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Care and Treatment Reviews – Dimensions responds to NHS Consultation

To help make our vision of an inclusive society where people have equal chances to live the life they choose a reality, we regularly respond to social care consultations. We’d like to share one of our responses with you, and urge you to share and support our response and help us drive change.

1.0 Introduction

1.1 Care and Treatment Reviews (CTRs) are multidisciplinary events that aim to comprehensively assess an individual’s support requirements, particularly those individuals residing in long stay institutions such as Assessment and Treatment Units (ATUs). The scope of a CTR is threefold:

  • Safety
  • State of current support
  • Discharge Plan

1.2 As a provider specialising in supporting people with behaviour that challenges out of ATUs, Dimensions has been asked to contribute to this review of CTRs. Many individuals at Dimensions have direct experience of CTRs and this paper represents a composite organisational view. Our response does not cover every topic outlined in the formal response paper. Instead, we have chosen to focus on the following key topics:

  • Frequency
  • Attendance
  • Discharge Plans
  • Families
  • Emergency Responses

2.0 Frequency

2.1 Everyone should receive one CTR every six months. In addition, a CTR should be completed 10 days following admission into an ATU.

2.2 HSCIC data for 2015-16 shows that half of all patients had a review within the preceding 6 month period. 21% of patients had a review between 6 months and one year ago. And 28% had not had a review at all in the preceding 12 months. The position is getting worse; a year previously, 77% had had a review in the allotted timescale.

2.3 Problems include:

  • A lack of suitably qualified individuals to chair CTR meetings
  • Availability of clinical experts
  • Lack of commitment to hold reviews

2.4 We believe that a wider range of individuals, including representatives from provider organisations, could be asked to chair and attend meetings. Meetings should be planned much further in advance. We would even suggest consideration of some form of penalty (reward) for responsible organisations that fail to (do) hold timely CTRs.

3.0 Attendance

3.1 Attendees at CTRs include relatives, experts by experience, psychiatrists, psychologists, occupational therapists, commissioners and members of clinical commissioning groups, and social workers.

3.2 Despite this broad base, it is Dimensions’ experience that very often the CTR is unaware of the full range of support options on offer, both locally and beyond, that could offer a viable alternative to the ATU. There’s a pervading view of “we’d theoretically like to discharge x but there’s nowhere safe to discharge him/her to.”

3.3 This frequently inaccurate view is often held most strongly by senior individuals who are employed by the ATU.

3.4 The meeting must find effective ways to challenge this view. Whilst it would not be appropriate for unconnected providers to attend the meeting, there should be the opportunity for the meeting to consider the full range of support options available – perhaps the local Commissioner or OT should be required to deliver a presentation outlining a summary of locally available support options.

4.0 Discharge Plans

4.1 The discharge plan – or lack thereof – is of paramount importance to the achievement of the Transforming Care agenda and in our experience discharge plans within CTR documents vary from inadequate to non-existent.

4.2 Discharge plans should be in place from point of entry into an ATU. No-one should be admitted without a plan for discharge. However, Dimensions experience of the discussion around discharge is that a range of barriers prevent early planning:

  • The person is not ready or may never be suitable for discharge because of the complexity of their needs – it is far too soon to start discharge planning
  • The team do not yet have a full understanding of the person
  • Discharge is theoretically a good idea but there is nothing suitable available in their area
  • Key panel members are unaware of successful community based support so lack a model from which to base their thinking

4.3 There is an understandable, real aversion to risk from the hospital team. Any change brings risk, and a move from a secure environment to community living does carry potential risk. Bad experiences, such as this one, do make the news. However, modern approaches to support planning together with the financial investment made possible by not funding a bed in a secure environment, allow for minimisation of risk. One statistic that has not been published to our knowledge is the offending rate amongst people who have left a low secure environment. Such a statistic might encourage conservative professionals to be bolder.

4.4 It is also our experience that few of the most senior people and decision makers in the room for a CTR have contemporary knowledge of the services available, or which could be made available, in their local area to support people with forensic, more complex or severe challenging behaviour. Fault for this lies not only with these individuals but also with providers whose promotion of their service, or service capability, has evidently not reached those in the CTR. Our most important recommendation is therefore that this knowledge gap must be tackled.

