Quality standard

Quality statement 3: Annual meeting

Quality statement 3: Annual meeting

Quality statement

Young people who will move from children's to adults' services have an annual meeting to review transition planning. [2016]

Rationale

Transition is a lengthy process that starts early, by school year 9 (aged 13 to 14 years) and continues past the point of transfer. Regular review of transition planning ensures that a young person's changing needs are taken into account. Transition planning should be reviewed at least annually, but for some young people, and their families or carers, the meetings may need to be more frequent, depending on their individual needs.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

Proportion of young people older than school year 9 (aged 13 to 14 years), who will move from children's to adults' services, who have had a meeting in the previous 12 months to review transition planning.

Numerator – the number in the denominator who have had a meeting in the previous 12 months to review transition planning.

Denominator – the number of young people older than school year 9 (aged 13 to 14 years) who will move from children's to adults' services.

Data source: Data can be collected from information recorded by health and care practitioners and provider organisations, for example from patient or client records.

Outcome

a) Proportion of young people (and their families and carers) who have transferred from children's to adults' services, who were satisfied with planning for transition and transfer (including their involvement).

Numerator – the number in the denominator who were satisfied with planning for transition and transfer (including their involvement).

Denominator – the number of young people (and their families and carers) who have transferred from children's to adults' services.

Data source: Data can be collected from information recorded by health and care practitioners and provider organisations, for example from a patient or client survey. Resources to support this could include the TIER Ready, Steady, Go programme which includes feedback on transition planning in its questionnaires for young people and their families and carers. Also, the National Confidential Enquiry into Patient Outcome and Death transition from child into adult healthcare young person and parent carer survey includes questions on transition planning.

b) Rate of non-attendance at meetings or appointments in adults' services for young people who were expected to transfer from children's to adults' services.

Data source: Data can be collected from information recorded by health and care practitioners and provider organisations, for example from patient or client records. For example, NHS Digital's hospital episode statistics (HES) includes data on hospital outpatient appointments and attendances.

c) Proportion of young people attending adults' services after transfer from children's services who continue to engage with services.

Numerator – the number in the denominator who continue to engage with services.

Denominator – the number of young people attending adults' services after transfer from children's services.

Data source: Data can be collected from information recorded by health and care practitioners and provider organisations, for example from patient or client records. For measurement purposes, this could be defined as engagement at 1 or 2 years after transfer or engagement at a specific age (such as 25 years) but can be adapted to fit local service characteristics.

What the quality statement means for different audiences

Service providers (children's and adults' health, mental health and social care providers) ensure that systems are in place for young people who will move from children's to adults' services, and their families or carers, to have an annual meeting to review transition planning with all practitioners providing support.

Health and social care practitioners supporting transition (such as hospital consultants, nurses, social workers, mental health workers, GPs, care coordinators or named workers) take part in an annual meeting to review transition planning for young people who will move from children's to adults' services. They ensure that they share the updated plan with young people and their families or carers after the meeting.

Commissioners ensure that they commission services that arrange an annual meeting with all practitioners to review transition planning for young people who will move from children's to adults' services.

Young people who will move from children's to adults' services have a meeting each year to talk about planning for the move and check that the plans are still suitable for them. The meeting should involve all practitioners supporting the young person, and their family or carers.

Families and carers of young people who will move from children's to adults' services are involved in a meeting each year to review planning for the move. The meeting ensures that families and carers feel involved and know about future changes to services and care that the young person will receive.

Definitions of terms used in this quality statement

Annual meeting

The annual meeting should involve the young person, their family or carers and input from all practitioners providing support.

The meeting can take place either in person or via teleconferencing or video.

The meeting should identify what is working well in the transition planning and what can be improved. The young person should be treated as an equal partner and their views taken into account. They should be supported to make decisions and build their confidence to direct their own care and support over time. At the meeting there should be a review of the young person's current:

  • clinical needs

  • psychological status

  • social and personal circumstances

  • caring responsibilities

  • educational and vocational needs

  • cognitive abilities, and

  • communication needs.

[NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendations 1.1.2, 1.1.4, 1.2.4 and expert opinion]

Equality and diversity considerations

Health and social care practitioners should consider the young person's travel and communication needs when deciding whether the annual meeting should take place in person or virtually.

Service managers should ensure a range of support is available, and used, to help young people communicate effectively at the annual meeting. This could include having a written record of how a young person prefers to communicate, such as a communication passport or 1-page profile, and using different ways to help the young person communicate, such as communication boards, digital communication tools and advocacy. [NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendations 1.2.11 and 1.2.12]. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.

Service providers should consider the best way to ensure that young people, especially those with complex needs, do not have to re-tell their story at each transition meeting. This could include making sure the same practitioners attend each meeting and/or developing and sharing a personal folder that includes key information about the young person. [NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendation 1.3.3]