Transition at 18 to Adult Services

1. Background

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 Integrated Care Board (ICB) 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.

2. Legal Context

There are three key pieces of legislation that place a duty on local authority and health sector partners around transition.

Key requirements from the Children and Families Act 2014

• Preparing for adulthood should start at the earliest opportunity;
• The Education Health and Care Plan process, including annual reviews should include an element of transition planning from Year 9 onwards;
• Young people with SEND should have independent careers advice;
• The local authority and the Integrated Care Board (ICB) must cooperate with each other to develop a transition health recommendation plan and to jointly commission services if required to meet specific outcomes. In Calderdale, this is supported through partnership governance: the Children and Young People's Partnership Executive, the Strategic Commissioning Group and the Joint Commissioning workstream delivering actions to embed the SEND reforms from the Children and Families Act 2014.

Key requirements from the Care Act 2014

• The local authority must carry out a transition assessment on a young person, young carer or an adult caring for a young person who is likely to have needs when they or the young person they are caring for turns 18, if the local authority considers there is significant benefit to the individual in doing so;
• The local authority will need to consider the needs of the person, what needs they are likely to have when they or the child they care for turn 18, and the outcomes they want to achieve in life;
• The local authority has a duty to provide advocacy to people who have substantial difficulty in understanding, using or communicating information if those people do not have an appropriate person to support them and if they are taking part in certain defined processes, e.g. needs assessment, review of care and support plan etc.

Key requirements from the Children Act (1989) Guidance and Regulations Volume 3: Planning Transitions to Adulthood for Care Leavers

• For disabled care leavers all agencies are required to work together and understand each other's roles, responsibilities, professional frame of reference and legal duties within the transition process. To ensure that this happens for disabled care leavers it is essential that specific protocols and agreements are drawn up in each local authority area, with the participation of all agencies. This will include children's and adult social care, children's and adult health, education, housing, youth offending, information, advice and guidance services, supported employment services and leisure services;
• Strategic planning approaches will need to be reflected at an operational level through protocols. These should identify the timing and mechanisms by which key professionals come together with young people to help to identify their needs and to plan individualised support packages. In order to avoid duplication, wherever possible, protocols will need to identify how the pathway planning process relates to other frameworks for planning the transition to adulthood for young disabled care leavers, such as those for special educational needs.

Key requirements from the Capacity Act 2005 Code of Practice

• Most of the Act does not apply to children under the age of 16, with the exception of some functions of the Court of Protection and offences of ill treatment and neglect;
• Most of the Act does apply to young people aged 16 – 17, although they cannot make some decisions covered by the Act, such as a Lasting Power of Attorney or some advance treatment decisions. There are additional requirements about consultation with family and carers for young people aged 16 – 17;
• The Act applies to young people over the age of 18 (subject to the various restrictions and specific provisions within the Act itself);
• The Mental Capacity Act (2005) applies to young people aged 16 and over. Under the MCA (2005) mental capacity is assumed and confirmed if the person is able to understand information given to them, retain the information, can weigh up the specific decision they are making to consider the balance of advantages and disadvantages, can communicate their decision. The deprivation of liberty safeguards within the MCA (2005) do not apply to young people under the age of 18. If a young person under the age of 18 is assessed as lacking capacity to consent, and the arrangements do not involve a deprivation of liberty, the consent may fall within the scope of someone with parental responsibility as set out in the Children's Act (1989);
• 'Lacking capacity under the Act' means a person who lacks capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken;
• The principles that must be followed are:
  
  Principle 1: A person must be assumed to have capacity unless it is established that he lacks capacity.' (section1(2))
  
  Principle 2: 'A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.' (section1(3))
  
  Principle 3: A person is not to be treated as unable to make a decision merely because he makes an unwise decision.' (section 1(4))
  
  Principle 4: An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.' (section 1(5))
  
  Principle 5: 'Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.' (section 1(6)).

Key considerations under Keep on Caring - Supporting Young People from Care to Independence (July 2016)

(See Supporting Young People from Care to Independence (July 2016)).

• This strategy calls for a revolution in the way that we think about supporting young people coming out of care. It asks local and central government to up their game as corporate parents, using the level of support that we expect a reasonable parent to provide for their child as the benchmark for how they should approach their role. And it provides a call to arms for wider society to better support care leavers, through engagement with the 'care leaver covenant';
• The 5 key outcomes:
  • Outcome 1: Better prepared and supported to live independently:
    • Corporate Parenting Principles
    • Care Leaver Covenant
    • Care Leaver Local Offer
    • Extending support from a Personal Adviser to all care leavers to age 25.
  • Outcome 2: Improved access to education, training and employment:
    • Work-based Learning;
    • Further Education;
    • Higher Education;
    • Employment.
  • Outcome 3 Experience stability and feeling safe and secure:
    • A safe and stable place to live;
    • Staying Put;
    • Staying Close;
    • Preventing homelessness;
    • Keeping care leavers safe from harm;
    • Supporting care leavers in the criminal justice system;
    • Supporting refugee and other foreign national care leavers.
  • Outcome 4: Improved Access to Health Support:
    • Mental Health;
    • Wide health issues.
  • Outcome 5: Achieving Financial Stability:
    • Financial Support;
    • Housing Costs;
    • Advice and Guidance.

