Are Community Treatment Orders being over-used?

Community treatment orders (CTO) are being handed out to mental health patients at 10 times the rate intended when they were introduced two years ago, new research shows. Dame Jo Williams wants to know why

Community treatment orders are the most recent incarnation of the structures designed to support 'care in the community', and have remained controversial since their introduction in November 2008.

As part of the Care Quality Commission's first annual report on the use of the Mental Health Act, published today, we have carried out a detailed study of how community treatment orders (CTOs) are working.

There are potential causes for concern, including variations in the quality of patient involvement while treatment is being planned, and a lack of understanding by some patients of what is expected of them. There is also a disproportionate number of patients from some black and minority ethnic groups placed on CTOs.

We are looking for a greater understanding of these issues as we continue to monitor how mental health services are using their powers and fulfilling their duties. We inherited this responsibility from the former Mental Health Act Commission.

On average, 367 CTOs have been made each month. This is at least 10 times the number anticipated at the time the legislation was introduced. Interestingly, CTOs do not appear to have reduced hospital-based detention, because we are seeing a rise in the number of detained patients.

CTOs were particularly intended for so-called 'revolving door' patients, who do not comply with their treatment or engage with community mental health services following their discharge. The order allows for them to be recalled if necessary.

We found, in a sample of over 200 patients, that 30% did not have a history of non-compliance or disengagement. This could be one of the reasons for the number of CTOs, and it poses an important question about the basis on which hospitals are making their judgments when applying these orders.

It suggests that 'defensive' practice, increasingly apparent in mental health services driven by concepts of risk rather than just treatment, may lead to CTOs being the default discharge power for detained patients, rather than a measure applied only to those for whom it is really needed.

We are now considering how we can extend CQC's Mental Health Act monitoring function – which is centred on visiting detained patients in hospital – to look across the whole pathway of care, including CTOs. This will help us to link the monitoring more closely with our new wider regulatory framework, which requires all health and adult care services to meet essential standards of quality and safety. Ensuring compliance with the standards is a means of levering improvement.

A theme that runs right through our report is the importance of patients being enabled and encouraged to participate in decisions about their care. Participation means empowerment. It gives the patient some measure of control over what happens to them. It is a basic human right.

We have found that the more patients are actively involved and provided with real choice in the provision of their care, the more that interventions such as the CTO appear to be useful in aiding the process of recovery.

While there are tensions and challenges involved in caring for people who are subject to detention under the Mental Health Act, restrictions on patients should always be applied within the legal framework that protects their rights. At CQC we will always put the interests of patients at the heart of our work.

*Dame Jo Williams is Chair of the Care Quality Commission