Supervised Community Treatment Order - Prof RNC Mohan

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  • A very comprehensive presentation, which is, I would say, a trademark of Prof Mohan's talks and lectures.
    I am finding it immensely helpful for a CTO audit presentation I will be doing.
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Supervised Community Treatment Order - Prof RNC Mohan

  1. 1. Supervised CommunitySupervised Community Treatment-Ground RealitiesTreatment-Ground Realities Prof.R.N.C.MohanProf.R.N.C.Mohan Consultant Psychiatrist and AssociateConsultant Psychiatrist and Associate Medical Director and Director of ClinicalMedical Director and Director of Clinical Effectiveness and Governance , BirminghamEffectiveness and Governance , Birmingham and Solihull Mental Health Foundation Trustand Solihull Mental Health Foundation Trust
  2. 2. Prior legal mechanisms in EnglandPrior legal mechanisms in England for compulsory CMH cfor compulsory CMH careare  Civil patients:Civil patients:  •• GuardianshipGuardianship  •• LeaveLeave  •• Supervised dischargeSupervised discharge  Forensic patients:Forensic patients:  •• Conditional dischargeConditional discharge  •• Treatment as a condition of bail, probationTreatment as a condition of bail, probation  or parole from prisonor parole from prison
  3. 3. SCT modelled on CDSCT modelled on CD  5 Differences5 Differences  Recall/revocationRecall/revocation  Conditions and MHT (CD not CTO)Conditions and MHT (CD not CTO)  MHT and its powers (CD not CTO)MHT and its powers (CD not CTO)  In conditional discharge there is no Part 4 or Part 4AIn conditional discharge there is no Part 4 or Part 4A  Nearest relative power of discharge! (CTO not CD)Nearest relative power of discharge! (CTO not CD)
  4. 4. Community Treatment PowersCommunity Treatment Powers (section 17A –G)(section 17A –G)  •• a duty on patient to accept communitya duty on patient to accept community treatmenttreatment  •• power of swift recall to hospital care, withoutpower of swift recall to hospital care, without re-certificationre-certification  •• police assistance available in that processpolice assistance available in that process  •• treatment without consent in a hospital ortreatment without consent in a hospital or clinicclinic  •• no ‘forced medication’ in the communityno ‘forced medication’ in the community
  5. 5. CTO’s in EnglandCTO’s in England Very high uptake! (?reaching an equilibrium)Very high uptake! (?reaching an equilibrium) Estimated 7000 CTO’s since 3Estimated 7000 CTO’s since 3rdrd Nov 2008Nov 2008 and about 5000 currently on CTO’sand about 5000 currently on CTO’s SOAD system has ground to a halt!!SOAD system has ground to a halt!! Tribunals under severe pressure!Tribunals under severe pressure!
  6. 6. SCT -PracticeSCT -Practice
  7. 7. Supervised Community TreatmentSupervised Community Treatment Orders (1)Orders (1) S17A(1): “The RC (initially a hospital clinician) may by order inS17A(1): “The RC (initially a hospital clinician) may by order in writing discharge a detained P from hospital subject to his beingwriting discharge a detained P from hospital subject to his being liable to recall in accordance with S17E”liable to recall in accordance with S17E” Available for patients on section 3 or unrestricted 37 (S17A(2))Available for patients on section 3 or unrestricted 37 (S17A(2)) S17A(4): Community Treatment Order (CTO) cannot be made byS17A(4): Community Treatment Order (CTO) cannot be made by RC unless:RC unless: 1) in his opinion “relevant criteria” are met AND1) in his opinion “relevant criteria” are met AND 2) AMHP states2) AMHP states in writingin writing that he agrees with RC’sthat he agrees with RC’s opinion and that it is appropriate to make orderopinion and that it is appropriate to make order Nearest relative cannot object to the CTO! But they can exerciseNearest relative cannot object to the CTO! But they can exercise their power to dischargetheir power to discharge
  8. 8. Supervised Community TreatmentSupervised Community Treatment Orders (2)Orders (2)  ““Relevant criteria” are (s17A(5)):Relevant criteria” are (s17A(5)): (a)(a) the patient is suffering from mental disorder of athe patient is suffering from mental disorder of a nature or degree which makes it appropriate for himnature or degree which makes it appropriate for him to receive medical treatment;to receive medical treatment; (b)(b) it is necessary for his health or safety or for theit is necessary for his health or safety or for the protection of other persons that he should receiveprotection of other persons that he should receive such treatment;such treatment; (c)(c) subject to his being liable to be recalled.. suchsubject to his being liable to be recalled.. such treatment can be provided without his continuing totreatment can be provided without his continuing to be detained in hospital;be detained in hospital; (d)(d) it isit is necessarynecessary that the responsible clinician shouldthat the responsible clinician should be able to exercise the power … to recall the patientbe able to exercise the power … to recall the patient to hospital;to hospital; (e)(e) appropriate medical treatment is available for himappropriate medical treatment is available for him
  9. 9. It is “necessary”…It is “necessary”…  No legal requirement for their to be “objectiveNo legal requirement for their to be “objective evidence” of poor compliance with medication/evidence” of poor compliance with medication/ past history of relapse or multiple admissionspast history of relapse or multiple admissions  CQC report 2010-evidence of its use asCQC report 2010-evidence of its use as preventive!! Early use!preventive!! Early use!  But likely to be challenged at tribunal hearingsBut likely to be challenged at tribunal hearings  May even be judicially interpreted!May even be judicially interpreted!
