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Transforming Care in Autism

How our service can help you

The Transforming Care in Autism TCA) Team provides indirect and direct clinical input to support health professionals and mainstream services (across Lambeth, Lewisham and Southwark) to work with autistic adults who are at risk of admission, or currently an inpatient in psychiatric hospitals.

For individuals in forensic services or those considered to pose a significant risk to others, they would be more appropriately referred to the Forensic Intellectual and Neurodevelopmental Disabilities (FIND) Community Team: email: oxl-tr.find@nhs.net or Tel: 02039276150

For individuals with a formal diagnosis of moderate to severe intellectual disability; they would be more appropriately referred to local Mental Health in Learning Disability: (MHLD) services: email: referralsmhld@slam.nhs.uk

The aim of the service is to:

  • reduce and, where possible, prevent the number of inpatient admissions and support a successful and timely discharge back into the community for autistic adults,
  • provide a service development pathway, involving supporting staff in inpatient and community mental health services to develop knowledge, skills and confidence in working with autistic services users who have mental health needs and/or present with behaviour that is deemed ‘challenging’.

  • Service Type: Community Service Service Borough Covers: Lambeth, Lewisham and Southwark Treatment type: Adult Mental Health Services (Specialist)

  • Contact the service

    Site Location: Maudsley Hospital Email: TCATeam@slam.nhs.uk Phone Number: 07718423537 - Shaun Byrne (Team Administrator)
  • Address: Bethlem Royal Hospital TCA Team 1st Floor Monks Orchard House Monks Orchard Road Beckenham,
    Kent,
    BR3 3BX
  • Business Hours/Visiting Hours: Monday – Friday, 9am – 5pm, excluding bank holidays

    • Other essential information

  • Conditions: Transforming Care in Autism; autism

Service offer

Crisis Pathway

An individual is considered to be in a crisis if they are at risk of being admitted or are already in an inpatient setting. At the point of crisis, the team can offer short-term support through assessment, formulation, and development of an intervention strategy in conjunction with relevant services across health and social care. This may include direct and indirect interventions from one or more members of our MDT; attendance at Care and Treatment Review (CTR) meetings, support identifying appropriate service provision; staff training; staff supervision and consultation.

Our initial point of intervention is to provide a professional or consultation meeting with existing local and inpatient professionals involved to gather information and create a formulation before deciding what further input will be appropriate. Our input/response will be bespoke and adapted according to individual needs and the resources and capability of the non-specialist service available.

The team can also offer network meetings as part of the open dialogue principles that have been adopted into our team. Open Dialogue is a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system or network meetings, which always include the patient.

As a team we are also able to offer Non-violent Resistance (NVR) groups to parents and guardians if the autistic service users we support. NVR is a parenting approach which has been shown to help in families where there are additional difficulties including neurodiversity, aggression and/or avoidance. The group uses NVR principles to improve relationships between parents/guardians and their (adult) children.

We consider a crisis resolved when the risk of admission is reduced or there has been a successful transition to the community and/or the treating team are able to provide ongoing support due to input from the TCA team.

Training, Supervision and consultation

The team can offer specialist input to mainstream SLaM services, including bespoke staff training, supervision, and consultation. The aim of this internal service development pathway is to increase understanding of autism, support non-specialist teams to carry out autism adaptations, and increased confidence working with this group. Examples of bespoke training we have provided in the past include Positive Behaviour Support Planning, Adaptions for Autism Spectrum Conditions, and Managing Risk, Clinical overlap between psychosis and autism.

We ask that SLaM teams in the first instance review the training offered on LEAP which staff can access to develop general knowledge on autism:

The Oliver McGowan Mandatory Training on Learning Disability and Autism (slam.nhs.uk)

Please send specific training requests and the areas or topics you would like cover to our email address – TCAteam@slam.nhs.uk

Referrals

We require a written referral and referral must be made by a one of our team. New referrals are discussed in our weekly team case discussion meetings every Tuesday morning. Currently, we do not operate a waiting list and we aim to process referrals as quickly as possible.

 Referral Form May 2025

Autistic adults can be referred if they meet all of the eligibility criteria.