4.5 There are many possible approaches to tackling this knowledge gap. Dimensions would support at least the following:

  • More prominent provider forums, hosted by a CCG or NHS footprint, possibly led by a self advocacy group like Learning Disability England, to which patients, CTR attendees and families are invited
  • A searchable online listing of providers identifying key components of their support provision
  • Mandatory training (or other exposure) for CTR delegates in modern approaches to support
  • Sharing of anonymised success stories, perhaps through a ‘best practice’ hub around Transforming Care

4.6 There are significant financial disincentives both for the ATU to discharge patients, and for the Local Authority to accept new demands on their budgets. The Dowry only kicks in after 5 years. Whilst these issues are part of a wider picture, we believe that local efforts must be made to treat every support package as if it was an integrated personal commissioning budget. This could include:

  • Incentivisation of transition arrangements (incentivising both the existing private provider, and the local authority)
  • Local agreement to a 1 or 2 year dowry, not a 5 year one

5.0 Families

5.1 Families often represent a catalyst for change. Those that shout loudly enough, do their own research, and lobby for their loved one to leave and ATU can often (not always) achieve success. However, in our experience many other families are isolated and uninformed about alternatives to hospital support.

5.2 Some families report bad experiences of inadequate community support that may have led or contributed to the hospital admission and understandably want assurances that their relative will be safe and well supported.

5.3 Few families have knowledge and experience of what good community based support looks like, they don’t know what is available locally, and they just don’t want their loved one to leave the safety and routine of a hospital environment. The Care and Treatment Review might be the first time that the possibility of discharge has been raised in a long time. Having placed their trust in one part of the system, another part of the same system is suggesting something quite different.

5.4 Without personal knowledge and clear evidence of successful alternatives, families can be unfairly disadvantaged as real partners in the discharge process. It can be particularly hard for the older parents who have seen many changes and no longer have the health to take an active role in ensuring their relative is well supported.

5.5 Supporting an isolated family, or one which doesn’t necessarily want change, to take a fully informed and active role in finding alternatives to hospital is a role requiring empathy, an understanding of the person’s history, and current best practice and possibilities. Family Consultants, such as those employed by Dimensions, who can offer independent, expert advice on the options based on the individual needs of the person and their family, are well placed to deliver this.

6.0 Quick solutions

6.1 Providers are often asked to provide accommodation and support at short notice. Patient X has to leave hospital in 6 weeks. What can be done for him/her?

6.2 Fast responses carry the greatest risk. A provider cannot expect to get to know the individual and their family in that period; cannot find and adapt a property; cannot recruit the right staff in a personalised manner. A gradual change is generally essential to build trust, open eyes to potential, and establish a new life without recurrence of behaviours.

6.3 If discharge planning begins at the admission CTR, an early relationship can be established with appropriate provider(s). Although the exact nature of support needed six+ months down the line will not be known, property can be sourced and a liaison manager appointed to develop relationships with the person and their family, and work alongside the therapeutic team to develop a clear model of support leading to sustainable discharge.

7. Summary of recommendations

7.1 A wider range of individuals, including representatives from provider organisations, should be asked to chair and attend CTR meetings.

7.2 CTR meetings should be planned much further in advance.

7.3 Consideration of a penalty/reward structure for responsible organisations that fail to/ hold timely CTRs.

7.4 The CTR meeting must be able to consider the full range of support options available – perhaps the local Commissioner or OT should be required to deliver a presentation outlining a summary of locally available support options.

7.5 Publish the offending rate amongst people who have left a low secure environment. Such a statistic might encourage conservative professionals to be bolder.

7.6 Tackle the support options knowledge gap amongst CTR members through:

  • More prominent provider forums, hosted by a CCG or NHS footprint, possibly led by a self advocacy group like Learning Disability England, to which patients, CTR attendees and families are invited
  • A searchable online listing of providers identifying key components of their support provision
  • Mandatory training (or other exposure) for CTR delegates in modern approaches to support
  • Regular sharing of anonymised success stories

7.7 Local efforts must be made to treat every support package as if it was an integrated personal commissioning budget. This could include:
• Incentivisation of transition arrangements (incentivising both the existing private provider, and the local authority)
• Local agreement to a 1 or 2 year dowry, not a 5 year one

7.8 Engage more family consultants to work with isolated family, or families which don’t necessarily want change, to take a fully informed and active role in finding alternatives to hospital.

7.9 Through discharge planning at the admission CTR, develop an early relationship with a range of appropriate provider(s) to build a practical picture of sustainable post-discharge support.