Supervised Community Treatment How is it likely to work in practice?

1. Supervised Community Treatment How is it likely to work in practice? Simon Lawton-Smith Mental Health Foundation

2. Overview • The drivers behind SCT • What SCT will allow in England and Wales • International comparisons, including Scotland • Do Community Treatment Orders (CTOs) work? • Summary: how will it work in practice?

3. The 2007 Act - the drivers • 1983 Act out-of-date: general shift from hospital to community services and more people with severe mental health problems cared for in the community • To break the “revolving door” cycle of deterioration in the community and repeated hospital readmissions • Concerns about public safety: Health Minister Paul Boateng (1998) - "non-compliance with agreed treatment programmes is not an option".

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5. Supervised community treatment • Criteria for SCT broadly: ~ the patient has a mental disorder requiring treatment ~ necessary for health and safety of patients or others that treatment given ~ appropriate medical treatment is available and can be provided outside hospital • designed for “a small proportion” of patients following detention in hospital, if there is a risk of a patient’s health deteriorating, or to the patient’s health or safety, or the safety of others • aimed at “revolving door” patients, though can be used after first detention • Department of Health view: a positive alternative to detention in hospital which will help to reduce the risk of social exclusion – should be seen as liberating, not restrictive • Patients cannot be forced to take medication in community – no “injection over the kitchen table” – but may be recalled to hospital for treatment as out-patients

6. What will SCT allow? • Discharge from hospital (but not from the powers of the Act) for patients detained for treatment under s.3 or unrestricted Part 3 patients • Not for patients living in community (unlike eg Scotland), but can follow first compulsory admission for treatment • Patients need treatment but not necessarily in hospital, and are subject to power of recall • Decision taken by the patient’s Responsible Clinician, and requires the agreement of an AMHP – and discussion with patient, family/carers and other professionals. Decision notified to hospital managers. • Decision must assess likely risk of patient’s condition deteriorating and the impact of that

7. Requires a care plan and a care co-ordinator (CPA) • CTO itself can specify conditions (eg patient making themselves available for examination; avoidance of known high-risk behaviour) • In cases of deterioration of health or non-compliance, Responsible Clinician should reconsider the SCT – recall to hospital may be necessary • After recall patient may be detained for treatment for up to 72 hours – remains an SCT patients even if spends one or two nights in hospital • Discharge process similar to discharge from hospital; Responsible Clinician may also discharge a patient at any time – must do so if patient no longer meets SCT criteria Revised Code of Practice to the 1983 Act – with effect from 3 November 2008. Increase from 170 pages to 388 pages!

8. International comparisons • CTOs have been around for many years (up to 20 or so) primarily in Australia, New Zealand, Canada and the United States • Different legislative criteria and systems but common aims – the hard-to-engage patient who is non-compliant with treatment • Often introduced after a high profile homicide – “Kendra’s Law” in New York State, “Brian’s Law” in Ontario • Number of people subject to CTOs varies between jurisdictions: 2 to 60 per 100,000 population • Numbers tend to rise year on year – though not everywhere – Canada quite stable while Australasia rising sharply

9. CTOs: International variations Lawton-Smith S: A Question of Numbers (King’s Fund, 2005)

10. International CTOs: reasons for variationsLawton-Smith S: A Question of Numbers (King’s Fund, 2005) Variations in use of CTOs can depend on, among other things • the scope of each piece of legislation • the attitude of mental health professionals towards compulsory community treatment and their understanding of their powers • the bureaucracy involved in making a community treatment order • the availability (or otherwise) of good community services to support people on CTOs • the number of available in-patient beds and lengths of stay • the overall prevalence of serious mental disorder among the population. As a general rule, the numbers of people placed under compulsory community treatment is small to start with, but builds up year on year - so the longer systems are in place, the larger the number of people subject to them.

