Community Treatment Order
Community Treatment Orders were introduced on 3/11/08, by new sections 17A-G being inserted into the Mental Health Act 1983 by the Mental Health Act 2007. In the Code of Practice it is called Supervised Community Treatment; in the Act those subject to CTOs are called community patients.
The nearest equivalent in the past was supervised discharge (after-care under supervision) under s25A-J. These provisions were repealed when CTOs were introduced, although arguably the CTO has more in common with extended ‘long leash’ s17 leave. Transitional provisions provided that, during the six months after 3/11/08, patients subject to after-care under supervision were to be assessed and the patient placed under s2, s3, guardianship, or a CTO, or discharged altogether. The relevant commencement order was Mental Health Act 2007 (Commencement No. 6 and After-care under Supervision: Savings, Modifications and Transitional Provisions) Order 2008.
For further information on CTOs, see Reference Guide chapter 15 (Supervised Community Treatment) and Code of Practice chapters 25 (Supervised community treatment) and 28 (Guardianship, leave of absence or SCT?).
The CTO was intended to cater for the ‘revolving door’ patient, but the Care Quality Commission has noted (CQC, ‘Monitoring the use of the MHA in 2009/10’, pp96, 99):
[T]here were 4,107 CTOs made in 2009/10, with a total of 6,241 orders in the 17 months from their introduction in November 2008 (figure 27). This is an average of 367 each month: a much greater use of CTOs than had been anticipated by the Department of Health before the power was introduced. … Over the year, we analysed a sample of 208 CTO second opinions … 30% of the patients in our sample did not have a reported history of non-compliance or disengagement
Subsequently the CQC reported that in 2012/13 there were 4,647 new CTOs made, and in 2013-14 there were 4,434 (CQC, ‘Monitoring the use of the MHA in 2013/14’, p35).
The government-funded OCTET randomised controlled trial (see Burns et al, ‘Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial’ (2013) 381 The Lancet 1627) tested whether CTOs reduce admissions compared with use of s17 leave, in situations where the RC was in ‘clinical equipoise’ about whether to use a CTO or s17 (therefore it only applied to those patients for whom the RC genuinely did not have an opinion on which would work better). The study found that at 12 months, despite the significant difference in length of initial compulsory outpatient treatment (median 183 days on CTOs but 8 days on s17) the number of patients readmitted did not differ between the two groups. The researchers’ interpretation was:
In well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.
Granting a CTO
A CTO is an option for s3 and unrestricted criminal patients (hospital order or 'notional s37'). It is therefore not an option for s2 patients, restricted patients, informal patients or out-patients.
Longer-term leave of absence may not be granted to a patient unless the responsible clinician first considers whether the patient should be discharged on a CTO (s17(2A)). Longer-term leave is defined as more than seven consecutive days, or an extension which would make the total period more than seven consecutive days (s17(2B)).
The criteria of which the RC must be satisfied are found in s17A(5):
(a) 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.
An AMHP must certify in writing that he agrees the criteria are met and that it is appropriate to make the CTO (s17A(4)). The process can be seen in the relevant statutory form: Form CTO1 section 17A - community treatment order.
The time periods for a CTO are the same as for detention under s3. It lasts initially for a maximum of six months, but can be renewed for a further six months and thereafter can be renewed for 12-month periods (s17C, s20A(3)).
There are two ‘mandatory’ conditions (so-called because they must be included in all CTOs: s17B(3)). These are that the patient must make himself available for examination:
- (a) in relation to renewal of the CTO (under s20A); and
- (b) in relation to a SOAD treatment certificate (under s64C(4)).
Other discretionary conditions can be specified if the RC and AMHP agree that they are necessary or appropriate for one or more of the following purposes (s17B(2)):
(a) ensuring that the patient receives medical treatment;
(b) preventing risk of harm to the patient's health or safety;
(c) protecting other persons.
These conditions could relate to matters such as residence, medication, engagement with community mental health services, illegal drugs, and exclusion zones.
There is no power to impose conditions in a CTO which have the effect of depriving a patient of his liberty (Welsh Ministers v PJM).