3. Strategic Context

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:

• Start healthy and stay healthy;
• Are safe at home, in school and in the community;
• Enjoy learning and achieve their best;
• Make friends and take part in activities;
• Stay in education and get a job.

The following points can be found in the Adult Health Social Care Vision:

• People with care and support needs focus on what they can do for themselves either independently or with family and community support;
• People are provided with good quality information, advice and support which is available to all, including those who fund their own care;
• Assessment will focus on building on people's strengths through a variety of options including work, being part of a local community, family, friends and social contacts;
• Individuals and families are supported to take positive risks through the Council encouraging a 'can do' approach;
• People are helped by social care to obtain other forms of funding whenever it is appropriate;
• People are treated with dignity and respect;
• We work actively in partnerships to deliver better outcomes for people.

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:

1. We promote early intervention and support for smooth transitions between children and adult services for disabled children and young people;
2. We work with key partners to strengthen integration between health, social care and education services, and with services provided by wider partners.

4. Scope

This protocol is concerned with the transition of young people with SEND and additional needs into adulthood. It covers:

• Children and young people who have an Education Health and Care (EHC) Plan, and those who do not;
• Young people aged 13 and over, up to young people aged around 25 years;
• Agencies involved in commissioning services, mainly Calderdale Council, Calderdale ICB and NHS England; and
• Agencies involved in delivering services, including Calderdale Council, health sector providers such as SWYFPT and CHFT, schools and education providers, and the voluntary, community and faith sector, including those providing statutory services such as the Pathways Leaving Care team, and those involved in wider services to and with communities.

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.

5. Transition Principles

Transition in Calderdale is underpinned by the following principles;

• Transition is a process, not a single action. Transition begins as early as needed, usually from age 13, and is completed when the young person concerned is safely and successfully established in adulthood;
• Transition is something that young people do, not something that is done to them. All processes will be person-centred and enable young people to participate in planning and decision making in the way that is right for that particular young person;
• Appropriate support will be offered where needed to enable young people to participate in the ways that are right for them. Options considered will include peer support, coaching, advocacy etc. Partners will use appropriate communication tools to support this participation;
• Transition will build on each young person's unique strengths, resilience and aspirations;
• Where it is likely that a care leaver will require continuing support from adult services, a formal referral will be made as early as possible from age 16, so that eligibility for this support is established in time for their 18th birthday. This should be a significant level of support in particular if someone will have accommodation needs;
• Young people and their families deserve honesty and respect. Where there are limits to what they can expect to receive, they will know well in advance what those limits are;
• Transition planning by all partners will be mindful of the impact on budgets for all organisations, and realistic in its goals.

6. Confidentiality and Information Sharing

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.

7. The Transition Profile

There are three key stages in the transition profile:

* 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.

8. Stage 1: Preparation

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:

1. If they are likely to meet the threshold for adult social care, if they probably will not receive adult social care aged 17-18 years, or if they are likely to be on the borderline;
2. What their health needs are likely to be and what might look like in terms of services;
3. What the young person's aspirations are at this stage and what might be realistic outcomes for them; and
4. The whole range of options likely to be available for them, including statutory and non-statutory support, family and friends' resilience and community services.

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.

9. Stage 2: Transfer

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.

10. Stage 3: Adjustment

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.

11. Review

1. This Protocol will be reviewed annually to ensure it is continuing to improve transition in Calderdale;
2. Partners in Calderdale will aim towards best practice in transition as set out in the benchmarks below (adapted from "Benchmarks for transition from child to adult health services" [1]).

[1] "Benchmarks for transition from child to adult health services" London South Bank University, Great Ormond Street Hospital for Children, 2014.

Appendix 1: Activities / Services Around Transition - By Organisation / By Yearly Cohort

Click here to see Appendix 1: Activities / Services Around Transition - By Organisation / By Yearly Cohort.

Appendix 2: Transition Exception Panel

1. Aim

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.

2. Key Functions

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:

• To consider early transfers for young people where that is appropriate;
• To consider tailored packages of support outside the usual service arrangements where that is likely to result in more positive outcomes for the young person concerned;
• To consider joint funding or other funding arrangements when that supports appropriate transitions for young people; and
• To provide a forum for other creative and innovation opportunities to be explored where these will benefit particular individual young people.

3. Membership

The Panel consists of:

4. Frequency of Meetings

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.

5. Meeting Support

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.

6. Review

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.