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

Jointly review current systems and practice to identify where changes are needed to support sharing responsibility. The Preparing for Adulthood programme's self-evaluation tools 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 Participation Works resources 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 1 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.

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 and Social Care'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:

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's guide to joint commissioning 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.

Ensure that everyone working with young people in transition up to the age of 25, in children's and adults' services, understands:

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:

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 Preparing for Adulthood's workforce development guide to supporting staff working with young people preparing for adult life may also be useful.

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

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.