NHS England's ‘Transforming Care’ initiative introduced care and treatment reviews (CTRs) for adults with intellectual disabilities and/or autism to avoid inpatient admissions, improve inpatient care quality and support timely discharge. CTRs are completed by an independent panel including an expert by experience, a clinician, and the commissioner. Since 2015, thousands of CTRs have been carried out. In a survey of ID psychiatrists involved in CTRs, many felt that discharge planning was limited by a lack of appropriate community placements. Proposed changes to the Mental Health Act indicate that CTRs should become statutory.

Our aim was to obtain the views of professionals working in intellectual disability services on the proposed reforms to the Mental Health Act and CTRs.

A mixed methods 34-item questionnaire exploring views of professionals working in ID services (n = 66) on the CTR process, their perception on its usefulness and the proposal to make CTR recommendations statutory. Survey shared with ID MDT professionals working in the UK. Of the respondents, 30% were psychiatrists, 29% psychologists and 21% nurses, with average length of mental health service of 18.2 years. More than 80% work in the NHS and most worked either in inpatient or forensic units.

Although in 80% of CTRs attended, patients have a current risk assessment and management plan, in less than 10% of CTRs attended were people ready for discharge and had a current discharge plan. In terms of CTR actions, 70% of the time, patients were receiving the right care, over 60% of the time, care was person centred, person's health needs are met and 50% of the time key areas of concerns were covered. In less than 40% of CTRs were the person's rights always upheld, family or carers always involved, medications being used appropriately or were there clear, safe and positive approaches to risk. Reasons for delayed discharges included no placement options (68%), no placement profile or community needs assessment (24%), placement funding disputes (23%), no agreed social care responsibility (18%) and no agreed community clinical care responsibility (18%). Only 7% of respondents felt CTRs were always useful, 44% felt they were sometimes useful and 23% often useful. Professionals had mixed views about whether CTRs should become statutory/enforceable (45%) versus those who did not (48%).

This is a survey with a relatively representative sample of MDT professionals involved in CTRs. It gives insight into the typical CTR process, duration, and professionals involved. It summarises the opinions of clinicians towards CTRs and their views on proposed changes.

There has been criticism surrounding the lack of clarity regarding treatments offered within forensic inpatient units for people with learning disability and co-existing mental health problems. The Ten-Point Treatment Programme is a framework for treatments within such settings. It incorporates the four stages of assessment and motivational work, foundation and offence-specific treatments, consolidation and relapse prevention and finally discharge management. Although evidence based and evaluated in outcome studies, explaining its content to those with learning disability can be problematic. Communication difficulties affect the way information is comprehended and interpreted from both a linguistic and pragmatic perspective in this group. The provision of Easy Read information can address this difficulty.

Our aim was to co-produce, with experts by experience, an easy read version of the Ten Point Treatment Programme; and to evaluate this resource.

This was a quality improvement project within an in-patient medium secure unit in England. The co-production of the easy read version was led by two speech and language therapists, two psychiatrists, one Education Manager and two experts by experience. The latter advised on content, wording, format and font. Content was adapted in line with standard easy read requirements and guidelines. Following a focus group meetings, a provisional easy read version was approved and introduced in the service. This service innovation was evaluated through semi-structured interviews with six experts by experience and ten multidisciplinary team members who had used the resource. Responses were transcribed and subjected to thematic analysis.

The three main themes covered in the evaluation responses related to accessibility, appearance and usefulness. The sub-themes under accessibility were the simplicity of vocabulary and short sentence length. Regarding appearance, the key sub-themes were about the effective use of colour, the inclusion of relevant and meaningful images, and the balance between words and pictures. On usefulness, the main sub-theme was about understanding the treatment pathway better and hence feeling motivated to engage. This was reflected by the staff group as well. There were some comments on accessibility that were less positive, including service user indications that the number and complexity of words were still high.

The co-produced easy read version of the Ten-point treatment programme has been received positively by service users and staff. For both groups, it brings clarity about the treatment pathway and its stages. It is incorporated into the admission pack for new admissions and features in new staff induction programmes.

Background:

The cumulative effect of having one or more prescription drugs with anticholinergic properties is known as the Anticholinergic Burden (ACB). ACB can increase mortality and morbidity. Adults with learning disability are a high-risk group for this.

Aims:

To evaluate Anticholinergic Burden (ACB) for adults with learning disability and co-existing mental health conditions and make practice recommendations.