  10. 10. COP Chapter 25.13COP Chapter 25.13  The primary obligation on clinicians is to RX Patients inThe primary obligation on clinicians is to RX Patients in the least restrictive way possible and that although CTOsthe least restrictive way possible and that although CTOs are less “restrictive” than compulsory admission toare less “restrictive” than compulsory admission to hospital they nevertheless do restrict the individual’shospital they nevertheless do restrict the individual’s liberty and should only be used where “necessary”.liberty and should only be used where “necessary”.  Necessary is distinguished from desirable and theNecessary is distinguished from desirable and the necessity is related to risk.necessity is related to risk.  The code states that a risk of deterioration does notThe code states that a risk of deterioration does not necessarily mean CTO is required: “The RC must benecessarily mean CTO is required: “The RC must be satisfied that the risk of harm arising from the patient’ssatisfied that the risk of harm arising from the patient’s disorder is sufficiently serious to justify the power ofdisorder is sufficiently serious to justify the power of recall the patient to hospital for RX”recall the patient to hospital for RX”
  11. 11. Examples when CTO’s have beenExamples when CTO’s have been discharged by the First tier Tribunaldischarged by the First tier Tribunal  Primarily because it was considered notPrimarily because it was considered not “necessary” that the RC has the power of recall“necessary” that the RC has the power of recall  A woman with a history of depression, divorced livingA woman with a history of depression, divorced living with 3 teenage children. She is ordinarily compliant andwith 3 teenage children. She is ordinarily compliant and engages well but when unwell she isolates and stopsengages well but when unwell she isolates and stops medication. She has had 3 admissions in the last 11yrs.medication. She has had 3 admissions in the last 11yrs. It was considered by the Tribunal that if monitoredIt was considered by the Tribunal that if monitored regularly any changes could be detected and she couldregularly any changes could be detected and she could be treated before she became too unwell to accept RXbe treated before she became too unwell to accept RX
  12. 12. Examples when CTO’s have beenExamples when CTO’s have been discharged by the First tier Tribunal ordischarged by the First tier Tribunal or RC’sRC’s  Primarily because it was considered notPrimarily because it was considered not “necessary” that the RC has the power of“necessary” that the RC has the power of recallrecall  A young woman on a first admission for aA young woman on a first admission for a psychotic illness. She is ambivalent aboutpsychotic illness. She is ambivalent about the diagnosis and RX but yet to show anythe diagnosis and RX but yet to show any pattern of non compliance.pattern of non compliance.
  13. 13. Examples when CTO’s have beenExamples when CTO’s have been discharged by the First tier Tribunal ordischarged by the First tier Tribunal or RC’sRC’s  Primarily because it was considered notPrimarily because it was considered not “necessary” that the RC has the power of recall“necessary” that the RC has the power of recall  Case scenario when relapse is not consideredCase scenario when relapse is not considered likely in the foreseeable future, for example alikely in the foreseeable future, for example a patients with bipolar illness with a cyclical historypatients with bipolar illness with a cyclical history who usually deteriorates at Christmas butwho usually deteriorates at Christmas but appeals against the CTO in Aprilappeals against the CTO in April
  14. 14. Supervised Community TreatmentSupervised Community Treatment Orders (5)Orders (5)  Effect of CTOEffect of CTO S3 suspended so authority will not expire (S17D(4))S3 suspended so authority will not expire (S17D(4)) P is not “detained” or “liable to be detainedP is not “detained” or “liable to be detained S20 will not applyS20 will not apply  RC must before granting S17 leave for more than 7 consecutiveRC must before granting S17 leave for more than 7 consecutive daysdays considerconsider making S17A ordermaking S17A order  Complexity and formal requirements of CTOs includingComplexity and formal requirements of CTOs including treatment provisions may incline RCs towards continued usetreatment provisions may incline RCs towards continued use of S17 leaveof S17 leave  The two alternatives are intended to distinguish between Ps whoseThe two alternatives are intended to distinguish between Ps whose management is hospital based and those whose management ismanagement is hospital based and those whose management is largely community based (explanatory notes para 108)largely community based (explanatory notes para 108)
  15. 15. 2 mandatory Conditions2 mandatory Conditions  Must make himself available for extensionsMust make himself available for extensions  Must make himself available for consent to RXMust make himself available for consent to RX purposes??? Can SOAD go to patient’s home??purposes??? Can SOAD go to patient’s home?? Capacitated consenting patients-TelCapacitated consenting patients-Tel conversation, worse case scenario-if P refusesconversation, worse case scenario-if P refuses to speak to SOAD-approvals after conversationto speak to SOAD-approvals after conversation with RC, CC and scrutiny of case noteswith RC, CC and scrutiny of case notes  Non NegotiableNon Negotiable  Potential recallPotential recall
  16. 16. Discretionary conditions of aDiscretionary conditions of a CTOCTO RC and AMHP may agree to attach conditionsRC and AMHP may agree to attach conditions thought ‘necessary and appropriatethought ‘necessary and appropriate’ for:’ for:  -- ensuring P receives medical treatmentensuring P receives medical treatment  - preventing risk of harm to P’s health or safety- preventing risk of harm to P’s health or safety  - protecting other persons- protecting other persons  •• Likely conditions for these purposes:Likely conditions for these purposes:  - live where directed (No DOL)- live where directed (No DOL)  - attend clinics for assessment and treatment- attend clinics for assessment and treatment  - receive visits from CMH staff- receive visits from CMH staff  - attend certain CMH programmes- attend certain CMH programmes  - abstinence from drugs or alcohol- abstinence from drugs or alcohol  - no association with certain persons and avoiding- no association with certain persons and avoiding high risk situationshigh risk situations
  17. 17. SCT-ConditionsSCT-Conditions  These can be varied by the RC withoutThese can be varied by the RC without involvement of the AMHP (?bad practice)involvement of the AMHP (?bad practice)  MHRT powerless to cancel or vary them ifMHRT powerless to cancel or vary them if they believe CTO itself should remainthey believe CTO itself should remain placeplace
  18. 18. Patient’s agreement-SCTPatient’s agreement-SCT conditions (COP)conditions (COP)  Crucial. Must seek to achieve it! If possible?Crucial. Must seek to achieve it! If possible?  They need not formally consent to a SCT but need toThey need not formally consent to a SCT but need to cooperate (or consider long term s17 leave)cooperate (or consider long term s17 leave)  Conditions must be minimum number consistent withConditions must be minimum number consistent with achieving the purposeachieving the purpose  Restrict P’s liberty as little as possible while beingRestrict P’s liberty as little as possible while being consistent with the purpose (consistent with the purpose (no DOLno DOL))  Must have a clear rationaleMust have a clear rationale  Must be clearly and precisely expressed, so that P canMust be clearly and precisely expressed, so that P can readily understand (readily understand (CQC concernCQC concern))
