Quality standard

Quality statement 2: Coordinated transition plan

Quality statement 2: Coordinated transition plan

Quality statement

Young people who will move from children's to adults' services have a coordinated transition plan. [new 2023]

Rationale

Having a transition plan that is coordinated across all services will make it clear when the care and support provided to a young person will move from children's to adults' services and how it will be delivered. Children's and adults' services should work together and with the young person and their family or carers to develop a coordinated transition plan that meets the young person's individual needs, is practical to implement, and avoids creating gaps in services due to variation in the age for transition between different services. This will help young people and their families and carers to know what to expect and reduce uncertainty and stress. It is recognised that for young people covered by health and social care or education legislation this will be part of a broader plan.

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 from school year 9 (aged 13 to 14 years) and above, who will move from children's to adults' services, who have a coordinated transition plan.

Numerator – the number in the denominator who have a coordinated transition plan.

Denominator – the number of young people from school year 9 (aged 13 to 14 years) and above, 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. From school year 9 (aged 13 to 14 years) and above is included for measurement purposes, although it is recognised that the starting time may vary in different services. Data on a personalised transition plan and coordination of age of start of 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 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) work together to develop and agree a coordinated transition plan with young people who will transition from children's to adults' services, and their families and carers.

Health and social care practitioners (such as hospital consultants, nurses, GPs, social workers, mental health workers, care coordinators or named workers) work with young people, and their families or carers, to develop a transition plan for the move to adults' services. They read the sections of the plan produced by other practitioners, to make sure the plan works as a whole. Where a named worker is in place, they will coordinate the transition plan.

Commissioners ensure they commission services that work together, and with young people, and their families and carers, to develop and agree a coordinated transition plan for the move to adults' services.

Young people who will move from children's to adults' services work with health and care practitioners to develop and agree a plan for moving that covers all the services they use. This will set out what changes there will be, as well as when and how those changes will happen.

Families and carers of young people who will move from children's to adults' services work with health and care practitioners to develop and agree a plan for the move. This will set out future changes to services and care that the young person will receive.

Definitions of terms used in this quality statement

Coordinated transition plan

Children's and adults' services should work together and with the young person and their family or carers to develop a transition plan that meets the young person's individual needs. Planning should involve all services and interagency teams providing support to the young person before and after transfer. The young person's GP should be involved; this will be critical when the young person does not meet the criteria for specialist adult health services or there are no adults' services in place. The transition plan should:

  • coordinate the age of non-statutory transitions to adults' services, to ensure a consistent approach

  • include the services that are available locally to support transition

  • be agreed with the young person and their family or carers (for example, by including a section for their comments and views)

  • link to other plans the young person has in respect of their care and support.

[NICE's guideline on disabled children and young people up to 25 with severe complex needs, recommendations 1.8.5, 1.8.6 and 1.8.7 and NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendations 1.2.4 and 1.3.9 and expert opinion]

Equality and diversity considerations

It will be important to adapt the transition plan to reflect the needs of young people with a learning disability or neurodevelopmental needs or both. Health and social care practitioners should ensure that transition planning is developmentally appropriate and considers each young person's capabilities, needs and hopes for the future, addressing their biological, psychological and social development in the broadest terms.

Transition support should take into account the young person's: maturity; cognitive abilities; psychological status; needs in respect of long-term conditions; social and personal circumstances (including culture and beliefs); caring responsibilities and communication needs. The plan should ensure that the point of transfer is not based on a rigid age threshold and takes place at a time of relative stability for the young person. [NICE's guideline on transition from children's to adults' services for young people using health or social care services, recommendations 1.1.2 and 1.2.3 and terms used in this guideline]

Service managers should ensure a range of support is available, and used, to help young people communicate effectively during discussions about the transition plan. 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 managers should ensure practitioners can respond to the specific needs of care leavers including the option to continue access to services beyond age 18 until care has been transferred to adults' services. Practitioners should ensure that the transition plan for care leavers is included within their pathway plan for leaving care. [NICE's guideline on looked-after children and young people, recommendations 1.8.4 and 1.8.10]