Transition to Adult Services for
CYP with Long Term Conditions
in the South West.
Jennie Shine
Quality Improvement Lead
SW Strategic Clinical
Network for Maternity and
Children
Network Priority
Outcome
Improved outcomes
and experience for
young people
transitioning in to
adult services
(Domains 2 and 4).
Ambition
Transformational
Elements
Reducing the
proportion of children
and young people
reporting a very poor
experience of
transitional care in
the SW.
Implementation of
agreed measurable
standards for all
commissioners and
providers (March
2015).
National context:
• One of major objectives of the National Clinical Director for
Children, Young People and Transition.
• Endorsed by NHS England / included in their Business Plan
2014/2015 & 2016/2017
• Mentioned in The Pledge: Better Outcomes for Children &
Young People (Transition to adult services - one of 4 new
potential indicators)
• Governance - reports to the NHS England CYP Board
• Our work is aligned to standards in CQC, NICE, Royal
Colleges, Dept of Ed.
Outcomes:
• Specialised service specification insert completed &
awaiting outcome of Specialised Services Review
• Working principles developed to inform CCG local
commissioning by the end of this year.
• Connections made with relevant initiatives and stakeholders
to spread and implement the work
• Better patient and family experience
• So ‘how’ is this happening…
SW SCN focus:
• What is the current situation in acute Trusts and CCGs?
• Using National work to identify key generic standards for
transition
• Test these with providers and patient organisations for
feasibility and gather feedback
• Hold SW wide events to enable sharing of best practice,
peer support and circulation of potential resources to
implement change
• Engage with CCG commissioners to offer standards as
guidance to contracting for transition and possible tool for
monitoring compliance
Transition Dashboard
• The key principles that have been taken from the
work in developing the National generic spec are
presented as a ‘dashboard’.
• This dashboard was used as a self assessment tool
for acute providers to see their current status in
delivering the principles.
• Providers felt this was a real eye-opener but also
gave a structure to moving forward.
• This tool forms the basis of a CQUIN and potentially a
monitoring tool for a CQUIN.
Transition Dashboard
TRANSITION DASHBOARD
Framework to assess Trust readiness to implement possible forthcoming standards of care for young people in transition
from paediatric to adult services.
Please (Red, Amber, Green) rate your Trust against the questions below and give details of anticipated barriers.
In order to share best practice, avoid reinventing the wheel and to offer peer support for this work, please forward any
documents you are happy to share to inform this process and help colleagues across the South West and ultimately our
Young People.
Thank you for your time.
STANDARD
Provision of young people
friendly services
Provision of transition
focused services
READINESS
INDICATOR
REQUIREMENT
(R/A/G)
Compliance with 'You’re Welcome' Has the Trust completed 'You're Welcome'
Quality Standards and 'Young
assessment?
person Friendly' services for young Link:
person appropriate services
https://www.gov.uk/government/publicatio
ns/self-review-tool-for-quality-criteria-foryoung-people-friendly-health-services
Named executive lead for
transition
Name:
Role:
Transition policy covering services Policy exists?
for young people (13 -25)
Please share.
developed, implemented and
reviewed annually with assurance
report to the Board and
commissioners
Policy is implemented across the Trust?
System in place to review policy annually?
System in place for reporting effectiveness to
the board?
COMMENTS & ANTICIPATED BARRIERS
Collation of dashboard responses:
Trust
Dashboard Indicator
1
2
4
5
6
7
8
9
10
11
12
13
14
You're Welcome
Named executive lead for transition
Trust Transition policy
Trust Transition Steering
Provider database identifying population of 13 – 25 year
olds with transition plans
DNA rates for 13 – 25 year olds tracked and managed
Patient safety incidents
Patient –Led Assessments of the Care Environment (
PLACE )
ONLY 1 AREA
ONLY 1 AREA
Patient survey
Provider’s training directory identifies relevant training
available
Published pathway and guidelines
ONLY 1 AREA
ONLY 1 AREA
SOME AREAS
ONLY
ONLY 1 AREA
All young people have assessments, action plans,
reviews and transfer reports documented
ONLY 1 AREA
ONLY 1 AREA
SOME AREAS
ONLY
ONLY 1 AREA
ONLY 1 AREA
SOME AREAS SOME AREAS
ONLY
ONLY
All parent carers of young people have access to support
and information
ONLY SOME
AREAS
ONLY 1 AREA
ONLY 1 AREA
All young people have the name of the health care
professional responsible for their transition co-ordination
SOME AREAS
ONLY
ONLY 1 AREA
All young people and their parent carers can identify the
person in their team
Multi-media information resources
All young people have access to peer support
SOME AREAS
ONLY
SOME AREAS
ONLY
ONLY 1 AREA
SOME AREAS
ONLY
Commissioning for Transition
• Commissioners invited to all events so far and
welcome at our SCN working group meetings.
• A children’s commissioners forum has been set up to
meet 3 x a year.
• In October’s meeting we discussed putting Transition
into the acute contracts for 2015/16.
• Developed a CQUIN with Glos and Kernow CCGs
which has been shared for internal discussion rounds
within all CCGs.
• We would like to see, at very least, some quality
markers included in each contract.
Next steps…
• Work with CCGs to add transition into the acute contracts for
2015/16
• Looking to develop a method of progress reporting to record
what changes are being made in Trusts.
• Looking to provide a patient reported measure to record how the
changes are affecting Children, Young People and families.
• Starting to expand the work to include SEND and CAMHS
populations, working with the Mental Health SCN.
• A lot of good practice across SW and the SCN has provided a
forum for sharing and peer support – this will be extended to the
wider aspects.
Over to you…
• How is your organisation seeking to improve
Transition?
• Are there any areas we can develop further with
you?
• How is it best to communicate and engage with all
organisations to include you in our work?
• Any questions or suggestions?