Implementation: getting started

This section highlights 4 areas of the transition from children's to adults' services for young people using health or social care services guideline that could have a big impact on practice and be challenging to implement, along with the reasons why change needs to happen in these areas. The reasons are given in the box at the start of each area. We identified these with the help of stakeholders and guideline committee members (see the section on highlighting recommendations for implementation support in developing NICE guidelines: the manual). The section also gives information on resources to help with implementation.

The challenge: adults' services taking joint responsibility with children's services for transition

See recommendations 1.1.5–6, 1.3.1, 1.5.9–11

Taking joint responsibility, as emphasised in the government's guidance supporting the Care Act and Children and Families Act, will help to ensure:

  • greater continuity and higher quality of care for young people using, and transferring between, children's and adults' services

  • better communication and more successful implementation of transition protocols

  • better outcomes for young people.

Equal responsibility

Managers and practitioners across children's and adults' services need to recognise that the structural and cultural differences between their services can make transition more difficult and confusing for young people and their families. Differences in areas such as IT systems, approaches to practice and how the services are accessed, organised, managed and led can result in a lack of confidence in adults' services on the part of young people, their families and children's services practitioners. This can make them reluctant to fully engage in the transition process and with adults' services.

What can commissioners, managers and practitioners do to help?
  • Jointly review current systems and practice to identify where changes are needed to support sharing responsibility. The self-evaluation tools produced by the Preparing for Adulthood programme may be helpful.

  • Involve young people and their families, together with professionals, to explore any concerns and assumptions that might limit the effectiveness of the transition process. These may include job roles and responsibilities, funding, understanding of the process and how it works, differing priorities and timescales, and issues with attachment or trust. The resources available from Participation Works may help.

  • Jointly review service provision to identify where there is no equivalent adult service to refer young people to, or where young people may need to transfer to more than one adult service. Establish a protocol outlining what to do in such circumstances.

  • Consider seconding people working in adults' services to children's services (and vice versa). Consider also creating a transitions team with workers from both services, to create a shared sense of responsibility for the process of transition and encourage the sharing of knowledge and experience.

The challenge: joint planning, development and commissioning of services involved in transition across children's and adults' health and social care

See recommendations: 1.1.6, 1.5.1, 1.5.5–6, 1.5.7–1.5.11

Joint planning, development and commissioning can result in:

  • the provision of developmentally appropriate support, and if necessary, services specifically tailored to young people up to the age of 25

  • better communication and joint working between services, and a more coordinated approach

  • better outcomes for young people.

A joint approach

Transition from children's to adults' services can be a complex process, spanning a range of agencies and specialisms. The absence of a coordinated approach to providing services across health, education and social care can result in ineffective communication, poor engagement, discontinuity of care and staff feeling unclear about the process and their role in it.

Adults' and children's services need to come together to pool funding, addressing the structural and cultural barriers that prevent them from achieving this. Transitional care should become a shared priority, despite the current pressures on public funds.

What can commissioners and managers do to help?
  • Develop a locally shared vision and policy for transition. Consider using the 4 areas outlined in the 'Preparing for adulthood' chapter of the Department for Education and Department of Health's Special educational needs and disability code of practice: 0 to 25 years (preparing for higher education or employment, independent living, participating in society and being as healthy as possible) to inform this process. Work with young people and their families to understand the impact of a poor transition and apply this knowledge to improve transition services.

  • Review local practices, systems and policies to determine whether the current approach is developmentally appropriate. In reviewing policies it may be useful to pay particular attention to:

    • consulting with young people alone when they are over 18, while supporting parental involvement

    • admissions of young people to adult wards

    • parental visits on adult wards, and

    • managing non‑attendance at clinics.

      The practice prompts in the guide Making a difference for young adult patients may help.

  • Develop joint commissioning arrangements and pooled budgets between children's and adults' services, across health, education and social care. Identify where there are barriers that prevent this from happening effectively. The Preparing for Adulthood programme has produced a guide to joint commissioning that may be useful, as may NHS England's Model specification for transitions from child and adolescent mental health services.

  • Use existing systems, for example hospital and social care IT and user record‑keeping systems, to identify young people in transition (up to the age of 25). This could help the commissioning and allocation of resources for transition across both children's and adults' services. It will also support ongoing quality improvement.