  19. 19. CTO patient profile-Churchill et alCTO patient profile-Churchill et al 20072007  MaleMale  Average age 40, Long history of mental illnessAverage age 40, Long history of mental illness  Previous admissionsPrevious admissions  Mainly Schizophrenia, bipolar.. Severe andMainly Schizophrenia, bipolar.. Severe and enduring Mental illnessesenduring Mental illnesses  Likely to be displaying psychotic symptomsLikely to be displaying psychotic symptoms especially delusions!especially delusions!  Sell neglecting, insightless, disengaging patientsSell neglecting, insightless, disengaging patients
  20. 20. Birmingham experience of first 100Birmingham experience of first 100 CTO patientsCTO patients  High up take has reached a steady state! Initially ACUSHigh up take has reached a steady state! Initially ACUS patients were transferred to CTO’spatients were transferred to CTO’s  First 100 took 6 months and now 18 months on 140 …First 100 took 6 months and now 18 months on 140 …  Mostly SZ, BPD….Mostly SZ, BPD….  Higher number of co-morbid substance misuseHigher number of co-morbid substance misuse  Majority had a history of violence(92%), 83% had selfMajority had a history of violence(92%), 83% had self neglected, 45% self harmedneglected, 45% self harmed  Higher than expected number of african carribeanHigher than expected number of african carribean service usersservice users  More CTO’s than expected looked after by CMHT’s asMore CTO’s than expected looked after by CMHT’s as opposed to AOTsopposed to AOTs  Frequency of contacts were lower in some CMHT’s dueFrequency of contacts were lower in some CMHT’s due to low numbers of CC. Not an issue to AOTto low numbers of CC. Not an issue to AOT  Being on a CTO gave priority for scarce IP bedsBeing on a CTO gave priority for scarce IP beds
  21. 21. SCTSCT  Placing a patient on a CTO, initial conditions,Placing a patient on a CTO, initial conditions, Revocation and Extension you need agreementRevocation and Extension you need agreement of an AMHP.of an AMHP.  If AMHP refuses , no appeal/second opinionIf AMHP refuses , no appeal/second opinion  Not for varying conditions, recall and discharge.Not for varying conditions, recall and discharge. Good practice will dictate a MDT discussion.Good practice will dictate a MDT discussion.
  22. 22. CTO1CTO1  Part 1 RCPart 1 RC  Part 2 AMHPPart 2 AMHP  Part 3 RCPart 3 RC  Carefully check before you fill in part 3 as major errorsCarefully check before you fill in part 3 as major errors cannot be corrected (cannot be corrected (s15 not amended for CTO’ss15 not amended for CTO’s))  Once dated CTO will commenceOnce dated CTO will commence  Patient can stay informally!!!Patient can stay informally!!!  It is possible to post date for it to start on a said date inIt is possible to post date for it to start on a said date in the near future!the near future!
  23. 23. Time periodsTime periods  6 months, 6 months and yearly!6 months, 6 months and yearly!  Exactly like s 3…Exactly like s 3…  Access to IMHA’s (ref. guide 15.29) (CQCAccess to IMHA’s (ref. guide 15.29) (CQC report concern)report concern)  Patient rights under 132 (ref. guide15.28) (CQCPatient rights under 132 (ref. guide15.28) (CQC concern)concern)
  24. 24. Recall to hospital from CTORecall to hospital from CTO  Recall, by notice (CTO 3)Recall, by notice (CTO 3) in writingin writing to P, if RC of opinion that:to P, if RC of opinion that:  •• P requires treatment in hospital for mental disorderP requires treatment in hospital for mental disorder  •• risk of harm to health or safety of P or others.risk of harm to health or safety of P or others.  Recall powers cannot be delegated , can be transferred to on call RC’sRecall powers cannot be delegated , can be transferred to on call RC’s  Effective only when served on the P, wherever possible must beEffective only when served on the P, wherever possible must be handed personally, through the letter box at the last known address orhanded personally, through the letter box at the last known address or post. (not appropriate in high risk situations , only for some breachespost. (not appropriate in high risk situations , only for some breaches for eg mandatory conditions) (First class post , deemed served on M-for eg mandatory conditions) (First class post , deemed served on M- W, F-Tuesday) letter box effective just after midnightW, F-Tuesday) letter box effective just after midnight  RecallRecall alsoalso possible forpossible for breach of conditionsbreach of conditions of CTO: eg, failure toof CTO: eg, failure to comply with treatment. Has to be a “proportionate” response!comply with treatment. Has to be a “proportionate” response!  Quite possible to recall a P who is fully compliant with all conditions butQuite possible to recall a P who is fully compliant with all conditions but on the basis of deterioration in health!on the basis of deterioration in health!  It is the subsisting s3 that provides the legal basis for recallIt is the subsisting s3 that provides the legal basis for recall
  25. 25. Recall to hospital from CTORecall to hospital from CTO  When recalled, force or restraint may be used to administer treatment;When recalled, force or restraint may be used to administer treatment; inpatient care may resume as part 4 will kick in.inpatient care may resume as part 4 will kick in.  After 72 hours in hospital, P must be released, or Re-detained andAfter 72 hours in hospital, P must be released, or Re-detained and CTO revoked (CTO 5). You do not have to wait for 72 hours revokeCTO revoked (CTO 5). You do not have to wait for 72 hours revoke conditions!!conditions!!  72 hours starts after P comes into hospital (including OPC/DH) not72 hours starts after P comes into hospital (including OPC/DH) not from the time recall notice is servedfrom the time recall notice is served  P can be transferred from OPC to IP unit (no statutory form, 72 hourP can be transferred from OPC to IP unit (no statutory form, 72 hour clock ticks away)clock ticks away)  72 hours cannot be extended (no 5(2) or second recall)72 hours cannot be extended (no 5(2) or second recall)  If revoked, entitled to further access to MHT.If revoked, entitled to further access to MHT. Automatic referenceAutomatic reference
  26. 26. Recall to hospital from CTORecall to hospital from CTO  Recall does not have to be to the same hospital,Recall does not have to be to the same hospital, could include a DGH (CTO 6 and CTO10)could include a DGH (CTO 6 and CTO10) (Authority to transfer and assignment of(Authority to transfer and assignment of responsibility to new hospital managers)responsibility to new hospital managers)  Recall can be to a OPC, DH… (Recall can be to a OPC, DH… (Copy of the recallCopy of the recall notice must be available out of hours)notice must be available out of hours) can becan be released on the same CTO anytime within 72released on the same CTO anytime within 72 hours by RC. No new statutory paper workhours by RC. No new statutory paper work
  27. 27. Role of crisis/home treatmentRole of crisis/home treatment teamsteams  Gate keeping requirement taken out byGate keeping requirement taken out by CQC for CTO recalls!!CQC for CTO recalls!!  It is good practice to talk to the IPIt is good practice to talk to the IP consultant quicklyconsultant quickly  Disputes recalling consultant vs HTT’sDisputes recalling consultant vs HTT’s (rare but possible)(rare but possible)  RC transfer must happen?RC transfer must happen?
