Community Treatment Orders

This section gives information about community treatment orders (CTO). It explains how your CTO is made and what your rights are. It explains how you can challenge your CTO if you don’t agree with it. This section is for people living with mental illness and their carers.

Overview

  • You can get a community treatment order (CTO) if you have been in hospital under the Mental Health Act. Your responsible clinician can arrange it.
  • A CTO means you will have supervised treatment when you leave hospital.
  • You will have to follow conditions if you are on a CTO. These conditions should help you stay well.
  • Conditions can protect you from harming yourself or other people. They can include where you will live or where you will get treatment.
  • A care coordinator will help you to manage your CTO.
  • If you break the conditions of your CTO you can be taken back to hospital. Your responsible clinician can take you back if they think that you are unwell. They can keep you in hospital for up to 72 hours while they decide what should happen next.
  • You can challenge a CTO if you don’t think you should be on one. You can get legal aid to pay for a solicitor to help you do this.
  • You have the right to see an Independent Mental Health Advocate (IMHA). An IMHA can help you to understand your rights and could help if you are not happy with any of your CTO conditions.

Key Words

Key Words

Some information on this page is quite complicated. This section explains some of the phrases and words that we use:

  • Approved mental health professional (AMHP): An AMHP is part of social services. They have a good understanding of mental illness and knowledge of mental health legislation. An AMHP could be a social worker, nurse or therapist. They can help to decide if you should be detained under the Mental Health Act. The role of the AMHP is to give a non-medical opinion when detention is being considered. Even if they have a medical background.

 

  • Responsible Clinician (RC): The RC is the professional who has overall responsibility for your care and treatment. Usually the responsible clinician will be a psychiatrist. The RC can also be a nurse, psychologist, social worker or occupational therapist.

 

  • Section 2 (s2) of the Mental Health Act: S2 means that you can be admitted to hospital for an assessment of your mental health. You can also get treatment. S2 lasts up to 28 days and can’t be renewed. If you need to stay in hospital after 28 days, you will be transferred to a section 3.

 

  • Section 3 (s3) of the Mental Health Act: S3 means that you can be admitted to hospital for treatment. It lasts up to 6 months but can be renewed.

 

  • Section 37 (s37) of the Mental Health Act: The criminal courts can use section 37 if they think you should be in hospital instead of prison. You must need treatment in hospital. This must be the best thing for your health or safety or to protect other people.

 

  • Second Opinion Appointed Doctor (SOAD): A SOAD will be asked to give a second opinion about your treatment if you refuse treatment, or you can’t consent to treatment. And you are under the Mental Health Act.

About

What is a community treatment order (CTO)?

A CTO allows you to leave hospital and be treated safely in the community rather than in hospital.

If you are under a CTO you will still be under the Mental Health Act. Even though you will live in the community.

A CTO means that you must keep to certain conditions. Your responsible clinician (RC) will write down your conditions for you. Your RC can make you go back to hospital if you don’t follow the conditions of your CTO. Your RC can also make you go back to hospital if they feel you have become unwell.

You can read more about CTO conditions further down on this page.

Your RC is in charge of your CTO. Ask the hospital if you are not sure who your RC is.

You can find out more about 'Mental Health Act' by clicking here.

Getting a CTO

How will my responsible clinician decide if I should have a community treatment order?

Before your responsible clinician (RC) puts you on a CTO they must make sure that:

  • you have a mental condition that needs medical treatment,
  • you need treatment for your health or safety, or to keep other people safe,
  • you don’t need to be in hospital to get the treatment that you need,
  • they can show why they need to bring you back you to hospital if necessary, and
  • you can get the right treatment in the community.

Your RC also needs to show that you won’t be able to manage your mental health without a CTO. A large part of this decision will be about recall to hospital. Your RC should think about if the hospital needs the power to recall you to help you recover.

Your RC should look at different things to help them decide if a CTO is the best option for you. This could include:

  • your mental health history,
  • your contact with services,
  • how you engage with treatment,
  • your attitude towards treatment and risk of becoming unwell in the future, and
  • if you will get support from family, friends or carers.