The challenge: improving front‑line practice with young people through training in developmentally appropriate services and person‑centred practice

See recommendations: 1.1.1–4, 1.2.3

Improving front‑line practice will ensure:

  • each young person approaching or entering the transition phase receives person-centred and developmentally appropriate care and support

  • young people are more likely to positively engage with services, and understand their own health and support needs

  • each young person is more likely to achieve their goals and hopes for the next stage of their life.

Improved practice with young people

To provide effective support to young people during their transition, practitioners need to understand the concept of developmentally appropriate care and what it means within the context of their role and service. Managers should ensure that practitioners focus on improving practice and receive the support and training they need to do so.

What can managers and practitioners do to help?
  • Ensure that everyone working with young people in transition up to the age of 25, in children's and adults' services, understands:

    • the principles of person‑centred care

    • young people's communication needs

    • young people's development (biological, cognitive, psychological, psychosocial, sexual, social)

    • the legal context and framework related to supporting young people through transition, including consent and safeguarding

    • supporting young people with special educational needs and disabilities

    • the need to support young people holistically, taking into account the outcomes to be achieved in respect of:

      • education and employment

      • community inclusion

      • health and wellbeing including emotional health

      • independent living and housing options

    • how to involve families and carers in a supportive, professional way.

  • Give all staff delivering direct care training that involves face‑to‑face interaction with young people, for example through shadowing.

  • Offer training or advice for staff not directly providing care. This could include, for example, listening to young people's views and experiences through e‑learning or case‑study videos, or through case‑based discussion.

  • Review the local approach to assessments to ensure they:

    • are person‑centred

    • consider the most appropriate communication methods

    • identify any mental capacity issues

    • identify and address any need for advocacy

    • share information with young people and their families

    • recognise and support the gradually evolving autonomy of young people, including self‑management of any health condition.

  • Plan and attend joint training in person‑centred planning and developmentally appropriate health and social care. Ensure the sessions genuinely involve people from various agencies who are involved in transition. Consider involving professionals already trained to support people of all ages (for example, clinical psychologists) to help inform the sessions. National Voices' My life, my support, my choice gives examples of what is important to young people and their families. The workforce development guide to supporting staff who work with young people preparing for adult life from Preparing for Adulthood may also be useful.

  • Seek opportunities for reflecting on practice and sharing learning – for example, during team meetings, supervision or hand‑overs.

The challenge: maximising opportunities for young people who have become disengaged or who are not eligible for adults' services to access care and support

See recommendations: 1.2.14–5, 1.3.8–9, 1.4.1–3, 1.5.7–8

Increasing opportunities for this group of young people to access services will:

  • ensure all young people receive the health and social care support that they need

  • reduce the likelihood that they will need a higher level of support in the future, and reduce the likelihood of further illness or increased risk of death

  • provide valuable information for strategic planning.

Ongoing contact and support

Managers and practitioners in children's and adults' services need to recognise the risk of young people becoming disengaged from services during transition and understand the impact this may have in the future. Care leavers, young offenders and young carers may be at particular risk. This risk of disengagement can be reduced by ensuring that transition planning is tailored to the young person, addresses any lifestyle changes, involves their GP and includes information and signposting to non‑statutory services.

What can managers and practitioners across health, education and social care do to help?
  • Use existing systems, for example hospital and social care IT and user record‑keeping systems, to identify young people in transition (up to the age of 25). Share this information, where possible, across all departments of all agencies involved in the young person's care. This should include young people in out‑of‑borough placements. The Social Care Institute for Excellence's guide to early and comprehensive identification may be useful.

  • Build strong and sustainable links with special schools, looked‑after children teams, and other local teams involved in supporting and protecting children to help identify young people who have disengaged, or may be disengaging, with services.

  • Work with young people and their families to understand and address the impact of a lack of appropriate services or differing service thresholds that make some people ineligible for adult care.

  • Ensure all young people have up‑to‑date information about the full range of care and support available to them. This should include support from primary care and pharmacy services. Ensure this is part of the information, advice and support provided to people in line with the Care Act. The Preparing for Adulthood guide to developing the preparation for adulthood section of the local offer may be helpful.

  • Where there is no adult service for a young person to transfer to, or there is a risk they may not engage with the adult service, ensure a detailed discharge letter is sent to their GP. Give the young person information about known and trusted third sector organisations who could provide support.

  • Explore the opportunities to work more flexibly with young people offered by technology. This could include consultations via Skype and sharing information using social media.

Need more help?

Further resources are available from NICE that may help to support implementation.

  • National Institute for Health and Care Excellence (NICE)