What is the North East London (NEL) learning disabilities and autism (LDA) Keyworking Service?

The NEL 0-25 LDA Keyworking Service is a new service delivered by North East London Foundation Trust (NELFT) across: 

Outer London: Barking & Dagenham, Havering, Waltham Forest and Redbridge. 

Inner London: City & Hackney, Newham, Tower Hamlets 

Keyworking case managers will work with 0-25 year olds with learning disabilities and or autism who are on local dynamic support registers (DSR) and at risk of admission, or who are already inpatients. Our aim is to: 

  • Avoid admittance
  • Reduce lengths of stay in inpatients locations
  • Improve children and young people’s experience and outcome

Our goal is to ensure children, young people and their families’ voices are heard and have the right support from services at the right time. Keyworkers will not replace any pre-existing health or social care plans or the professionals currently working with children and young people. They will work in partnership with the professionals, children and young people and their families to deliver support. 

When will the service be available?

The Keyworking Service will be available for 0-17 year olds from September 2023 and 18-25 year olds by Monday, 1st April 2024. 

How will cases be referred to the Keyworking Service?

Keyworking caseloads will come from the DSRs, not from direct referrals from services or self-referrals. However, anyone with a learning disability and or autism diagnosis can self-refer or be referred to the DSR list holder to be added to the list/DSR review process. 

Keyworking case managers will join the existing DSR case Multidisciplinary Team (MDT) review meetings and will be allocated cases to support children and young people who would benefit from enhanced support and intervention that meet agreed criteria:

  • Have a diagnosis of a learning disability, autism or both
  • Are 0-17 years old (18-25 year olds will be assessable from 1st April 2024)
  • Reside in NEL geographic area
  • Are on the DSR at crisis point which means:
    • Amber or red - at highest risk of admission or
    • Blue - are currently in hospital (including those on a discharge pathway, to provide support during and post discharge to the community) 

What will the Keyworking Service do?

The NEL Keyworking Service will support existing workforce and activity within the local system and will not replace existing roles within the system. The keyworking involvement will be agreed at the DSR MDT review meetings on a case-by-case basis and could include: 

  • Social prescribing
  • Care navigation
  • Follow-up of Care (Education) and Treatment Reviews (CETR/ CTR) recommendations/actions
  • Maintaining communication / follow-up between families and the various professionals involved in their care and treatment
  • Advocacy
  • Support development of personalised care and support plans
  • Supporting Transitions - Communicating/explaining changes to education, health service provision and and transition between children’s and adult DSRs to support a smoother transition (17.5 – 19yrs)
  • Provide clinical input from Keyworking Senior Practitioner’s for more complex cases

Keyworking Service will not:

  • Be responsible for the maintenance of the DSR
  • Coordinate CETR/CTR panels
  • Fund support packages
  • Deliver clinical/specialist interventions
  • Be responsible for commissioning, purchasing support/equipment/interventions
  • Replace any existing service a person is receiving

What are dynamic support registers and care (education) and treatment reviews?

A DSR is a list of people with a learning disability and autistic people who need support because they are at risk of going into hospital if they do not get the right care and treatment in the community.  

Care (education) and treatment reviews (C(E)TR) are independent meetings about someone’s care and treatment run by a C(E)TR panel which includes people who are not involved in their everyday care to ensure independence, including experts by experience.

More information is available at: Dynamic Support Register and Care (Education) and Treatment Review policy and guidance | Local Government Association 

How will the Keyworking Service work with existing services?

The keyworking case managers will work closely with local DSR holders and C(E)TR coordinators. To agree and review keyworker intervention case-by-case. The workers will be co-located in local Child and Adolescent Mental Health Service (CAMHS)/Social Care sites where possible to foster effective partnership working. 

Keyworkers will join existing learning disability and autism related MDT meetings and interface with all services involved in the care of a child or young person that is on the register – CAMHS, social care, education, etc. Involvement will be reported case by case at the DSR MDT review meetings 

What about those children and young people who are not on the DSR?

They can be referred to the DSR list holder to be added to the lists and therefore included in the DSR MDT review meetings.