Everything You Want to

Know About Community

Treatment Orders

What is a Community Treatment Order?

A Community Treatment Order (CTO) is an Order imposed on certain categories of psychiatric in-patients at the point when they are discharged from hospital. The Order is designed to ensure that these patients continue with their treatment when they resume living in the community.


What is the point of a Community Treatment Order?

Some patients have to live with long-term mental health conditions that are prone to relapse. Schizophrenia and Bi-polar Disorder are good examples of these types of conditions. Such conditions may, on occasion, require treatment in hospital as an in-patient. Often patients suffering from these conditions, when discharged, are thought to require ongoing treatment in the community in order to reduce the risk of further relapses in the future.

The clinical team may have some doubt about whether the patient will agree to treatment in the community and CTOs are there to ensure that the patient does comply. The theory is that by requiring patients to accept treatment in the community, the clinical team will be able to avoid the need for further hospital admissions in the future.


Who might end up with a CTO?

CTOs can only be imposed on patients who are about to be discharged from hospital having been detained under Section 3 or Sections 37, 47 or 48 of the Mental Health Act 1983. CTOs cannot, therefore, be imposed on:

  • Patients who have been treated in hospital on a voluntary basis
  • Patients who have been detained only for assessment under Section 2 of the Mental Health Act
  • Restricted patients detained under Part III of the Mental Health Act.

The vast majority of CTOs will be imposed on patients who have been detained for treatment under Section 3 or who have been made the subject of a Hospital Order under Section 37 of the Mental Health Act.

CTOs will not be imposed in the case of all Section 3 or Section 37 patients; it is only those who are deemed to meet the relevant criteria (see below).

Note that there is no minimum age for the imposition of a CTO.


How will a patient know whether she/he is to be made the subject of a CTO?

When a patient is approaching the end of his/her stay in hospital and his/her consultant (also known as Responsible Clinician or ‘RC’) is considering discharging the Section or Hospital Order, she/he will then tell a patient whether they are thinking of imposing a CTO. It will not be imposed without the patient’s knowledge, and the patient will be given written notification of the CTO when it is imposed.


When does a CTO begin?

The CTO begins at the point at which the patient is discharged from his/her Section or Hospital Order. A CTO can only be given once the Section or Hospital Order is at an end (it is not technically the end of the Section; the Section is merely suspended, but the effect is largely the same). The two things happen at the same time; the end of the Section or Hospital Order and the start of the CTO.


Who is responsible for imposing the CTO?

The patient’s consultant or Responsible Clinician is the person responsible for making the Order. The CTO can only be imposed, however, if an Approved Mental Health Practitioner (AMHP) agrees, in writing, with the proposed Order. A CTO cannot therefore be made by a RC alone. If the RC and an AHMO agree, they will fill out the appropriate form and send it to the Hospital Managers.


What are the relevant conditions that have to be met before a CTO can be imposed?

The RC and AHMO have to be satisfied that:

  • The patient is suffering from a mental disorder of a nature or to a degree that makes it appropriate for them to receive medical treatment.
  • It is necessary for the patient’s health or safety, or for the protection of others, that the patient should receive such treatment.
  • Subject to being liable to recall, the treatment can be provided in the community.

It is necessary for the RC to have the power to recall the patient to hospital.

Appropriate medical treatment is available.

The Mental Health Act Code of Practice states that the RC "must be satisfied that the risk of harm arising from the patient’s disorder is sufficiently serious to justify the power to recall the patient to hospital for treatment".


Does the patient need to consent to the CTO?

The strict answer to this question is "no", but if the RC/AMHP insists on the CTO and a patient will not consent, it reduces the likelihood of the patient being discharged from hospital. If a patient is unhappy about the proposal to impose a CTO, they should raise their concern with the RC or AMHP. If the CTO is still to be imposed and if the patient remains unhappy, they might want to consider agreeing to the CTO, thereby getting discharge, and then exercising their right to appeal to against the CTO to a Tribunal.


How does a CTO operate?

The CTO will specify conditions, which the patient is made subject to. There are two conditions that are compulsory and which will be attached to every CTO. These are:

  • A condition that, where necessary, the patient makes themselves available for examination by the RC when/if the RC is considering whether to remove the CTO.
  • A condition that, where necessary, the patient makes themselves available for examination by a second opinion doctor (certain types of treatment can only be given with the agreement of the second opinion doctor).