  28. 28. SCTSCT  No powers for entry if the patient refusesNo powers for entry if the patient refuses  May need common law emergency powersMay need common law emergency powers  Police powersPolice powers  S 135 (2) after issuing recall orS 135 (2) after issuing recall or  In emergency situations s 135 (1) generalIn emergency situations s 135 (1) general provisions to take to a POS before issuing recallprovisions to take to a POS before issuing recall on CTO3on CTO3
  29. 29. Absent without leave after recall on aAbsent without leave after recall on a CTO or goes away after coming toCTO or goes away after coming to hospitalhospital  Can be taken into custody by AMHP, Police or staff ofCan be taken into custody by AMHP, Police or staff of hospital or any one authorised by the managers.hospital or any one authorised by the managers.  This must be before the end of the CTO or 6 monthsThis must be before the end of the CTO or 6 months from the 1from the 1stst day of absence whichever is laterday of absence whichever is later  If it is more than 28 days absence CTO will end firstIf it is more than 28 days absence CTO will end first week after return unless confirmed by RCweek after return unless confirmed by RC  If it is less than 28 days will run its course until expiry ofIf it is less than 28 days will run its course until expiry of the CTOthe CTO  Will not apply if the P leaves the country but can beWill not apply if the P leaves the country but can be picked up if returns within the time periodpicked up if returns within the time period
  30. 30. CTO Recall-Patient absconds afterCTO Recall-Patient absconds after coming incoming in  Treat him as absent without leave (s18)Treat him as absent without leave (s18)  Can be brought back any timeCan be brought back any time  If comes or brought back on day 1 or 2 noIf comes or brought back on day 1 or 2 no problems if necessary and if criteria are metproblems if necessary and if criteria are met proceed to revocationproceed to revocation  If comes back or brought back on day 3 or comeIf comes back or brought back on day 3 or come after expiry of 72 hours , there will be a fresh 72after expiry of 72 hours , there will be a fresh 72 hourshours  Revocation of the CTO needs to happen ASAPRevocation of the CTO needs to happen ASAP or Patient releasedor Patient released
  31. 31. CTO recall- 72 hours lapses withoutCTO recall- 72 hours lapses without revocation in error-bad practicerevocation in error-bad practice  If necessary on call consultants need toIf necessary on call consultants need to do revocation. eg patient recalled on ado revocation. eg patient recalled on a Friday on a 4 day long bank holiday weekFriday on a 4 day long bank holiday week endend  Patient has to be discharged from a legalPatient has to be discharged from a legal point of viewpoint of view
  32. 32. What if the patient is so unwell?What if the patient is so unwell?  Persuade him to stay informally-highlyPersuade him to stay informally-highly unlikelyunlikely  No 5(2) to extend the 72 hours!No 5(2) to extend the 72 hours!  Or issue a second recall (??after a shortOr issue a second recall (??after a short period out of hospital) and face potentialperiod out of hospital) and face potential legal challengelegal challenge
  33. 33. Community Treatment Orders -Community Treatment Orders - OutlineOutline  If CTO revoked, then by S17G:-If CTO revoked, then by S17G:- It is as if P was never discharged from hospitalIt is as if P was never discharged from hospital P becomes detained/liable to be detained againP becomes detained/liable to be detained again S20 renewal operates as if P were admitted on theS20 renewal operates as if P were admitted on the day of revocationday of revocation  AWOL provisions and consequential extensionsAWOL provisions and consequential extensions amended to cover CTOsamended to cover CTOs
  34. 34. Community Treatment Orders - OutlineCommunity Treatment Orders - Outline CTO Ps and Tribunal applications (1)CTO Ps and Tribunal applications (1) (amended(amended S66):-S66):- P on CTO can go to Tribunal when CTO made, revoked orP on CTO can go to Tribunal when CTO made, revoked or extendedextended  The NR can apply following a barring order being madeThe NR can apply following a barring order being made under section 25under section 25  Managers must refer P on CTO to Tribunal 6 monthsManagers must refer P on CTO to Tribunal 6 months from date of admission under S2 or S3 (S68(2))(subjectfrom date of admission under S2 or S3 (S68(2))(subject to S68(3)), and as soon as possible if the CTO isto S68(3)), and as soon as possible if the CTO is revokedrevoked  Sec of State can refer P on CTO to TribunalSec of State can refer P on CTO to Tribunal  S72(1) amends criteria for Tribunal to discharge P onS72(1) amends criteria for Tribunal to discharge P on CTOCTO
  35. 35. Extension of CTO (3)Extension of CTO (3)  No specific requirement for anyone apart from RCNo specific requirement for anyone apart from RC toto examineexamine patientpatient  No specific requirement for S20A(8) AMHP toNo specific requirement for S20A(8) AMHP to discuss with RCdiscuss with RC  S20A(9) consultee identified on but does notS20A(9) consultee identified on but does not signsign Form CTO 7Form CTO 7  S20A(8) AMHPS20A(8) AMHP mustmust sign Part 2 of Form CTO 7sign Part 2 of Form CTO 7  Extension of CTO is occasion for mandatoryExtension of CTO is occasion for mandatory consideration by managers of whether to dischargeconsideration by managers of whether to discharge patient under S23patient under S23  Form CTO 7 cannot be rectifiedForm CTO 7 cannot be rectified  Extension gives rise to right to apply to TribunalExtension gives rise to right to apply to Tribunal
  36. 36. SCT treatment provisionsSCT treatment provisions  Capacity threshold introduced as for ECTCapacity threshold introduced as for ECT  Treatments vary depending on whether theTreatments vary depending on whether the patient has capacitypatient has capacity  No enforced treatment in the community for aNo enforced treatment in the community for a capacitated patientcapacitated patient  Enforced treatment allowed after recall inEnforced treatment allowed after recall in hospitalhospital  Those with no capacity treatment is allowed inThose with no capacity treatment is allowed in the community including benign force that isthe community including benign force that is proportionate to the degree of harm (MCAproportionate to the degree of harm (MCA principles) or with the consent of donee underprinciples) or with the consent of donee under LPA or court appointed deputyLPA or court appointed deputy
