Tools and resources

Working with young people to plan person-centred care and support for admission to and discharge from inpatient mental health settings

2. Effective communication and joint working between teams and organisations supporting young people and families

2. Effective communication and joint working between teams and organisations supporting young people and families

The guideline and legislation

The guideline recommends that health and social care practitioners in hospital and community services should plan discharge with the person and their family, carers or advocate. It goes on to recommend that planning should be collaborative, person-centred and suitably paced (recommendation 1.5.1). The SEND code of practice underlines the importance of joint working throughout. In particular sections 3.40 and 3.41 underline:

  • When commissioning training for professionals, partners should consider whether combined service delivery, training or a common set of key skills would help professionals and providers adapt to meeting the needs of children and young people with SEN or disabilities in a more personalised way. This could include commissioning 'key working' roles to support children and young people with SEN and disabilities and their parents, particularly at key points such as diagnosis, EHC plan development and transition.

  • Consider whether and how specialist staff can train the wider workforce so they can better identify need and offer support earlier – for example, educational psychologists or speech and language therapists training professionals such as teachers or GPs to identify and support children and young people with mental health problems or speech and language difficulties, respectively. This may involve NHS Local Education and Training Boards. Some areas have involved parent carers in delivery of workforce development programmes.

Examples

Some local areas have multi-agency transition teams that, as part of their remit, work with child and adolescent mental health services (CAMHS) to support young people and families.

In Liverpool, this team is based in social care and supports young people with a range of needs. They hold multi-agency transitions meetings with health colleagues to discuss the transition of young people with complex needs between agencies, including from hospital to home and community support. This approach has had a positive impact and has increased communication between services, built relationships, shared knowledge and identified more early intervention.

The London-based Connecting Care for Children (CC4C) programme aims to improve support for young people and families by embedding joint working across teams and services. Some of the local CC4C work involves setting up children's health hubs in GP surgeries. These hubs are where multidisciplinary teams meet to discuss cases, share specialist knowledge with each other and hold sessions directly with young people.

Local learning

Teams and organisations at the workshop reported that they need better information about each other to give to families and to use themselves so they are confident in how best to link up, share expertise and offer the best support. They identified a number of methods they had employed which are set out below.

Joint planning

Finding time to work together when not dealing with a crisis or negotiating funding can be a positive experience for practitioners. Using this time for joint planning or training provide excellent opportunities for practitioners to build networks, understand roles and practice, and work together more effectively.

Communication

Taking a high level, strategic approach to developing and reviewing multi-agency protocols and pathways for young people with mental health problems can improve communication between teams and:

  • provide ways to formally include young people and families in the development and review process, so they can give their views on what support should look like and where it is needed

  • increase clarity on eligibility criteria, referral and funding processes, including any limitations

  • bring clarity to language; for example, what do practitioners from a range of organisations understand by 'recovery', 'co-production' and 'person-centred'?

  • provide an opportunity to work with commissioners to check data and cross-reference existing and likely numbers of young people who will use the service (for example, over a 5 year period), to inform future support

  • support timely planning for transition arrangements into adult services (see also NICE's guideline on transition from children's to adults' services for young people using health or social care services and NICE's quality standard on transition from children's to adults' services).

Operational joint working can also have a significant impact on the quality of support. When services operate individually, young people and their families can be referred and re-referred between them unnecessarily. This can result in parents feeling like it's a full-time job to find and access support. Teams can help address this issue by drawing together families and practitioners to cross-reference existing and planned support. A young person may have existing support plans if they are looked after, have a disability or receive additional support at school. In addition, they may then have crisis plans, discharge and recovery plans, and Care Programme Approach documentation. Any gaps or duplication in proposed support need to be identified.


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