Eligibility criteria

Inclusion criteria:

  • Adult service; be 18+ years-old
  • Have a confirmed diagnosis of autism, including Asperger’s syndrome and pervasive developmental disorder (please send a diagnostic report with confirmation of autism with the referral)
  • Must be registered with a GP and live in the boroughs Lambeth, Lewisham or Southwark
  • Must be on/or eligible for the Dynamic Support Register (DSR) and be categorised as red/amber due to risk of admission to mental health psychiatric hospital or already inpatient
  • Must be open to another SLaM team who will continue to hold clinical responsibility for the duration of TCA input

Exclusion criteria:

  • Registered with a GP and/or live in the Croydon borough as Croydon has not commissioned our service
  • In forensic service or poses a significant risk to others
  • Diagnosed with a moderate to severe intellectual disability
  • Not open to another SLaM team

Our team

  • Principal/Lead Clinical Psychologist
  • Consultant Psychiatrist
  • Systemic Family Therapist
  • Assistant Psychologist
  • Occupational Therapist
  • Speech and Language Therapist
  • Clinical Nurse Specialist
  • Behaviour Support Practitioner
  • Administrator

Resources

Prior to any input starting, you may wish to consider:

Frequently Asked Questions

Why the team exists:

  • The need for our service emerged when it became apparent that autistic adults without a learning disability were falling between service gaps and not receiving the care they needed.
  • Autistic adults commonly experience mental health conditions. They can experience barriers to accessing timely support from health and social care services. Some autistic adults are admitted to mental health hospitals because there is a lack of autism-specific support in the community when they are in crisis. An admission is sometimes the most appropriate clinical intervention, but some autistic people stay in hospital for longer than needed because of a lack of autism-specific input on the ward or because it is unclear how best they can be supported in the community.
  • Some professionals working in mainstream mental health services do not have much knowledge about autism or experience of working with autistic people.
  • The Learning Disability and Autism (LDA) strategy (previously Transforming Care Agenda) had been developed by the NHS so that autistic adults at risk of admission to a mental health hospital or in hospital can be offered autism-specific support when they need it, to help reduce risks and avoid lengthy inpatient admissions.

 

Who works in the team?

Please see website for details on TCA Team members. Click on the tab named Our Team.

Service Detail - South London and Maudsley

 

What if a service user is admitted to a physical health ward?

  • The service is only commissioned to support autistic services users at risk of psychiatric admission within SLAM services i.e. due to mental health difficulties and/or behaviour that challenges. Therefore, we are unable to support autistic service users who are admitted on physical health wards. However, TCA would welcome a referral once the service user returns to a South London and Maudsley team and meets the eligibility criteria. 

 

Can the TCA team support autistic service users who are under the age of 18?

  • No. The service is for adults aged 18 years old and above.

 

Can the TCA team provide support for non-SLAM services?

Only SLaM teams for adults can refer to TCA, however we can provide some support to non SLaM services, e.g. providing autism training for a placement where a service user is residing. As with all our input, this can only occur in instances where another SLaM team is holding clinical responsibility.

 

How long can the TCA team provide support?

The TCA provides short-term input, although, the length of time varies according to the need of the autistic individual.

 

What support can be offered from the TCA team?

  • The TCA is a multidisciplinary team which may provide the following:
  • Consultations which involve discussions with the autistic service user, their family and professional network. Recommendations and signposting are provided to support the service user and their personal and professional networks.
  • Drop-in sessions for SLaM teams, which includes advice and consultation from our Consultant Psychiatrist and Clinical Nurse Specialist.
  • Psychological input, in a limited number of cases, which includes direct and indirect work with the autistic service user and their support and professional network e.g. Family Therapy, Open Dialogue/Network meetings and Non-Violent Resistance training for parents/caregivers, and psychoeducation sessions for the autistic service user.
  • Specialist assessments for autism related needs e.g. sensory assessments, communication and/or behavioural assessments.
  • Supporting and developing autism relevant care and support plans including communication/autism passports and Positive Behaviour Support plans.
  • Supporting the sensory needs of autistic service users – our Occupational Therapist and Peer Support workers can visit your team to offer advice around how to make adaptation to the environment to better support the sensory needs of autistic service users. Our team is also currently running a Quality Improvement project: ‘Facilitating Optimal Care and Understanding Sensory Needs’ - as part of this project we are providing 10 service users on our caseload personalised sensory kits, and we are offering training tailored to wards around autism and sensory needs.  

 

Does TCA provide 24-hour crisis care?

  • No. TCA operates within the hours of 9am to 5pm, Mondays to Fridays, excluding bank holidays.

 

Does the TCA team provide autism diagnostic assessments?

  • No. The TCA requires an autism diagnostic report to be provided as one of the requirements of the referral.