  37. 37. SCT- SOAD certificatesSCT- SOAD certificates  3 months from first administration of medication or 13 months from first administration of medication or 1stst month on a CTO whichever is later.month on a CTO whichever is later.  Otherwise need a mandatory SOAD certificateOtherwise need a mandatory SOAD certificate regardless of whether the patient is consenting orregardless of whether the patient is consenting or not. CQC advice is to ask for a SOAD after 48 hoursnot. CQC advice is to ask for a SOAD after 48 hours on a CTO!!on a CTO!!  SOAD certificate can authorise treatment when recalledSOAD certificate can authorise treatment when recalled under part 4A (BDZ’s, Hypnotics, IM medications)under part 4A (BDZ’s, Hypnotics, IM medications) otherwise part 4 kicks in. May need a fresh certificate!otherwise part 4 kicks in. May need a fresh certificate! Old certificates bad practice?Old certificates bad practice?  SOAD delays emergency provisions s64C, s64GSOAD delays emergency provisions s64C, s64G (internally generated forms modelled on s62) document(internally generated forms modelled on s62) document that you are using these due to SOAD delays! CQCthat you are using these due to SOAD delays! CQC Advice! Do not stop oral or depot medication and riskAdvice! Do not stop oral or depot medication and risk relapse!relapse!
  38. 38. Examples of how time periods willExamples of how time periods will work in practicework in practice  Example 1- The patient already has a part 4 certificate.Example 1- The patient already has a part 4 certificate. No new part 4 A certificate need be obtained for the firstNo new part 4 A certificate need be obtained for the first month on a CTOmonth on a CTO  Example 2- The patient has been receiving medicationExample 2- The patient has been receiving medication for just under 3 months, so no part 4 Certificate andfor just under 3 months, so no part 4 Certificate and patient is placed on a CTO. No need for part 4Apatient is placed on a CTO. No need for part 4A certificate for another month. (just under 4 monthscertificate for another month. (just under 4 months without any certificate-HRA challenge?)without any certificate-HRA challenge?)  Example 3- The patient has been receiving medicationExample 3- The patient has been receiving medication for a month and placed on CTO. No need for a part 4Afor a month and placed on CTO. No need for a part 4A certificate for further 2 monthscertificate for further 2 months
  39. 39. SCT- SOAD certificatesSCT- SOAD certificates  3 months from first administration of medication or 13 months from first administration of medication or 1stst month on a CTO whichever is later.month on a CTO whichever is later.  Otherwise need a mandatory SOAD certificate regardless ofOtherwise need a mandatory SOAD certificate regardless of whether the patient is consenting or not. CQC advice is to askwhether the patient is consenting or not. CQC advice is to ask for a SOAD after 48 hours on a CTO!!for a SOAD after 48 hours on a CTO!!  SOAD certificate can authorise treatment when recalled under partSOAD certificate can authorise treatment when recalled under part 4A (BDZ’s, Hypnotics, IM medications) otherwise part 4 kicks in.4A (BDZ’s, Hypnotics, IM medications) otherwise part 4 kicks in. May need a fresh certificate! Old certificates bad practice? Can beMay need a fresh certificate! Old certificates bad practice? Can be used if not lapsed.used if not lapsed.  SOAD delays emergency provisions s64G (internally generatedSOAD delays emergency provisions s64G (internally generated forms modelled on s62) document that you are using these due toforms modelled on s62) document that you are using these due to SOAD delays! CQC Advice! Do not stop oral or depot medicationSOAD delays! CQC Advice! Do not stop oral or depot medication and risk relapse!and risk relapse!
  40. 40. Part 4APart 4A  Certificate requirements (strict time periods and otherCertificate requirements (strict time periods and other criteria) not to be confused with authority to RX.criteria) not to be confused with authority to RX.  Certificates do not give you the authority to RXCertificates do not give you the authority to RX  SOAD’s role is to certify that a RX plan is appropriateSOAD’s role is to certify that a RX plan is appropriate and not to comment on capacity, consent ….(whetherand not to comment on capacity, consent ….(whether there is legal authority to RX)??irony!there is legal authority to RX)??irony!  Authority to RX (consent, substituted consent and orAuthority to RX (consent, substituted consent and or emergency provisions 62, 64)emergency provisions 62, 64)
  41. 41. How long is the SOADHow long is the SOAD authorisation valid?authorisation valid?  Unless stipulated without limit of time.Unless stipulated without limit of time. SOAD’s can put conditions and time limitsSOAD’s can put conditions and time limits  Or If there is variation in the treatmentOr If there is variation in the treatment planplan  ?Even if no variation is good practice to?Even if no variation is good practice to ask for a fresh SOAD certificate after 1ask for a fresh SOAD certificate after 1 yearyear
  42. 42. Whose responsibility it is to let theWhose responsibility it is to let the patient know of the SOAD decisionspatient know of the SOAD decisions  Definitely the RC!Definitely the RC!  There must be documented evidence inThere must be documented evidence in the case notesthe case notes
  43. 43. SCTSCT  Can come in as an in-patient informally without aCan come in as an in-patient informally without a formal recallformal recall  If then tries to leave recall may be necessaryIf then tries to leave recall may be necessary  Out of hours one cannot do a 5 (4) or 5(2) asOut of hours one cannot do a 5 (4) or 5(2) as SCT patients are not informal and seen asSCT patients are not informal and seen as “community” patients“community” patients  Out of hours on call consultant can issue recallOut of hours on call consultant can issue recall notice.notice.  It is not a legal requirement to do direct medicalIt is not a legal requirement to do direct medical examinationexamination  Revocation may need a direct medicalRevocation may need a direct medical examinationexamination  Recall also can be to a DGHRecall also can be to a DGH
