CETRs and the Dynamic Support Register

Care, Education and Treatment Reviews (CETRs) and the Dynamic Support Register (DSR) are ways of trying to identify and improve support for children and young people with learning disabilities, autism (or both), if they also have “behaviour that challenges”, including behaviour arising from a mental health condition. The aim is to reduce the risk of people ending up in hospital or the criminal justice system when they could have been supported to stay in their community.

Dynamic Support Register (DSR)

The Dynamic Support Register (DSR) is a local list of people with a learning disability, autism (or both) who are at risk of going into an in-patient facility or the criminal justice system if they do not get the right care and treatment in the community.

Every area must have a DSR and the local health commissioners are responsible for ensuring the DSR is up to date and active. In Sussex, the DSR this is the responsibility of the NHS Sussex Integrated Care Board (ICB).

How does the DSR work?

Specialised mental health professionals should meet regularly to look at the local DSR and check the current position for each person on it. The idea is to keep an eye on this set of children, young people (and adults) and be ready to respond if the risk is going up for any of them. They use a colour coded system to identify current level of risk for each individual.

If there are growing concerns about an individual and it looks like they might tip over into being admitted to hospital soon, it could be the right time to think about setting up a Community CETR/CTR.

Who gets onto the DSR?

Health commissioners who maintain the DSR for their area may not be aware of all the people who should be on the register.

Anyone who knows a child or young person can refer them to the DSR if they are at risk of going into hospital due to their mental health or their behaviour may become more of a challenge to services. This includes health, education, and social care staff as well as parents, carers and the young person themselves.

The local processes for the DSRs in Sussex are being updated and the best way for a parent or young person to refer themselves is not clear, so if you want to do this speak to a mental health professional working with your child.

A child or young person does not have to have an EHC Plan to be on the DSR and it is recognised that some autistic children may not be well-known to services until things have already started to go downhill for them. On the other hand, there will be plenty of children and young people who are autistic, have learning disabilities or both who don’t need to be on a DSR as they are not at any risk of ending up in hospital due to their mental health or behaviour.

Care, Education and Treatment Review (CETR)

If there are growing concerns about an individual on the DSR, and it looks like they might end up being admitted to hospital soon, it could be the right time to set up a CETR.

The Care Education Treatment Review (CETR) is a meeting that focuses on the support and care for a child or young person with a learning disability, autism (or both) if they also have behaviour that challenges the people around them, including behaviour arising from a mental health condition.

For adults (18+) no longer in education, this is called a Care Treatment Review (CTR).

Sometimes there may be a multidisciplinary review held instead, where the professionals working with the child or young person come together but with a less formal process, so it will be important to check which is happening.

Types of CETR

There are three types of CETR for different situations.

  • Community CETRs for children and young people at significant risk of admission to in-patient care. These look at what can be done to meet their needs in the community so admission to hospital is prevented.
  • Urgent CETRs, also called Blue light or Local Area Emergency Protocol (LAEP) pre-admission CETRs for children and young people who are at the point of admission to in-patient hospital care. These look at whether admission is really necessary, and if anything could be done to meet needs safely in the community instead.
  • In-patient CETRs for children and young people who are in hospital. If they were admitted without a CETR beforehand, there must be one held within two weeks. If they stay in hospital longer, a meeting should happen every 3 months or sooner if something changes. These should look at whether they still need to be there and plan for a successful discharge. Some young people may be admitted to a mental health hospital and diagnosed as autistic whilst they are there. They should have a CETR once this has happened.

Who gets a CETR?

CETRs are focused on children and young people who have learning disabilities or are autistic or both, whose behaviour challenges those around them and creates a risk that they will end up as an in-patient in hospital, for example in an assessment and treatment unit (ATU). They may:

  • be seeing or waiting to be seen by specialist behaviour services
  • have had hospital services in relation to their mental health
  • be in a 52-week school
  • be involved with youth offending services

But they can also be children and young people who look like they are heading in that direction if things are not put in place to prevent this.

These children and young people should be on the local Dynamic Support Register.

