Sir: Tom Burns (Psychiatric Bulletin, November 1999, 23, 647-648) is right to suggest that different ways of asking the question ‘what are Community Treatment Orders (CTOs) for?’ will lead to different conclusions as to their usefulness. He formulates the question as “is there a group of patients who are poorly served by the present legislation, who are currently repeatedly subject to compulsory admission and whose welfare would be better served by CTO?” and concludes, yes, there is. This is a small group of patients, ‘a handful per team’. An examination of the annual reports of the Mental Welfare Commission for Scotland or the Mental Health Act Commission for England and Wales show the rise over time of the use of compulsory measures since their introduction. Use of leave of absence (LOA) over 12 months rose in Scotland from 22 patients in 1988 to 129 patients in 1994 (Reference Atkinson, Gilmour and DyerAtkinson et al, 1999). At 31 December 1994 there were 92 patients on LOA over 12 months, of whom 30 had been on LOA over 24 months. This would seem to be less than the ‘handful per team’ suggested by Burns and would suggest that CTOs would be used more extensively as time goes on.

In Scotland leave of absence has functioned as a de facto CTO and could be used indefinitely, until restricted to 12 months by the 1995 Patients' in the Community Act. The Act also introduced Community Care Orders (CCOs). CCOs are constantly referred to as a failure because so few are used. Is a power only seen as successful if it is used a lot?

The Green Paper (1999) is widening the number of patients who could be subjected to a CTO from those subject to LOA. Nevertheless, it is worth considering what has happened to the patients on LOA beyond 12 months following the new restriction. We are currently analysing data on this very question, but it is clear, even anecdotally, that many patients discharged from extended LOA have done well with no measure of compulsion; they have not all been put on CCOs, nor have they all been returned to hospital. A number of psychiatrists have commented to us ‘maybe I was too cautious’.

We use past behaviour as the best predictor of future behaviour. Following this principle, and looking at the behaviour of psychiatrists, we can assume that any sanction which exists will be used and as time goes on used more extensively.