Two men looking at a book

Vidushi interviewed participants of ROTA’S Healthy, Mobilised and BAME Project.

Community Treatment Orders (CTOs) were introduced in England and Wales in 2008, following the Mental Health Act of 2007. They are a mechanism of offering people supervised treatment following their discharge from hospital. The rationale behind CTOs is to keep “revolving door patients” out of hospital – patients that are in a cycle of disengaging with medical care, relapsing and readmission. Within the first 17 months from the time of their introduction, 6237 CTOs were made, more than ten times the number anticipated by the Department of Health (NHS Information Centre, 2010). Research has shown a disproportionate number of people from Black, Asian and Minority ethnic (BAME) communities being put on CTOs, with higher than average rates for people from South Asian and Black Groups, making it particularly interesting to explore quality of care in these cases (Count Me in Census[1] 2010).

The motivation behind CTOs is to allow patients to integrate into society while being monitored medically as well, hence affording them the luxury of settling back into their regular lives with the benefit of support and medical supervision.  However, while examining these treatments in the context of patients from BAME communities, a plethora of issues emerge; leading to concerns on the efficacy and quality of care given to people of these communities.

During my work with ROTA, I had the opportunity to interview people on CTOs from the Tamil community in London to find out the quality of care given to them. Initially, these interactions made me consciously aware of the fact that perhaps the biggest concern surrounding their treatment was the language barrier that existed between them and their care workers.  This meant that while they adhered to their routine check-ups and hospital visits, they were on some level alienated from their care plan simply because they did not fully understand the communication leading up to such a support scheme. Patients interviewed were unaware of the section under which they were detained, and uninformed about the course of action they were entitled to take. There is a sense of assumed capacity that pervaded the care plans of patients interviewed. Such assumptions are unacceptable at best because they make patients more vulnerable than they should ever be.

In some cases, I found that the purpose of CTOs is sometimes lost in the desire to maintain procedure. While periodic consultations and scheduled calls are carried out as promised, integral aspects of day to day living such as access to basic amenities, clean living conditions as well as spiritual well being did not feature in care plans given to the patients I interviewed. For CTOs to be successful, particularly in the present context, they must be an amalgam of many areas of support. Physical and spiritual health along with social integration can have a deep impact on mental health. Research has shown that around 75% of patients suffering from mental health problems prefer psychological or psychosocial treatment (McHugh et al, 2013), however patients interviewed were not given the chance to choose an alternative to drug treatment. One person I interviewed during this time is a chain smoker, but this was not integrated into his care plan, and his unacceptable living conditions were not addressed by his care coordinator either. He was diagnosed as schizophrenic, and was advised by his doctor to spend some time talking to people with the same medical condition as him. He expressed his discomfort in that exercise, and it is not difficult to imagine why. One cannot help but think that while CTOs find the target in such cases, they fail to achieve their goal. Another patient, while sharing her experience under CTOs talked about the inaccessibility of support in case she needed it outside the schedule provided to her, and added her reluctance in revisiting the hospital as an afterthought, describing it as “stressful.”   

Care plans given to people on CTOs cannot be generally prescribed as their application is intrinsically subjective. One size simply does not fit all. By disregarding patients’ racial and cultural nuances, blanket application of a support system will seldom serve its purpose. The barometer of success for CTOs is not ensuring patients stay out of hospitals, it is ensuring that they need not stay out of their society. A greater race and cultural appreciation of this, whilst adhering to procedure, will give considerable scope for CTOs to be effective in the context of BAME communities.



[1]Carried out by the Care Quality Commission (CQC) and National Mental Health Development Unit (NMHDU).