Health Needs – DSRs and C(E)TRs

The purpose of C(E)TRs are to reduce the number of people with a learning disability or autism living in 
an inpatient hospital unnecessarily. This means to avoid admission wherever possible, or to plan discharge. The most important thing about a C(E)TR is that it is about the child, young person or adult and they should have chance to talk and share their views in any decisions.

Any inpatient admission should be based on very clear reasons why certain needs can only be met in hospital.

The review will look at 4 areas:

1. Is the person safe?
2. Are they getting good care now? This will include whether physical needs (and educational if CETR) are being met and what provision is required if not.
3. What are their care plans for the future?
4. Can care and treatment be provided in the community?

C(E)TRs are run by a group of people called a C(E)TR panel. C(E)TR panels should include people who are not involved in the child, young person’s, or adult’s everyday care to help the panel be independent. This helps the panel to be independent when they discuss the care and treatment required at the C(E)TR meeting. The panel members listen to those involved in the care (of the child, young person or adult). They look at the notes and check that the care and plans are working well.

A C(E)TR will be chaired by the commissioner (someone from the authority paying for the current services). They will usually be the Chairperson for the C(E)TR. If they are unable to attend
the review they must delegate authority to undertake this role to someone who can.

A Chairperson is someone who:

• runs the meeting
• ensures that all panel members feel able to contribute to the review
• makes sure the meeting is run well
• makes sure panel members’ views are reflected in the final report and recommendations
• makes sure that everything that was agreed at the meeting goes into an action plan
• makes sure the agreed actions listed in the action plan go ahead

There must also be two independent experts on the panel. One expert-by-experience, and one clinical expert.

An expert by experience. (Someone with relevant lived experience or a family member
of someone with relevant lived experience). They will

• supports the meeting
• help to decide what is in the action plan

A clinical expert. (Someone with a relevant health professional qualification and active registration with a relevant professional body. They should also hold professional indemnity insurance that covers them to practise on an independent basis. They will:

• independently check the care and treatment.
• support the meeting.
• help to decide what is in the action plan.

As well as the 3 people named above on the panel, other people will be invited to the meeting. These include:

• the child or young person
• someone they trust such as a family member, a friend or carer
• health professionals
• social care professionals
• advocates or self-advocates
• an education professional
• someone from their community team

If the review is for a child or young person (CETR), the inclusion of a children’s social care or
education professional on the panel should be considered.

If the review is for a person with specific physical health needs or a complex medication regimen, the panel may need a further clinical expert (eg a pharmacist).

The ICB will be responsible for the recruitment and support of experts by experience (often through a locally developed expert hub) and clinical experts, where appropriate, delegating responsibility at a place-based level.

C(E)TRs can be requested at any time and may be held in a hospital or in the community. They can last for several hours, depending on the complexity of the situation and needs.

In the community, C(E)TRs should happen if admission is a risk and looks at the extra support needed at home and in the local area. Getting the right care and treatment at the right time could mean only going into hospital when it is really needed.

For those held in the inpatient unit in which the child or young person is placed, the C(E)TR will be to make plans to support going home when well enough.

For adults in Assessment and Treatment Units (ATUs), CTRs should happen every 6 months. In secure services, it should be every 12 months.

For children and young people, a CETR should be every 3 months.

You can find out more about the ‘trigger points’ in 13.1 of the NHS Dynamic support register and Care Education and Treatment Review policy and guide

Anyone can ask for a C(E)TR but one would only be agreed if the support needs show there should be one.

Sometimes other people might ask for there to be a C(E)TR such as:

• A family member or carer
• The person who plans and pays for your care
• An advocate – someone trusted to support you and speak up for you
• The team who support you while you stay in hospital
• The team who support you in the community

The request is made to the Case manager, who will:

• identify key concerns
• consult clinical team
• consider appropriateness of a C(E)TR at the person’s current stage in the pathway
• ensure any issues that do not require a C(E)TR are addressed and escalated as required

If the person has capacity to consent to the meeting, they should be given all the information they need to engage in the process (easy read resources are available on the NHS CTR Policy Page).

It is a good idea to ask for a list of people who will be attending the C(E)TR, so that any specific questions can be directed to the right people.

C(E)TRs should focus on discharge or avoiding admission. Consider the type of support is needed and why. Write a list of:

• Any current concerns about the care and support being given now
• Anything that is missing from the support being received now
• What will be needed in the future

If possible, research ideas for what support could be put in place to avoid admission or support discharge. Mencap can provide suggestions of providers, behaviour specialists and information about housing.

If there is concern that there is a risk of admission because of a lack of local services rather than a need for an inpatient hospital admission, the following questions could be asked:

• What needs are there that can only be met in hospital and not in the community?
• What assessments will be completed?
• What treatment will be provided? How long will this take?

If it is not covered at the end of the CTR/CETR ask:

• What are the recommendations? Who will deliver each action? When will it be completed by?
• What is the date for the next CTR/CETR meeting?

You should receive a written record of the meeting within two weeks including key decisions and actions. The record (report) should be written in a way that is easy to understand. For any difficult words, a request can be made for someone to go through it or the action plan with you. You can use this document to prepare for the next Review and to regularly request updates on progress. You can continue to look for suitable options alongside the care co-ordinator and suggest these.

The report is sent by the Chairperson to:

• you and the people who manage your care and treatment.
• the people who were at the C(E)TR.

If you feel that the C(E)TR was inadequate, you should in the first instance discuss this with the care coordinator or the Chairperson of the review. If you have a problem with your C(E)TR you can speak to someone you trust to support you. Such as:

• A family member
• the named nurse
• an advocate

If you are unable to move things forward, here are some further options to consider:

• Make a formal complaint about the CTR/CETR. Your local area should have a local CTR complaints policy, or you can complain through the standard complaints process of the commissioning authority.
• Seek specialist legal advice. Mencap can provide further information and in some circumstance refer you to a solicitor for legal advice.