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Supervised Community Treatment (SCT) & Guardianship



Supervised Community Treatment



· `Supervised Community Treatment' (SCT) is the name given the overall approach to care enabled by the introduction of the Community Treatment Order or CTO (s17A) · See sections 17A ­ 17G MHA 1983


· The SCT provisions allows some patients with a mental disorder to live in the community whilst still subject to powers under the MHA 1983. · Only those patients who have been detained in hospital for treatment (i.e. s3 or certain forensic sections) will be eligible for SCT. · Patients on SCT remain under compulsion and are liable to recall to hospital for treatment. There is no lower age limit


The Criteria

The RC and the AMHP must agree that the following criteria are met:a) the patient is suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment; b) it is necessary for his health or safety or for the protection of other persons that he should receive such treatment; c) subject to his being liable to be recalled as mentioned in paragraph (d) below, such treatment can be provided without his continuing to be detained in a hospital; d) it is necessary that the responsible clinician should be able to exercise the power under section 17E(1) below to recall the patient to hospital; and e) appropriate medical treatment is available for him. s17A

Se7ng up and undertaking assessments for SCT

· A decision about whether or not to put someone on SCT is made by the patient's Responsible Clinician (i.e. the professional with legal responsibility for them whilst they are on section 3 or forensic sections such as s37) and an Approved Mental Health Professional.


The RC role

· `The responsible clinician must be satisfied that the patient requires medical treatment for mental disorder for their own health or safety or for the protection of others, and that appropriate treatment is, or would be, available for the patient in the community. The key factor in the decision is whether the patient can safely be treated for mental disorder in the community only if the responsible clinician can exercise the power to recall the patient to hospital for treatment if that becomes necessary.'

25.7 COP


The AMHP role

`The AMHP must decide whether to agree with the patient's responsible clinician that the patient meets the criteria for SCT, and (if so) whether SCT is appropriate. .... In making that decision, the AMHP should consider the wider social context for the patient. Relevant factors may include any support networks the patient may have, the potential impact on the rest of the patient's family, and employment issues.'

COP 25.24


AMHP role (con5nued)

· So the AMHP is expected to go beyond simply deciding if the criteria for s17A (CTO) are met, they are also expected to decide whether, in this patient's particular circumstances, the use of the order is `appropriate'. · The other role the AMHP has is to decide whether any additional conditions that an RC wants to set are `necessary or appropriate' for any of the reasons to be found on slide 12.


Mandatory Conditions

Every community treatment order( CTO) must specify the following conditions:that the patient makes her/himself available for the purposes of being examined in connection with (1) the order's extension, and (2) the furnishing of a Part 4A certificate (CTO11) The patient may be recalled to hospital if s/he fails to comply with either of these two conditions.


Other conditions

Other conditions may be imposed as long as they are `necessary or appropriate', for one or more of the following reasons:

­ ensuring that the patient receives medical treatment and/or ­ preventing risk of harm to the patient's health or safety and/or ­ it is necessary to protect other people


Effect of making an order

· The authority to detain the patient in hospital is suspended. · The authority to treat people against their will under Part 4 of the Act is also suspended (Part 4A governs treatment instead) · The renewal provisions in section 20 do not apply to the patient. SCT is extended under section 20A


Consent & treatment rules

· Detained patients are subject to Part 4 · SCT Patients of all ages in the community are subject to Part 4A instead of Part 4 ( except when recalled to hospital). · This means that they can't be treated without their consent if they have capacity to consent ­ and (except in emergencies) can't be treated forcibly if they lack capacity ( unless someone consents on their behalf)


Treatment rules for children

· Parents or those with parental responsibility cannot give consent to treatment for an under 16yr old on SCT (because the child is still subject to a section of the MHA) However, it is important to involve those with parental responsibility in the care planning process, especially if the care plan relies on them to deliver medication or care.



· · · ·

The clinician responsible for the treatment may treat an under 16yr old in the community if...

The child has competence and agrees Or They have assessed and established the child does not have competence to make treatment decision The child does not object, or not so that force is needed to administer the treatment The treatment is provided by or under the direction of an Approved Clinician who is also in charge of the treatment


For a young person aged 16 or 17

The young person has capacity and agrees to the treatment or The person giving the treatment has assessed their capacity to make the treatment decision and is satisfied that they do not have capacity, They are not objecting to the treatment to the point that force is required and The treatment is given by, or under, the direction of the approved clinician in charge of it.


