To CTR or not to CTR? That is the question bugging Sam Sly, as she continues to try and move people out of assessment and treatment units.
Over the past couple of years, I have spent a lot of my working life involved in two types of planning and review with people with learning disabilities and autism who have unfortunately been caught up in the specialist assessment and treatment systems: Care & Treatment Reviews (CTRs) and Life Planning.
I have, of late, started to question the purpose and capacity of CTRs to support the positive discharge of people from hospital, and worry that it is just becoming another NHS tick-box exercise.
I am also becoming frustrated that Life Planning, which develops a plan and service specification centred around the person and their family, is not becoming the default NHS and local authority approach for preventing admission and discharging people, as it seems to me – and those who have experienced it – to be the most logical pathway for the job.
CTRs were brought in several years ago as part of NHS England’s commitment to transforming services for people with learning disabilities and/or autism who display behaviour that challenges, including those with a mental health condition, post-Winterbourne View.
The CTR’s aim is to bring: “A person-centred and individualised approach to ensuring that the treatment and differing support needs of the person with learning disabilities and their families are met and that barriers to progress are challenged and overcome,” according to the NHS policy guidance. In a nutshell, reviewing those people at risk of, or already in, hospital and ensuring they have the right ‘treatment’ and that a plan to move out is on the table.
The flaws in the system I have experienced are:
• Plans are still often service-led as commissioners are coming from a medical model of care
• The information available to build plans comes from the hospital and focuses on deficits, not strengths
• The quality of the meetings varies widely and sometimes the wrong people attend them – many don’t know the person well
• Meetings don’t focus on the person’s strengths and attributes
• Action plans don’t seem to lead to action!
Life Planning is a facilitated process that looks at where the person wants to live, what their home needs to look like, who or what is needed to support them, what their goals are, what they want to do with their time and the important things people need to know about them to support them well. The result is a fully signed-up-to specification that can be used to find a house, support provider – if needed – and an action plan to make things happen.
The CTR process was said to introduce a level of external scrutiny to existing processes, in effect offering those in hospital a degree of ‘second opinion’. However, I would argue that instead of a second opinion by a stranger what makes the most sense is gathering together the opinions of the right people – those who know the person best – who are then helped through the Life Planning process to think about what would make the best person-centred service for them.
CTRs were initiated with a target of supporting the discharge of 50% of people who were inpatients on April 1, 2014 by the end of March 2015. This never happened and is not likely to by even 2020. I am now attending CTRs that seem to have just become an additional meeting to tick off alongside tribunals, manager hearings and Care Programme Approach meetings. We need to try something different and stop wasting more taxpayers’ money.
So, my challenge to NHS and local authority commissioners – and NHS England Special Commissioning Groups – is to give Life Planning a go. Trial the process instead of CTRs for a while and see if it gives better outcomes. Here are the reasons why:
• Everyone in hospital needs a plan to get out, and the sooner a Life Plan is developed the sooner treatment can be focused on discharge
• Discharge can start the day someone is admitted if a Life Plan is prioritised
• Life Planning takes roughly the same time as a CTR to facilitate – half to one day – so is as cost-effective
• A Life Plan gives a person-centred service specification so you know what housing, support and community input someone will need
• The specific nature of the planning means commissioners can shape a more person-centred provider market from the specifications
• Families like them and say they feel listened to and involved – often for the first time
• People like them and are at the centre of their planning – often for the first time
• Life Planning costs roughly the same as CTRs – and if social workers and case managers were trained to be facilitators it would cost nothing
• Life Planning includes only those who know the person well, so no need to pay for expensive professionals to attend who can give little input because they are remotely involved.
What have you got to lose?
About the author
Sam Sly is a freelance regulation, health and social care consultant. She was formerly co-owner and operational director of Beyond Limits. Sam is a registered social worker and has worked as an inspector, approved social worker, part of the Change Team following the investigation into Cornwall NHS Partnership Trust, commissioner, managed an NHS Campus closure in Bournemouth, helped local authorities transform adult and children’s services and is a trainer and planner around personalisation and using individual budgets. www.enoughisenough.org.uk