 

Can the TCA team provide case management or care coordination?

  • TCA is a service which only works alongside a community mental health team (CMHT) or inpatient ward. We do not provide case management or care coordination, as this will be provided by the CMHT or ward.
  • TCA supports mental health teams in providing support to the autistic individuals. Therefore, we require mental health teams to hold clinical responsibility and case management for the entire duration of TCA support.

 

Does the TCA team provide support for Croydon services?

  • No. The TCA is only commissioned to offer support to Lewisham, Southwark and Lambeth.

 

How can a referral be made to the TCA team?

 

How is TCA able to support someone who has been accessing CAMHS services/when CAMHS support is ending?

  • CAMHS teams are encouraged to refer young people they are working with to adult mental health services through the standard relevant pathways. The TCA team are only able support adult services users and their teams, so a referral from adult mental health services to the TCA team would be more appropriate

 

What is a Care (Education) and Treatment Review (C(E)TR) meeting and how can I initiate this meeting for a service user who is inpatient or at risk of admission?

A Care, Education & Treatment Review (CETR) is a meeting about a child or young person who has a learning disability and/or autism and who is either at-risk of being admitted to or is currently detained in an in-patient (psychiatric) service.

This review can be initiated by the care coordinator by contacting the appropriate commissioner for the borough that the autistic individual resides in.

Service users can have or request for a CTR at any age, but the Education component is for service users who are under 18years.

·   To organise a CTR, please contact the respective commissioner:

o   Lambeth – Indra Mohan- Indra.Mohan@slam.nhs.uk

o   Lewisham – Collette Meehan- Collette.Meehan@lewisham.gov.uk

o   Southwark – Katy Cleary SouthwarkDSR@seldonics.nhs.uk or Southwark.LDA@seldonics.nhs.uk

 

TCA is not commissioned for Croydon. For enquiries regarding Croydon  commissioner, please contact: - swlicb.croydontrp1@nhs.net

 

What is a Dynamic Support Register (DSR) and how can I add the autistic service user I’m supporting to the register?

The Dynamic Support Register (DSR) is for children, young people and adults with a Learning Disability and/or Autistic Spectrum Disorder. Its purpose is to help get the right care and treatment in the community for those at risk of admission to hospital or placement breakdown, by working with the person, their family and their support network and by promoting better joint working across services.

The autistic individual can be added to the register by contacting the Learning Disabilities and Autism Lead after the autistic individual had signed the consent form. If they decline being added to the DSR register, a capacity assessment and a best interest meeting may be arranged to ascertain if they have the capacity to make an informed decision.

Please contact appropriate commissioner to arrange a DSR using these contact details below:

o   Southwark – Katy Cleary SouthwarkDSR@seldonics.nhs.uk or Southwark.LDA@seldonics.nhs.uk

o   Lambeth - Indra Mohan - Indra.Mohan@slam.nhs.uk

o   Lewisham – Collette Meehan- Collette.Meehan@lewisham.gov.uk

 

Where else can I get advice or support?

Karina Marshall Tate (the Nurse Consultant in Learning Disabilities) and Sophie Doswell (Consultant Psychologist across the adult Autism and ADHD pathway) run a weekly Learning Disability and Autism (LDA) drop-in session every Thursday afternoon at 2pm, for professionals working with adults with possible or diagnosed autism and / or learning disability. Bookings are arranged via the Nursing Directorate – nursing-directorate@slam.nhs.uk .  

  The adult Neurodevelopmental pathway has an Education & Research meeting on alternate Friday afternoons (4-5pm), where there is the opportunity for any SLaM service to present a complex or difficult to manage patient. The meeting is attended by the MDT working across the adult autism and ADHD services. Angie – angela.degen@slam.nhs.uk   – arranges the meeting and you can email to book a slot for the meeting to present

  Consultant Connect – Consultant Psychiatrists and Non-Medical Prescribers working across the adult Neurodevelopmental pathway are on the Consultant Connect rota and can be contacted to give advice to SLaM staff. Advice is also available from the specialist adult ASD and ADHD service 9-5pm, Monday to Friday via Consultant Connect (Install the Consultant Connect app on your phone and search for ‘mental health – adult ADHD and autism’)

 

Where can I find some resources for supporting the autistic service users that I’m supporting?

TCA website Link: https://slam.nhs.uk/search/service/transforming-care-in-autism-302

NAS Link: https://www.autism.org.uk/

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