Requesting a CETR

Anyone closely involved with a child or young person can request a CETR and it should happen if the risk level is high enough. If the young person is over 18 and no longer in education, it would be a CTR (Care Treatment Review). If they should be in education, but perhaps the placement has broken down, it can still be a CETR and this can be one of the issues that is covered.

Consenting to a CETR

The commissioner has to get consent before a CETR can go ahead. For children this is from the parent. For young people aged 16 and over, this will be from them. If the young person does not have capacity to consent, then a Best Interests decision must be made about the CETR taking place in line with the Mental Capacity Act.

Who attends a CETR?

The meeting is led by a panel comprised of:

  • A chairperson, a commissioner who is responsible for relevant services but who is not involved in the child or young person’s everyday care
  • A clinical (medical) expert
  • An expert by experience – someone who has lived experience of people and families with learning disabilities, autism or both

Apart from the panel, the meeting should also include:

  • the child or young person themselves
  • parents/family members
  • people involved in the child’s education, treatment and care e.g., head teacher, social worker, psychiatrist, mental health nurse.

CETRs and EHC plans

CETRs are not instead of an EHC Plan. Most children with EHC Plans will never need a CETR. Some children may have a CETR who don’t have an EHC Plan. Sometimes the CETR panel may recommend that a request for EHC needs assessment is made now. If they have an EHC Plan this will be part of the evidence the panel look at.

How the CETR meeting works

The information below tells you how a CETR works in practice, but there was new guidance on DSRs and CETRS in 2023 so the NHS Sussex are reviewing how things should be done locally so there may be some changes soon. At the moment, in-patient CETRs/CTRs happen quite regularly but community ones are less used.

Before the meeting

Arrangements should start at least two weeks before the meeting. This gives time to get consent, for the panel to learn about the child, check their medical history and current support and education plans, make contact with the family and send them information explaining what is happening. The child or young person should be sent a booklet to explain CETRs and a planner to fill in to give their views, with support to capture this if they need that. See Further information below to download copies of these.

The commissioner who convenes the meeting should also think in advance about how the child or young person can be supported to take part positively and comfortably on the day.  This could include thinking if they may need an advocate.

On the day

The meeting is usually in person, but attending via a video call should be possible. The commissioner should finalise the agenda (what will be talked about and in what order) so everyone can contribute. The panel will make time available to meet the child or young person and their parent carers separately from the people invited because they provide the child’s care, treatment and education. The panel will invite people in to talk about the care the child is getting and answer questions. They will be looking at whether the child or young person is getting the right care, education and treatment. They will look at:

  • Is the person safe?
  • Are they getting good care now?
  • What are their care plans for the future?
  • Can care and treatment be provided in the community?

They have a list to help prompt them to cover everything. This is called the Key Lines of Enquiry or KLOE. See ‘Find out more’ below for a link to read the guides for panels at each sort of CTR/CETR if you want to know more about what the panel should be asking.

The commissioner and the independent experts discuss what they have heard and think about their recommendations before the meeting ends. CETR meetings can be quite long, possibly most of a day. The child or young person and their parent don’t have to sit through all of it. The panel should speak to the child or young person and family at the end to give them some verbal feedback about what they have heard, what recommendations they expect to make and what happens next.

The panel use what they have heard to write up a report with recommendations and an action plan.

After the CETR meeting

This report should be sent to the family and everyone who took part within two weeks. The recommendations and actions should go on the child or young person’s medical record.

There must be a plan to review what happens as a result and check recommendations are followed up and actions are carried out.

Currently the recommendations don’t have legal force but there are proposals for change to the Mental Health Act to put CTR/CETRs on a statutory footing soon.

Getting help with CETRs

Parents: If your child or young person needs a CETR it’s likely that things are pretty stressful and difficult for you as a family at that point. There is a good guide written for families by the parent-led organisation Bringing Us Together (see Find out more below). If you are getting close to a CETR, we recommend you read this. You can contact SENDIASS for information and advice.

Young People: The Children and Young People’s Worker at SENDIASS can give information and advice about CETRs. She may be able to help you plan for the meeting or help explain things that are recommended by the panel, for example if it is suggested that an EHC Plan may be needed. If you are held in hospital under the Mental Health Act (often called being sectioned) you have a right to an Independent Mental Health Advocate and they can help you with a CETR.