Publication reference: PRN00117
Care (Education) and Treatment Reviews (C(E)TRs) were developed as part of NHS England’s commitment to improving the care of children, young people and adults with a learning disability and autistic people in England. They were designed to bring an additional challenge and scrutiny to existing health and care review processes, an alternative perspective and expert insight. When people are at risk of admission or are admitted to a mental health hospital, C(E)TRs are an essential person-centred process. Following the creation of integrated care system oversight panels as part of the national safe and wellbeing reviews, it was identified that the panels provided a helpful additional level of governance to ensure that people with a learning disability and autistic people who were being cared for in a specialist mental health inpatient setting were safe and well. The panels also helped to ensure that where concerns were raised immediate remedial action was taken.
Purpose and function
Development of the Care (Education) and Treatment Reviews (C(E)TR) policy has been in co-production with multiple key stakeholders and utilised learning from the integrated care system (ICS)oversight panels developed during safe and wellbeing reviews.
The ICS oversight panel’s overall aim is to co-ordinate and support activity (and where necessary formal intervention) so that implementation, outcomes and actions of C(E)TRs are targeted when needed.
The ICS oversight panel should review the escalated C(E)TR report and actions, assure themselves that the person is safe and well, and consider if any further action is needed to support the person’s progress or discharge.
Integrated care boards must ensure system partners are working with people and families to provide the right care, education, and treatment to avoid the need for an admission to a mental health hospital and ensure good care for all.
The approach to oversight is characterised within the NHS Oversight Framework (by the following key principles:
- working with and through ICS, wherever possible, to tackle problems
- a greater emphasis on system performance and quality of care outcomes, alongside the contributions of individual healthcare providers and commissioners to system goals
- matching accountability for results with improvement support, as appropriate
- autonomy for ICS and NHS providers as a default position
- compassionate leadership behaviours.
The framework describes the oversight process as following an ongoing cycle of:
- monitoring ICS and NHS organisation performance and capability
- identifying the scale and nature of support needs
- co-ordinating support activity (and where necessary formal intervention) so that it is targeted where it is most needed.
Oversight panels should also consider their role in conjunction with the following additional guidance:
- Learning disability and autism – framework for commissioner oversight visits to inpatients
- Host commissioner guidance
In line with the Dynamic support register and Care, (Education) and Treatment Review (C(E)TR) guidance, each integrated care system must develop (or maintain) an oversight panel that includes at a minimum:
- the ICS learning disability and autism senior responsible officer
- at least one expert by experience with appropriate skills and training
- a social care/local authority senior representative
- provider collaborative representation
- a senior clinician with expertise in learning disability and autism.
Panels may wish to consider the benefit of including a member who co-ordinates or is responsible for the dynamic support register.
Each oversight panel must have a terms of reference that reflects the oversight guidance and policy.
Criteria for case review
Panels must convene at least quarterly (more frequently if helpful) and should review the Care (Education) and Treatment Reviews (C(E)TRs) of people for whom concern has been expressed. This group must include, but is not exclusive to, people:
- with long stays
- for children and young people, with a stay of six months or longer
- for adults, with a stay of 12 months or longer (unless restricted by the Ministry of Justice)
- in long-term segregation or who are regularly secluded or subject to very restrictive practices
- who are placed in units or wards that the Care Quality Commission rates as inadequate
- who have made complaints about care, or their family has, and these have not been resolved through formal escalation routes to the satisfaction of all involved
- for whom a safeguarding investigation has been raised
- who have requested escalation, or their family has
- where the responsible commissioner has requested escalation
- where the advocate has requested escalation
- who have declined a C(E)TR on two or more occasions (consider capacity and best interest decision as per the Mental Capacity Act 2005 and NHS England shared decision-making.
The Integrated Care Board Oversight Panel should review the C(E)TR report and recommendations to assure themselves that the person is safe and well and consider if any further action is needed to support the person’s progress or discharge. The panel should specifically consider:
- the care and treatment the person is receiving
- the person’s physical health and wellbeing
- the person’s safety: including to confirm appropriate measures have been taken in response to any safeguarding concerns
- for those whose discharge is delayed, whether all partners are working to support discharge as soon as possible
- for those subject to significant restrictions, whether measures are in place to reduce these as soon as possible
- for those considered to have been placed in the wrong environment, whether mitigating safeguards are in place to support their care and wellbeing
- whether the person’s human rights are being upheld
- all quality assurance intelligence regarding the commissioned service, such as host commissioner reports and safeguarding information
- the need for ownership of any actions as the result of a review
- whether there are any issues that cannot be addressed at the integrated care system level and require escalation to the relevant regional team
- How C(E)TR review findings can feed into the integrated care system delivery plan.
Consideration for communication with the individual and family carers and advocates
Each integrated care system panel must have a process and timescale for communicating with individuals, family, and advocates. Panels must be able to evidence and share how decisions are reached and who is accountable for how this information is fed back.
Confidentiality and data sharing
All oversight panels must be able to demonstrate compliance with the six principles of the data protection Act Data Protection Act 2018 which are summarised below.
- Personal data shall be processed lawfully, fairly and in a transparent manner in relation to individuals.
- Personal data shall be collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes.
- Personal data processed must be adequate, relevant, and limited to what is necessary in relation to the purposes for which they are processed.
- Personal data shall be accurate and, where necessary, kept up to date.
- Personal data shall be kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data are processed.
- Personal data shall be processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction, or damage, using appropriate technical or organisational measure.
Where there are concerns about the safety and wellbeing of the person that meet the threshold for a safeguarding referral, oversight panels must ensure that local adult or child safeguarding processes have been followed. If new concerns are shared as part of the oversight panel meeting, then appropriate action (and referral where appropriate) must be taken by a named person in line with local safeguarding procedures.
Evaluating progress and measuring impact
Each integrated care system oversight panel must monitor Care (Education) and Treatment Reviews (C(E)TRs) implementation and effectiveness by ensuring provision of additional support and scrutiny. Oversight panel meetings should consider:
- whether the C(E)TR policy is being adhered to and that panels are working successfully (see policy appendix 11)
- whether the C(E)TR standards are being met
- whether or not people are admitted following a community C(E)TR and, for those admitted, whether length of stay following C(E)TRs are falling
- rates of admission among people whose admission was previously avoided through the provision of additional support, and of re-admission following discharge from an inpatient setting
- whether C(E)TRs are a positive experience for people and their families
- whether people and families have an improved experience of care and support following a C(E)TR
- whether C(E)TR intelligence is being collated and acted on in response to concerns raised about the quality of care, both at individual and collective levels (for example, regarding specific providers).
Further support, guidance and examples of good practice are available on our website.