What is the dynamic support register?
The dynamic support register is for people who have been diagnosed with a learning disability or autism (or both) who require further input as they are at risk of being admitted into inpatient services, or there is a risk of a placement breakdown. There are ratings on the DSR, including green, amber and red and these determine what level of intervention and support a person requires to support them within the community.
Where did it come from?
The transforming care programme and agenda is aimed to improve the health and care services that autistic people and those with intellectual or learning disabilities access the right care, at the right time and supporting them to remain in the community.
It aimed to ensure that individuals remain close to home and prevent inappropriate hospital admissions and if an admission is required, support to ensure that this is for a shorter period, with clear admission goals and safer discharges.
NHS England introduced the care [education] and treatment review policy which called for areas to have a dynamic support register. There was an updated document in January 2023, giving clearer guidance on dynamic support registers, to highlight those most at risk of either hospital admission or placement breakdown.
The register can help highlight those who most at risk for a hospital admission and are eligible for a care and treatment review (CTR, 18 years and over) or a care educational and treatment review (CETR, under 18 years)
Roles and responsibilities
In Lincolnshire, the Enhanced Support and Liaison Service within Lincolnshire Partnership NHS Foundation Trust (LPFT) has oversight of the DSR.
The most appropriate children and young people’s mental health team in LPFT is responsible for their caseload on the DSR, this includes:
- ensuring appropriate consent is given to be part of the DSR or a capacity assessment undertaken and best interest documents completed
- reviewing DSR cases on a weekly basis, including a multi-disciplinary team (MDT) meeting with other relevant professionals
- ensuring all autistic children and young people or those with a learning disability accessing CAMHS crisis and enhanced treatment team are placed on the DSR (with appropriate consent) as either amber or red
- updating the DSR where risk has changed, adding or removing individuals as appropriate
- completing an urgent admission avoidance plan
- allocating a CYP keyworker to support those identified as red or amber on the DSR
For children and young people who are in 52-week residential school or college placements, their social worker or lead practitioner is responsible for their caseload on the DSR. This will be supported by the CYP liaison practitioner within the Enhanced Support and Liaison Service.
If a professional external to LPFT notifies and has an individual accepted onto the DSR, they are responsible for them while they remain unopen to an LPFT team. They will be supported by the CYP liaison practitioner within the Enhanced Support and Liaison Service.
The process
To be entered onto the register, individuals must:
- have a confirmed autism diagnosis or intellectual disability diagnosis or both
and
- be at significant risk of admission to mental health or specialist hospital
or
- show evidence of deterioration in their mental health or an increase in behaviours of concern which may, or has previously resulted in a placement breakdown or cannot currently be managed within their current living environment
or
- be transitioning from an inpatient to community setting
Also, for consideration are individuals:
- regularly presenting in crisis at accident and emergency
- being identified as requiring a specialist 52-week placement in partnership with children’s services and action is being undertaken to identify a placement
- being placed in a specialist 52-week residential school
- having no effective planned transition from children to adult services, especially if in inpatient services
To enable individuals to be placed on the DSR, consent of the child must be given (where assessed as being Gillick competent). Where gaining consent from a child is not appropriate, parental consent can be given. If it is felt that the individual lacks the capacity to consent, a best interest decision must be made in line with the Mental Capacity Act 2005 and its code of practice.
The NHS uses a triage assessment tool to assess your risk, it will tell if you are
- red - high risk
- amber - medium risk
- green - low risk
Everyone who is assessed can go on the DSR, those most at risk will be discussed in fortnightly meetings with multiple agencies to support unblocking barriers that may prevent individuals from remaining in the community. This means that everyone involved in your care knows that you are at risk. The professionals around you need to work together to make sure you are supported. This could be a CTR or CETR, local area emergency protocol or professionals meeting.
The only personal details on the DSR are your date of birth, NHS number and the reason you are at risk.
You can withdraw your consent at any time by telling anyone from LPFT involved in your care.
Ratings
A dynamic support risk tool has been developed that includes 12 scored questions. This provides clinicians and the wider team with a starting point to help inform clinical decision-making while considering red, amber, green (RAG) ratings and inclusion to the DSR.
Everyone on the DSR must have a RAG rating assigned to them. The rating will help inform and suggest next steps and the additional support that can be offered.
These ratings are from the NHS England, dynamic support register and care (education) and treatment review: policy and guidance (2023).
The RAG ratings
The ratings are red, amber, green or blue.
Additionally, there are four key questions which if the answer to all is yes would indicate a red rating:
- does the child or young person have an unstable or untreated mental health condition?
- do they present with significant behavioural challenges?
- are they being supported in an unstable environment or by changing staff teams?
- have they presented in crisis at A&E in the last month?
There will be times where an appropriate admission to either a mental health or specialist hospital is required.
At the point of admission, an individual who is on the DSR will move to blue on the RAG rating, or if an individual in not already on the DSR will be added as blue (with appropriate consent), this will indicate that they are an inpatient. The individual will remain on blue until the point of discharge.
During the discharge planning stage, the Enhanced Support and Liaison Service will ensure that the correct community teams are in place ready for discharge if this is needed. Upon discharge, the individual will move to red on the DSR for a minimum 2-week period. Children and young people will be offered enhanced post discharge support from the CAMHS crisis and enhanced treatment team for a minimum of 14 days. The individual will be discussed in the relevant Lincolnshire DSR system wide meeting while they remain red on the DSR.
Self notification process
An agreed process has been created for individuals with autism or an intellectual or learning disability, their families, or carers to self-notify for inclusion onto the Lincolnshire DSR.
For more information about how to self notify, email the Enhanced Support and Liaison Service.
Providing the individual meets all the criteria for addition to the DSR a letter will be sent.
If further information is required, the notifier will be contacted, and it will be discussed in the relevant DSR meeting.
Following the meeting a letter will be sent accepting or declining addition to the DSR.
If the individual or person notifying does not agree with the outcome of the review, they can appeal the decision by emailing the team, providing additional information to support with the appeal process.