11. The Scottish experience Scottish law (unlike the 2007 Act for England and Wales) requires • medical treatment available that is likely to prevent the disorder or relieve some of its symptoms • significant risk to patient or other person if treatment not provided • impaired decision-making about their treatment • authorisation by independent Tribunal Scottish arrangements considered fair for the patient and no “horror stories” – powers being used responsibly Pre-Act estimate of 200 people under CTOs at any one time. In fact, 388 people under CTOs as at October 2007 Geographical variations (high use in Edinburgh and Glasgow – none in the Orkneys) Numbers of people detained in hospital have dropped, so overall level of compulsion broadly similar to before the Scottish Act

12. Scotland: people under CCTOsMWC data – 2007 data provisional: may be underestimate as some people of “indeterminate status”

13. Current community powers SCT not coming out of the blue – in fact, very similar to current powers • Guardianship (s.7 of the 1983 Act) – remains for those with long-term social care / welfare needs • Supervised Discharge (s.25 of 1983 Act) – repealed • Leave of Absence (s.17 of 1983 Act) – only for short-term use (after 7 days SCT must be considered as an alternative) Current use of community powers in England and Wales c. 2,900 people already under guardianship and supervised discharge c. 5,000 people under Assertive Outreach Teams (with history of violence)

14. Do CT0s work? CTOs are intended to • ensure compliance with medication, thereby helping to control or lessen symptoms of serious disorders • reduce incidents of aggression and contact with the criminal justice system; • Keep people out of hospital and reduce (re)admissions to hospital • keep people in better mental and physical health, enabling them to retain social contacts, housing, jobs etc

15. The evidence base Evidence from a number of international studies (often considered methodologically faulty) is inconclusive. • Dawson (2005) – results almost always reveal significant therapeutic benefits; greater compliance with outpatient treatment, especially medication, enhanced social contacts and reduced readmissions. • Cochrane Review (2005) – based on the only two RCTs, both in the USA: compared to control group, no statistically significant differences in engagement with services; readmissions; social functioning; offences resulting in arrest or homelessness. • Institute of Psychiatry, for the Dept of Health (2007) – meta-analysis of all international CTO research. DOH: “it is very difficult to secure reliable evidence in this area, and that as a result there is very little conclusive evidence to demonstrate that SCT is either effective or ineffective”. No evidence that CTOs impact significantly on total number of homicides, but may have an impact in individual cases (Appleby, 2006, suggests 1 in 6 homicides might be prevented)

16. Homicides by people with a mental illness: Canada[CTOs introduced in 1990s]Solved cases where police investigating officer assessed a disorder Homicide Survey, Statistics Canada, Toronto

17. Homicides by people with a mental illness: New Zealand[CTOs introduced in 1992]Simpson et al ANZJP 2006; 40:804-809

18. Homicides by people with a mental illness: Australia [CTOs introduced in 1990s]Australian Institute of Criminology, National Homicide Monitoring Program 1990-2004

19. Summary: how will it work in practice? Depends on a number of variables, eg: • Professionals’ view of ethics and effectiveness / understanding of powers • Public perceptions and media pressure • Availability of appropriate community services to meet care plans • Bed numbers • Bureaucracy – (LOA simpler) • Patient acceptance • Rate of discharge from SCT • Research evidence on effectiveness

20. Future numbers under SCT? Possible numbers of people under SCT: • Few to start with, but growing year on year – maybe 15-20 people per Primary Care Trust in first year • Geographical variations (eg London probably high numbers) • If follows trend in Scotland (8/100,000 pop. after 2 years), then may be c.3,500 - 4,000 people in England and Wales under SCT by end of 2010 • Over 10-15 years may grow to 7,800-13,000 people – or as little used as Supervised Discharge? Impact on other mental health services • Resources – people with less severe problems may miss out

21. To find out more • Code of Practice, chapters 25 (SCT), 28 (Guardianship, LOA or SCT?) and 29 (Detention and SCT: renewal, extension and discharge) ~ Online: www.tsoshop.co.uk - £16.50 • Implementation of the Act – CSIP leading ~ www.csip.org.uk ~ Jim Symington, CSIP National Programme Lead for the Act: jim.symington@londondevelopmentcentre.org