Your RC and an approved mental health professional (AMHP) must both agree to make a CTO.

An AMHP and RC can only put you on a CTO when they are getting ready to discharge you from hospital. They can’t put you on a CTO after they have discharged you from your section.

Your RC should tell you if they are thinking about making a CTO. You should work with your RC and AMHP to decide what treatment you will have and where you will have it.

You can ask your carer or relatives to be involved in the discussion about your CTO. Your RC should try to include people involved with your care.

An Independent Mental Health Advocate (IMHA) can also support you. An IMHA can tell you what your rights are and help you to put your views across to professionals. They are independent to the NHS and free to use.

You can also get support from an IMHA when you are in the community on a CTO.

You can find more information about ‘Advocacy’ by clicking here.

Will I get guardianship or leave of absence instead of a community treatment order?

Your responsible clinician (RC) might think that you are not ready to be discharged from the Mental Health Act. But they might think that you are well enough to live in the community for a short or longer time.

Your RC could choose the following options for you:

  • Community treatment order (CTO),
  • Guardianship, or
  • leave of absence

Your RC will think about which option is the best for your needs.

From our experience a CTO is the most common option for people who live with a mental Illness.

What is Guardianship?

Guardianship means that you will have a guardian. A guardian will be someone from your local authority, such as a social worker. Or someone the local authority has chosen, known as a ‘private guardian’. This person could be a relative or friend.

Your guardian will have 3 legal powers. They can:

  1. decide where you live,
  2. arrange for you to go to appointments, such as to the hospital for medical treatment,
  3. make sure a doctor, approved mental health professional (AMHP) or other professional can visit you at your home.

Guardianship isn’t often used. Most people will be able to get the care that they need in the community without the need for a guardian.

You are more likely to have guardianship instead of a community treatment order (CTO) if:

  • focus is on your welfare rather than on your medical treatment,
  • there is little risk that you will need to go back to hospital under the Mental Health Act, and
  • you need the local authority to decide where you should live.

Guardianship doesn’t give anyone the right to treat you if you don’t agree to it.

What is leave of absence?

Leave of absence means you can leave the hospital for a short, fixed amount of time.

Your RC has to agree to give you leave under section 17 of The Mental Health Act. It is also known as ‘Section 17 leave.’

Leave will usually be for less than 7 days. But it can last up to 1 month.

If leave is for a longer period, your RC should think about if a CTO or discharge would be more suitable. Leave is sometimes given for a longer period to see if you are ready to be discharged from the Mental Health Act.

Your RC will explain what you can and can’t do when you are on leave. These are known as ‘conditions.’

Community Support

What support will I get in the community if I am under a community treatment order?

Your local mental health team and local authority have a duty under Section 117 of the Mental Health Act to:

  • meet needs that you have because of the mental health condition that caused you to be detained, and
  • reduces the chance of your condition getting worse, so you don’t have to go back into hospital.

Your needs will be supported through the care programme approach (CPA).

What is Section 117 aftercare?

Section 117 (S117) aftercare means that the services you get when you leave hospital are free. Even if you had to pay for the service before you went into hospital. But you will only get free aftercare for services that support your mental health needs.

S117 can include both treatment needs and social care needs.

You should get after-care for as long as you need it.

You have a right to get s117 after-care if you have been detained under sections 3, 37, 45A, 47, 48 of the Mental Health Act.

What is the Care programme approach (CPA)?

CPA means that you will get a care plan and a care coordinator. Your care needs will be written on your care plan. Your care coordinator must:

  • make sure you get the services that you need, and
  • review your care plan.

Your care coordinator should give you a written copy of your care plan. And make appointments to see you.

You can find out more information about:

  • Care programme approach by clicking here.
  • Section 117 aftercare by clicking here.

Forced treatment & conditions

What conditions will my community treatment order have?

Your community treatment order (CTO) will explain what you can and can’t do. These are called ‘conditions.’ You must follow them.

The conditions will be based on what your needs are. There are 2 conditions that all CTO’s will have. You need to make sure that you are available for a medical exam if:

  1. Your responsible clinician (RC) needs to see you to decide if you should stay on your CTO, or
  2. a second opinion appointed doctor (SOAD) asks to see you.

