The Care Programme Approach and the end of indefinitely renewable Leave of Absence in Scotland

Objective To consider the relationship between the restriction of leave of absence (LOA) to 12 months, the introduction of community care orders (CCOs) and the implementation of the Care Programme Approach (CPA). Design Multiple methods were employed: scrutiny of Mental Welfare Commission for Scotland (MWC) records; questionnaire to consultant psychiatrists and mental health officers (MHOs) regarding attitudes; survey of psychiatrists in respect of outcomes for named patients.

Patients in Scotland can be subject to compulsion in the community in three ways: leave of absence (LOA), Community Care Orders (CCO) and Guardianship.The latter is not used in relation to enforcing medication and is not discussed here.The Mental Health Act 1984 allows patients detained on a Section 18 to live in the community on LOA.The understanding was that this allowed similar treatment without consent in the community as Section 18 allowed in hospital.LOA was renewable indefinitely in Scotland until the Mental Health (Patients in the Community) Act 1995 which restricted it to 12 months.This Act also introduced CCOs which required patients to comply with conditions approved by a sheriff.These conditions could include where the person lived, where they spent time and the requirement to give access to staff.Although it was believed that CCOs did not allow patients to be compelled to take medication, the majority of CCOs contained conditions that implied or directly stated that patients should comply with medication 3 .The Scottish Office guidelines 4 indicate that good practice requires that all patients on LOA or a CCO should have care plans that comply with the Care Programme Approach (CPA) 5 .A questionnaire survey indicated that almost all mental health officers (MHO) 6 and three-quarters 1 Greater Glasgow Health Board (1996)  The Care Programme Approach and the end of indefinitely renewable Leave of Absence in Scotland of consultants agreed with this, although there were some reservations about its appropriateness in all cases 7 .
As part of a wider study evaluating the impact of the Mental Health (Patients in the Community) Act 1995 in restricting LOA and introducing CCOs, the relationship of these new measures to CPA was investigated.Details of the full study including methodology are given elsewhere 8,9 .Since this study was started community-based compulsory treatment orders (C-B CTOs) have been introduced in the new Mental Health (Care and Treatment)(Scotland) Act 1995 10 .This also introduces the need for care plans to be approved by mental health tribunals for patients subject to compulsory treatment.Possible implications of this are discussed.

METHODOLOGY
Information for the study comes from three sources, records of the Mental Welfare Commission for Scotland (MWC) to identify patients, a follow-up survey to consultant psychiatrists about named patients and an anonymous questionnaire to consultants and MHOs about the 1995 Act.

Population
The MWC receives details of all patients in Scotland detained under the Mental Health (Scotland) Act 1984.Their records were scrutinised to find all patients whose LOA reached the new limits between 1 April 1996 when the Act was implemented and 31 December 1998 and all those who were placed on a CCO between these dates.

Named patient survey
A questionnaire was designed to collect follow-up data on all these patients.This was sent to the patient's Responsible Medical Officer (RMO).The RMO at the time of discharge from LOA was identified from the MWC case records.For many patients the RMO had changed and RMOs were asked to indicate to whom care had been transferred.Thus, 308 questionnaires were sent to 146 RMOs regarding 266 named patients.The questionnaires were sent in May 1999 and a reminder in June 1999.

Journal of Mental Health Law September 2004
Full details of the survey and views about the Act are reported elsewhere 12 , however the detailed comments regarding the development of CPA across Scottish Local Authorities are reported here.

Ethics approval
Ethical approval was granted by the Multi-Centre Research Ethics Committee for Scotland and 13 Local Research Ethics Committees.

Patients
Two hundred and sixty-six patients were identified from MWC records.The details of the numbers in each health board and estimated rates per 100,000 population are given in Table 1.Any patients from Orkney or Shetland on LOA are included in Grampian Health Board

Development of CPA across Scotland
The data in local authorities who therefore co-determined the implementation of the policy at the smallest unit at which it was possible to gather opinion on its success.
Small numbers in some areas make comparisons difficult but there is broad agreement between the two professions as to the development of CPA in their area.Only a minority of local authorities, 9/32 (28%), were described as having well developed CPA by both sets of professionals and 6/32 (19%) were described as having poorly developed CPA.

