In this commentary, a critical analysis and evaluation of the influence of Community Treatment Order (CTO) as a policy and legislation on individuals with mental health is demonstrated.
In accordance with the Nursing and Midwifery Council (NMC, 2018) code of confidentiality, the name of my patient has been pseudonymised, hence the name Mr Edward Band was adopted.
Mr. Band is a 53 year old white Caucasian who has a long history of substance abuse from age 13 and thus, diagnosed with paranoid schizophrenia (ICD 10, v 2016). Mr Band was previously sectioned on section 3 of the Mental Health Act (1983) as amended in 2007, but following his discharge meeting at the inpatient unit, his Responsible Clinician (RC) and an Approved Mental Health Professional (AMHP) from the local authority strongly believed that Mr Band has a history (according to Mr Band’s case note) and still poses a strong risk of non-compliance with medication and non-engagement with mental health services, therefore they decided to discharge him on a Community Treatment Order (CTO) in order to support him with medication compliance and engagement with the services. This is an accordance with rules and standards of the Trust’s policy and the requirements of the Mental health Act (1983) CTO regulations.
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Community Treatment Order (CTO) is a legislation under the (Mental Health Act, 1983) as well as policy and it is an order that allows suitable patients to be safely treated in the community rather than under detention in hospital whilst providing a way to help prevent relapse and any harm to the patient or others (Placement Hospital, 2016). Suitable or eligible patients under this act are patients currently subjects to section 3 or section 37 of the (Mental Health Act, 1983) however, these patients must be deemed to be at risk of non-compliance with medication and non-engagement with the mental health services (Weich et al. 2018).
In my placement area CTO was designed to ensure that the statutory requirements in respect of the (Mental Health Act, 1983) were adhered to as well as following the guiding principles as specified in the statute (Code of Practice: Mental Health Act 1983). (Placement Hospital, 2016).
On his first contact with the Community Mental Health Treatment Team (CMHT) an Initial Assessment was done in accordance with the Trust policy on admissions and treatment of patients in the community (Placement Hospital, 2016). In order to meet Mr Band’s needs at CMHT, a comprehensive and systematic assessment of his physical, psychological and social needs was formulated and documented in partnership with Mr Band and his family. This has satisfactorily followed the requirements of the Nursing and Midwifery Council (NMC, 2019) code of conduct and also the values and principles of patient centred care as specified in care Act 2014 (department of Health and Social care, 2018). To also ensure that Mr band will receive high quality an individualised assessment of his needs and choices was put in place through a process known as Care Programme Approach (CPA) as stated in (Department of Health, 2008). His CPA has addressed the issues as regards to his risk management, crisis and contingency plans were put in place to effectively support Mr Band should a deterioration of physical and mental health occurs.
However, as CTO was introduced in 2008 through the Mental Health Act (2007) as part of a wide-ranging reform of mental health law, there have been rising concerns about their use both on evidential and ethical grounds (Vergunst,F. et al. 2017). Even though CTO’s were designed to deliver less restrictive alternative in the community, manage risks and to prevent relapse as against being detained in the hospital, (Campbell et al. 2019) has argued that it sometimes compromises the rights of service users and also always putting professionals in an ethical dilemma and yet failed to deliver the desired benefit or outcome. In addition, (Light, 2014) argued that CTO has damaged the therapeutic relationship that has existed between patients and healthcare professionals as patients see it as coerciveness. (Gupta, et al. 2018) suggested that a conflict of interest exists between the principles of respecting autonomy and of the power to coerce patients, and, the principles of least restrictive practice and of the imposition on liberty.
The Care Quality Commission (2015) report urged healthcare providers to always provide an adequate care plan for all patients on CTO as its success and effectiveness is dependent on the care plan in place for that individual. A meta analytical review conducted by (DeRidder et al. 2016) stated that the most important factors that have undermined the effectiveness of CTO’s were lack of adequate supported accommodation and the failure to enforce adherence and compliance in the community.
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CTO’s were deemed ‘ineffective’ by some professionals especially when they are faced with non-compliance according to (Franklin et al. 2000) as cited in (The Kings Fund, 2008) as the Act did not give powers to the Responsible Clinicians (RC) to treat a patient without his consent but the act allows for a possible recall to hospital should your Responsible Clinician (RC) in conjunction with an Approved Mental Health Professional (AMHP) agree that the patient has deteriorated in mental state and hence poses a risk to self or others. The statute (Community treatment Order 2007).
