Community Treatment Orders - Complex Journeys (CTOs)

This research explored the social care and environmental factors associated with the discharge and renewal of a Community Treatment Order (CTO) and recall to hospital.

The published findings included the report, Stroud, Julia, Haynes, Philip (2018) Social Factors, Care and Community Treatment Orders : Service User and Practitioner Perspectives. This formed part of a research trajectory that examined Community Treatment Orders over a period from 2013-2022.

The research for the 2018 report was funded by National Institute for Health Research, School for Social Care Research (Ref.C088/T15-011/UBJS-P84) in collaboration with Sussex Partnership NHS Foundation Trust. It aimed to:
> Identify and understand the factors, particularly the social care and social environmental factors, associated with the discharge or renewal of a CTO and with recall to hospital.
> Identify the social interventions and support provided and to explore whether these were experienced as helpful by service users, in order to inform good practice.
> Explore and understand whether relationships (personal and professional) or loneliness were influential in CTOs being renewed or discharged, or there being a recall to hospital.

Background

At the time of the study, concerns over mental health had focused on trauma, depression, anxiety and the mental health of young people. However, earlier concerns had been with the risk management of people with severe mental illness and Community Treatment Orders, introduced in 2008 by the Mental Health Act 2007, were of central, strategic importance to address these issues.

Community Treatment Orders enabled service users to be discharged and treated in the community, specifying conditions and include a power of recall to hospital. 

Six peer researchers from the CAPITAL Project Trust and the Lived Experience Advisory Forum (LEAF) of Sussex Partnership Trust were involved in the 2016-18 study, developing the survey questionnaire, interview questions and reviewing data analysis. The peer researchers also led the development of a film about the project. The study benefitted from a Project Advisory Group who advised throughout and consisted of members of the Peer Researchers Group, the researchers and all relevant professional practitioners. Ethical and governance approvals were gained from the Health Research Authority, the University, the Trust and other relevant organisations. 

Service users and practitioners both considered CTOs to be concerned with compliance, but social factors were taken into account as providing evidence for and against renewal, recall and discharge decisions.

Service users were negative about medication because of side effects. Views were paradoxical, however, and some reported developing ‘maturity’ towards medication.

Service users were generally pragmatic about CTOs, seeing them as a way out of hospital: for some they offered stability, supportive relationships and wide ranging social activities. Loneliness was minimally reported by those interviewed.

Both care coordinators and service users reported positive and supportive relationships which had developed in the context of CTOs. These can be seen as an important social intervention which may not have developed but for the CTO: they appear an essential component of making a CTO work well.

In terms of resources, practitioners expressed concern about bed availability for recalls and reducing community resources generally. Some felt CTOs could be made to ‘free up’ beds.

In terms of practice, service users felt that more time was needed talking about medication and they also reported that they were often not well engaged with the formalities surrounding CTOs (e.g. care planning, reviews, Tribunals).
Recruitment of service users to the study was challenging and possibly only the more positive became participants.

Conclusions

Community Treatment Orders
 
Service users on CTOs form a discrete group with defined characteristics and have great need of supportive services. Data from this study supported the suggestion that CTOs can offer an important care option between detention and treatment in hospital and voluntary treatment in the community. Use of CTOs was high, and renewals and revocations correspondingly so. Greater understanding of the reasons for these proved important. It was also important to debate whether recall to hospital should define whether a CTO is successful or not. Notwithstanding this, intensive community resources and support were needed. Processes and responsibilities for recall and the availability of psychiatric beds required review.

The importance of the working relationship between the service user and care coordinator

Data from service users and practitioners provided strong evidence that the working relationship between the Care Coordinator (and mental health team) and a service user was of key importance. This engagement can be understood as an important social intervention, providing support and militating against isolation. The stability which emerged for the service user provided a platform from which to access social activities and recovery. In an environment where the forms and processes in social care often predominate, this relationship can be understood as a key message for mental health care.

Social environment and activities

Practitioners described considerable efforts to support service users and engage them in social activities; service users also described wide ranging activities, many of which they had organised themselves. While compliance with medication and risk remained a dominant discourse for both practitioners and service users in relation to CTOs, social factors were found to be influences in decision making, providing evidence for and against discharge, renewal and recall.

Attitudes to medication

Service users were pragmatic about CTOs but were negative about medication; however, paradoxical views were expressed, with attitudes toward medication changing. It was as though service users were describing a journey (‘I don’t know whether it is a case of medication or my maturity through the illness’). Service users wanted more opportunities to discuss medication, the CTO and also more attention needs to be paid in practice to their involvement in the formal processes associated with the CTO (care planning, reviews and tribunals).