CARE & TREATMENT REVIEWS Induction for expert advisors - - PowerPoint PPT Presentation

CARE & TREATMENT REVIEWS

Induction for expert advisors

Programme:

• Background
• What is the job to be done? Why?
• Why are people with learning disabilities in hospitals?
• Understanding challenging behaviour
• What is care and treatment?
• The care and treatment review process
• Role and requirements of expert advisors
• What does it intend to do and how?
• Potential problems
• Support

Who are the people whose care and treatment is being reviewed?

David

• Lived with parents all his life
• Stalwart of local community
• Interests in steam trains – family trips
• Sudden change in behaviour – ‘not normal’
• Police ‘riot squad’
• Parents cannot cope – hospital admission
• Physical symptoms
• Parathyroid tumour
• Fixed but moves to live independently

Evan

• 26 yrs old
• Severe autism
• Self-injury (banging head) since age of 5
• Abused in residential home
• Now in hospital under mental health act
• In isolation
• Evidence of traumatic brain damage (2° to

SIB)

Mary

• Has lived in her own home for 10 years after 30 years of

living in hospitals

• Admitted to hospital because family could not cope with

behaviour

• Admitted because that was the ‘norm’ in those days
• Rapid cycling bipolar disorder
• Large amounts of medication
• Is overjoyed to be able to be visited by her family at

birthdays and Christmas

• Would be traumatised by re-admission to hospital
• Has a staff team who love and respect her and are

determined that she should remain in her own home.

Six out of 11 care workers who admitted a total of 38 charges of neglect or abuse of patients at a private hospital have been jailed. Five other workers from Winterbourne View near Bristol were given suspended sentences after the acts of abuse were uncovered by BBC Panorama.

BUT…

There is a long history of neglect, institutionalisation and abuse:

• Ely Hospital 1968-9
• Longcare 1998
• Cornwall 2006
• Sutton and Merton 2007

and more ….

• The abuse of people in hospital care is

appalling in itself AND ALSO:

• People with learning disabilities should not be

living in hospitals

What is the situation for people with LD in England?

• 985,000 people with intellectual disabilities

in England (2007 Centre for Disability Research, Lancaster University)

• 132,300 adults with learning disability using
• services. (2008/9)
• 10-15% present challenging behaviour
• “more demanding” challenging behaviour is

shown by 64% of people identified as showing challenging behaviour;

• around 50% of people with “more demanding”

challenging behaviour live with their families.

• 48% of patients mainly described as receiving learning disability

services in mental health facilities in England and Wales had been detained under the Mental Health legislation on admission

• In England, a reduction (24%) in the overall number of in-

patients from 4,435 in 2006 to 3,376 in 2010.

• Within that, the proportion of patients in independent sector

provision rose from 21% to 32% and the number of independent sector providers increased (from 48 to 61).

The challenge now:

Why are people admitted to hospital?

ENVIRONMENT

Challenging behaviour:

Shift focus from individual to carers / environment / professionals Challenge to the system:

• Better understanding
• More effective responses
• Creativity / flexibility
• Less punitive / aversive responses

SO THAT:

• Behaviour will be less often – no longer have same

function

• OR
• People are better able to cope with the behaviour

Challenge is to be accepting and at the same time creative and capable

• find more creative responses and solutions
• overturn traditional or longstanding responses
• adopt counter-intuitive ideas
• question the necessity for the established

reputation and practice around the individual

Challenge is to be accepting and at the same time creative and capable

• take managed risks
• adopt a greater flexibility of roles and

responsibilities

• establish creative and unconventional working

partnerships between individuals, community supports, voluntary and statutory agencies, professionals.

‘Instead of responding to the person we typically react to the behaviour’ ‘Most of what passes as assessment seems to be denial about the mutuality of our common condition’

Herb Lovett ‘Our job is not to fix people, but to design effective

environments’

Rob Horner

‘Difficult behaviours are messages which can tell us important things about a person and the quality of his or her life’

David Pitonyak

What is Care and Treatment?

(from Mental Health Act 2007)

“medical treatment" includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care This means medical treatment in its normal sense as well as the other forms of treatment mentioned. Psychological interventions include cognitive therapy, behaviour therapy and counselling.

What is Care and Treatment?

(from Mental Health Act 2007 – Explanatory notes)

"Habilitation" and "rehabilitation” describe the use of specialised services provided by professional staff, including nurses, psychologists, therapists and social workers, which are designed to improve or modify patients' physical and mental abilities and social functioning. This can include helping patients to learn to eat by themselves, to improve communication, or preparing them for a return to normal community living.

