Transition from children’s to adults’ services

Process

Proportion of young people who are moving from children's to adults' services who have a named worker to coordinate care and support before, during and after transfer.

Numerator – the number in the denominator who have a named worker to coordinate care and support before, during and after transfer.

Denominator – the number of young people who are moving 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. Data on having a key worker before, during and after transition is included in the National Confidential Enquiry into Patient Outcome and Death transition from child into adult healthcare audit toolkit which can be implemented locally.

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 locally 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.

Named worker

The named worker is a role rather than a job title. This should be one of the people from among the group of workers providing care and support to the young person, who has been designated to take a coordinating role. The young person should help decide who this person should be. It could be, for example, a support planner, a nurse, a youth worker, an allied health professional or another health or social care practitioner. It could also be someone who already has the title keyworker, transition worker or personal adviser. The transition process is lengthy and it would be expected that the named worker may change over time.

A named worker should oversee, coordinate and deliver transition support, including the transition plan. They should be the main link with other practitioners, particularly if a young person receives care from more than one service. They should arrange appointments for the young person, act as their representative, direct them to other services and sources of support, and support the young person's family or carers if appropriate.

The named worker should be involved throughout transition, supporting the young person before and after transfer until a time agreed with the young person and their family or carers. The named worker should hand over responsibilities to a practitioner in adults' services (if the named worker is based in children's services) and give the practitioner's details to the young person and their family or carers.

The named worker should ensure that support with education and employment is offered. For disabled young people in education, the named worker should liaise with education practitioners to ensure comprehensive student‑focused transition planning is provided. [NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendations 1.2.5 to 1.2.10 and NICE's guideline on disabled children and young people up to 25 with severe complex needs, recommendation 1.8.12]