CPA and individual patients
Replies were received to the named patient survey from 130/146 (89%) consultants for at least some patients.Of the 308 questionnaires, 250 (81%) were returned, of which 231 (75%) were analysed (the remainder being blank or the patient was unknown to the RMO).There is some information available for 195/266 (73%) of the patients in relation to the impact of CPA.Details are given in table 3.For 8% of the patients for whom forms were returned, the RMO either missed out the questions on CPA or reported they did not know the impact of CPA on that patient's care.
Of the 195 for whom information is known 82 (42%) were not included on CPA.If only the 113 (58%) patients who were included on CPA are considered, for 63 (56%) consultants considered the patient's care was enhanced, for 45 (42%) CPA made no difference and in 2 (2%) cases CPA impaired care.For 82 patients psychiatrists said that to their knowledge they had not been included on CPA.Thus for the group as a whole, only one third had enhanced care from CPA.  "Patient him/her self refused to be included on CPA."

Not included
"CPA unsuccessful as scuppered by patient's behaviour and failure to comply with conditions of CCO." In the two cases where CPA was believed to have impaired care only one comment was made: "CPA also is too unwieldy to cope with patient's changeableness." CPA was not necessarily available or well developed in all areas but only one comment made reference to this.This relates to a patient who moved between health boards.The end of study LOA RMO, who was also once again RMO at time of the survey, said "CPA was not available in this area until [after time of discharge from LOA] but I don't think it would have made any difference." The RMO for a period of inpatient treatment in another health board for the same patient said, "CPA ensured that contact was maintained with patient while in the area but progress after his/her return to X last year is unknown." For the patients who were not included in CPA a further 25 (total 32%) comments were made.There were three themes.Firstly, CPA was described as too bureaucratic, eg: "The staff involved know the problems with the patient and the CPA would just create unnecessary bureaucracy." Secondly, that CPA is seen as pointless as it cannot enforce medication: "CPA of no value in ensuring compliance with medication so not used." "Compliant by the time we introduced CPA."

Journal of Mental Health Law September 2004
The third theme indicated that the patient already had co-ordinated care and that CPA did not add anything to this, eg: "CPA not used as patient seeing members of team who meet regularly with patient and has own private accommodation and occupation is through [X] dept with whom [patient] has regular contact.Non NHS agencies not involved with this patient." "Decision was made not to proceed to CPA as patient was settled at end of LOA.Also, all professionals involved meet on a regular basis anyway to discuss his/her problems with him/her and appropriate action taken from there."

