Page last updated at 05:00 GMT, Tuesday, 29 September 2009 06:00 UK

Medics 'break' community care law

Depressed man
Doctors say they have to use a loophole to administer CTOs

The government seriously underestimated the number of psychiatric patients who would need to be forced to take medication, the BBC has learned.

It predicted 300 community treatment orders in the first year but 10 times as many applications have been made.

Psychiatrists told BBC File on 4 this had left them having to "bend the rules" when unable to get signatures of two doctors that are needed on orders.

But a minister responded that CTOs were making a difference to people's lives.

In the first 10 months since CTOs came into force in 2008, 3,777 applications have been made, according to the Care Quality Commission, the independent regulator of social care in Britain.

Under a CTO, severely ill patients must take their medication or face being returned to a psychiatric unit.

Two doctors should sign the order but psychiatrists claim the huge volume of CTOs makes this difficult.

CTOs came into effect under amendments to the 2007 Mental Health Act which gave psychiatrists the power to send a patient straight back to hospital if they refused to take their medication.

Doctors' dilemma

Consultant psychiatrist Dr Tony Zigmond, of the Newsam Centre at Seacroft Hospital, Leeds, told BBC File on 4 the second opinion system had major problems.

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"This is partly because of the very large number of CTOs that have been put in place - far greater than the government predicted - and partly because it has proven very difficult for second opinion doctors to see the patient," he said.

Dr Zigmond added: "One of the problems has been the recruitment of second opinion doctors - there are just not enough of them."

The Care Quality Commission, which said the government under-estimate had put a strain on services, has advised doctors to invoke a clause in the 2007 act which allows CTOs to continue without a second opinion.

The law states that this get-out clause should apply in an emergency where treatment is "immediately necessary" to save a patient's life, prevent a serious deterioration of their condition, alleviate serious suffering or stop them behaving violently.

But Dr Zigmond said these conditions did not apply in the regular administration of CTOs, putting psychiatrists in an impossible position and leaving them torn between breaking the law or leaving their patients unmedicated.

"That's why it is such an unsatisfactory position - one either puts the patient and perhaps others at risk by not giving treatment or one gives treatment and is perhaps breaking the law.

"The vast majority continue to medicate even if that is bending or breaking the law."

'Advice ignored'

Another psychiatrist, who did not want to be named, told File on 4: "The sheer numbers of CTOs in place have overwhelmed the service. The Department of Health made a serious miscalculation.

"Some of my patients have not been seen by a second opinion doctor even after three months of being on a CTO."

Marjorie Wallace, chief executive of the mental health charity Sane, said: "It's a pity that what set out to be a provision to help patients to be treated in the community should have been so ill-prepared.

"We fear that the shortage of psychiatrists may affect the number of people who could otherwise benefit and potentially compromise the protective safeguards written in the new Mental Health Act."

Tom Burns, professor of social psychiatry at Oxford University, who advised the government on CTOs, said the politicians ignored advice and were too ambitious in their implementation of the policy.

"This is a perfect example where some preliminary legislation might have made it possible to introduce a pilot scheme to run three or four years."

Louis Appleby, National Clinical Director for Mental Health at the Department of Health, said: "Community treatment orders are making a real difference to people's lives and provides an important legal framework to help professionals ensure that patients get the treatment they need.

"Doctors do not need to bend any rules to use them; the Mental Health Act gives them the legal authority they need to treat people.

"There is no shortage of psychiatrists; the issue is how many psychiatrists train to be second opinion doctors. There are 65% more psychiatrists than there were 10 years ago, most of whom can apply to become second opinion doctors.

"The Care Quality Commission is encouraging more psychiatrists come foreword to become second opinion doctors."

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