  44. 44. SCT patientsSCT patients  In practice may end up on a s2, s4, s 135, s 136, 5(2),In practice may end up on a s2, s4, s 135, s 136, 5(2), 5(4) inadvertently5(4) inadvertently  S3 has to be very rare!!!!S3 has to be very rare!!!!  ?Not unlawful if not known at that time that they were on?Not unlawful if not known at that time that they were on a SCTa SCT  S5 cannot be done on a CTO patient as they areS5 cannot be done on a CTO patient as they are deemed community patients. Need to legalise thedeemed community patients. Need to legalise the situationsituation  135,136 is ok. Can run in tandem. Issue recall if135,136 is ok. Can run in tandem. Issue recall if necessary or release!necessary or release!  S2, S4 issue recall or release and discharge from S2S2, S4 issue recall or release and discharge from S2  Strong recommendation-Fax machine and CTO3 formsStrong recommendation-Fax machine and CTO3 forms by the bed sideby the bed side
  45. 45. SCT patient on a new 3-rare!SCT patient on a new 3-rare!  What is the status of the patientWhat is the status of the patient  CTO will cease to have effect as s6(4) suggests that theCTO will cease to have effect as s6(4) suggests that the original s3 ceases to have effect.original s3 ceases to have effect.  Now will be on a new s3 and new consent to RXNow will be on a new s3 and new consent to RX provisions!! Unfair? HRA??provisions!! Unfair? HRA??  Ref guide 15.138Ref guide 15.138  If this happens P need to be put on a new CTO onIf this happens P need to be put on a new CTO on dischargedischarge  A new 3 will not cancel a CTO if it was made on theA new 3 will not cancel a CTO if it was made on the basis of an unrestricted hospital order (37, 51),basis of an unrestricted hospital order (37, 51), Hospital Direction (s45A) or Transfer Direction (47,Hospital Direction (s45A) or Transfer Direction (47, 48)48)
  46. 46. Effect on CTO of new orders orEffect on CTO of new orders or Directions made under part 3Directions made under part 3  s47s47  s48s48  s45As45A  S51S51  CTO will cease to have effect!CTO will cease to have effect!  As new order/direction brings to an end old applicationAs new order/direction brings to an end old application under s3 and other part 3 orders and Directionsunder s3 and other part 3 orders and Directions  Unless the conviction is quashed within 6 months andUnless the conviction is quashed within 6 months and s22 will apply as if the Order or Direction nevers22 will apply as if the Order or Direction never happened and the P had instead been in prison sincehappened and the P had instead been in prison since the order/direction was madethe order/direction was made  P automatically becomes a CTO patient if within 6P automatically becomes a CTO patient if within 6 months of the quashed order or directionmonths of the quashed order or direction
  47. 47. Effect of being imprisonedEffect of being imprisoned  CTO will remain in force for up to 6 monthsCTO will remain in force for up to 6 months  Beyond that will cease to have effect!Beyond that will cease to have effect!  Can be treated as if they have gone AWOL if releasedCan be treated as if they have gone AWOL if released within 6 monthswithin 6 months  If CTO has expired or about to expire you will have 1If CTO has expired or about to expire you will have 1 week from the time P comes back or brought back to doweek from the time P comes back or brought back to do the extension under 20A or 21B if he has been recalledthe extension under 20A or 21B if he has been recalled whilst in prisonwhilst in prison  If not recalled CTO will expire on the day of the releaseIf not recalled CTO will expire on the day of the release from custodyfrom custody
  48. 48. CTO patient received into s7CTO patient received into s7 guardianship-what is the status of CTOguardianship-what is the status of CTO  CTO will cease to have effectCTO will cease to have effect  Reception into guardianship brings to anReception into guardianship brings to an end any previous application for detentionend any previous application for detention (s3)(s3)
  49. 49. Who is the RC if a patient is recalled toWho is the RC if a patient is recalled to a DGH or detained in a DGH?a DGH or detained in a DGH?  Has to be an approved clinician! DGHHas to be an approved clinician! DGH consultants are not!consultants are not!  Local arrangements! LiaisonLocal arrangements! Liaison psychiatrists? Otherwise patient’spsychiatrists? Otherwise patient’s consultant (CMHT or IP)consultant (CMHT or IP)  For 5(2) no requirement for them to beFor 5(2) no requirement for them to be AC’s. They can nominate a deputyAC’s. They can nominate a deputy
  50. 50. SCT patient temporarily in LondonSCT patient temporarily in London  136 POS transfers possible136 POS transfers possible  Can be admitted informally to a unit in LondonCan be admitted informally to a unit in London  Recall notice can be faxed and admission to aRecall notice can be faxed and admission to a unit in London including RC transferunit in London including RC transfer  Recall and transfer to one of your unitsRecall and transfer to one of your units
  51. 51. SCT ExtensionsSCT Extensions  RC plus AMHP (does not have to be theRC plus AMHP (does not have to be the same AMHP involved in placing thesame AMHP involved in placing the patient on a CTO)patient on a CTO)  What if patient ends up in London andWhat if patient ends up in London and Extension is due? You have to go thereExtension is due? You have to go there with an AMHP , unless RC transferwith an AMHP , unless RC transfer happens. As only RC can do thehappens. As only RC can do the EXtensionEXtension
  52. 52. Ending of CTOEnding of CTO CTO ends if:CTO ends if:  Period runs out and CTO not extended.Period runs out and CTO not extended.  Discharged under s.23 or by MHT.Discharged under s.23 or by MHT.  RC revokes CTO following patient’s recall.RC revokes CTO following patient’s recall.  ““Otherwise ceasing to have effect” s3, s7, s 47,Otherwise ceasing to have effect” s3, s7, s 47, s 48s 48
  53. 53. Situations that have or could giveSituations that have or could give rise to doubts at Tribunalsrise to doubts at Tribunals  Appropriate RX is not available- a patient is prescribedAppropriate RX is not available- a patient is prescribed psychology sessions but is not available or on a longpsychology sessions but is not available or on a long waiting listwaiting list  Patient complies and engages for reasons independentPatient complies and engages for reasons independent of the CTO- Special relationship with a CPN, SW orof the CTO- Special relationship with a CPN, SW or MedicMedic  The risks are insufficient eg the main is risk is long termThe risks are insufficient eg the main is risk is long term neglect, which could be managed with suitable serviceneglect, which could be managed with suitable service interventionintervention  Use of CTOs for children and for compliant LD patientsUse of CTOs for children and for compliant LD patients