The RC may then impose other conditions, but only if they are NECESSARY or APPROPRIATE to:

  • Ensure the patient receives treatment.
  • Prevents the risk of harm to the patient’s health or safety.
  • Protects other persons.

These discretionary conditions might be, for example, a condition that the patient resides at his home address, agrees to take prescribed medication, or agrees to provide urine samples.


Does the patient have to stick to these conditions?

No, but they may well be in big trouble if they do not. If the patient doesn’t stick to the conditions, the patient runs the risk of recall to hospital. The RC has the power to recall if she/he thinks that the patient needs fresh treatment in hospital, and the RC will take into account compliance with the conditions when deciding whether to exercise that power. Also, breach of either of the two compulsory conditions (see above) gives the RC the power to recall without any further ado.


What if a patient is unhappy with the conditions?

A patient can raise their concerns with the RC, who has the power to vary or suspend the conditions. If the patient receives no joy there, the patient can apply to a Tribunal.


What are the Responsible Clinician’s powers of recall?

The RC can recall the patient if she/he fails to comply with either of the two compulsory conditions, or if the RC is of the opinion:

  • That the patient needs hospital treatment AND
  • There would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled.

The RC therefore has quite a wide discretion about whether to recall, and any decision to recall may well be linked to a breach of a condition. It is important to note that a recall may not necessarily be linked to a breach of condition, and a patient may find themselves being recalled even where they have complied with the conditions attached to the CTO.


What happens when a patient is recalled?

The patient will receive notice of the recall in writing and will need to return to hospital initially for a period of up to 72 hours. During that 72-hour period the RC and the AHMO will decide what they think should happen next. Essentially one of two things will happen: either the CTO will be revoked (brought to an end) or it will be allowed to continue and the patient will resume living in the community. Sometimes a few hours or a day or two in hospital is all that is needed to get things back on an even keel, and CTOs won’t be revoked in these cases; rather, the patient will return home, subject to the CTO, as before.


What happens if the CTO is revoked?

The RC can revoke if she/he thinks that the patient needs to be admitted for treatment and the AMHP agrees. If the RC and AMHP disagree then they will notify the Hospital Managers in writing that the CTO is to be revoked. Technically the original Section or Hospital Order was only suspended and the patient will therefore revert to being a detained patient under either Section 3 or Section 37 (or in some cases, Section 47 or 48).


How long does a CTO last?

Initially, for six months. It can then be renewed for a further six months, and then for a period of twelve months at a time.

The CTO can only be renewed when the RC is satisfied that the criteria that justified the CTO in the first place still exist. The RC must examine the patient before renewing. The RC must obtain the AMHP’s agreement.


How can the CTO be brought to an end?

It can be brought to an end in the following ways:

  • The RC may choose not to renew the CTO when the current period expires.
  • The RC may discharge the patient from the CTO because it is no longer required. This can happen at any point during the CTO.
  • In Section 3 cases (not others) the patient’s nearest relative can discharge them from the CTO (although if they do, the nearest relative must give the Hospital Manager 72 hours' notice, during which time the RC may 'bar' the discharge if they feel the patient, if discharged, would act dangerously to himself/herself or others).
  • In Section 3 cases (not others) the Hospital Managers can discharge the patient from the CTO upon application.
  • In all CTO cases, the CTO will be revoked if the patient is recalled to hospital for more than 72 hours.
  • In all cases the CTO can be brought to an end by the decision of the Tribunal.

What about applying to a Tribunal?

Any patients subject to a CTO can apply to a Tribunal for discharge from the CTO. The patient can apply once during each period of the CTO (during the first six months, the second six months, the next 12 months etc). A patient can also apply for a Tribunal within the first six-month period following the CTOs revocation.


What about referrals to Tribunals?

Whether an application is made to a Tribunal by a patient or not, a Tribunal will automatically sit and consider the cases of CTO patients in the following circumstances:

  • Where the CTO has been revoked and the patient is back in hospital as a detained patient (this is in addition to the patient’s right to apply to a Tribunal).
  • Six months has passed since they were originally detained (on a Section) and there has been no Tribunal in the intervening period.
  • In long-term CTO cases, where three years has elapsed since any Tribunal hearing.

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© 2008 Butler & Co. Solicitors - Mental Health Law and Family Law in Taunton, Somerset.