The distinction between habilitation and rehabilitation depends in practice

• n the extent of patients' existing abilities "rehabilitation" is appropriate only

where the patients are relearning skills or abilities they have had before.

What is Care and Treatment?

(from Mental Health Act 2007 – Explanatory notes)

“medical treatment” - the purpose of which is to alleviate, or prevent a worsening of, the disorder

• r one or more of its symptoms or

manifestations.

What does the Care and Treatment Review do?

• Support the individual and their family to have a voice
• Support professionals to work together with the

person and their family to support discharge from hospital

• Asks why the person needs to be in hospital, and if

there are care and treatment needs why can these not be carried out in the community?

• If the resources and support are not be in place to

support someone’s discharge, then to make clear recommendations about what needs to be done to get to the point of a safe discharge.

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?

Who is in the review team?

• The CCG commissioner responsible for the

individual’s community package of care and treatment ( or someone delegated by the commissioner with delegated authority on behalf

• f 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)

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

Carrying out a Care and Treatment Review

• Regional teams will set up the review
• Lead commissioner will contact the service user

and their family

• Review team will meet at the start of the day and

plan how they are going to work

• The commissioner leading the review will be

responsible for making a record of the main findings and recommendations

• The aim of the day is to have open and honest

discussions and to support people to find solutions and unblock barriers to discharge

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

The Care and Treatment review is NOT there to:

• Assume that there will be an ‘automatic’

discharge for the person being reviewed

The aim of the reviews is that many fewer people should be staying in hospital care – but it is important that when someone is discharged from hospital that they are safe and that the services that will be supporting them in the community are skilled and robust enough to make sure that the person is not let down.

So what detailed questions will the review team be asking? (see the assessment form for full details)

• Is there a comprehensive treatment plan

based on a joined-up formulation* and diagnosis?

• Do these treatments need to be delivered in

hospital?

• Has the person / their family been involved in

working out their treatment plan?

So what detailed questions will the review team be asking? (see the assessment form for full details)

• Is there a comprehensive treatment plan

based on a joined-up formulation* and diagnosis?

• Do these treatments need to be delivered in

hospital?

• Has the person / their family been involved in

working out their treatment plan?

* Formulation is a process of making sense

• f a person’s difficulties in the context of

their relationships, social circumstances, life events, and the sense that they have made of them. It also takes into account the views of family / carers. A formulation, together with a diagnosis, should explain what needs to be done to help the individual and how people will know if this has been successful.

So what questions will the review team be asking?

• What is the balance between the positives

and negatives of remaining in hospital?

• Is the person being harmed psychologically or

physically by staying in hospital?

• Is hospital making things worse rather than

better?

So what questions will the review team be asking?

• How has risk to the person themselves and to
• thers been assessed?
• Has this included the family?
• What risks are there to the person’s human

rights?

So what questions will the review team be asking?

• Is there a clear plan of Positive behavioural

support in place?

• And will this be able to be continued in the

community?

So what questions will the review team be asking?

• Have different models of support and different

providers been considered in thinking about the person’s future support?

• Does the person and / or their family feel that

they have been listened to and their feelings taken into account?

So what questions will the review team be asking?

• Have there been proper assessments of

capacity?

• Who is making sure that the person’s rights

are being protected?

What support is available for the review team?

• The review team, through the lead

commissioner can escalate concerns through a number of routes including:

– CCG Contracts. – NHS England – CQC

• if there are quality concerns in relation to a

service the lead commissioner will be responsible for following these up

What support is available for the review team from the National Transforming Care Team?

• Providing the Instructions and Toolkits
• Providing budget for regional teams
• Providing support “buddies” from the

improving lives team (ILT)

• Providing a list of Clinical Reviewers who can

be contacted to back up local resources

What support is available for the review team from the National Transforming Care Team?

• Enabling access to clinical reviewers (via the

ILT “buddy”)

• Road testing the process in October 2014
• Providing introductory training and support
• Developing a national panel to offer additional

support and expertise to reviewers for particular areas of expertise, for example. Mental Capacity Act; Pharmacology.

What support is available for the review team from the National Transforming Care Team?

• Providing central guidance and support:

anne.webster1@nhs.net (CTR lead) rogerbanks@nhs.net (co-lead part time)