  54. 54. Service context for use ofService context for use of CTOsCTOs  •• Length of inpatient stays must be possible (bedLength of inpatient stays must be possible (bed availability is key )availability is key )  •• Co-ordination of inpatient and outpatient careCo-ordination of inpatient and outpatient care  •• Availability & intensity of CMH servicesAvailability & intensity of CMH services  •• Attitudes & skills of community psychiatricAttitudes & skills of community psychiatric nursesnurses  •• Availability & quality of supportedAvailability & quality of supported accommodationaccommodation  •• Availability of Police help with recall to hospitalAvailability of Police help with recall to hospital
  55. 55. Chapter 28 COPChapter 28 COP  GuardianshipGuardianship  Longer term Section 17 leaveLonger term Section 17 leave  SCTSCT
  56. 56. Long terms section 17 leaveLong terms section 17 leave  Case law, less bureaucratic, it is not an order, noCase law, less bureaucratic, it is not an order, no need for agreement with AMHP, Rx governed byneed for agreement with AMHP, Rx governed by less complex part 4, no 72 hours limit onless complex part 4, no 72 hours limit on recall….recall….  Govt is clear about seeking to dissuadeGovt is clear about seeking to dissuade clinicians from avoiding using CTO’sclinicians from avoiding using CTO’s  Whilst the Govt is keen to point out that theseWhilst the Govt is keen to point out that these powers designed for “revolving door” patientspowers designed for “revolving door” patients that criteria does not appear in the act.that criteria does not appear in the act.
  57. 57. Long leash section 17 leaveLong leash section 17 leave  Highly discretionaryHighly discretionary  Relies heavily on the judgement of oneRelies heavily on the judgement of one person RCperson RC  No clear structureNo clear structure  Use highly variable across the countryUse highly variable across the country  Little research into its use across theLittle research into its use across the countrycountry  Less HRA compliantLess HRA compliant
  58. 58. Advantages of SCTAdvantages of SCT  Structured frame workStructured frame work  Clearer criteriaClearer criteria  Mandatory SOAD certificate even if theMandatory SOAD certificate even if the patient is consenting (safe guard)patient is consenting (safe guard)  Automatic reference after revocation (safeAutomatic reference after revocation (safe guard)guard)
  59. 59. Section 17 long term leave (COP)Section 17 long term leave (COP)  Still a legal routeStill a legal route  Suitable to test out dischargeSuitable to test out discharge  Suitable to those patients whom you knowSuitable to those patients whom you know there is a high chance of immediate recallthere is a high chance of immediate recall  Suitable for transfers to DGH’s for RX of aSuitable for transfers to DGH’s for RX of a physical illnessphysical illness  Suitable for transfers to a PICU, MediumSuitable for transfers to a PICU, Medium secure facility…secure facility…  Often has to be used due to bed pressuresOften has to be used due to bed pressures  Biggest advantage is its simplicityBiggest advantage is its simplicity
  60. 60. What are the real Differences between S17What are the real Differences between S17 and S17A?and S17A?  S17 within exclusive power of the RCS17 within exclusive power of the RC  Requirement of hospital element for long leash S17Requirement of hospital element for long leash S17  S17 conditions more easily enforceableS17 conditions more easily enforceable  S17 patients continue to be covered by Part 4S17 patients continue to be covered by Part 4  Renewal/extension procedures differRenewal/extension procedures differ  S17 patient may be placed in the custody of anotherS17 patient may be placed in the custody of another  No power of conveyance or return under S17ANo power of conveyance or return under S17A  S17 available for wider group of detained patientsS17 available for wider group of detained patients  Additional/different SOAD requirements for CTOAdditional/different SOAD requirements for CTO  Much less formal process for S17Much less formal process for S17  CTO recall can be to a different hospitalCTO recall can be to a different hospital
  61. 61. S17 extended leave and CTO’s andS17 extended leave and CTO’s and MHRTMHRT  These have to be a proportionateThese have to be a proportionate responseresponse  Patients must continue to meet the criteriaPatients must continue to meet the criteria for detention/compulsionfor detention/compulsion  AMT must be available!AMT must be available!
  62. 62. SCT and functionalised teamsSCT and functionalised teams  Inpatient RC who places the patient on a SCT mustInpatient RC who places the patient on a SCT must organise 117 meeting and SCT meeting withorganise 117 meeting and SCT meeting with crisis/community/AOT consultant to agree conditions andcrisis/community/AOT consultant to agree conditions and the care package.the care package.  How can the conditions be set without prior agreementHow can the conditions be set without prior agreement from the RC who is going to look after the patient? Whofrom the RC who is going to look after the patient? Who will be the decision maker for recall? There must at leastwill be the decision maker for recall? There must at least be a telephonic conversation between RC’s and a carebe a telephonic conversation between RC’s and a care coordinator must be present at the pre dischargecoordinator must be present at the pre discharge meeting.meeting.  RC can change in any direction (Need to have aRC can change in any direction (Need to have a robust local procedure)robust local procedure)
  63. 63. Can a CMHT consultant do a CTO?Can a CMHT consultant do a CTO?  RC transfer must happen prior to that.RC transfer must happen prior to that.
  64. 64. Adequacy of contact by CC’s or RCAdequacy of contact by CC’s or RC or othersor others  Weekly?Weekly?  Bi weekly?Bi weekly?  Monthly?Monthly?
  65. 65. Who is the RC during a short recallWho is the RC during a short recall IP stay for up to 72 hoursIP stay for up to 72 hours  IP consultant or CMHTIP consultant or CMHT  Local procedures!Local procedures!
