The introduction of community treatment orders will pose significant challenges to local service providers. Mark Barnett explains

The Mental Health Act 2007 comes into force on 3 November 2008. It introduces supervised community treatment in the form of community treatment orders. Patients subject to an order can be treated in the community for their mental disorder without their consent.

Only patients detained under section 3 or unrestricted part 3 patients are eligible for supervised community treatment. The patient's responsible clinician can place the patient on a community treatment order, with the written agreement of the approved mental health professional, provided the following criteria are met:

  • the patient is suffering from a mental disorder of a nature or degree that makes it appropriate for him to receive medical treatment;

  • that treatment is necessary for his health or safety or for the protection of others;

  • such treatment can be provided without the patient's continuing detention in hospital;

  • the responsible clinician must be able to exercise his power to recall the patient;

  • appropriate medical treatment is available to the patient.

The responsible clinician will need to assess the risk of the patient's condition deteriorating once he is discharged to the community. In doing so, he should be mindful of the patient's history of compliance with medication, attitude to treatment (and the community treatment order itself) and external factors, such as the conditions into which the patient will be discharged.

The importance of planning

The act's code of practice emphasises the importance of good care planning and support in the community. Adequate consultation with the patient will also be essential. While a patient does not have to consent to supervised community treatment, if he does not, the likelihood of its success will be reduced.

The responsible clinician and approved mental health professional will also have to consider which conditions to attach to the treatment order. There are two mandatory conditions, these being that the patient must make themselves available for assessment either when needed for consideration of extending the order, or to enable a second opinion appointed doctor to provide authorisation for compulsory treatment.

There is otherwise no prescriptive list of what such conditions might be, but they should only be attached if they are "necessary or appropriate" to ensure the patient receives medical treatment, to prevent the risk of harm to the patient's health and safety, or to protect other people.

The teeth of the community treatment order are in the threat of recall or revocation. At any time while the patient is on an order, the responsible clinician can recall him for a period of up to 72 hours. He can do this if, in his opinion, the patient needs treatment in hospital and there is a risk of harm to the patient or others, notwithstanding compliance with any conditions. Beyond that, the responsible clinician should consider revoking the order altogether, meaning the patient would revert to detained status under the act. Clearly, this has implications for the availability of beds for patients who are recalled from their community treatment order.

Radical change

In introducing these orders, the act appears to make some radical changes. However, whether patients on the orders will see the benefit and achieve earlier discharge remains to be seen. A Department of Health report in 2007 decided that due to a lack of reliable evidence it was still not possible to conclude whether community treatment orders would be beneficial or harmful.

There seems little doubt, however, that these orders will present significant challenges to mental health service providers in monitoring and managing service users who are on them, placing yet more pressure on community resources. A King's Fund report in September 2005 estimated that over a period of 10 to 15 years, the number of patients subject to a community treatment order could be between 7,800 and 13,000.

Detailed care planning will be necessary and any conditions attached to the treatment order will need to be kept under regular review, in particular if the patient's circumstances change. Improvements in the patient's mental health should arguably lead to the suspension of one or more of the conditions, in particular if the trust is to avoid accusations that it is inappropriately restricting the patient's liberty.

While the threat of recall or revocation of the order will in many cases ensure compliance, there will inevitably be patients who will be recalled to hospital. In practice, a patient should not be recalled unless it is known that there is a bed available, although they can be recalled for outpatient treatment. The suitability of this will depend on the reason for recall, as it is questionable whether recalling for outpatient treatment would be appropriate where the patient represented a risk to himself or others.

While patients can be recalled to any hospital and not just the hospital to which they were originally detained, this is bound to place additional pressures on bed management.