Transition Pathway
Context
The term “transfer” is often used to describe the handover of a child’s care from one service to another. That handover should be planned and managed as a process, for which the term “transition” is more
appropriate (DH 2006). Children and young people experience many significant transition points between health care services, as well as those between schools, university and other educational settings.
Thirty percent of children and young people also experience transitions in relationships as a result of parental separation, divorce or remarriage. Together, all these transitional phases can have an impact on
adherence to therapeutic regimes and retention by supportive health care services. (RCN 2013) Young people generally have considerable reserves of resilience and optimism which help them to overcome
difficulties and make the move from systems and services designed for children and teenagers to those of the adult world.
As children and young people move along the transition pathway the issue of consent and confidentiality becomes more significant. If the person is under the age of 16 (a minor), nurses and midwives must
be aware of local protocols and legislation that affect their care or treatment. Consent of people under 16 is very complex, so local, legal or professional organisation advice may need to be sought. (NMC
2014) In short, practitioners need to be aware of and competent in the procedures for gaining consent for treatment and referral to specialists services for young people without the agreement of parents and
carers. As a good practice guide, every effort should be made to involve parents and carers in decisions regarding their child’s care however where this is not possible and/or beneficial for that child/young
person practitioners should make an assessment of Gillick competence using Frasier guidance and ensure this is documented in line with locally agreed protocols. (NSPCC 2014).
This pathway is designed to guide Health visiting and School Nursing teams and other partners in developing robust care pathways for school entry, moving from primary to secondary school and moving on to
adult provision). The pathway adopts a life course approach and recognises that children and young people including those with additional health needs may encounter numerous transitions within the life
course that are not solely defined by age. For this purposes there has been some consideration of the transition along the 0-19 service model.
A Life Course Approach
0 years –
community
5 years – school entry
11 years – secondary
school
16 years – further
education
19 years - adult
** Some young people
require an ongoing link
beyond 19+ and provision
will continue to 25 years
Framework
.
Transition of Children and Young People with Long Term Conditions (LTC) to Adult Services
Transition of Children and Young People through the life Course who are at Risk of
Significant Harm
Getting transition right for children with LTC should be seen as a whole system approach; early help
(including the support of Specialist community Public Health nursing) will improve health outcomes,
keeping children/young people out of hospital for longer and/or reduce the need for hospital admissions
into adult life. The government reforms detailed in Children and Families Bill (2013) intend to
transform the system for children and young people with special educational needs (SEN), including
those who are disabled, so that services consistently support the best outcomes for them. It intends to
do this by replacing statements and learning difficulty assessments with a new birth- to-25 Education,
Health and Care Plan, extending rights and protections to young people in further education and training
and offering families personal budgets so that they have more control over the support they need. This
may mean the planning of transition into adult services for these young people is delayed. When
participating in the planning transition of services practitioners should:-
Safeguarding and promoting the welfare of children can be defined as; protecting children
from maltreatment, preventing impairment of children's health or development, ensuring that
children are growing up in circumstances consistent with the provision of safe and effective
care and taking action to enable all children to have the best chances. Child protection is part
of safeguarding and promoting the welfare of children and refers to the activity that is
undertaken to protect specific children who are suffering, or are likely to suffer, significant
harm. (DFE 2013). The specialist community public health function involves a capacity not
only to participate actively in public health provision but also ensure it is practised within a
safe environment. (NMC 2004) Throughout the life course this means services designed to
promote health outcomes for children and young people should consider a seamless
approach to the transition and should:-










Embrace children and young people’s enthusiasm for ‘growing up’ and not just concentrate on
the young person’s health problem
Understand that as they grow older children and young people need to be increasingly
involved with and leading on the management of their LTC taking responsibility for their own
health.
Consider that an increasing number of children with complex disorders that only a few years
ago were fatal in infancy or childhood now survive into adolescence and adult life, presenting
new challenges.
Understand that although coping with the adult world may be seen as a normal part of
development, many young people cannot cope with the frustration and anxiety and disengage
with the process leading to deterioration in their condition which can have serious
consequences on their health and wellbeing.
Ensure the concept of transition is introduced to children, young people and their families long
before it becomes an issue.
Ensure transition process begins early – ensure all professional perspectives are considered it
is helpful to embed medical transition within the broader context of growing up and/or moving
on i.e. HV views should be considered when a child is entering school including producing a
health care plan if appropriate, the views of education staff should be considered when a
young person is being considered for transfer to adult health services.
Identify the skill set required for child/young person to function in an adult clinic – a transition
check list may be useful.
Liaise with the child and family and specialist services to identify the child/families
understanding of the disease process, treatment and possible side effects. This knowledge
and understanding should be re-assessed at key points during the transition process.
Consider ‘welcoming’ teams or process within receiving services to ensure that families,
children/young people understand specific service provisions ie what services are available.
Ensure a child’s records are available for review wherever possible – this ensures that vital
information is not missed and so that families do not feel they have to keep ‘telling their story’
at each transition point. Ie 0-19 records, CAF, discharge summaries or other locally agreed
processes.
Add complex needs pathway link her