A baseline audit was carried out over a period of 1 month on those treated within two specialist in-patient units in England. Routinely collected information including diagnosis, prescribed medication, clinical outcomes (Clinical Global Impression – CGI) and side-effect scales (ACB calculator, Anticholinergic Effect on Cognition – AEC, Liverpool University Neuroleptic Side-effect Rating Scale – LUNSERS, Glasgow Antipsychotic Side-effect Scale – GASS) were collated and analyzed using quantitative methods.

19 patients were included. Mean age was 37 years, 89% (n = 17) were male and 95% (n = 18) of white British ethnicity. The clinical diagnoses included 74% (n = 14) with mild learning disability, 68% (n = 13) with a major mental illness (psychosis or affective disorder), 53% (n = 10) with autism and 32 (n = 6) with a personality disorder. 89% (n = 17) were on antipsychotics, 63% (n = 12) on mood stabilizers, 58% (n = 11) on antimuscarinic drugs for antipsychotic side effects, 58% (n = 11) on anxiolytics, 32% (n = 6) on antidepressants and 89% (n = 17) on medication for physical conditions. Including pro re nata (prn) medication, the mean ACB calculator score was 6.68 and 4.21 on the AEC scale. On LUNSERS, the mean score was 23.13 (medium side effects), on GASS 8.87 (mild or absent side effects), on CGI efficacy index 6 (decided clinical improvement with side-effects not significantly interfering with functioning) and on CGI global improvement 2.37 (much improved).

The ACB in people with learning disability and mental health problems is high. While an ACB calculator score of 3+ is described as associated with increased mortality and morbidity in the general population, the mean score in this sample was double that if prescribed prn medication was included. Medication prescribed for both mental and physical health reasons. Despite the high ACB, they show good clinical improvement and functioning regarding their mental health. The scores on other side effect scales are not exceedingly high either. There is a need for more research to set the specific practice standards regarding ACB measurement and monitoring in this group. Adequate health education for patients and staff should be a priority to maintain vigilance regarding ACB effects.

Mental health comorbidity is higher in those with learning disability especially those who are within forensic services than the general population and diagnostic overshadowing is a particular problem. Hence, all behavioural or mental health related presentations are often attributed to the learning disability and vice versa without an adequate investigation of the causes of learning disability. This is a case report of a young male with mild LD with longstanding mental health and behavioural problem who was described as having a personality disorder in the community. Systematic diagnostic evaluation showed the presence of 22q11.2 Duplication Syndrome. While adding to the sparse literature on the behavioural and physical phenotype of the syndrome, it also allowed his mental health presentation to be re-formulated. This changed his treatment plan and outcome.

28-year-old, single, Caucasian male with delayed developmental milestones who was referred to Children Mental Health Services for behavioural difficulties and ADHD-like features. In early adulthood, behavioural problems continued with aggression towards others and was under the care of a community mental health team although with lack of diagnostic clarity and poor compliance. Violence towards self and others led to several short hospital admissions, mainly because he tended to discharge himself against medical advice. The predominant diagnostic formulation was one of a young man with mild learning disability + psychosis related to substance misuse + personality disorder. Facing multiple charges of assault, the court, on medical advice, gave him a hospital order to a medium secure unit for people with learning disabilities where he went through a detailed and systematic diagnostic evaluation that revealed several new findings. Based on this, he went through the 10-point-treatment programme.

Clinicians need to be aware of diagnostic overshadowing leading to misattribution and consequently poor treatment. In this case, the sensory impairments associated with 22q11.2 Duplication Syndrome affected his communication. His tunnel vision led him to bump into people in pubs and other public places giving impression of deliberate antisocial behaviour. The atypical autism, learning disability and co-existing mental illness further complicated the picture. Confirmation of the underlying genetic syndrome and its physical and behavioural phenotype led to a different diagnostic and psychological formulation from the earlier one which was based on a personality disorder. It also allowed more targeted treatment strategies and the patient could be discharged back to the community from a secure hospital setting.

22q11.2 Duplication Syndrome is a rare genetic syndrome that can cause learning disability. Its physical and behavioural phenotypic features described in literature, were all present in this patient. In addition, this case report highlights three previously unreported findings: Cochlear Nerve Atresia, Tubular Vision, the Characteristic groove and skin fold on the back of the scalp and the presence of a schizoaffective mental illness.