Despite some research evidence and reviews that CTO does not reduce ‘revolving door patients’ or hospital re-admission for example, a randomised control study by Oxford Community treatment Order trial (Burns et al, 2013). However, in their meta analytical study (Bardell-Williams et al, 2019) it was found that CTO’s have significantly reduced hospital re-admissions, length of inpatient stay and also increased the frequency of mental health service engagement by patients especially patients with schizophrenia. However, having studied and also followed events in Mr Band’s care in my placement area, the benefits of being on CTO could be clearly observed and this was also confirmed in a positive feedback form returned by Mr Band which stated that he was overall satisfied with the services from CMHT.
- Bardell-Williams, M. et al. (2019) ‘Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis’, International Journal of Law and Psychiatry, 62, pp. 85–89. doi: 10.1016/j.ijlp.2018.11.007.
- Burns, T. et al. (2013) 'Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial', The Lancet, 381(9878), pp. 1627-1633. doi: 10.1016/S0140-6736(13)60107-5.
- Care Act 2014, c23. Available at: https://www.legislation.gov.uk/ukpga/2014/23/section/25. (Accessed: 20 July 2019).
- Care Quality Commission (2017) Mental health Act: A focus on restrictive intervention reduction programmes in inpatient mental health services. Available at: https://www.cqc.org.uk/sites/default/.../201701207b_restrictivepractice_resource.pdf (Accessed: 16 July 2019).
- Campbell, J. et al. (2019) ‘Community treatment orders and mental health social work: Issues for policy and practice in the UK and Ireland’, International Journal of Law and Psychiatry, 64, pp. 230–237. doi: 10.1016/j.ijlp.2019.04.003.
- Care Quality Commission (2015) Monitoring the Mental Health Act in 2014/15. Available at: https://www.cqc.org.uk/sites/default/files/20161122_mhareport1516_web.pdf (Accessed: 14 July 2019).
- Department of Health (2008) Refocusing the care programme approach: Policy and Positive Guidance. Available at: https://webarchive.nationalarchives.gov.uk/.../http:/www.dh.../dh_083649.pdf. (Accessed: 16 July 2019).
- Department of Health and Social care (2018) Care and support statutory guidance. Available at: https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance. (Accessed: 22 July 2019).
- DeRidder, R. et al. (2016) Community treatment orders in the UK 5 years on: A repeat national survey of psychiatrists. BJPsych Bulletin, 40(3), 119-123. doi:10.1192/pb.bp.115.050773.
- Gupta, S. et al. (2018) ‘Community treatment orders in England: Review of usage from national data’, BJPsych bulletin, 42(3), 119–122. doi:10.1192.
- International Classification of Diseases (2016) Schizophrenia, schizotypal and delusional disorders (F20-F29). Available at: https://icd.who.int/browse10/2016/en#/F20-F29 (Accessed 14 Jul. 2019).
- Light, E. (2014) The epistemic challenges of CTOs: Commentary on … Community treatment orders. The Psychiatric Bulletin, 38(1), 6-8. doi:10.1192/pb.bp.113.045732.
- Mental Health Act (1983) Code of Practice. Available at: https://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983. (Accessed: 14 July 2019).
- Mental health Act 2007, c.12. Available at: http://www.legislation.gov.uk/ukpga/2007/12/part/1/chapter/4. (Accessed: 17 July 2019).
- Mental Health Act 1983, c.20. Available at: https://www.legislation.gov.uk/ukpga/1983/20/section/3 (Accessed: 14 July 2019).
- National Institute for Health and Care Excellence (NICE, 2018)Psychosis and schizophrenia in adults: prevention and management. Available at: https://www.nice.org.uk/guidance/cg178. (Accessed: 16 July 2019).
- Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurse, midwives and nursing associates. London: Nursing and Midwifery Council.
- (Placement Hospital) (2016) (Placement Hospital) MHA: Community Treatment orders Policy. Hertfordshire: (Placement Hospital).
- Rugkåsa, J. et al. (2014) ‘CTOs: what is the state of the evidence?’ Social Psychiatry and Psychiatric Epidemiology, 49(12), pp.1861-1871.
- The Kings Fund (2008) Briefing: Supervised community treatment. (SCT). Available at: https://www.kingsfund.org.uk/.../briefing-mental-health-act-2007-simon-lawton-smith. (Accessed: 16 July 2019).
- Weich, S. et al. (2018) ‘Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study’. BMJ Open, 8(10), p.e024193.
- Vergunst, F. et al. (2017) ‘Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study’, Social Psychiatry And Psychiatric Epidemiology, 52(11), pp. 1375–1384. doi: 10.1007/s00127-017-1442-5.
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