Your RC and an approved mental health professional (AMHP) will decide what other conditions you need to make sure:

  • you get medical treatment,
  • your health and safety are protected, and
  • other people are protected from harm.

The RC can only set conditions for one of the reasons above. The AMHP must agree to the conditions before a CTO can be made.

Conditions can include:

  • where you will live,
  • where you will go for treatment, or
  • staying away from things that can make you unwell, such as alcohol or drugs.

There should be as few conditions as possible. Your RC should explain why they have made each condition.

You should tell your RC if something happens and you think you might break your conditions. Or if your mental health improves. Your RC can change or pause your conditions.

Can I be forced to have treatment under a community treatment order?

If you have the mental capacity to make decisions health professionals can’t give you treatment if you don’t want it. Even in an emergency. They can only give you treatment you don’t want if you are recalled to hospital.

If you refuse treatment, your responsible clinician (RC) could recall you back to hospital to have it. Your RC should think about different ways to get you help before recalling you. For example, your RC may allow you to stay on your CTO, if there is different treatment for you to try, which you are willing to take.

Any medication that you are prescribed for a mental disorder must be provided to you free of charge.

What will happen if I lack mental capacity?

If you lack mental capacity to decide about treatment, other people will make a decision for you. This is called a ‘best interests’ decision.

Your decision maker is most likely to be your RC or the medical professional who is making a decision about your treatment.

Your decision maker has a duty to consult with other people before a decision is made about your treatment. These people are:

  • anyone who you have said that you want involved with your care,
  • anyone involved with your care,
  • anyone interested in your welfare such as your close relatives,
  • any attorney if your Lasting Power of Attorney (LPA) for health and welfare has been registered, and
  • any court appointed deputy.

Your attorney for health and welfare or a court appointed deputy may be able to agree or refuse treatment for you.

If you don’t have an attorney or deputy your responsible clinician will decide what treatment you should have. Unless:

  • you made a valid ‘advanced decision’ that says you don’t want that treatment, or
  • the Court or Protection disagrees with the treatment.

You can be given treatment by anyone in an emergency without your attorney, deputy or advanced decision being consulted. But only if you don’t have the mental capacity to make the decision.

An emergency means:

  • your life is at risk,
  • your mental health will get worse without treatment, or
  • you are a danger to yourself or others.

You can find out more information about:

  • Mental capacity and mental health by clicking here.
  • Money matters: Dealing with someone else’s money or benefits by clicking here.
  • Planning your care: Advanced Statements by clicking here.

What happens if I don’t follow the conditions?

Your responsible clinician can send you back to hospital if you don’t follow the conditions of your community treatment order (CTO). Going back to hospital is known as being ‘recalled’. Doctors won’t recall you as a punishment.

If you don’t follow your conditions your RC should:

  • think about if it is still safe for you to be in the community,
  • change your condition if necessary, and
  • recall you to hospital if they need to.

They should make sure you have enough support to continue your treatment in the community.

My carer is worried about me. Can they speak to my responsible clinician?

If your health is getting worse, your carer can tell your responsible clinician. The hospital should have a local procedure for how family concerns are looked at and acted on.

Kevin's Story

Kevin is detained in hospital under section 3 of the Mental Health Act. He wants to leave hospital and asks for a Mental Health Tribunal (MHT). The MHT decide that Kevin can leave hospital but has to go onto a CTO. He meets with his RC and they decide what the conditions of his CTO should be. Kevin and his RC agree that he will take his medication every day and keep appointments with his care coordinator. The approved mental health professional (AMHP) agrees with the conditions. Kevin stops taking his medication and misses 4 appointments with his care coordinator. The RC recalls Kevin back to hospital and assesses his mental health. The RC and AMHP decide that Kevin can stay on his CTO but they will change a condition. He needs to have his medication as an injection every month and not tablets every day. Kevin agrees to follow the new condition. The RC makes the change to his CTO.

Kevin

Advocacy

What is an independent mental health advocate and how can they help me?

You have the right to see an independent mental health advocate (IMHA).