For a young person aged 16 or 17yrs

· Alternatively, the Court of Protection, or a deputy appointed by it, could consent on behalf of a 16 or 17 year old who lacked capacity

· The treatment proposed must not conflict with a decision made by the young person's deputy or the Court of Protection (if someone has been appointed by the court to take on such a role.)



· In emergencies force can be used to give immediately necessary treatment to a child or young person without competence/capacity, as long as it is proportionate to the risk of harm they would otherwise face. · That treatment does not have to be by or under the direction of the approved clinician · And it can be given even if a deputy appointed by the Court of Protection objects.



· It is not possible to treat a competent child or young person in the community if they object to the proposed treatment · except in an emergency, it is not normally possible to treat a child or young person in the community who lacks competence or capacity if force would be needed to administer the treatment · In such circumstances it would be necessary to recall the child or young person to hospital to administer treatment


Treatment certificates and the SOAD role

· After the first month of SCT (or 3 months after the patient

was first given medication whilst on section ­ whichever is the latest), a SOAD certificate ("Part 4A certificate) is needed for medication even if the patient has capacity and is consenting to the treatment.


Power of Recall

· The responsible clinician may recall a patient on SCT to hospital if in her/his opinion: a) the patient requires medical treatment in hospital for his mental disorder; and b) there would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled to hospital for that purpose.



The RC may also recall the patient if he fails to comply with either of the `compulsory' conditions

a) that he makes himself available for examination for the purpose of an extension report or b) To see a SOAD to complete a Part 4A certificate.


How recall is effected

· The responsible clinician needs to complete a recall notice. This notice must be either ­

­ Handed to the patient (in which case it takes effect immediately) ­ Delivering the notice by hand to the patients usual or last known address (in which case it take effect the following day) ­ Posted 1st class (in which case it takes effect after 2 working days)


The Effect of Recall

· Once the notice to recall has been served the patient (if he does not return) will be treated as AWOL and can be returned to the hospital. · This means that the patient can be taken to the hospital named in the recall notice, by force if necessary. · If you cannot gain access to the patient, you could use s135 (2).


Recalling in emergency situa5ons

· The recall notice can only be issued by the RC · Cover arrangements should be in place to ensure that another AC is available to take on the role of the RC when the usual RC is not available (e.g. Out of hours, annual leave) · Thus, the recall notice can be issued by the AC who is for the time being acting as the patient's RC · If a SCT patient is picked up by the police on a s136, there is also the option of transferring the patient to another place of safety (such as a ward that knows the patient) until the RC is available, if the place identified is happy to act as a `place of safety.'

The authority to treat...

· The authority to treat comes back into force once the patient has returned to hospital. · The 72hr period starts from the time that person is accepted by the hospital (the patient doesn't have to be returned to the `responsible hospital', but the hospital must be named on the recall notice.)


Treatment on recall

· On recall the patient will be subject to Part 4 again- but Section 62A makes some exceptions to the normal rules about certificates. · The CTO11 which the SOAD completes in the community can also be used to authorise treatment on recall.


Revoking the Community Treatment Order

Where a patient on SCT is recalled, the RC may revoke the community treatment order if: · · he is of the opinion that the section 3 criteria are satisfied and an AMHP agrees with that opinion and that additionally decides that it is appropriate to revoke the order.


The effect of revoca5on is..

· that the managers have the same power to detain the patient under section 6(2) as if s/he had never been discharged; · and for section 20 renewal purposes the patient is deemed to have been admitted under section 3 (or other equivalent sections) on the day the order is revoked.


How long SCT lasts and what happens at the end of each period of SCT

· SCT lasts for 6 months, 6 months and then for period of 12 months (like s3) · However, at the end of each period, an AMHP must agree with the RC that the patient still meets the criteria for SCT, and that it is `appropriate' to extend the order. If the AMHP does not agree, the SCT cannot be extended.


