CTOs in England and Wales

In England and Wales, CTOs allow the treating team to make conditions in a number of different domains. An individual can be required to attend for appointments with services, reside in particular accommodation, or adhere to medication. However, CTOs do not allow for the forcible administration of medication in the person’s home. Two mandatory conditions apply in all cases: for the individual to attend for assessment by a second opinion approved doctor (SOAD) when requested and to present for assessment regarding renewal of the order at the appropriate time. ^{10,Reference Dawson, Gostin, McHale, Fennell, Mackay and Bartlett11}

Across different jurisdictions, the legal powers to compel allow for clinical discretion. This means that there are no situations where a clinician must use a CTO, rather that there are situations where he/she may use one. The use of CTOs varies substantially between and within jurisdictions. Dawson ^{Reference Dawson12} proposes that much of this variation can be explained by the manner in which clinicians use their discretion. Given the relative lack of research evidence on which to base their decision, he suggests four main factors play a part in clinical decision-making:

1. 1 the legal structure of the CTO regime

2. 2 the community mental health services available

3. 3 the clinician’s views about the possible impact of coercion on his/her relations with patients

4. 4 the expectations of third parties for use of the scheme.

The use of CTOs in England and Wales has substantially outstripped predictions, with nearly 3000 orders being enacted in the first 8 months. ^{Reference Dawson12} By March 2010, over 6000 orders had been made in England alone. ¹³ A lack of research evidence or clinical consensus regarding their usefulness may have contributed to CTOs being used more widely than forecasted. ^{Reference Appelbaum14-Reference Dawson, Romans, Gibbs and Ratter16} It is important, therefore, to ascertain the views of those using CTOs in regard to their usefulness and disadvantages.

CTO use internationally

Crawford and colleagues ^{Reference Crawford, Hopkins and Henderson1} sent a short postal survey to consultant psychiatrists in England and Wales in 2000 when changes to the Mental Health Act were being debated. This survey focused on attitudes towards the planned extension of compulsory powers into the community. Of 1171 respondents, 46% were in favour of a system allowing compulsory treatment in the community. The remainder either disagreed (35%) or were unsure (19%). Written comments confirmed a considerable polarisation of views, with some believing that the introduction of compulsory community powers was long overdue, whereas others believed such measures would be anti-therapeutic. In New Zealand, where similar legislation was established in 1992, a survey of consultant psychiatrists conducted in 2002 found that the vast majority (79% of 284 respondents) preferred to work in a system with CTOs. ^{Reference Romans, Dawson, Mullen and Gibbs17} Clinicians in New Zealand believed that when appropriately used the benefits for individuals of being on a CTO outweighed the disadvantages. A smaller survey of 50 psychiatrists in Saskatchewan, Canada, reported that 62% of respondents were satisfied or extremely satisfied with the effect of CTOs on patient care. ^{Reference O'Reilly, Keegan and Elias18} Two studies in the USA exploring clinicians’ views on outpatient commitment through interviews ^{Reference Scheid-Cook19} and discussions based around clinical vignettes ^{Reference Swartz, Swanson, Wagner, Hannon, Bums and Shumway20} revealed similar opinions: appropriate use of compulsory community treatment was regarded as preferable to involuntary hospital admission.

Study design

In this paper we report on a survey of members of the Royal College of Psychiatrists in England and Wales, which explored their views and experiences of CTOs 12-18 months after their introduction. The survey instrument was based on that used by Romans and colleagues in New Zealand. ^{Reference Romans, Dawson, Mullen and Gibbs17} We aimed to determine mental health clinicians’ views about CTOs on a range of issues that might be expected to influence how CTOs are being used.

Method

‘Which system would you prefer to work in?’

Respondents were asked whether they would prefer to work in a system with or without CTOs. In our sample, 60% expressed a preference for a system that included CTOs compared with 79% in New Zealand and 46% in the previous UK sample ^{Reference Crawford, Hopkins and Henderson1} (Fig. 1).

Fig 1 ‘Which system do you prefer to work within/Are you in favour of or against compulsory treatment in the community?’ Comparison between our survey and the previous UK ^{Reference Crawford, Hopkins and Henderson1} and New Zealand ^{Reference Romans, Dawson, Mullen and Gibbs17} surveys. CTO, community treatment order.

‘What is the impact on the therapeutic relationship?’

Respondents were asked whether they considered that CTOs helped, hindered, or had no effect on their therapeutic relationships with patients. Some participants gave more than one answer to this question, stating that the answer depended on the patient. Of those who gave a single response (n = 520), 45.8% thought that CTOs helped, 19.8% that they hindered and 34.4% that they had no effect on the therapeutic relationship. The psychiatrists in New Zealand who responded to this question were a little less positive regarding the effects of CTOs: 42.1% believed that CTOs helped, 31.2% that they hindered and 25.2% that they had no effect on therapeutic relationships.

‘What are the important factors in your decision to use a CTO?’

The survey presented 12 factors and asked respondents to rate the importance of each when making the decision to use a CTO on a five-point Likert scale with 1 signifying very important. Their rating for each item, and how it compares with the New Zealand survey, is shown in Table 1.

This question also produced 49 written comments, many of which emphasised the importance of providing the best possible care in the community (particularly ensuring adequate accommodation), reducing readmission, and promoting recovery in specific patient groups, particularly ‘revolving door’ or ‘nomadic’ patients. A number of respondents alluded to complex organisational politics involved in the decision to use a CTO, such as the preference or recommendation of the mental health review tribunal, pressure from within mental health services or from carers, and/or the obligation on responsible clinicians to consider a CTO.