An IMHA can help you understand:

  • your rights under the Mental Health Act (MHA), including your discharge rights,
  • the rights that other people have, such as your family, the parts of the MHA that affect you,
  • any conditions or restrictions to which affect you, or
  • any medical treatment you are receiving and the reasons for that treatment.

With your agreement the IMHA can do the following.

  • Meet with you in private.
  • Look at your health records. 
  • Speak to the people treating you.
  • Represent you. They can speak or write for you.
  • Go with you to meetings about your treatment and care.
  • Help you to apply to a tribunal.

If you would like to talk to an IMHA you can contact the service yourself or ask someone else to do it for you. You could ask your:

  • care co-ordinator,
  • responsible clinician,
  • ward staff, or
  • nearest relative

Use an internet search engine to find an IMHA service. Use search terms like ‘Independent mental health advocacy Leicestershire.

FAQs

What questions are frequently asked about going back to hospital?

Will I have to go back to hospital if I break my community treatment order conditions?

If you break a condition you are unlikely to go back to hospital immediately. Your responsible clinician (RC) should only recall you back to hospital if:

  • you act in a risky way,
  • they think you need treatment in hospital, or
  • you don’t attend an appointment with your RC, or second opinion appointed doctor (SOAD).

You might not be recalled if you have a good reason for not going to an appointment.

Will I have to go back to hospital if I stop taking my medication?

Your RC may recall you if you stop taking your medication. Your RC will only recall you if they think that you will become unwell again. You may be able to stop a recall if you:

  • agree to take medication again, and
  • can explain to your RC why you stopped taking your medication.

What will happen if I am recalled back to hospital?

If your RC recalls you to hospital, they will give you a written recall notice. Anyone from your mental health team can give you the written notice. Your team should try and give you the notice in person, but they can send the notice in the post.

When you get the recall notice you will have to go back to hospital. You may be able to go to hospital on your own. You may have time to make personal arrangements. For example, get someone to look after your pet.

Your care coordinator can go to hospital with you. An ambulance or the police can take you to hospital if you are very unwell or aggressive. Going back to hospital should be as stress free as possible. You can ask for a relative, carer or friend to go with you.

What will happen when I arrive at the hospital?

A psychiatrist will assess your mental health when you get to the hospital. They should do this within 72 hours. This will help the team to decide what the next step should be.

Appropriate treatment will be provided. Clinicians should ask for your consent before they treat you. But you can usually be forced to have treatment if you don’t want it.

How long can my responsible clinician (RC) keep me in hospital?

Your RC can keep you in hospital for up to 72 hours while they decide what to do.

Your RC and AMHP will end your CTO if they decide to keep you in hospital for more than 72 hours. This is called revoking the CTO. They will put you back onto the section of the Mental Health Act you were on before you had your CTO.

An AMHP must agree with your RC before they can revoke your CTO. If the AMHP doesn’t agree with your RC, your CTO won’t be revoked. This means that you will stay on your CTO.

Why has my CTO been revoked?

Your CTO may be revoked if:

  • your RC thinks that you need treatment in hospital, and
  • an AMHP agrees with the RC and believes that your CTO should be revoked.

What will happen if I don’t go back to hospital?

If you don’t go back to hospital when asked, you may be treated as absent without leave (AWOL). Being AWOL means that the police, a social worker, community psychiatric nurse, or AMHP can take you back to hospital.

Your hospital will have a policy on what happens when someone is AWOL. You can ask to see this.

The hospital should ask the police to get involved if they think you are at risk. The local magistrate’s court can allow the police to go into your house and take you to hospital. The police should have a warrant to go into your house without your permission. You may hear this warrant called section 135(2).

You can find out more information about:

  • Section 135 by clicking here.
  • Going into hospital by clicking here.

Useful contacts

Care Quality Commission
If you have concerns or a complaint about the way the Mental Health Act has been used you can contact the Care Quality Commission.

Telephone: 03000 616161. Press ‘1’ to speak to the mental health team.
Address: CQC Mental Health Act, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
Email: enquiries@cqc.org.uk
Website: www.cqc.org.uk/

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