Overview of the Assessment and Review System

Last modified: February 28, 2019
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This section aims to explain what the current local and a national care and treatment system looks like in the context of this guide.  

The NHS England Transforming Care programme was developed to help improve health and care services so that more people with learning disabilities, autism or both who have a mental illness or whose behaviour challenges services can live in their own communities, with the right support and close to home. This would mean that fewer people need to go into hospital for their care.

Care and Treatment Reviews

The programme consists of a number of work streams.  One of these, called Care and Treatment Reviews (CTRs), focuses on three things:

    • reducing the number of people reaching crisis in their community and ending up in hospital for assessment and treatment;
    • making sure that care meets the person’s needs fully if in hospital; and
    • trying to reduce the length of inpatient stays by focussing on current and future care planning, including plans for leaving hospital.

A CTR is carried out at pre-defined periods (see below) by an independent panel of expert reviewers and can be held in hospital or in the community. 

For Children and Young people, it is called a Care, Education and Treatment Review (CETR), to make sure that their education needs are considered alongside health and care. Detailed National Policy and guidance governs the whole process to make sure that reviews are carried out to a consistent high standard.

CTRs and CETRs seek to answer four questions from the perspective of the patient.

    • Am I safe? 
    • What is my current care like? 
    • Is there a plan in place for my future? 
    • Do I need to be in hospital for my care and treatment?

Most importantly, the patient and their family (with the patient’s consent, if required) can also take part in the review and have their voices heard.

CTRs are held as follows: 

    • prior to admission, as required;
    • post-admission (within four weeks of admission or within two weeks for children and young people);
    • every six months for adults in non-secure hospitals; 
    • every 12 months for adults in secure hospitals; and
    • every three months for children and young people in hospital.

Community CTRs 

The aim of a community CTR is to prevent a hospital admission where it is being actively considered or sought because of an impending crisis in the community.  

The CTR panel will include the views of all those involved in supporting the individual in order to prevent an inappropriate hospital admission. It will look at your loved one’s needs and the care they require. The panel can then establish whether they need to be admitted to hospital or whether their care and treatment needs could continue to be met effectively and safely in the community through additional and/or alternative support and interventions. 

Inpatient CTRs

Inpatient reviews held at regular intervals will comprise a panel consisting of the responsible commissioner, representatives of the care team including the ward manager, psychiatrist and therapists. 

Other health and social care professionals and strategic commissioners will be invited to attend as required. Independent members of the panel will consist of a clinical expert and someone with lived experience of learning disabilities, autism or both. The agenda will allow for detailed assessment of the needs of the patient, current care and discharge planning.

For children and young people, the CETR should also include appropriate representation from children’s services to enable the educational needs of the child of young person to be discussed and addressed.

You can find out more about CTRs by reading Bringing Us Together’s  CTR family Survival Guide at: https://www.ndti.org.uk/uploads/files/CTR-Survival-Guide-Aug-2017-1.pdf

Further Information 

Care and Treatment Reviews: Policy and Guidance

https://www.england.nhs.uk/wp-content/uploads/2017/03/ctr-policy-v2.pdf

Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition: 

Service model for commissioners of health and social care services

https://www.england.nhs.uk/publication/service-model-for-commissioners-supporting-people-with-a-learning-disability-andor-autism-who-display-behaviour-that-challenges-including-those-with-a-mental-health-condition/

Transforming Care for People with Learning Disabilities – Next Steps

https://www.england.nhs.uk/wp-content/uploads/2015/01/transform-care-nxt-stps.pdf

Care and Treatment Reviews homepage

https://www.england.nhs.uk/learning-disabilities/care/ctr/

CTR/CETR Code and toolkit

https://www.england.nhs.uk/publication/care-and-treatment-review-code-and-toolkit/

How do local health and care services know who needs urgent help?

Local monitoring and intervention should take account of the following: 

    • Is the person placing themselves or others at serious and/or significant risk of harm? 
    • Is the person’s community placement or tenancy at risk of irretrievable breakdown and does this pose a significant risk to the safety of the person and/or others?
    • Is hospital admission being considered?
    • Has the person had an unplanned hospital admission in the last year?
    • Has the person been supported by a crisis team or similar to avoid a hospital admission in the last year?

National policy also emphasises the need for Clinical Commissioning Groups (CCGs) and commissioners to continue to maintain and develop this proactive approach to monitoring and intervention. This is because:

    • it requires close, collaborative working across Health, Education and Social Care to enable an improved understanding of the local population and facilitate joint working;
    • it assists commissioners to monitor individuals, identify existing gaps in current service provision and design; and
    • it enables partnership working with relevant stakeholders, to consider the types of resource required to provide more robust community-based alternatives.

Factors that may place someone at risk of admission

Factors that may put someone at risk of hospital admission could include:

    • significant life events and/or change such as bereavement or abuse;
    • unstable/untreated mental illness;
    • pain or distress from physical health issues (both diagnosed and undiagnosed); 
    • previous history of inpatient admission(s);
    • anyone subject to the provisions of the Mental Health Act (MHA) or Deprivation of Liberty Safeguards (DOLS);
    • presenting increased or significant episodes of behaviour that challenges;
    • being supported in an unstable environment or by a changing staff team;
    • not being previously known to learning disability services;
    • having no fixed address;
    • being in contact with the Criminal Justice System (CJS);
    • presenting ‘in crisis’ at Accident and Emergency (A&E) department;
    • having no family carers/advocates;
    • having drug and alcohol addiction problems;
    • having no effectively planned transition from child to adult learning disability services; 
    • being placed in specialist 52-week residential schools; 
    • having recently been discharged from long stay hospital beds;
    • being in receipt of services from youth offending teams; and 
    • those in receipt of Continuing Health Care (CHC) funding.

(NB: This list is not exhaustive and is based upon local criteria.)

Local Monitoring and Intervention

There are two important components of the CTR system which are used in the community to assess and manage risk and cope with any developing crisis: These are the Dynamic Risk Register and the Local Area Emergency Protocol which are explained below.

Dynamic Risk Register

A Dynamic Register is used by local health and care teams to identify and prioritise the needs of people living with learning disabilities and/or autism who have a mental illness or behaviour that challenges, who may be at risk of admission to a mental health hospital. This might be as a result of a change in needs and/or a failure in their care and support. 

The Dynamic Register aims to improve awareness of need and allow more responsive commissioning to ensure that those who need help the most are supported to stay well, have appropriate support to remain in the community and avoid unnecessary admissions to hospital.

Those on the Dynamic Register may be known in a number of ways, including previous contact with local intensive support teams, social care or local authority services, and/or community learning disability teams. They may previously have had periods of inpatient care or be in 52 week residential school placements.

Dynamic Register FAQs

1. Who should be on the Register?

Provided consent has been obtained beforehand, any person with learning disabilities, autism or both who is experiencing the factors listed on page 35 is at risk of inpatient hospital admission and can be placed on the dynamic register.

2. Who decides who goes on the Register?

With appropriate consent, the relevant CCG, LD Complex Needs Panel or equivalent, Multi-Disciplinary Team (MDT) get together routinely to discuss cases in order of need

3. Can parents ask for their son/daughter to be assessed to go on the list? 

Yes, this would be welcomed as you are likely to know if there is difficulty arising better than anyone, it is better to have a community CTR to anticipate and reduce the likelihood of a crisis developing.

4. Can families ask for a CTR if their loved one is not on the Register?

Yes (please see above). It may be that the person is not known to services (e.g. someone without a diagnosis or living with ‘high functioning’ autism who was managing well but a sudden change is causing difficulties).

5. Is the Register for all ages?

Yes, the register is used for children, young people and adults.

6. Is the Register for people with mental health concerns as well?

Yes, if the person has a Learning Disability or Autism.

7. How often are those on the Register reviewed?

Everyone on the register is assessed regularly to make sure that they are getting the help they need. For example, those with the highest priority could be checked daily and others with the least priority perhaps monthly.

8. Are people told when they are placed on the Register and when they come off?

Yes decisions must be made with the consent of the person involved.

9. Is there an official definition of a crisis in this context?

Anyone at risk of admission to hospital or in need of more support to prevent escalating behaviours that challenge is at crisis point.  This may include family/carers or school staff struggling to meet a young person’s needs and/or if the young person’s change in presentation is putting themselves or others at risk.

10. If a crisis happens who is responsible for requesting a CTR? 

Anyone who is providing care or support for the person can request a CTR, including parents. If there is not time to arrange a CTR, a Local Area Emergency Protocol may be used to carry out an emergency review

Local Area Emergency Protocol 

The Local Area Emergency Protocol is designed to help health and care services to respond quickly to an unexpected potential crisis that must be dealt with immediately. Anyone involved in the care of a person with learning disabilities, autism or both can raise concerns about an individual who is at risk of being admitted to hospital unnecessarily. 

The Protocol lays down how crisis situations are managed if there is no prior knowledge of the escalating risk and no time to hold a community CTR. An emergency meeting should then be organised and chaired by the lead commissioner (either an emergency meeting or teleconference) with the aim of averting the crisis and avoiding an inappropriate admission to hospital. 

Due to time limitations, the emergency protocol does not usually involve an independent expert panel (as with CTRs).

What do good outcomes look like?

The National Service Model for Commissioners of Health and Social Care services outlines what local services should look like if they are to effectively meet the needs of children, young people and adults with a learning disability, autism or both who display behaviour that challenges, including those with a mental health condition.

Although every local area will be different, the service model outlines nine core principles. These are written from the perspective of a person using such services and what they should expect.

1 I have a good and meaningful everyday life.
2 My care and support are person-centred, planned, proactive and coordinated.
3 I have choice and control over how my health and care needs are met.
4 My family, paid support and care staff get the help they need to support me to live in the community.
5 I have a choice about where I live and who I live with.
6 I get good care and support from mainstream health services.
7 I can access specialist health and social care support in the community.
8 If I need it, I get support to stay out of trouble.
9 If I am admitted for assessment and treatment in a hospital setting because my health needs cannot be met in the community, my care and treatment will be of high quality, and I will not stay in hospital longer than I need to.

Running consistently through all nine principles are five human rights-based outcomes called ‘Golden threads’ which should be reflected in local commissioning strategies.

Quality of Life Personalised care and support, dignity and respect
Keeping people safe Protecting from harm, openness and positive risk-taking
Choice and control Self-determination and support when needed
Support & interventions These must be provided in the least restrictive manner possible
Equitable outcomes Accessible, reasonably adjusted community-based health and social care

The National Service Model therefore sets the standard that all Local Authorities and Clinical Commissioners must aspire to in order to satisfy the reasonable expectations of someone who might use such services. 

Further Information 

Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition

https://www.england.nhs.uk/publication/service-model-for-commissioners-supporting-people-with-a-learning-disability-andor-autism-who-display-behaviour-that-challenges-including-those-with-a-mental-health-condition/

Meeting The Challenge – guides for families: Guides on getting the right support for people with a learning disability and behaviour that challenges 

http://www.challengingbehaviour.org.uk/information/information-sheets-and-dvds/assessmentandtreatmentunits.html

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