Rights and Protec5ons:

· The right to appeal to the Tribunal for discharge · The right to ask the hospital managers to discharge them · Automatic annual referral to the tribunal (if the child or young person doesn't appeal themselves) · The right to support from an IMHA · The SOAD's agreement to any medication that the responsible clinician wishes the patient to take whilst in the community · The involvement of an AMHP in making, revoking and extending the order · The right of the nearest relative to order their discharge


The Purpose of Guardianship

· The purpose of guardianship is to enable patients to receive care outside hospital when it cannot be provided without the use of compulsory powers. Such care may or may not include specialist medical treatment for mental disorder. COP 26.2 · Guardianship therefore provides an authoritative framework for working with a patient, with a minimum of constraint, to achieve as independent a life as possible within the community. Where it is used, it should be part of the patient's overall care plan. COP 26.4

The criteria:

· Only someone aged 16yrs or over can be made subject to guardianship · The patient must have a mental disorder of a `nature or degree' that make it appropriate to use Guardianship · It must be necessary in the interests of the welfare patient or for the protection of other people · (a young person who is a ward of court

The Powers of Guardianship

There are 3 powers associated with guardianship:1. the power to require the patient to live in a particular place - and the authority to both take them to that place and return them to that place if they leave without permission. 2. they can require the patient to attend for treatment, work, training or education at specific times and places (but they cannot use force to take the patient there); 3. they can demand that a doctor, approved mental health professional (AMHP) or another relevant person has access to the patient at the place where the patient lives.

`The purpose of guardianship is therefore primarily to ensure that the patient receives care and protection rather than medical treatment. Although guardians have powers to require patients to attend for medical treatment, they do not have any power to make them accept the treatment.' Reference Guide 19.8


The process for pu7ng someone on Guardianship:-

· In most cases two doctors and an AMHP must assess and agree that the patient fits the criteria for Guardianship ­ and that the care plan wouldn't work without the additional authority that the order provides. · It is also possible to transfer a patient who is currently detained in hospital on s2 or s3 using s19 directly into Guardianship ­ as long as the LSSA agrees.

Process 2

· The recommendations from the doctors, and the application from the AMHP, will need to be accompanied by a clear care plan detailing which powers are required and how they might be used. · Applications for Guardianship are made to the Local Social Service Authority who must have a process in place for accepting them.


Process 3

· The AMHP must consult the patient's nearest relative if practical · If the Nearest relative objects, the Guardianship could not proceed unless a court agrees to displace the NR. · Once Placed on Guardianship, the Local Social Service Authority is usually `the Guardian' (although it is possible to appoint a `private' guardian.)

· The LSSA must accept the application before the Guardianship can come into effect. · They also take on a similar role to that played by the Hospital Managers ­ to ensure those on Guardianship know their rights, and at regular intervals (for example when the Guardianship is renewed after 6 months, 6 months then annually) to decide whether the person still meets the criteria or should be discharged.

Delega5ng Guardianship responsibili5es

· The LSSA can delegate the practical aspects of the order (such as providing a member of staff to visit the person on a regular basis) in the same way that it delegates other aspects of responsibility via partnership agreements. · However, it cannot delegate its powers to agree to the order or to discharge the order. The LSSA MUST consider discharge whenever it receives a recommendation to renew the order.


Going back into hospital

· Someone subject to Guardianship may go back into hospital either informally or on s2 or 4 without their Guardianship lapsing. · However, if the person is assessed and put onto a s3 their Guardianship would lapse · It is also possible to transfer the pa5ent from guardianship to hospital on the basis of two medical recommenda5ons for s3 and an AMHP applica5on for s3.



· Guardianship lasts for periods of 6 months, six months and then 12 months. · Within 2 months of the end of each sec5on, the pa5ent must be seen by their Responsible Clinician or Medical aZendant, who must decide whether or not to recommend that the order be renewed · The Social Service Department, when they receive the report must consider whether or not to renew the order (they have the right to


Protections available to young people subject to Guardianship

· The right to appeal to the Tribunal to discharge the section · The right to ask the LSSA to discharge them from Guardianship · Access to support from an IMHA whilst they remain subject to Guardianship · (the automatic annual referral to the Tribunal service does not apply to Guardianship.)


44 pages

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