Once the CTO begins, it is only the RC who can vary, add to, or remove conditions: he does not need to consult anyone else, and the Tribunal has no power of variation.
It is possible to use a CTO on discharge from a first hospital admission.
It would be unlawful to detain someone under s3, if the s3 criteria are not met, purely to then discharge them onto a CTO.
The consent to treatment provisions which apply during the CTO are found in Part 4A (s64A-K). For details, see Reference Guide chapter 17 (Medical treatment of Supervised Community Treatment patients (Part 4A)) and Code of Practice chapters 23 (Medical treatment under the Act) and 24 (Treatments subject to special rules and procedures).
Recall and revocation
Once a CTO is in place, the following actions can be taken:
- The patient can be recalled to hospital for up to 72 hours;
- Once recalled, the CTO can be revoked, which resurrects the detention;
- Alternatively, once recalled, the patient can be released back onto the CTO (which would automatically happen after 72 hours unless the CTO is revoked);
- The patient can be discharged from the CTO at any time.
The RC can (but is not obliged to) recall the patient:
- for breach of a mandatory condition (s17E(2)) or
- if in his opinion (s17E(1)):
(a) the patient requires medical treatment in hospital for his mental disorder; and
(b) 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 to hospital for that purpose.
Breach of a discretionary condition is just a factor which will be taken into account when considering the criteria above.
Recall permits detention in hospital for a maximum of 72 hours (s17F(6)) during which it must be decided whether to revoke the CTO or release the patient back onto the CTO.
The CTO can then be revoked if (a) the RC believes the s3 admission criteria are met, and (b) an AMHP agrees with that opinion and thinks revocation is appropriate (s17F(4)). The process is simpler than for re-sectioning the patient (e.g. there is no need to consult the nearest relative).
The underlying authority for detention lies dormant for the duration of the CTO (s17D) and is resurrected by revocation (17G).
However, for calculation of renewal dates and eligibility periods, the detention is treated as having begun on the day of revocation (s17G(5)).
Recall and subsequent release have no effect on eligibility periods.
Appeals and references
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If an application is made by the patient while detained but he subsequently is placed on a CTO, the application does not lapse but Tribunal proceedings continue, and this does not affect any other entitlement to apply to the Tribunal: AA v Cheshire and Wirral Partnership NHS Foundation Trust  UKUT 195 (AAC). The same logic should apply in reverse, i.e. when the patient applies on the CTO but it is subsequently revoked.
A community patient can also appeal to the hospital managers at any time. The managers of the responsible hospital can discharge the CTO (s23(2)(c)). The "responsible hospital" is the hospital in which he was liable to be detained immediately before the community treatment order was made, subject to section 19A (Regulations as to assignment of responsibility for community patients) (s17A(7)).
Automatic references must be made by the managers of the responsible hospital at certain times:
- As soon as possible after revocation of the CTO (s68(7)).
- Six months after the beginning of the s3 admission, or any immediately previous s2 admission, if there has been no Tribunal application or reference (discounting any made during the s2) (s68(2)). For details see the separate section on automatic references.
- Three years after the last consideration of the case by the Tribunal (or one year if the patient is not yet 18 years old) (s68(8)).
- There is no power to make a reference to be made when a patient subject to after-care under supervision is placed on a CTO under the transitional provisions. This point is currently the subject of an appeal to the Upper Tribunal.
- The SoS for Health has the power to refer at any time (s67).
The following page explains the introduction of CTOs, and contains some external links:
Kathryn Walsh, 'Community treatment orders fail to reduce psychiatric readmissions for people with psychosis' (The Mental Elf, 14/5/13). The government-funded OCTET randomised controlled trial (see Burns et al, 'Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial' (2013) 381 Lancet 1627) tested whether CTOs reduce admissions compared with use of s17 leave, and found that at 12 months, despite the significant difference in length of initial compulsory outpatient treatment (median 183 days on CTOs but 8 days on s17) the number of patients readmitted did not differ between the two groups. The researchers’ interpretation was: 'In well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.'