Evidence base and economic impact of community treatment orders

The recent article by Owino (Psychiatric Bulletin, July 2007, 31, 241–243) highlights that community treatment orders are not greatly different from the current provisions of section 17 leave. I believe that the evidence base and economic impact of the new orders require further consideration.

A well-resourced, systematic and independent review of community treatment orders was conducted by Churchill (2007). This large review considered the findings of 72 studies conducted in 6 different countries over the last 30 years and concluded that there is very little evidence to suggest that they are associated with any positive outcomes. Furthermore, there is some evidence, and widespread agreement, that they cannot work as intended without adequate resources, and it is widely acknowledged that they will not work without the general support of mental healthcare providers.

The Cochrane review by Kisely et al (2005), which only includes two trials of community treatment orders, concludes that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. Regarding economic impact of the community treatment, the Kings Fund report by Lawton-Smith (2005) provides a detailed economic forecast. The report suggests that, over a period of 10–15 years, the number of people subjected to community treatment orders in England and Wales might rise to between 7800 and 13 000 at any one time. The financial cost predictions in England and Wales will be £3.4 million in the first year, later increasing to £21.2 million in 2014/15. This is to be considered against savings related to reduced use of hospital beds, of which it estimates saving £8.7 million in the first year, increasing to £47.7 million in 2014/15 (Department of Health, 2006).

Given the lack of credible evidence to support community treatment orders and the indication by Owino that they are not greatly dissimilar to the current provisions of section 17 leave, it is difficult to understand why the government has pursued their implementation. Arguments that they have been more convinced by the political notion that the orders will help improve public safety must also be considered against the evidence that they may also lead to cost savings through closure of in-patient beds.