“Well, he keeps taking other people’s milk.” Top tips for Care and Treatment Reviewers

Julian Hill, a registered nurse, has been taking part in Care and Treatment Reviews (CTRs) for people with a learning disability, autism or both for the last two years and he provides a few of his top tips for reviewers.

Is just one of the very curious responses I have heard to the question, “so, why does he need to be in hospital?”

CTRs were invented just over two years ago and are part of NHS England’s response to the stark realisation that too many people with a learning disability were stuck in long term hospitals with not enough oversight from the NHS Commissioners funding these types of placements.

As an independent nurse I do lots of interesting things but CTRs are the one thing that has the most positive direct impact and I love doing them. The independence allows you to be naturally disruptive from a clinically informed perspective. On this day, you have a duty of care to one person and it is very liberating for you and for them (literally).

As part of a CTR panel with an expert by experience (either a family carer or a person who has a learning disability), I have shone a light on to the care of people who are seriously stuck in the hospital system.

“Why are they in hospital?” is one of the key questions to be asked but often a far more illuminating one is, “tell me about John?” That very simple question leads to a discovery of how the professional feels about someone they are caring for, sometimes you hear about a fantastic person who has very particular needs and support. Regularly you will hear about somebody who has a hopeless life, is risky and will need to be in hospital for another few (mostly ill defined) number of years.

I am yet to meet anybody who can’t – now or at some time in the future – have a good quality life in the community. The vast majority I meet could be in the community now; they just need the service to be built around them. The challenge in a CTR is to articulate what that may look like in a credible way.

A few top tips for other CTR reviewers:

  • One – “accept nothing, question everything” (Johnny Rotten c’76) – do dig around, it’s no use to just listen to the care team explaining why someone should stay in hospital care. You need to poke around the care records. If someone needs psychological therapy, you need to go and find the evidence that this is happening, and if it is, what the conversations in the sessions are. Are the sessions leading to the goal that was set?
  • Two – make an alliance with the expert by experience; with a convincing rationale for a community care package from the two of you, the argument for discharge will find much less resistance.
  • Three – don’t be afraid to take the lead, mostly on conversations but sometimes with the day. Some commissioners will need different support to others. Talk to them about what they would find helpful from you, if you are an experienced nurse with good leadership skills, show them. Not all commissioners come from clinical or learning disability backgrounds so they need you to be able to deconstruct the person’s care. Vigorously discuss alternative ways of supporting the person and making smart recommendations to ensure a timely discharge or avoid admission.

You get to spend some time with amazing people at CTRs – all with one common problem, they need to meet someone who can see their potential, hold their hope and clearly describe their journey back in to the community.

In March 2017 NHS England refreshed the CTR policy following consultation. The latest update is a new e-learning programme designed to support challenging values and shifting power to the individual. This e-Learning programme is for Expert advisers- both experts by experience and clinical advisers, Commissioners, provider services and other professionals, tribunal and legal services, and health and social service staff.

You can visit the CTR pages on NHS England’s website here.

You can access the CTR e-learning without registering via open access here.

Julian Hill

Julian is an experienced nurse with 30 years in the fields of learning disabilities and mental health.

He works independently and is firmly committed to the principles of Care and Treatment Reviews.

He believes that people with a learning disability, autism or both should almost never be admitted to hospital. If there is no other option; then it is only appropriate to admit when the person has very clear treatment outcomes and a discharge package in place

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  1. Anonymous says:

    Well said Julian – keep up the good work. It really is making a difference – even if it doesn’t always feel like it at the time.

  2. Anonymous says:

    What an inspiring piece…..there is hope yet. Thank you