Multi-agency and joint team working

The guideline and legislation

The guideline has an emphasis on joint working in and beyond health and social care. It recommends that service managers work with each other to proactively identify and plan for young people with transition support needs (recommendation 1.1.6). The guideline also recommends that each health and social care organisation should nominate a senior executive to be accountable for the development and implementation of a transition strategy and policies (1.5.1). The special educational needs and disability code of practice 0-25 also underlines the importance of joint working (SEND code of practice section 3.56) as does the joint CQC and Ofsted SEND inspection framework:

It is important to note that these inspections will evaluate how effectively the local area meets its responsibilities, and not just the local authority. The local area includes the local authority, clinical commissioning groups (CCGs), public health, NHS England for specialist services, early years settings, schools and further education providers.

The framework for the inspection of local areas' effectiveness in identifying and meeting the needs of children and young people who have special educational needs and/or disabilities, page 8.

Example

Services report that they need better information about each other to give to families and also use themselves so they are confident in how best to link up, share expertise and jointly support young people. Developing the Local Offer (SEND Code of practice section 4) provides a focus for this work. Work completed by the South East London Pathfinders group with the Preparing for Adulthood team sets out the range of services that could be involved in delivering effective local support. This includes young people and their families as key partners, and services including:

job centre plus
housing providers
health, education and social care
transport and leisure services.

It provides a useful checklist for areas bringing together key groups in transition planning and can be found in Developing the Preparation for Adulthood Section of the Local Offer – A guide.

Learning from local areas

During transition, which is a long process, different joint working models may be needed and a range of partners involved at different points. Strong local leadership was identified as important in achieving joint working; bringing together agencies, young people, families and providers and developing sustainable and effective relationships. The table below sets out points from the workshops along with the recommendations they link to in the guideline.

Guideline reference	Local area learning – multi-agency and joint team working
Recs: 1.5.1; 1.5.2	Leadership – joint working
	Identify a senior lead as 'transition champion'. This will promote engagement in strategic and operational meetings, provide a focus for work and visible support at a senior level across organisations, and sponsor transition as a key issue in wider strategic discussions.
	Make links with other key staff including the Designated Medical Officer (DMO) (SEND code of practice section 3.46) and commissioners including for housing and transport.
	Sponsor strategic planning groups with key partners from health, education and social care and encourage input from teams including looked after children, CAMHS and youth offending.
	Work with managers and commissioners to include the option of cross team funding and resource sharing in pathways so teams can more easily joint work and share expertise. For example, children with disabilities and looked after children teams.
	Support teams to identity a transition lead and build this role into individual and team work plans.
	Locate staff together to improve general knowledge of services and support. For example, one day a week, secondments or joint training to support with specific advice (including clinicians) and improve general knowledge of services and support.
	Raise awareness with a range of services including drugs/alcohol, CAMHS, sexual health, targeted youth programmes and employment advice as they need to understand and be able to engage with young people with SEND.

In addition to leadership, the workshop attendees identified a number of learning points on multi-agency and joint team working including using the Local Offer, transition protocol and local pathways to check how well support is working and plan more effective joint working in future. The table below sets out points from the workshops along with the recommendations they link to in the guideline.

Guideline reference	Local area learning – multi-agency and joint working
Recs: 1.1.5–1.1.7; 1.5.3; 1.5.9; 1.5.10	Share initial assessment information across services and use a single point for initial referral and re-referral to save time and make sure young people and families are directed to the most appropriate support earlier. This can also be used to monitor waiting times for support or intervention after referral/initial assessment as long delays (for example, to occupational therapy) can have a significant impact on the effectiveness of the intervention and long-term advantages for the young person.
	All key services need to be actively signed up to the protocol commitments, pathway formats and to providing information for the Local Offer. Having services like CAMHS or Looked After Children teams signed up increases the range of support/expertise available and demonstrates a commitment to joint working.
	Link up local pathways so teams working with, for example, unaccompanied young people or those seeking asylum can work together on possible pooling of resource or staff skills to meet their needs.
	The Local Offer needs to include and promote good quality non-specialist services who have the skills to support young people with SEND. If there is a gap in local support bring this into discussion as part of the commissioning cycle plan.
	Develop shared transfer arrangements. Young people and families can benefit from early meetings/clinic visits with named staff in each service. Use the Designated Medical Officer (DMO) (SEND Code of practice section 3.46) in planning this support.
	Maintaining the information in the Local Offer needs to be built into a programme of work/job description and have a named lead.

Transition from children’s to adults’ services for young people using health or social care services

Tools and resources

Tailored resource