can now be put on a CTO at the point at which they are discharged from hospital. The effect is that they are made subject to a set of conditions designed to regulate their behaviour, and are also liable to recall to hospital without the need for a formal assessment under the MHA. This regime (very similar to the conditional discharge regime in respect of restricted patients) is meant to provide a coercive framework within which a patient’s co-operation with treatment is more likely to be achieved, and further hospital admissions avoided.
The provisions concerning CTOs (also referred to as supervised community treatment or SCT) are set out in sections 17A–17G of the MHA 1983, as amended by the MHA 2007, and are considered in this chapter.
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20.2 ELIGIBLE PATIENTS
Any unrestricted patient who has been detained in hospital for treatment under section 3, 37 or 47 of the MHA 1983 (section 17A, Schedule 1, Part I, and section 47(3)) is eligible for the imposition of a CTO. A CTO may not, therefore, be imposed on a patient who has been detained only for assessment under section 2. Nor may it be imposed on a restricted patient (section 41(3)(aa)).
20.3 DECISION TO IMPOSE A COMMUNITY TREATMENT ORDER
If there is to be one, a CTO will be imposed at the point at which the patient is discharged from liability to detention in hospital. Whether to impose one is a decision for the patient’s RC, who must, firstly, satisfy himself that the relevant statutory criteria are met.
20.3.1 Criteria
According to section 17A(5) of the MHA 1983, the criteria which must be met before a CTO can be imposed on a patient are:
(a) the patient is suffering from a 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.
In other words, the RC must conclude that the patient still needs treatment for his mental disorder, that this no longer needs to be as an in-patient, that the patient can therefore be discharged, but that he needs to be subject to the power of recall to hospital.
20.3.2 Power of recall
Very often, discussions around the need for a CTO will focus on the central issue of whether the RC needs the power of recall (section 17A(5)(d) of the
MHA 1983). When deciding on the need for this power, section 17A(6) requires that the RC shall:
(6) … in particular, consider, having regard to the patient’s history of mental disorder and any other relevant factors, what risk there would be of a deterioration of the patient’s condition if he were not detained in a hospital (as a result, for example, of his refusing or neglecting to receive the medical treatment he requires for his mental disorder).
The point is clear. The power of recall hanging over the patient is designed to persuade him to comply with the treatment that is offered. The greater the risk therefore of non-compliance with treatment, and the greater the risk of a deterioration in his mental health as a result, the greater the case is for the power of recall as part of the CTO.
The RC would, however, ordinarily need to point to a patient’s history of non-compliance (and consequent deterioration) before he could say that other options had been exhausted and that the power of recall had therefore become necessary. As the 1983 Code points out (para 25.7), 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’.
20.3.3 Agreement of the approved mental health professional
The only significant procedural safeguard at the outset is that the RC must obtain the agreement of an AMHP, both that the criteria are met and that the CTO is appropriate (section 17A(4) of the MHA 1983). In this respect, the role of the AMHP is to ‘consider the wider social context for the patient’ (1983 Code, para 25.24). Somewhat surprisingly, therefore, the AMHP need not have had any previous involvement in the patient’s care, nor even have met the patient.
20.3.4 The patient
In theory, a CTO may be imposed without the consent of the patient. However, it may not be used to force a patient to do something against his will (see para 20.4) and in practice is only likely to work, therefore, if there is a degree of consensus from the outset. Although reluctant, many patients will agree to the CTO because it signals their discharge from hospital.
A CTO may be imposed on a patient who lacks the capacity to agree to it.
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20.3.5 Leave under section 17 of the Mental Health Act 1983
The RC is expected to consider the possibility of a CTO whenever a patient is granted long-term leave under section 17 of the MHA 1983. Indefinite leave or leave for a specified period of more than 7 days may not, therefore, be granted unless the RC has first considered whether to put the...
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