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Cited by 13Healthcare Decision-Making and RestraintsPsychiatric care and mental health servicesHistorical Psychiatry and Medical Practices

Use of community treatment orders and their outcomes: an observational study

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Weich, Scott, Duncan, Craig, Twigg, Liz, McBride, Orla, Parsons, Helen, Moon, Graham, Canaway, Alastair, Madan, Jason +4 more·2020·Health Services and Delivery Research
DOI 10.3310/hsdr08090
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Abstract

Background: Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives: To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design: Secondary analysis using multilevel statistical modelling. Setting: England, including 61 NHS mental health provider trusts. Participants: A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures: Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources: The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results: There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81). Limitations: Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once. Conclusions: Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death. Future work: These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation. Study registration: The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623). Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

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  • Decisions can vary significantly across judges and institutions despite similar clinical contexts.

    “decisions can vary significantly across judges and institutions despite similar clinical contexts”

    From A hybrid fuzzy logic–Random Forest model to predict psychiatric treatment order outcomes: an interpretable tool for legal decision support (2025) · cites this paper as Weich et al., 2020

    The Results (page not provided) report significant variation in community treatment order use between provider trusts and local areas after adjustment for patient characteristics, including care cluster. That supports variation across institutions in broadly comparable clinical contexts, but the paper does not report variation across judges; its Scientific summary Background says that in England these orders are a matter for health-care providers. (LLM, conf=0.86)

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Authors
Weich, S., Duncan, C., Twigg, L., McBride, O., Parsons, H., Moon, G., Canaway, A., Madan, J., Crepaz-Keay, D., Keown, P., Singh, S., & Bhui, K.
Affiliations
  • University of Warwick (GB)
  • University of Portsmouth (GB)
  • Ulster University, Derry-Londonderry Campus (GB)
  • University of Southampton (GB)
  • Mental Health Foundation, London, UK
  • Newcastle University (GB)
  • Queen Mary University of London (GB)
Corresponding author
Weich, Scott
ORCID
Venue
Health Services and Delivery Research
Publisher
National Institute for Health and Care Research
Published
2020-02
Volume
8
Issue
9
Pages
1-76
ISSN
  • 2050-4349 (ISSN-L)
  • 2050-4357
DOI
10.3310/hsdr08090
OpenAlex
W3009378668
Cited by
13
References
6
Citations by year
2025: 4 · 2024: 2 · 2023: 2 · 2022: 3 · 2021: 2
FWCI
0.69
Type
journal article
Language
en
Open access
Licence
Locations
  • Health Services and Delivery Research (publishedVersion, cc-by)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • ePrints Soton (University of Southampton) (submittedVersion)
  • Warwick Research Archive Portal (University of Warwick) (submittedVersion)
Funders
Health Services and Delivery Research (HS&DR) Programme (14/52/40)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
  • Social Sciences › Psychology › Clinical Psychology › Historical Psychiatry and Medical Practices
Keywords
community treatment orders, mental health services, psychosis, length of hospital stay, mortality, health care costs, severe mental illness, deprivation, provider variation, England, NHS trusts, Black patients, male patients, deinstitutionalization, community mental health services, forensic mental health services

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