  66. 66. AC/RC change in any directionAC/RC change in any direction  Consent to treatment needs to beConsent to treatment needs to be reviewed.reviewed.  New COP page 217 says a new consentNew COP page 217 says a new consent to RX form (58, 58A) needs to be done asto RX form (58, 58A) needs to be done as the old one ceases to authorise RX?the old one ceases to authorise RX?  ? Need for deviation and to have a? Need for deviation and to have a sensible clearly thought out policysensible clearly thought out policy
  67. 67. Are CTOs ConventionAre CTOs Convention Compliant?Compliant?  Safeguards of procedure and forms, involvement (sometimes) ofSafeguards of procedure and forms, involvement (sometimes) of AMHP, regulation of treatment under Part 4A mean structureAMHP, regulation of treatment under Part 4A mean structure probably compliant (better protection than S17 leave)probably compliant (better protection than S17 leave) However:-However:-  No doctor required to make, extend, recall from or revoke a CTONo doctor required to make, extend, recall from or revoke a CTO  No involvement of AMHP in variation of conditionsNo involvement of AMHP in variation of conditions  Managers have no jurisdiction over conditionsManagers have no jurisdiction over conditions  Tribunals cannot amend conditionsTribunals cannot amend conditions  What if conditions amounted to a deprivation of liberty?What if conditions amounted to a deprivation of liberty?  Recall does not need an AMHPRecall does not need an AMHP  Will CTOs delay indefinitely patient’s full discharge?Will CTOs delay indefinitely patient’s full discharge?  If ACUS P placed on CTO then revoked – new S3 periodIf ACUS P placed on CTO then revoked – new S3 period commenced without necessarily the involvement of doctorcommenced without necessarily the involvement of doctor
  68. 68. SCT’s-ethical considerationsSCT’s-ethical considerations  They have been described as a “lobster pot” easy to putThey have been described as a “lobster pot” easy to put on but very difficult to get off.on but very difficult to get off.  As the patient is on a s 3 or 37 at the time they areAs the patient is on a s 3 or 37 at the time they are imposed , the criteria are likely to be met. (easy to putimposed , the criteria are likely to be met. (easy to put on)on)  Difficult to get off. If they are working well, tribunal isDifficult to get off. If they are working well, tribunal is likely to leave it in place, If it is not working particularlylikely to leave it in place, If it is not working particularly well (a number of recalls) it can be argued that that iswell (a number of recalls) it can be argued that that is why it should stay in place!why it should stay in place!
  69. 69. Patient experiences in otherPatient experiences in other countriescountries  AmbivalenceAmbivalence  Positive feelings such as freedomPositive feelings such as freedom  Negative feelings of coercion and stigmaNegative feelings of coercion and stigma  Some patients do not like additional tribunalSome patients do not like additional tribunal referencesreferences  Some patients do not like to see SOAD’sSome patients do not like to see SOAD’s
  70. 70. A responsible clinician exercisesA responsible clinician exercises considerableconsiderable discretiondiscretion, when, when deciding:deciding:  •• to place a patient on a CTO on leaving hospitalto place a patient on a CTO on leaving hospital  •• to seek renewal of the CTOto seek renewal of the CTO  •• to advocate strongly for the CTO at a hearingto advocate strongly for the CTO at a hearing  •• to recall the patient to inpatient careto recall the patient to inpatient care  •• to discharge a patient from a CTOto discharge a patient from a CTO  >>>>>> the powers provided ‘may’, not ‘must’,the powers provided ‘may’, not ‘must’, be used.be used.
  71. 71. Some dilemmas for cliniciansSome dilemmas for clinicians  •• Impact on therapeutic relationshipsImpact on therapeutic relationships  •• Extent of control to exercise over outpatientsExtent of control to exercise over outpatients  •• Ethics of use to assist families, 3rd PsEthics of use to assist families, 3rd Ps  •• Use in sub-optimal service environmentsUse in sub-optimal service environments  •• Non-standard uses: eg, in rare conditionsNon-standard uses: eg, in rare conditions  •• Giving patients unfair priority for servicesGiving patients unfair priority for services  •• Promoting dependence on the MH systemPromoting dependence on the MH system  •• Use of recall (or revocation) processUse of recall (or revocation) process  •• Length of use (the ‘dilemma of discharge’)Length of use (the ‘dilemma of discharge’)
  72. 72. Key uses of CTOs: NZKey uses of CTOs: NZ clinicians' viewsclinicians' views  •• ensure contact with patients, so negotiationsensure contact with patients, so negotiations can continue about carecan continue about care  •• ensure compliance with medicationensure compliance with medication  •• enhance patients’ insight into their illnessenhance patients’ insight into their illness  •• prevent or identify relapseprevent or identify relapse  •• facilitate accommodation and social supportfacilitate accommodation and social support  •• create a stable situation, so other forms ofcreate a stable situation, so other forms of therapy, activity, psychological change maytherapy, activity, psychological change may occur.occur.
  73. 73. Patients in NZ held generallyPatients in NZ held generally favourable opinions of CTOsfavourable opinions of CTOs because:because: •• They assessed it in light of their prior patient career &They assessed it in light of their prior patient career & negative experience of institutions.negative experience of institutions. • It allowed more freedom and control over their livesIt allowed more freedom and control over their lives than hospital care.than hospital care. • They valued the sense of security and enhanced accessThey valued the sense of security and enhanced access to services.to services. • They valued the ongoing support of mental healthThey valued the ongoing support of mental health professionals and accommodation providers.professionals and accommodation providers. • They viewed it as a transitional step from a chaotic to aThey viewed it as a transitional step from a chaotic to a more stable form of life.more stable form of life.
  74. 74. How might CTOs work ?How might CTOs work ? Through what mechanisms ?Through what mechanisms ? Directly: through the enforcement processDirectly: through the enforcement process Indirectly: through the therapeutic relationshipIndirectly: through the therapeutic relationship Structurally:Structurally:  binds into place a ‘structure for care’binds into place a ‘structure for care’  commits service providers to care of patientcommits service providers to care of patient  gives patients priority for caregives patients priority for care  supports the family’s insistence on treatmentsupports the family’s insistence on treatment  gives housing providers the confidence to caregives housing providers the confidence to care

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