DISCUSSION
The response rate from psychiatrists to the named patient postal survey was sufficiently high for us to assume that the data is representative as there is no real reason to suppose the sample is biased in any particular way.
The figure of 58% of patients being on CPA compares well with the 61% estimated by consultants in the postal questionnaire of their LOA patients on CPA but is slightly less than the MHOs' estimate of 71% 13 .The two populations are not entirely similar in that the named patient survey was for predominately post-LOA patients.Nevertheless, this is a group of patients for whom there is considerable concern about their continued management and for whom, despite the Scottish Office good practice guidelines, somewhat under two-thirds were on CPA.There are probably two main reasons why a patient was not on CPA.
Firstly, CPA development varied across Scotland and may not have been available for some patients.Secondly, although most psychiatrists agreed with the Scottish Office guidelines, 22% of consultants actively disagreed with the recommendation 14 .It is unlikely that the 42% of patients in the named patient survey who were not on CPA were all patients of this group of psychiatrists or in areas where CPA development was poor.There were probably other reasons why patients were not placed on CPA.For some it would seem the guidance was regarded as inappropriate.At the end of LOA, these patients' needs were not seen as complex and, thus, CPA was seen as unnecessary.This may be either because the period of LOA allowed the situation to be stabilised or because LOA was an over cautious response.In other cases patients may have benefited from CPA but consultants chose not to use it.This may have been because it was seen as overly bureaucratic or because it could not compel or ensure compliance with medication.These were the same failings psychiatrists attributed to CCOs 15 .CPA was described as useful, however, for some patients who declined services.It could ensure monitoring of mental state and allow appropriate measures to be taken before a crisis developed thus preventing further complications in patients' affairs.
The variation in the use of LOA across the country is of note, but appears to follow no particular pattern in relation to Health Board.Previous research 16 looked at the variation in the use of LOA between health boards over time.There is no apparent relationship between use of LOA and deprivation.Studies of those patients for whom psychiatrists in England would have liked to use a hypothetical community treatment order showed that not all psychiatrists with adult community care patients used LOA 17 .
Lack of CPA may not indicate that the principles of collaboration were not being adhered to but rather that this was not done in the formal name of CPA.A number of comments indicated that CPA would add nothing to current management.In some cases this would seem to account for the suggestion that CPA had made no difference to the patient's care.This should not necessarily be interpreted as saying CPA is redundant.A safety net may still be appropriate even if no one falls.
The comments about bureaucracy, echoing as they do comments made about CCOs, require further consideration.What is being complained about?Is it an administrative load and additional paperwork or is 'bureaucracy' a euphemism for all the meetings involved and the time taken by multi-disciplinary care and consultation?Comments indicated both meanings but numbers are too small for conclusions to be reached.In depth interviews would be required to elucidate this issue.The administrative load carried by consultants with multiple patients on section, LOA, CCO and CPA, however, should not be underestimated 18 .
There is some evidence of patients having positive views on their experience of CPA 19 , but how, if at all, this relates to their status in relation to the Mental Health (Scotland) Act 1984 is not known.
Before the introduction of the 1995 Act the use of lengthy LOA was on the increase 20 .There was consistent opposition to its restriction by psychiatrists on the grounds that it would mean that they would not be able to maintain high risk and vulnerable patients in the community without it 21 .It is therefore important to understand why the CPA that was intended to ensure that these patients did not fall through the gaps between agencies was not extensively used.Community Care Orders were also little used 22 .It is not possible to tell from this research if the low use of formal non coercive collaborative methods is due to lack of resources such as clinical time or to antipathy to the philosophy behind these approaches.Alternatively LOA is seen as justified when the only need perceived by services is that the patient continues to take their medication.
The Mental Health (Care and Treatment) (Scotland) Act 2003 raises the prospect of renewed requirements for formal care plans.It will be the MHOs duty to prepare a care plan in conjunction with the patient's psychiatrist after consulting with a wide group of involved and interested parties.The Act lays out what the care plan will need to specify.These plans will be presented to a mental health tribunal who will have the power to authorise or reject them.For patients who are to be placed on a C-B CTO this can be seen as enforcing CPA on psychiatry.Since this will now be a legal responsibility Health Boards and Local Authorities as well as individual consultants and MHOs will have to take it on board.The MHO will have a stronger role in the new legislation in relation to care planning than under current arrangements for CPA.Whether this, the time scale involved for application for compulsory treatment, and the legal imperative will make any difference to

Table 1 .
Study population by health board n = 266 Table 2 comes from the questionnaire to MHOs and consultants.There were 246/293 (84%) responses from consultants and 259/315 (82%) responses from MHOs.Of those professionals working with detained patients, 202/244 (83%) of MHOs and 160/208 (77%) of consultants responded to the question about how well was CPA developed in their area.Details by local authority are given in Table 2.Although CPA is largely health led, MHOs are employed by

Table 2 .
Views on the development of CPA by local authority from MHOs and consultants who treat patients detained under theMHA 1984

Table 3
Views on the impact of CPA by Health Board from consultants with patients who reached the legal limit ofLOA n = 195

The Care Programme Approach and the end of indefinitely renewable Leave of Absence in Scotland 107
Comments were made by psychiatrists for a minority of patients (76, 36%).Of the 63 consultants who said CPA enhanced their patient's care, 25 (40%) made comments.The main themes were in the usefulness of bringing people together, enhancing the patient's role in their treatment and managing difficult situations.eg:Where consultants believed CPA had added nothing to patient care, 19 (40%) made comments.Most reflected the view that CPA was unnecessary as the patient's needs were straightforward or CPA reflected what was already happening, eg: "(Patient) needs are relatively simple and would have been met with or without the CPA." "(Patient) wants are minimal (house is his/her own, income is adequate, self care is basic but adequate) as long as he/she receives his/her medication.""CPA ensures good staff liaison -no difference to management."Two consultants, however, raised different issues: