Stream E – Clinical leadership: using dynamic risk registers to prevent admissions and Care and Treatment Reviews to facilitate discharge Dr Roger Banks and Dr Salim Razak discuss clinical leadership and clinical culture and the dynamic process for risk stratification before describing C(E)TRs, their outcomes so far and their role in achieving successful discharge into the community.

1. Clinical
Leadership
- dynamic risk
register and C(E)TRs
Dr Roger Banks
Senior Psychiatry Lead
National Learning Disability Programme
Dr Salim Razak
Consultant Psychiatrist
Avon and Wiltshire

2. LEADERSHIP
CULTURE /
ENVIRONMENT
ESSENTIAL
CLINICAL SKILLS
AND ROLE

3. • Interrelationship between:
• Clinical skills
• Environment / culture (behaviours and attitudes)
• Leadership

4. Core Culture in Transforming Care
• Flexible and collaborative working
• Working together with people with LD and families
• Proactive working that is prepared to challenge and find ways of
overcoming barriers
• Proactive and confident working with complex and dysfunctional systems

5. CL and CC in Transforming Care and the
Learning Disability Programme
• Decreasing the use of hospital beds
• Stop regarding hospital as home
• Stop placing people far away from their families and home
• Enable people to move out of unnecessarily lengthy hospital stays
• Ensure Care and Treatment Reviews carried out and with QA
• Developing more robust and capable community supports
• Developing the workforce
• Reducing health inequalities
• Reducing morbidity and mortality
• Working in partnership with families

6. Why dynamic registers and C(E)TRs?
• Too many people in specialist mental health and learning disability
hospitals without discharge dates
• Too many people being admitted to specialist mental health and learning
disability hospitals
• Need for “2nd opinion” (Norman Lamb)

7. The challenge in 2014:

8. Dynamic register?
• Acknowledgement that, most people who present significant behavioural
challenges and who are at risk of a break down of their supports to live
ordinary lives in the community – are already known to services.
• Why, therefore, wait for a crisis before committing time and resources to
providing the right support in the right place at the right time

9. Dynamic register?
• The term dynamic register is used in the national service model to
describe a process for risk stratification of the local population of
people with a learning disability, autism or both who present behaviour
that challenges
• As a minimum, each Clinical Commissioning Group (CCG) would be
required to develop a register of those ‘at risk of admission’.
• Proactive monitoring intervention and support.

10. Dynamic Risk Stratification Process

11. Care (Education) and Treatment Reviews
• Introduced in October 2014
• Business as usual – November 2015
• Audit / engagement
• Policy review and update 2017

12. What does the C(E)TR do?
• support people with learning disabilities and their families to be listened to and equal
partners in their own care and treatment pathway
• prevent people with learning disabilities being admitted unnecessarily into inpatient
Learning Disability and Mental Health hospital beds
• ensure any admission is supported by a clear rationale of planned assessment and
treatment together with defined and measurable outcomes
• ensure all parties work together with the person and their family to support
discharge into the community (or if the only option, to a less restrictive setting)
at the earliest opportunity. Local authority involvement in all CTRs is best practice,
ensuring that relevant issues can be fully addressed and all solutions explored for
the safe discharge of individuals into community based settings.

13. What does the C(E)TR do?
• support a constructive and person-centred process of challenge to
current care and treatment plans where necessary
• identify barriers to progress and to make clear and constructive
recommendations for how these could be overcome
.

14. Key Questions in the Care and Treatment
Review?
• Is it safe?
• Is it effective?
• Is their experience of the care good?
• Why does this care and treatment have to continue in hospital?
• Is the person and their family involved in decisions about care and
treatment as equal partners ?
• What needs to happen to support discharge into the local community?

15. Who is in the review team?
• The commissioner responsible for the individual’s community package of
care and treatment ( or someone delegated by the commissioner with
delegated authority on behalf of the commissioner) and where
appropriate a local authority commissioner will also join the panel
• An Expert by Experience
• A Clinical Advisor (e.g. psychiatrist, psychologist)

16. What is the role of expert advisors?
• To work as a team carrying out the review of an individual’s service
• To contribute another view based on experience: professional and / or
personal
• To bring experience of working with others to support people who present
behavioural challenges in the community and to avoid hospital admission
• To improve communication with service users and families to understand
better their views and experience
• To promote Equality, Diversity and Human Rights
• To challenge where appropriate

17. Carrying out a Care and Treatment Review
• The aim of the day is to have open and honest discussions and to
support people to find solutions and unblock barriers to discharge
• Inclusion of individual and family members
• To commit adequate time and detail to the review
• To escalate concerns and make safeguarding referrals if necessary

18. The Care and Treatment review is NOT there to:
• Blame people
we are interested in finding out who are the people who are most able to be helpful in moving the person
towards discharge. If there are people who hold views that seem to be preventing this then the review’s job is
to explore their reasons in detail and to find ways of addressing the concerns they have in a more constructive
way
• Pursue complaints
it is very likely that the reviewers will encounter complaints that have been made or may reveal information
that leads to a complaint. It is not the responsibility of the review to get involved in these, but to make sure that
the people who are supposed to deal with the complaints have been notified.
• Argue with clinical diagnosis
there may be disagreement between people about any diagnosis that has been applied during the person’s
time in hospital. The review’s job is not primarily to argue against this but to explore in greater detail why the
diagnosis has been given and what this really means in terms of being able to support the person to be
discharged from hospital. The review should be asking if there is any diagnosis that would require the person
to stay in hospital

19. The Care and Treatment review is NOT there to:
Discharge or admit (“do CETRs work?”)
But to advise and jointly set SMART recommendations between the
commissioner and the clinical teams

20. Pre-admission Care and Treatment Reviews (total)
20
• Data from regional data collections, collected 15 February 2018
• Pre-admission CTRs between 1 April 2016 and 31 January 2018 = 1,500
• This records the number of CTRs, not necessarily the number of individuals, as it is possible a person may have had more than one pre-admission CTR within the year if
not admitted

21. Inpatient Care and Treatment Reviews (total)
21
• Data from Assuring Transformation, as at 31 January 2018. Data is rounded & suppressed in accordance with NHS Digital’s guidance to minimise disclosure risk from
small numbers.
• Outcomes as recorded for CTRs between 1 April 2016 - 31 January 2018
• 5,740 inpatient CTRs are recorded as being completed between 1 April 2016 - 31 January 2018 for England

22. Pre-admission Care and Treatment Reviews (< 18)
22
• Data from regional data collections, collected 15 February 2018
• Pre-admission CTRs between 1 April 2016 and 31 January 2018 = 295
• This records the number of CTRs, not necessarily the number of individuals, as it is possible a person may have had more than one pre-admission CTR within the year if
not admitted

23. Inpatient Care and Treatment Reviews (< 18)
23
• Data from Assuring Transformation, as at 31 January 2018. Data is rounded & suppressed in accordance with NHS Digital’s guidance to minimise disclosure risk from
small numbers.
• Outcomes as recorded for CTRs between 1 April 2016 - 31 January 2018
• 660 inpatient CTRs are recorded as being completed between 1 April 2016 - 31 January 2018 for England

24. What have C(E)TRs delivered?
• Change in the balance of power for people with learning disabilities and
family members
• The ability to challenge the current care and treatment plans
• Detailed review of care and treatment plans (KLOEs)
• SMART goals and recommendations
• Greater direct engagement of commissioners, family members and
others
• Reduced admissions
• Gradual decrease in inpatient numbers
• Raised profile of experts by experience

25. Key Lines of Enquiry
• Does the person need to be in hospital?
• Is the person receiving the right care and treatment?
• Is the person involved in their care and treatment?
• Are the person’s health needs known and met?
• Is the use of any medicine appropriate and safe?

26. Key Lines of Enquiry
• Is there a clear, safe and proportionate approach to the way risk is
assessed or managed?
• Are any autism needs known and met?
• Is there active planning for the future and for discharge?
• Are families/carers listened to and involved?
• Are the person’s rights and freedoms being upheld?
• Are specific considerations being given to the needs of children and
young people? (CETR)

27. BUT
• These gains only happen if the C(E)TR is carried out properly (in line with
standards)
• People are still taking short cuts
• Not every one who should have a C(E)TR is getting one
• Standards of recommendations and follow up are variable

28. rogerbanks@nhs.net

29. C(E)TRS in practice – some reflections
• Dr Salim Razak