Can you Critically evaluate the current legal framework relating to Community Treatment
Orders (CTOs) and analyse the impact on patient health outcomes for patients in England
and Wales. Please draw up evidence from all countries in the world with CTO or similar
provision and suggest how health outcomes could be developed in England and Wales.
The current legal framework relating to Community Treatment Orders (CTOs) in England
and Wales
The impact of the current legal framework relating to Community Treatment Orders
(CTOs) on patient health outcomes for patients in England and Wales

Review of health outcomes of people receiving CTOs
If CTOs were effective and were used effectively, they might lead to an
overall reduction in requirement for in-patient treatment and a decline
in the number of patients detained on treatment sections.10 Two older
American randomised controlled studies (RCTs) of similar measures
failed to find clinical benefits, but it has been argued that they had
significant methodological drawbacks, for example, in that they excluded
high-risk patients.11,12 Subsequent American studies have claimed to
demonstrate benefits, especially when considered as part of a wider
public health system involving the criminal justice system.7 Given the
difference in psychiatric service provision, these studies may have
limited applicability to the UK. The OCTET study, a RCT which was
carried out soon after the introduction of CTOs, did not find clinical
benefits.13 However, this study has been criticised as having significant
methodological problems, such as again excluding high-risk patients and
the fact that the CTOs were only used for a brief period of
time.14,15 Small naturalistic UK clinical studies using before and after
methodologies have reported positive outcomes.16–18 Swartz and
Swanson (2015)15 suggested that RCTs may not be the best way to
study these complex tools, and that larger, naturalistic studies may be
more appropriate. A Care Quality Commission (CQC) 2009/10 report
claimed that a third of CTO patients in England did not have a reported
history of non-adherence or disengagement.19
There were two motivations for introducing CTOs in
England and Wales2: to reduce ‘revolving door’ admissions
associated with non-adherence with care by a small
group of patients, and to allow treatment in the least
restrictive setting, in accordance with the Human Rights
Act (1988). While it was originally envisaged that around
10% of eligible patients would be placed on CTOs, the
figure is currently closer to 30%.3 Since more CTOs are
issued than are ended each year, the number of patients
subject to CTOs has increased over time. Almost five thousand
CTOs were issued in 2016–2017, with use varying
between demographic groups: rates of CTO use for males
(11.4 per 100 000 population) were almost twice the rate
for females (6.6 per 100 000 population), and the rate for
black and black British people (60.1 per 100 000 population)
was almost nine times the rate for those of white
ethnicity (6.8 per 100 000 population).4 Use also varies
between National Health Service (NHS) (provider)
Trusts.5 6

Review of best practice evidence for provision of CTOs: national and international
evidence
Initially current CTO provision and England and Wales will be reviewed with history of
development of law related to CTO provision.
Secondly, health outcomes for people receiving CTOs will be reviewed. Such health outcomes
include adherence to long-acting antipsychotic injections (LAIs), emergency visits,
hospitalisations, duration of hospitalisations, crimes and/or police involvement, compliance to
treatment.
Furthermore, association between level of Coercive elements of CTOs and health outcomes will
also be investigated.
Thirdly, best practice evidence will be reviewed in England Wales.
Finally, I will gather best practice evidence available from international countries applicable to
CTO provision. There are currently, key gaps in the knowledge of CTO provision.
Community Treatment Orders have been in Scotland since 2005, but were availed in England
and Wales in 2008.
Community treatment orders (CTOs) have been available in Scotland
since 2005 and in England and Wales since 2008. The provision of
powers to compel in the community was controversial within the
healthcare and legal professions, among those who use services and
among organisations working on their behalf. Indeed, an alliance was
formed in 2008 in England and Wales of 32 different organisations from
all these stakeholder groups to express concern regarding the proposed
introduction.1 In Scotland a CTO can be commenced in the community,
whereas in England and Wales it can only be made when a patient is
discharged from involuntary treatment in hospital. The most common
discretionary conditions written into the orders are to take medication
and to see clinical team members, although powers are potentially wider.
In England and Wales the CTO is initiated by the clinician. This is entirely
discretionary and there are no situations in which one must be used. In
Scotland the decision to grant a CTO rests with the mental health
tribunal, on the advice of clinicians and mental health officers. This
allows considerable scope for variation in practice. Defferent factors
influencing the variable use of CTOs have been proposed by
Dawson,2 including:




the legal structure of the CTO regime
the community mental health services available
the clinician's and practitioner's views about the possible impact of
coercion on their relationships with patients
the expectations of third parties.
Attitudes of psychiatrists in England and Wales were surveyed by
Crawford et al3 in 2000, when 45% of the 1171 respondents were in
favour of a system allowing CTOs. In our survey of psychiatrists in
England and Wales shortly after the introduction of CTOs this proportion
had risen to 60%.4
Since their introduction in England and Wales, CTOs have been used
extensively. The Care Quality Commission reported that 18 942 CTOs
had been used in England and Wales by 31 March 2013 and on that date
5218 patients were on a CTO.5 The overall number of patients subject to
a CTO shows a year on year increase of 10%.5 The only randomised
controlled study of the effectiveness of CTOs1 included 333 participants
and demonstrated no difference between those subject to a CTO and
those not over a 12-month period across a wide range of outcomes. The
study has proved to be controversial and engendered a number of
critical commentaries.6
In Scotland, where CTOs have been available for longer, their use has
also increased, to the extent that in 2013–2014 they accounted for 41%
of the total number of compulsory treatment orders, reflecting a
significant drop in the number of hospital-based orders (the remaining
59% of all compulsory treatment orders) and consequently, a continued
shift to the community for people subject to compulsion.7 Given these
trends, we decided to compare and contrast the views of psychiatrists
north and south of the border.