Evaluating the effects of Community Treatment Orders (CTO) in England

The University of Southampton requires HES, Mental Health and Civil Registration (Deaths) data for use in a project aiming to address the need for evidence of the effectiveness of Community Treatment Orders (CTOs) in different clinical and social circumstances answering calls from the Care Quality Commission and the House of Commons Health Committee for research into this issue.

This work is research in the public interest as it aims to improve care for all patients considering undergoing this type of process – informing clinicians and commissioners of variation and outcomes and complications to support work to improve and standardise treatment selection choices.

The University of Southampton has determined that there are no moral or ethical issues from dissemination of data for this purpose. Once received from NHS Digital, the data being processed by the University of Southampton will be pseudonymised and will be compliant with the ICO's "Anonymisation: managing data protection risk" code of practice.

The aims of this research project are:

1. To explore spatial and secular variation in the use of Community Treatment Orders (CTOs) in England over a four-year period (2011/12 to 2014/15), including variation between people, places and services and over time in the likelihood of patients on Sections 3 and 37 being placed on CTOs, and in the frequency and time to subsequent events including recall, revocation, readmission and discharge from CTO.

2. To describe and model associations between CTO use and outcomes, namely re-admission, time spent in hospital, time spent in intensive psychiatric care or forensic units, episodes of seclusion and restraint, community mental health service contacts, criminal justice system contacts, Accident & Emergency Department attendances and deaths, after adjusting for propensity to require compulsory treatment.

3. To test the hypotheses that outcomes associated with CTOs (including the re-admission and the adverse outcomes listed in (3) above) vary between people and places. These models will be used to explore which patients, if any, benefit from CTOs and the types of places and service context where CTOs might have the greatest impact on patient and service-level outcomes.

4.To model the additional health care costs associated with CTOs (including administrative and regulatory costs) and the impacts of increasing or decreasing their use using a range of projections.

‘Mental Health (MH)’ data will be used to address these questions. A cohort of mental health users will be selected from MH data and these records will be linked with corresponding Hospital Episode Statistics Accident and Emergency and Civil Registration (Deaths) records.

Community Treatment Orders (CTOs) were introduced to the Mental Health Act in 2007 in England and 2008 in Wales allowing patients detained in hospital to continue treatment in the community under specific conditions. To be eligible for a CTO, a patient must be detained in the hospital under the Mental Health Act on a section that allows for compulsory treatment. Around 20,000 patients have been placed on CTOs since 2008. CTOs were introduced to reduce the ‘revolving door’ phenomenon (frequent re-admission to hospital by small number of people with severe and persistent mental illness) and to provide treatment in the least restrictive setting. In practice CTOs tend to be applied at the end of an admission, following complete remission, as a means of optimising treatment adherence in those likely to default or disengage from care. Patients and carers perceive CTOs as coercive and mainly concerned with medication adherence. The use of CTOs remains controversial as its applications seems to run counter to the notions of ‘preventative’ and ‘least restriction’ for which CTOs were introduced to the mental health care system.

The Oxford Community Treatment Order Evaluation Trail (OCTET) compared discharge from hospital on a CTO with discharge from the hospital under section 17 of the Mental Health Act. No significant differences between the groups were found. Swartz et al (1999) randomized 264 severe and persistent mentally ill patients to either CTO or voluntary care following discharge. The results showed that schizophrenia patients on CTO for longer than 180 days had fewer hospital admissions and spend less time in the hospital then the controls receiving voluntary care. Limitations of these trial studies include small sample size, sample selection (exclusion of specific patients, refusal of participation by specific patients). In addition, the relative brief duration of follow-up might be too short to observe beneficial outcomes. Observational studies evaluating CTOs have been undertaken in diverse settings, at different times, using different methods. Results from these studies are inconsistent. Discrepant findings about CTO outcomes highlight the importance of local context. Understanding the effects of local context may also be the key to explaining persistent ethnic inequalities in CTO use.

This lack of evidence for the effectiveness of CTOs is problematic for policy makers, service commissioners and providers and for those who receive mental health care. CTOs require stringent governance and therefore place significant demands on the already stretched NHS mental health budgets. CTOs also reduce satisfaction with care and increase stigma. The Care Quality Commission and the House of Commons Health Committee have called for research into the ‘value of CTOs in different clinical and social circumstances. The House of Commons Health Committee has noted:’… that the evidence base for this policy remains sparse…’ and recommended ‘…,a fuller analysis of the value of a CTO in different clinical situations’.

Using Lower Super Output Area (LSOA), ONS staff will link NHS Digital MH data to the publicly available data, i.e. Indices of Multiple Deprivation (Department for Communities and Local Government) and aggregate LSOA Census 2011 (ONS) data. This is to further explore the spatial variation in CTO use in England. Effectiveness of CTO will be measured in relation to compulsory treatment. The exposed group will be patients discharged from the hospital on CTOs, the unexposed group will be patients discharged from hospital treatment orders but not subject to CTOs. The two groups will be matched on time of discharge, service provider, and propensity score. The NHS Digital data will be used to determine the effectiveness of CTOs compared to compulsory treatment.

Primarily this project will lead to submission of academic papers describing spatial and secular variations in the use of CTOs in England, the effectiveness of CTOs, and healthcare costs associated with CTOs. Results from the project will be presented at internal and external conferences. Findings from the research will be used to engage with public/ third sector organisations or mental health care providers during meetings or conferences. The Mental Health Foundation is a key partner in this research project. With their help two expert reference groups will be recruited: one with carers/mental health care users and one with mental health care professionals. These reference groups will meet to discuss the study aims and methods as well as comment on the released non-disclosive results and support dissemination of findings.

