A keeps someone on a section while they live at home, with a power to bring them back.
What is a community treatment order?
A community treatment order (CTO) under s17A lets the discharge a detained patient onto conditions, with a power to recall them. It lets suitable patients be treated safely in the community, and helps stop the 'revolving door' of relapse (Code 29.5, 31.6).
Their section is suspended, not ended (s17D). They don't have to consent formally, but they should be involved and prepared to go along with the treatment (Code 29.17).
Who can be put on a CTO?
Only patients detained under section 3, or unrestricted Part 3 patients such as those on a s37 hospital order. Not s2 patients, and not restricted patients (Code 29.8). Someone on s17 leave still counts.
A tribunal can also recommend that the RC considers one (s72(3A); Code 29.19).
Community treatment order criteria
The RC must think all five are met (s17A(5)):
- A mental disorder of a nature or degree that makes it appropriate for them to receive medical treatment.
- Necessity. The treatment is necessary for their health or safety or to protect others.
- Treatment outside hospital. It can be given without detaining them, as long as they can be recalled.
- The recall power is necessary. The RC must weigh the risk of deterioration out of hospital, for example from refusing or neglecting treatment, given their history (s17A(6)).
- Appropriate medical treatment is available for them.
Risk of relapse alone isn't enough. The Code wants reasonable evidence of benefit, such as a clear link between stopping medication and relapse, and evidence that recall, not informal admission, may be needed (Code 29.16).
How a CTO is made: step by step
- The RC decides the criteria are met, after early discussion with the patient and their carers (Code 29.10).
- An meets the patient and decides whether they agree, looking at the wider social context (Code 29.22).
- They agree any extra conditions. The AMHP must agree them before the CTO is made (s17B(2)).
- They complete Form CTO1, with the AMHP's agreement in Part 2, and the RC sends it to the managers (reg 6(1)). The start date can be a little after signing, to allow for discharge arrangements (Code 29.26).
If the AMHP doesn't agree, there's no CTO, and you shouldn't look for another AMHP (Code 29.25).
CTO conditions: what's allowed
- Two are mandatory. Being available for examination when an extension is being considered, and for a 's certificate (s17B(3)).
- Others need a purpose. They must be necessary or appropriate to make sure the patient gets treatment, prevent harm to their health or safety, or protect others (s17B(2)).
- Few and clear. Typically where and when to have treatment, where to live, and avoiding known risk factors (Code 29.31, 29.32).
- No deprivation of liberty. The RC has no power to impose conditions that deprive someone of their liberty (Welsh Ministers v PJ [2018] UKSC 66).
- Changing them. The RC can vary them on Form CTO2, or suspend them, without the AMHP's agreement (s17B(4), (5); Code 29.40).
Conditions can't be enforced: there's no power to detain, treat without consent or bring someone back to a place (PJ, paras 17 and 18). Breaking one, other than the mandatory two, doesn't by itself justify recall (Code 29.49).
Recall to hospital: when and how
The RC can recall a patient who needs treatment in hospital for their mental disorder, if there'd be a risk of harm to them or others without recall. Breaking a mandatory condition is the other ground (s17E). The RC needn't examine them first (Code 29.45).
- Give oral reasons first where it's safe, and tell family and carers (Code 29.52).
- Complete Form CTO3. It only works once served: handed to the patient, at once; delivered by hand to their usual or last known address, the next day. Posting is rarely appropriate (reg 6(5), (6); Code 29.53, 29.55).
- Once it's served, they can be treated as and brought in. If you can't get access, consider a s135(2) warrant (Code 29.54, 29.57).
- The hospital records when detention starts on Form CTO4. It can be any hospital, and treatment can then be given as an outpatient (s17E(3); reg 6(3); Code 29.59).
The 72 hours after recall, and revocation
They can be held for up to 72 hours from the start of detention under the notice (s17F(6), (8)). They're still a CTO patient, applies, and the RC can release them at any time (s56(4); Code 29.61). Section 5(2) can't extend the 72 hours.
A SOAD's CTO11 can name treatments that may be given on recall, and then no new Part 4 certificate is needed for them (s62A).
To revoke, the RC must think the s3 criteria are met, and an AMHP must agree in writing, on Form CTO5 (s17F(4)). If the AMHP disagrees, the patient leaves at 72 hours, still on the CTO (Code 29.67).
Give reasons before and after revoking (Code 29.68). The patient is detained as before, with a new six-month period (s17G(5)), and the managers must refer them to the tribunal as soon as possible (s68(7)).
How long does a community treatment order last?
Six months, then six months, then a year at a time (s20A). To extend it, the RC examines the patient in the last two months, consults someone else involved in their treatment, and reports on Form CTO7. An AMHP must agree in writing (s20A(4), (8), (9)).
The managers must then consider discharge (Code 38.12). The longer they go without recall, the more you should question whether it's still needed (Code 32.13).
It also ends on revocation, or on discharge by the RC, the managers, the tribunal or, for Part 2 patients, the nearest relative (s17C, s23). The RC must discharge as soon as the criteria aren't met, not let it lapse (Code 29.76).
