Community treatment orders (CTOs) – where service-users are forced to take medication, but do not have to be detained in hospital – were introduced in 2008 through Labour’s Mental Health Act.
The introduction of CTOs came despite concerted opposition from service-users, and mental health and other disability organisations, and their use has far exceeded predictions.
The Department of Health expected the use of CTOs to build up gradually over five years, so that by 2013 around 3,000-4,000 people would be on CTOs at any one time.
But the Health and Social Care Information Centre has reported that, on 31 March 2013, there were 5,218 people subject to a CTO, an increase of 454 (10 per cent) on the previous year.
There were 4,647 CTOs made during 2012-13, an increase of 427 (10 per cent) on the previous year.
And rather than helping people avoid compulsory detention, there has been a steady increase in the number of mental health service-users being detained under the Mental Health Act in hospital.
In 2008-09, there were 27,946 detentions during the year, but by 2012-13 this had risen to 32,224.
CTOs can force a patient – many of whom have diagnoses of schizophrenia or bipolar disorder – to take certain drugs, attend regular assessments, or live at a particular address, with their clinician having the power to recall them to hospital for up to 72 hours without a formal readmission.
Now disabled campaigners are saying it is time to scrap CTOs.
Liz Sayce, chief executive of Disability Rights UK, said: “When the last government brought in community treatment orders, the theory was that they would be applied to a few hundred people a year and less people would be compulsorily detained because they would just be able to live in their own homes.
“The theory was that this should be in the interests of liberty because slightly fewer people would be detained in hospital.”
But research by academics led by Professor Tom Burns, head of social psychiatry at Oxford University, suggests that CTOs do not alter the likelihood of patients being hospitalised again, but do have a negative impact on service-users’ human rights.
They compared CTOs with old-style section 17 leave, which gave a patient a period of leave from an inpatient unit, followed by discharge and voluntary treatment if that went well.
The only thing that differed between the two groups was that those on CTOs received compulsory treatment for an average of about six months, compared with an average of just over one week for the section 17 group.
Professor Burns said last year: “The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms. Their current high usage should be urgently reviewed.”
His conclusion was particularly significant because he had previously been a cheerleader for CTOs, and even advised the government on their introduction.
He said that he and his colleagues had been “a bit stunned” by their results, as he had supported their introduction for about 20 years, but admitted that “the evidence is staring us in the face that CTOs don’t work”.
The Department of Health said last year that it would “consider the implications of this report carefully”.
And the Commons health select committee called on ministers to review the current operation of CTOs, and said it was “struck that the evidence base for this policy remains sparse”.
Sayce said: “It seems to me that in the light of that research evidence [by Professor Burns] and his statement and the fact that the numbers are not what were predicted, that actually the government has some serious questions to answer. It’s time for CTOs to be got rid of.”
Denise McKenna, a member of the Mental Health Resistance Network (MHRN), said she and her fellow activists were “totally opposed to any form of forced treatment”.
She pointed to the case of Jean Cozens, who killed herself on Christmas Day 2012 while she was on a CTO because she felt it was ruining her life.
In a video she had posted online just a fortnight before she died, she said: “Being on a CTO is a form of slavery.”
Cozens, an MHRN founder member, said she felt the treatment she received as a result of the CTO was “humiliating”, “horrible” and “disgusting”.
She was placed on the CTO, she said, because she was a “revolving door” patient who had had several admissions to hospital, but the anti-psychotic drug “never made me feel better. It’s always made me feel worse.”
Sayce said the UK government could find that – when it is examined next year by a UN committee – mental health law in England does not fully comply with the UN Convention on the Rights of Persons with Disabilities.
Sayce said there was also a need for a reform of mental capacity law, currently covered by the Mental Capacity Act.
She called for both acts to be replaced by a new, joint piece of legislation, that “is fair and treats people with respect and enables people to have choice whenever they are able to”, and takes “a very different approach to risk assessment”.
She said: “I think we have become incredibly risk-averse in society and certainly in services. That creates a culture in which people use coercion rather than take what seems like a risk.
“Usually in society you are subject to loss of liberty when you have committed a crime, not because you might commit a crime in the future.”
The Department of Health is currently consulting on changes to the Mental Health Act’s code of practice, and says it has proposed changes to the chapter on CTOs in the light of the research by Professor Burns.
The consultation document says the chapter on CTOs has been revised to “take account of experience of, and research into, the use of CTOs since their introduction in 2008” and now emphasises the need for the responsible clinician to “consider carefully the appropriateness of a CTO for the individual”.
A Department of Health spokeswoman said: “Community Treatment Orders (CTOs) can help people with mental health problems live safely in the community and professionals make decisions to use them based on a person’s individual needs.
“We regularly review their use and are currently proposing changes, such as a greater emphasis on alternatives to CTOs, as part of a wider review of the Mental Health Act Code of Practice.”
But these changes simply direct healthcare professionals to existing guidance on alternatives to CTOs (section 29.4 of the new draft code of practice), and explain the circumstances in which a patient should be discharged from a CTO (section 29.72 of the new draft code).
DNS has tried repeatedly – and unsuccessfully – to clarify with DH whether it wants healthcare professionals to use fewer CTOs.
6 August 2014