The University of Southampton will be the sole data controller and The Office for National Statistics (ONS) will be the data processor of the data supplied by NHS Digital under this Agreement. NIHR are funding the work of the department and in return expect the University of Southampton to undertake research such as this but neither body can access data nor has a role in analysis or interpretation.

NHS Digital created a cohort of Mental Health patient records based on the following criteria:

Patients that have or had a MH spell of care open within the period from April 2011 to March 2015 that includes:

a) any associated Mental Health Act Event Episode/s where the legal status is coded as one of a list of supplied codes indicating detention under specific sections of the Mental Health Act or the Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991, or;

b) any associated Supervised Community Treatment Episode

NHS Digital then generated a file of pseudonymised Mental Health patient identifiers.

Using this file, NHS Digital determined the relevant HES ID using a bridging file. NHS Digital then extracted the relevant HES and Civil Registration (Deaths) records for those patients identified within the Mental Health cohort. Two bridging files were created i.e. a HES/Civil Registration bridging file and a Mental Health/HES bridging file. NHS Digital extracted the remaining Mental Health data records for the cohort. From the Civil Registration (Deaths) data, the field 'Date of Death' was replaced with the derived month and year of death only.

The Mental Health data is classed as sensitive. All of the linked data is classed as pseudonymised.

The multiple files were transferred to the secure environment at ONS Secure Research Service’ (SRS) in Titchfield where ONS staff use the LSOA to link the NHS Digital data to publicly available data (Indices of Multiple Deprivation and aggregate LSOA Census 2011 data) as described above. All data linked to NHS Digital data are non-identifiable and publicly available.

The secure environment at ONS Secure Research Service’ (SRS) Titchfield uses state-of-the-art secure information technology and procedures which provide physical, hardware and software security.

Data will be only stored and processed within ONS Secure Research Service’ (SRS), Titchfield.

As a result of the data processing the study team will produce a final project for NIHR and submissions to peer reviewed journals and make presentations at conferences and develop briefing documents for health care providers and leading mental health charities.

These outputs will present the results of statistical models developed using the data that have been supplied. The study team will report model coefficients and measures of model quality. Any reported data will be at an aggregate level only with small numbers supressed. Neither individuals nor health provider trusts will be identified. Disclosure vetting procedures by ONS ensure that these intentions will be followed.

The dissemination and communication approach is two fold:

a) The findings will be of direct policy relevance and will ensure that they are shared at the earliest opportunity with the Care Quality Commission (who have statutory responsibility for use and oversight of the Mental Health Act, on behalf of the Secretary of State for Health), Department of Health, Chief Medical Officer, the Royal College of Psychiatrists, NHS Confederation and NICE. The study team are undertaking the research in partnership with the Mental Health Foundation (MHF) to ensure the analyses also focus on the outcomes and associations of greatest importance to service users, and that our findings are translated into actionable conclusions. The MHF has an established and effective communications strategies which the study team will make use of to ensure the results reach the widest possible audience. This will involve Briefing Papers which will be available on line and in hard copy, hyperlinks to the reports via MHF web pages and press releases. Finally, there will be workshops held for key stakeholders in the three regions from which the clinical academic applicants are drawn

b) The study team will also pursue more traditional modes of academic dissemination by submitting the findings to high impact journals alongside the required submission to the NIHR Journals Library, and by presenting these at national and international scientific conferences.

It is not envisaged that the research will generate exploitable technologies but should such a situation eventuate the study team will ensure that the universities liaise as required with NIHR and NHS Digital.

The final report to NIHR must be approved before further outputs can be sought, this approval is currently underway. It is envisaged peer review comments will need response and likely further data access and outputs are likely through to 2022. The initial output intention (the NIHR report) was met within the previous approved period of data access.

There is considerable disquiet at present about CTOs. These have been used far more extensively than was anticipated, despite a lack of empirical evidence of effectiveness in improving outcomes. Clinicians continue to place large numbers of patients on CTOs, despite their unpopularity with patients and concerns among regulators. The results of this research will therefore be of great interest. The study will describe when, where and for whom these are being used, and whether variation between places and people (especially different ethnic groups) is changing over time. It will also determine, with a high degree of statistical power, whether CTOs are associated with differences on a wide range of outcomes, including mortality. The hypothesis will test that these outcomes vary with patient and service characteristics, and will use the findings to model the costs of CTO use were numbers of orders to rise, fall or stay the same and will answer questions that cannot be addressed by means of a randomised clinical trial, and at a fraction of the cost.

The lack of evidence for the effectiveness of CTOs is problematic for policy makers, service commissioners and providers and for those who receive (and those who care for people receiving) mental health care. CTOs require stringent governance and therefore place significant (and costly) administrative demands on already stretch NHS mental health budgets. They are perceived by patients and carers as coercive and focused on ensuring medication compliance at the expense of other forms of treatment and (social) support. CTOs may reduce satisfaction with care and increase stigma without achieving any positive health or social care gains. The Care Quality Commission and the House of Common Health Committee have called for research into “the value of CTOs in different clinical and social circumstances”, for instance by evaluating whether CTOs are having an impact on ‘revolving door’ patients, something that clinical trials cannot address and whether and how CTO use is related to uses of other parts of the MHA, given accelerating detention rates. It is possible that services in which large numbers of patients are placed on CTOs are also places with high rates of compulsory admission.

With NIHR approval, an advance summary of the research was provided and cited by the Wessely Independent Review of the Mental Health Act. Further detail on the study is eagerly awaited as the Review enters its discussion and implementation phases and we are keen to seize this opportunity to ensure significant impact. The extended data access will facilitate this achievement, offering, for the first time, insights into the practicalities of CTO use drawing on a large ‘real-world’ population study and providing a grounded evidence base for determining the future of CTOs.