1. Supervised Community Treatment Order (SCTO)  HOW CTOS ARE WORKING IN PRACTICE  ITS EFFECTIVENESS AND CHALLENGES By Olive Onwualu AMHP/Senior Social Worker

2. CTO background On November 3 rd 2008 Supervised Community Treatment Orders (SCTOs) became available for the first time in England and Wales Under Amendments made to the Mental Health Act 1983 (MHA) for England and Wales, CTOs were introduced for severely ill, so called ‘revolving door’ patients in November 2008. Aim was to introduce a new form of delivering involuntary out patient treatment to supplement the existing leave regime under section 17 of the Act. Section 17 Leave is granted to detained patients by RC subject to conditions as considered necessary in the interests of patients or for the protection of others.

3. How CTOs are working in practice  Responsible Clinician (RC) makes an application for a CTO if AMHP agrees.  CTOs last for 6 months, extended for 6 months by RC if AMHP agrees, then annually.  The patient can appeal to the Tribunal once in each period of the CTO and automatic reference procedures

4. How CTOs are working in practice cont… Automatic Tribunal if CTO is revoked Hospital Managers can discharge from CTO Nearest Relative can discharge from CTO by giving 72 hours notice (can be barred by RC but only on dangerousness grounds) CTOs only available for patients on s3, 37, 45A, 47 or 48 Not available for shorter term detained pastimes (s2, 4 etc)

5. How CTOs are working in practice cont…  Significant regional variations in the use of CTO e.g. CTO is not used at all in Wales  In my team, more patients are put on s.3 for the purpose of putting them on CTO  CTO is an order for patient discharge from detention subject to possibility of them being recalled to hospital for further medical treatment

6. Criteria for CTO  Patient must be suffering from mental disorder  of a nature or degree which makes it appropriate for him to receive medical treatment  It is necessary for his health or safety or for the protection of others that he should receive such treatment  Must be on.s3,  Subject to him being liable to be recalled… such treatment can be provided without his continuing to be detained in hospital;  It is necessary that the RC should be able to exercise the power …to recall the patient to hospital;  Appropriate medical treatment such as patient seeing RC, CPN, SW, taking their medication is available.

7. CTO requirement on patient  There are two mandatory conditions which will always apply:  The patient must make himself available for RC examination regarding extension of the order; or  For examination by a Second Opinion  RC may recall a patient if the patient fails to comply with the mandatory conditions if agreed by AMHP  No lower age limit for CTO

8. Effectiveness of CTO According to NHS information center: numbers of people detained under the MHA rose by 1, 692. The 3.5% increase brings the total people detained under the act just under 50,000 in one year and represents the largest increase in three years. The figures also showed CTOs continued to be issued at a high rate with 4,103 issued in 2009-2010.

9. CTO effectiveness cont...  The introduction of SCTO remains controversial for a range of reasons: legal, ethical, empirical.  There are issues about convincing scientific evidence for its effects (despite widespread international adoption).  Complex ethical balance of personal autonomy against a need for care and public safety.

10.  According to The Oxford Community Treatment Order Evaluation Trial (OCTET) the only methodology which will convincingly address these is Randomised Controlled trials (RCT)  RCTs are recognised as the most rigorous methodology and the ‘gold standard’ for testing new treatment  OCTET posits that RCT is designed to fill the evidence gap.  As a result- there is now two main options for clinicians regarding patients who need ongoing supervision in the community : CTO or section 17 leave.

11. Sources  Primary legislation:  The Mental Health Act 1983 (as amended)  Secondary legislation:  Mental Health Act (Hospital, Health Education and Social Care Chamber) Rules 2008.  Guidance:  Reference Guide  The Code of Practice  Textbooks:  Barber, Brown and Martin (2009) Mental Health Law in England and Wales, Learning Matters  Jones (2008) Mental Health Act Manual 11 th edition, Thomson Sweet and Maxwell

12. Sources cont...  Fennell (2007) Mental Health – The New Law, Jordan's  Bowen (2007) Blackstone’s Guide to the Mental Health Act.