Title: Evaluating the Effects of Community Treatment Orders (CTOs) in England Using the Mental Health Minimum Dataset
Funder: Department of Health and Social Care

Abstract: Background Community Treatment Orders (CTOs) were introduced in England 2008 to allow patients detained in hospital for treatment under the Mental Health Act (2007) (MHA) to be discharged under specific conditions. The extent of their use was unexpected: around 20,000 patients have been placed on CTOs to date. Variation in use occurs, and patients of black and minority ethnicity appear to be over-represented among those on CTOs. Evidence of effectiveness is sparse, and the three clinical trials worldwide failed to show effects on clinical outcomes. Results from observational studies are more mixed. Main research question Are there quantifiable outcomes associated with CTOs, after adjusting for patient characteristics? Aims We will (1) explore spatial and secular variation in CTO use in England over a four-year period (from 2011/12, including variation between people (especially by ethnic groups) and places over time; (2) 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 patient characteristics; (3) test the hypotheses that outcomes associated with CTOs vary between people and places; and (4) model the 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. Design Secondary analysis of four years of data (from 2011/12) of the Mental Health Minimum Dataset for England (MHMDS), analysed using multilevel statistical models (MLM), as repeated cross-sectional surveys and as a cohort. The exposed group will be patients discharged from hospital on CTOs and the unexposed group will be individuals matched on time of discharge, service provider and propensity score (a derived variable representing propensity of being placed on a CTO). Initial analyses will describe patterns of CTO use and any changes between places and providers over time. We will investigate associations between CTO use and the study outcomes (as above). We will model variance in this association between places and over time to test the hypothesis that there is statistically significant variation in the effects of CTOs. By linking MHMDS to other administrative data (e.g. Census and deprivation indices), we will test whether age, sex and socio-economic status and area-level factors explain this spatial variation. We will identify where and for whom CTOs ‘work’ (if at all).We will model health care costs associated with CTOs using different trajectories of use. Benefits and potential impact There is disquiet about CTOs, which are used more often than anticipated despite a lack of evidence of benefit and unpopularity with patients. We will describe when, where and for whom these are being used, and whether variation between places and people is changing over time. We will determine whether CTOs are associated with differences on a wide range of outcomes, including mortality. We will test the hypothesis that these outcomes vary with patient and service characteristics, and we will use our findings to model the costs of future CTO use. We will answer questions that cannot be addressed by randomised clinical trials, and at a fraction of the cost.

Lay abstract: Community Treatment Orders (CTOs) were introduced in England in 2008, allowing patients detained in hospital for treatment of mental disorders under the Mental Health Act (2007) (MHA) to receive treatment in the community rather than in hospital. It was also hoped that CTOs would reduce ‘revolving door’ admissions. Around 20,000 patients have been placed on CTOs in England since 2008, three times more than originally expected. This has taken place against a background of increasing compulsory admissions to hospital. Black and minority ethnic (BME) service users are more likely to be placed on CTOs than their white counterparts. People who are placed on CTOs feel they are used mainly to make them take medication. Although CTOs have been widely used in many countries, there is little high quality scientific evidence that they reduce subsequent admissions to hospital. Three clinical trials have been carried out (the most recent in England), and none showed significant benefits. Observational studies (which follow patients up over time), have produced mixed results but these vary in quality and can be difficult to compare because of different methods and settings. CTOs might be helpful for certain groups of patients and one US study found that people with schizophrenia stayed out of hospital longer when on a CTO, especially if this continued for 6 months or more. There may be other outcomes (like fewer A&E visits or better physical health) that have not been studied very often. We will undertake a population-wide study of CTO use and outcome in England, using 4 years of ‘real life’ data from the Mental Health Minimum Dataset (MHMDS). MHMDS contains information on all contacts with NHS-funded adult mental health care in England, which service providers are required to upload quarterly. By combining datasets across different years and linking this to other data (including A&E data and death records), we will find out whether CTO use is changing over time and if they are used more often in some places, or for some kinds of people. We will also find out if people who are placed on CTOs are (re-) admitted to hospital less often than patients who are not on CTOs, and whether they have fewer contacts with the police and courts. We will also try to find out if the effects of CTOs are different in different parts of the country (for instance in cities versus rural areas) or for different groups of patients. Finally, we will estimate the full costs of CTOs (including administrative time) and predict how these would change if fewer (or more) people were placed on CTOs. We will work with the Mental Health Foundation (MHF) to recruit two advisory groups: one made up of mental health services users (including people who have been on CTOs) and carers, and a second group of mental health professionals. These groups will help us understand the ‘real world’ settings in which CTOs are used, and what type of information would be of most use to users, carers, providers and service commissioners. This will help us present our results effectively. The results of this research will be of direct relevance to policy makers and we will share these as soon as we can with the Care Quality Commission, the Department of Health and others. We will also work with the MHF and our own universities to ensure the results are shared with service users, carers and the general public.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH