SCOPE OF THIS CHAPTER
The aim of this protocol is to support our vision for transition for young people in Calderdale, whereby young people move into adulthood ready to safely and successfully achieve their goals.
This vision sees transition as a process that builds on each individual young person's strengths, resilience and aspiration. Young people are active agents in this, working in partnership with families, communities and agencies to move into a safe, successful and happy adulthood.
Young people generally transfer from child to adult health services at 16, 17 or 17.5; from child to adult social care services at 18; from school-based education to further education between 16 and 19, and to higher education from 18. However, there will be exceptions to these general arrangements. Child and Adolescent Mental Health Services (CAMHS) provide services up to age 18, though a consultant may wish to continue to lead a young person's health care post 17, and young people with Education Health and Care Plans may still access aspects of children's services along with support from adult social care services until the end of school year 13, at age 19. Our protocol reflects the fact that age-related policies of different agencies do not fit easily with the realities of the transition process for all young people with SEND, and allows for a flexible approach to meet individual need.
AMENDMENTThis document was reviewed locally and completely rewritten in January 2017.
Transition into adulthood is a time of great change and pressure for all young people. Young people with additional needs, including special educational needs and disabilities (SEND), face many of the same challenges as their peers who do not have additional needs. However, young people with SEND also face additional complexities, for example about the ending of services they have accessed as children, or about access to new adults' services, or about support they need to access new opportunities, such as employment or independent living.
Adults Health and Social care and Calderdale Clinical Commissioning Group (CCG) completed a review of the support available to adults with a learning disability in Calderdale. The review showed that transition to adulthood was a time of uncertainty for families. Families wanted to have more information and advice about the support and opportunities that might be available in adulthood. They said that clarity regarding the process of transition was required to help support and guide them through the process.
There are three key pieces of legislation that place a duty on local authority and health sector partners around transition.
This protocol sits within the overall strategic framework provided by Calderdale Children and Young People's Partnership Executive (CYPPE) strategic planning framework, and is part of how we work to ensure that all children in Calderdale are happy, safe and successful.
Successful transition helps to deliver the framework's strategic priorities:
The following points can be found in the Adult Health Social Care Vision:
This protocol also helps the Calderdale Health and Wellbeing Board deliver on its promises to disabled children, young people and their families, as expressed through the Disabled Children's Charter which has embedded within it principles of safeguarding and hearing the voice of the child. Two of the Charter commitments relate directly to the objectives of this protocol:
This protocol is concerned with the transition of young people with SEND and additional needs into adulthood. It covers:
Responsibility for supporting successful transition is wider than just social care. Throughout this document, when we talk about children's services or adults' services, this includes all partners delivering services for children and young people or all partners delivering services for adults, including schools, GPs, NHS trusts, voluntary sector groups and others.
Transition in Calderdale is underpinned by the following principles;
Partners involved in transition will share information as appropriate and when necessary.
Partners will be asked to sign the Calderdale Information Sharing Protocol, if they are not already signatories to this. That Protocol allows partners to share information about young people safely and within any relevant safeguarding or data protection rules.
Wherever possible, young people and their families should only have to tell their stories once.
Any handover points will include a full handover of all relevant information.
Partners will ensure all information that they are responsible for is up to date, accurate and comprehensive, ready for any handover.
There are three key stages in the transition profile:
|Stage||1. Preparation||2. Transition||3. Adjustment|
|Who is most likely to take the lead?||Key worker(children's services including schools) Young person Family||Key worker (adults or children's services) Young person Family||Young person Family Key worker (if there is one) from adults' services|
* The preliminary evaluation can be informal and a natural part of ongoing assessment and planning.
It is the point at which professionals, families, parents, carers and most importantly young people start to discuss the overall direction of travel for that young person's move into adulthood. No firm decisions are made or options ruled out, but there is a discussion and documentation of the likely options and outcomes, based on the young person's strengths, ambitions, preferences and resilience.
Appendix 1: Activities / Services Around Transition - By Organisation / By Yearly Cohort, sets out in more detail what happens at each stage, and who is responsible.
Partners working with young people in Calderdale will begin a preliminary evaluation of outcomes and options, well ahead of transition, so that young people, their families and the agencies who work with them know what to expect, and can take any actions necessary to make sure transition is successful.
This preliminary step can include planning for self-care and using the adults' services self-assessment tool to give a broad idea of likely support needs for the future.
No decisions will be made at this point, and no options will be rejected, but young people and the team around them may want to consider:
This preliminary evaluation can help young people and their families think about what they want to achieve and what they need to think about over the next few years. This can form the basis of a Moving On strategy that will be kept under review as the strengths, needs and aspirations of the young person change.