Can a CTO patient refuse treatment?
- Capacity, consenting. Treat with consent. Once the certificate rule below applies, medication needs a certificate: CTO12 from the approved clinician, or a SOAD's CTO11 (s64C(4), (4A)).
- Capacity, refusing. You can't treat them in the community. If they need treatment in hospital and there'd be a risk of harm without it, recall them (s64C(2)).
- Lacking capacity. You can treat if they don't object, or object but no force is needed (s64D). It mustn't conflict with a valid advance decision, an attorney, a deputy or the Court of Protection. Once the certificate rule below applies, they'll need a SOAD's CTO11.
- Emergencies. If they lack capacity and treatment is immediately necessary, force is allowed only to prevent harm to them, and in proportion to it (s64G).
Certificates are needed from the later of one month after the CTO starts and three months after medication was first given in detention (s64B(4), s64C(3), s58). See consent to treatment.
Community treatment orders and DoLS
Someone on a CTO who lacks capacity may need to live in a care home in a way that deprives them of liberty. That needs or a Court of Protection order alongside the CTO, if it doesn't conflict with the conditions (Code 31.9).
If they need detaining in hospital for their mental disorder, recall them: the can't authorise it (Code 31.10). Deprivation of liberty is now judged under AGNI, not the old acid test.
Rights and safeguards on a CTO
- Information. The managers must explain the CTO, its conditions, recall and tribunal rights, out loud and in writing (s132A; Code 4.13).
- An IMHA. CTO patients qualify (s130C(2)(c)).
- The tribunal. Once in each CTO period, and within six months of a revocation (s66). See the Mental Health Tribunal for automatic referrals.
- The nearest relative. For patients who came from Part 2, they can order discharge on 72 hours' notice, which the RC can bar (s23(2)(c), s25(1A)).
- Aftercare. Section 117 aftercare applies for as long as the CTO lasts (s117(2)).
- What's coming. The 2025 Act will tighten the criteria and conditions and add a community clinician's agreement. None of it is in force yet.
A worked example
A 41-year-old man on a CTO after a s3 admission for schizophrenia misses two depots. His sister says he isn't sleeping and is shouting at the neighbours. At home he has capacity and refuses the depot.
You can't give it at home against a capacitous refusal, and missed doses alone don't justify recall. But he's relapsing, so he needs hospital treatment and there'd be a risk of harm without recall. The RC can serve CTO3. Keeping him past 72 hours needs revocation with an AMHP's agreement (CTO5).
The rules in brief
- Who. Patients on s3, or on an unrestricted hospital order or transfer. The RC makes it, with an AMHP's written agreement (Form CTO1).
- Criteria. Treatment is needed for their health or safety or to protect others, and it can be given in the community. The RC needs the power to recall, and appropriate treatment must be available.
- Conditions. Two are mandatory: being available for examination for renewal, and for a SOAD. Others must be necessary or appropriate for treatment, preventing harm or protecting others.
- Recall (CTO3). If they need treatment in hospital and there'd be a risk without it, or they breach a mandatory condition. Up to 72 hours, then revoke (CTO5, with an AMHP's agreement) or let them go.
- Length. 6 months, then 6, then 12, on an extension report (CTO7) with an AMHP's agreement.
- Treatment at home. A capacitous refusal stands (). Medication needs a certificate (CTO11 from a SOAD, or CTO12 if they consent) once the later of the CTO's first month or the original three-month period has passed.
Read more: MHA 1983, s17A · MHA 1983, s17E · MHA Code of Practice 2015, chapter 29: Community treatment orders
Questions trainees ask
What is a community treatment order?
A under s17A discharges a patient on s3 or an unrestricted hospital order from hospital onto conditions, with a power to recall them for up to 72 hours. Their section is suspended, not ended.
How long does a CTO last?
Six months, then six months, then a year at a time, extended by the on Form CTO7 with an 's agreement.
Can you give medication to a CTO patient who refuses?
Not in the community if they have capacity. If they need treatment in hospital and there'd be a risk without it, you can recall them for up to 72 hours.
What section is a community treatment order?
Section 17A of the Mental Health Act 1983. Sections 17B to 17G cover the conditions, recall and revocation, and covers treatment in the community.
Can a CTO patient be recalled for missing an appointment?
Not for that alone. Recall needs a need for treatment in hospital plus a risk of harm without recall, or a breach of one of the two mandatory conditions.
Does a patient need capacity to be put on a CTO?
No. A CTO doesn't need consent or capacity. Capacity matters for treatment: a capacitous refusal stands in the community, but someone lacking capacity can be treated if they don't object or no force is needed.
Can a CTO deprive someone of their liberty?
No. The Supreme Court held in PJ that CTO conditions can't do that. If someone lacking capacity needs it in a care home, that needs or a court order alongside the CTO.
Test yourself
A man on a CTO has capacity and refuses his depot at the clinic. What can you do there and then?
Show the answer
B. Under Part 4A, a capacitous refusal in the community stands. Recall is the route if the criteria are met.
Quick-fire
A CTO recall lasts up to
Show the answer
72 hours