‘How important are the following factors in discharging a patient completely from a CTO?’

We presented 15 possible reasons for discharging a patient from a CTO and asked clinicians to rate the importance of each one as applied to their practice, again on a five-point Likert scale. As previously, we have ranked these in order of the importance attributed to them based on the mean score given, with 1 signifying the highest level of ascribed importance, as shown in Table 2.

‘Please rate the impact of the following mechanisms in influencing how CTOs work’

Respondents were presented with nine possible mechanisms by which CTOs may affect patient outcome and were asked to rate their importance. The three mechanisms considered most important (represented by the lowest mean) were: ensuring medication adherence for a lengthy period during which other changes can occur (1.95), ensuring a greater period of stability (2.26), and signalling to the patient that they have a serious mental health problem which needs active management (2.28). The same three mechanisms were considered most important in the New Zealand survey. The remaining factors, in order of importance, were: a CTO commits service providers to the person (2.76), gives others the confidence to care for the person (2.79), binds community services in place (2.89), encourages the individual to take responsibility (3.15), mobilises social support for the individual (3.25); and the individual gives up conflict areas to external agents (3.30). Again, these rankings are very similar to those in the New Zealand study.

’In your experience, how important are the following factors in undermining the effectiveness of CTOs?’

Nine possible factors which could potentially act as barriers to the effectiveness of CTOs were rated by respondents. Those considered most undermining (i.e. lowest mean score) were judged to be substance misuse (2.06), lack of supported accommodation for people with challenging behaviours (2.17), and failure to enforce medication adherence (2.45). The same three factors were identified in the New Zealand study. The remaining items, in rank order of the importance attached to them, were: unavailability of some medications in injectable form (2.84); inadequate access to psychological therapies (2.90); lack of trained mental health staff (3.08); inadequate access to recreational opportunities (3.09); premature discharge by courts or tribunals (3.21); and difficulty managing this service user group in rural areas (3.47).

Factors discouraging clinicians from using CTOs

Eight factors which might discourage the use of CTOs were also rated by respondents. No individual factor was considered the most clearly important by respondents as mean ratings (low scores indicating high importance) for the most important three factors were clustered close together: concern for the person’s civil liberties (2.61), the administrative burden (2.62), and the degree of coercion involved (2.81). The remaining items, in rank order, were: preference for the use of in-patient leave (3.20); availability of SOADs (3.20); concern about being held responsible for the individual’s conduct (3.34); cultural politics (3.49); and increased cost to the mental health service (3.82). Again the responses were very similar to those from the New Zealand study.

Factors in the introduction of CTOs to England and Wales

Six possible factors which may have played a role in the introduction of CTOs in England and Wales in 2008 were presented for respondents to rate. In rank order of perceived significance these were:

1. 1 to enforce better community services and follow-up for those at risk

2. 2 a response to public pressure (in respect to acts of violence committed by individuals with mental illness)

3. 3 a result of procedural evolution - moving from Sections 17 and 25 to a more explicit framework for treating those with mental illness in the community

4. 4 to reduce pressure on acute psychiatric beds

5. 5 to reduce coercion by reducing the length of in-patient stay in psychiatric hospitals

6. 6 a result of international research evidence.

Support for the introduction of CTOs in England and Wales

Clinicians were then asked to rate their level of agreement with several general statements regarding CTOs. Statements with a mean score of >3, suggesting overall agreement with them, were (ranked from stronger to weaker support):

1. 1 ‘I feel that CTOs complement existing legislation to provide a greater choice of treatment options for clinicians’

2. 2 ‘The increase in compulsory powers that may result from the introduction of CTOs is appropriate for the potential clinical and social benefit for patients’

3. 3 ‘I supported the introduction of CTOs’

4. 4 ‘There is sufficient clinical guidance for me to feel comfortable placing patients on CTOs’

5. 5 ‘I think the benefits of CTOs can already be seen’.

Those statements with a mean of >3, suggesting overall disagreement, were (ranked from strongest to weakest disagreement):

1. 1 ‘The introduction of CTOs has been a retrograde step for mental health services’

2. 2 ‘Well-resourced voluntary community services could provide the same benefits as CTOs without extending compulsory powers’

3. 3 ‘There is insufficient clinical evidence for me to feel comfortable placing patients on CTOs’

4. 4 ‘I think that in the long term, the use of CTOs will not show any overall benefit’.

Key themes in respondents’ written comments

Written comments by clinicians reflected a wide range of opinion and highlighted differences within the profession regarding the use of community compulsion and attitudes towards it. A number of respondents described CTOs as providing the ‘best possible care’ for certain individuals and being ‘ethically acceptable’, and the potential for CTOs to ‘promote recovery’ was cited more than once. Others expressed strong negative views of CTOs, describing them as ‘a waste of time’, ‘more bureaucratic’ without added benefits, ‘unethical’, or ‘a power of conveyance and little else other than covert persuasion’.

There was astonishing variation when respondents were asked to estimate how many orders they believed would be used each year in England and Wales, with a range from 20 to 300 000. Whereas the estimates at the extreme ends of this continuum probably reflect strong views about CTOs and not serious suggestions regarding levels of use, the most commonly given figure was 2000 per annum, substantially less than that recorded since November 2008.