The key structure for this review and planning will be the Education Health and Care (EHC) Planning Framework. Actions to prepare for transition will be included in EHC Plans and transition outcomes discussed with young people regularly.
For young people without EHC Plans, other existing plans will be used to document and review the actions necessary to prepare for transition, e.g. Short Breaks, Pathways leaving care plan, health recommendation plan or education plan.
All plans for young people with SEND and other additional needs will include a Moving On strategy that will outline the outcomes for transition and the actions needed ahead of transition and handover. Any specific goals will be agreed with the young person as part of this process. These will be kept under review as part of existing review processes, e.g. SENCO annual review, EHC review process.
The Moving On strategy will also identify who will lead the handover stage (see Section 9, Stage 2: Transfer).
The three categories set out in the diagram below are important. The support at adulthood will be very different for each of the three groups, and so the actions to prepare for adulthood will be very different.
For the Tier 1 group, who will not receive any specialist adults' services support and will be expected to access universal services, a key focus will be resilience and community support. The preparatory actions might include: an orientation session to understand what universal services are available; independent travel training; training on how to use the Local Offer to find directly accessible services etc.
For the Tier 4/5, who will continue to receive intensive support as adults, the focus may be more about: the handover between services; building new relationships with adults' providers; investigating personal budgets etc.
Click here to view the Stage One – Preparation Flow Chart.
The Transfer stage will take place at the point at which the young person is ready. This will not necessarily mean a change of services at exactly 18 years old. Funding only will change at 18 years.
A change of funding is not a reason to trigger the transfer stage. If payment of a service becomes adults' services' responsibility before the young person is ready to access an adult service, commissioners from adults and children's services will work together to allow the adults' commissioner to support that young person within children's services.
The transfer changes will be triggered by a Transition Assessment, carried out at the relevant time depending on services and circumstances. Transition assessment for children looked after outside Calderdale will be earlier than for those looked after within the district.
Partners will be alert to opportunities for earlier transfer when that is in the interest of the young person concerned, and will bring those opportunities to the Transition Exception Panel (see Appendix 2: Transition Exception Panel).
The assessment will help create a more specific and detailed Moving On plan, which will identify the right time for that particular young person to leave children's services and move into adults' services, whether targeted or universal.
This may be on a staged basis, e.g. with a young person moving to adults' health services before they move to adults' social care.
The handover stage can be led by a key worker from either children's or adults' services. A decision will be made following consultation within children's and adults' services as part of the Moving On plan. The transfer should be led by someone with whom the young person has a meaningful relationship. There will be a contingency plan in place to cover key workers' absence during the transfer stage.
For young people who will be moving into universal services in adulthood, the transfer process will be led by children's services. They will be provided with information that is accessible and up to date to help them understand the universal, voluntary and community offer that will be available to them.
The young person will be consulted directly on the transfer, in whatever way best suits that young person's communication abilities and preferences. There will be scope for the young person to raise concerns separately from parents and carers.
The transfer process will support the young person to make decisions and build their confidence to direct their own care and support over time.
The timing of the transfer will be agreed in partnership with the young person and their family and take into account any other changes that are happening and any other pressures, e.g. exams.
The transfer stage takes into account any relationships that the young person has built up in children's services. This includes relationships with professionals and other children and young people using services. Where appropriate, plans for the future for the young person will include maintaining relationships and will reflect the young person's aspirations and personal group and will be in line with the principles of the Mental Capacity Act (2005) where that applies.
Additional time will be built into any appointments to handle transition issues, which are likely to be most intense at transfer.
Family and carers will be given the opportunity to express concerns, supported to understand the implications of the Mental Capacity Act (2005) and plans are in place to address concerns identified. The views of the young person will guide how parents and carers are involved. All partners will recognise that views of young people and their parents and carers are different and should be respected.
Introductory meetings will be arranged where relevant, especially if moving into minimal supported services/ universal services, e.g. an introductory, informal meeting with a GP for those moving from consultant to GP led care. Part of the Transfer plan will be about building familiarity with adults' services, e.g. holding joint or overlapping appointments, visiting adults' services with the key worker etc.
A timely and comprehensive handover of information will take place between providers where necessary.
Transition continues beyond the point of handover, up until the point at which the young person is safely and successfully functioning within an adult environment.
The time taken for adjustment will vary for each individual, but will be as a minimum, either the time defined in relevant legislation or a minimum of 6 months before and after transfer.
Partners recognise that under Statutory Principle 3 of the MCA (2005) young people have the right to make decisions which others may deem to be unwise. Where a young person is making a capacious decision not to engage with services, and the professional assessment is that this may result in the young person being exposed to risk, all efforts will be made to positively reengage with the young person. Where the young person continues to decide not to engage with services the worker shall seek advice from the Adult Services MCA Lead and if necessary the case may be escalated to MCA Clinic or to Risk Enablement Panel. In keeping with the principles of the MCA (2005) the young person shall be supported to engage with the Risk Enablement escalation process. If there is evidence that the young person has substantial difficulty in understanding the escalation process and has no other appropriate person to support them, they shall be offered access to a Care Act Advocate.
During this adjustment stage, the main point of contact for the young person will be adults' services, including Adults Health and Social Care within the Council and wider adults' services within health.
There will be a continuity of healthcare provider for at least the first two attended appointments after transfer.
Adults' services will ensure there is advocacy support available for young people adjusting to adults' services, offering this as widely as possible in addition to the duty to provide advocacy in specific circumstances as set out by the Care Act 2014.
Children's services will continue to support where this is in the best interests of the young person and within the limits of available resources. For example, a school may provide one-off pastoral advice to an ex-student who is struggling with a particular issue, but would not be able to act as key worker to support that young person with a complex challenge.
Children's services will ensure that a cut off point is agreed for any ongoing support that a young person might receive as they are settling into adulthood. This will be agreed with the young person and documented as part of the exit strategy planning process.
Adjustment will be supported by a gradual withdrawal or reduction of support where necessary.
|1. Moving to manage a health condition or social care needs as an adult||Young people and their parents and carers are offered advice and information in a clear and concise manner about how to manage their health condition as an adult.|
|2. Support for gradual transition||The young person as they progress through the transition process is gradually prepared and provided with personally understandable information and support.|
|3. Co-ordinated child and adult teams||The young person is supported through a smooth transition by knowledgeable and coordinated child and adult teams.|
|4. Services are 'young people friendly'||Young people are provided with care and in an environment that recognises and respects that they are a young adult, not a child or an older adult.|
|5. Clear Information||Concise, consistent and clear written documents and other materials containing all relevant information about the young person's transition is provided to the teams involved in the transition process.|
|6. Parents and carers||Parents and carers are included in the transition process gradually transferring responsibility to the young person.|
|7. Assessment of readiness||The young person's readiness for transition to adult care is assessed, in line with the Mental Capacity Act (2005).|
|8. Involvement of key people e.g. GP, school, social workers||The team around the young person is informed of the plan for transition and is able to liaise with other relevant teams to facilitate services requested/ needed by the young person.|
|9. Transition process fit for purpose and reflecting best practice||This transition process to be monitored twice a year and reviewed annually by the Disabled Children and Young People's Strategy Board.|
 "Benchmarks for transition from child to adult health services" London South Bank University, Great Ormond Street Hospital for Children, 2014.
The aim of the Panel is to ensure young people transition into adulthood at the time that is appropriate for them, with the appropriate support and with support around them to help them achieve positive outcomes.
In particular, the Panel will support decision-making for those young people who need a more flexible timescale and/or a managed move into adulthood.
The Panel will seek to find the most cost effective option that is compatible with the best interests of the young person concerned.
The Panel does not have any delegated decision-making functions, but it will support those decision-makers from partner agencies in making the most appropriate and cost-effective decisions.
Decision-makers agree to follow the Panel's direction for those cases which are within their own particular caseload and/or budget management.
The main functions of the Panel are:
The Panel consists of:
|Acting Service Manager (Chair)
Strategic Commissioning, Children and Young People's Services, Calderdale Council
Adult Learning Disabilities, Adults Health and Social Care, Calderdale Council
|Manager, Pathways Service|
|Service Manager - Children Looked After
Children and Young People's Service, Calderdale Council
|SWYT manager, Community Mental Health and Early Intervention Teams|
The Panel will meet on an exception basis, only when there is a case that provides an opportunity outside of the usual service procedures.
Any partner who identifies an opportunity for the Panel to consider will contact the Chair of the Panel with details of the case.
The Chair of the Panel will then call a meeting as soon as possible.
The Panel meeting will be supported by the Commissioning Support Officers, from the Children's Commissioning Team.
It will be chaired by the Service Manager – Strategic Commissioning.
The need for and impact of this Panel will be reviewed in 12 months time from the date when the Transition Protocol was first approved.
Only valid for 48hrs