Consider that families do not necessarily see transition as significant in a child’s
journey; the family stay the same during this period it’s the systems and
professionals that change.
Ensure that transition is seamless; this builds the confidence of children, young
people and their families that ‘things will stay the same’.
Ensure early communication with families prior to transition creating the opportunity
for ‘‘thinking time resource’ – so that families can anticipate what their needs might
be.
Consider that positive transition experiences will have an impact on attainment as it
will; increase school readiness, improve school attendance, which will often improve
academic attainment and increase independence and ability to access adult health
services which will contribute to prevention of ill health and disease in adult life. Ie
dentist service, GP services, sexual health services, smoking cessation etc.
Develop ongoing links with universal health services beyond 19+. For some
children/YP this may be required (including those with Child Protection plans) to
ensure the ongoing reduction of significant harm. (ie discharge to GP services).
Consider which professionals actually need to have direct contact with families and
minimise the amount of ‘visits’ – i.e. consider multi-agency joint visits where possible
Include children, young people and their families in decisions and communications to
ensure they are informed about who is the lead health professional.
Ensure assumptions regarding non-engagement are not made- it is important for
professionals to build trusting relationships at each transition point.
Develop Joint HV/SN health records to ensure all significant information is recorded
and communicated.
Develop Robust locally agreed transfer processes to ensure pertinent information is
shared between other services as required (ie identified support services)
Health Visiting and School Nursing Programme: Supporting the implementation of the new
service offer: No 5: Safeguarding children and young people: enhancing professional
practice: working with children and families
Compassion in practice: Nursing, Midwifery and Care Staff: Our Vision and Strategy
support the core values of public health nursing. School nurses have the potential to transform
the care, advice and support that people receive. Compassionate care values and behaviours
should be at the centre of all interventions and particularly at times when service deliver may
mean changes in relationships and when clinical expertise is required. The 6c’s will promote
professionals in building trusting relationships with children, young people and their families in
order to ensure improved health outcomes
Care

Commit to providing care in a range of settings in
order to provide services that are accessible and
visible

Ensure the completion of health screens and
understand criteria for appropriate referral to
specialist services in a timely manner.

Deliver the healthy child programme 0-19.
Compassion

Ensure an open, honest and non-judgemental
approach when delivering care

Develop trusting relationships and give early
information to families particularly when referrals to
other services are required.

Recognise that children live in homes not in
organisations – services should be child focussed
NOT service focussed.
Competence

Develop skill mix teams

Ensure all staff are appropriately trained to deliver
services

Ensure all care givers (including families and
education staff) are competent and confident to
deliver care.

Develop evidence based packages of care that are
regularly updated

Ensure equipment and resources are regularly
serviced and calibrated to ensure accurate results
data
Communication

Ensure information sharing protocols are in place and
understood – providing a flow of information.

Develop electronic 0-19 health records

Embrace modern technology to deliver improved
health outcomes and access to information for staff,
children, young people and their families.
Courage

Seek opportunities to provide innovative care that is
child/family focussed

Support children, young people and their families to
make decisions that will lead to improves outcomes

Develop strong working relationships with
commissioners and other stakeholders to speak on
behalf of children and young people when service
provision is inadequate including seeking solutions.
Commitment

Demonstrate a commitment to improve the emotional,
mental, physical and social health and wellbeing of
children young people and their families.

Seek opportunities to provide high quality services to
the local population.

Commit to working collaboratively with children,
young people and their families, specialist services
and the wider multiagency team.
Primary Actions
Optimising 0-19 services at local service level will ensure the best possible outcomes for children, young people and their families, reduce duplication of provision therefore increase
service capacity and ensure a universally delivered service that is seamless. This involves influencing commissioning, working in partnership with service users and key
stakeholders and adapting national guidance (including this pathway) when planning local arrangements for transition. This pathway can contribute to improving the seamless
delivery of services by considering the following actions:Commissioning

Identify health visitors and school nurses at all levels but particularly those leading services work closely with commissioners to improve the service offer and provision to children and
young people across the pathway in order to ensue services are effective, efficient and relevant to the local population.

Ensure professional Public Health representatives are involved in shaping the direction of universal 0-19 services in order to maintain a strong professional identity and high standards of
care.

Ensure a clear professional representation at strategic level in order to influence future commissioning.

Support Commissioners in gaining a clearer insight of the role of school nursing to ensure the effective delivery of the Healthy Child Programme

Ensure commissioners gain clear access to professionals with joint accountability and responsibility to develop working positive relationships with provider organisations.
Conflicting Agendas

Identify a clear understanding of roles for practitioners working within universal services in order to ensure a reduction in duplication for children/young people and their families.

Develop robust key performance indicators and quality data to ensure the core universal offer is delivered and to identify and measure an enhanced offer.

Ensure commissioners have sight of Department of Health service specification and academic calendar when planning services and re-procuring services.

Identify the unique selling point (USP) of service delivery in order to identify areas of delivery that may be duplicated across the pathway thus potentially building capacity.

Identify the core service particularly where there are reductions in workforce, ensuring that this is prioritized in terms of service delivery in order to reduce health inequalities.

Introduce skill mix teams in order to share expertise and skills and maintain and support specialist community public health (SCPHN) role

Identify additional funding streams including but not restricted to income generation, applying for professional grants and identifying additional work stream contracts bid for outside of
current service specification. See Nursing Technology Fund Mary Seacole Awards and Burdett Trust for Nursing.
Communication

Promote innovative practice through local professional forums, regional and national events i.e. SAPHNA and CPHVA conferences and forums, and using social media ie participating on
twitter, webinars etc.

Embed transition pathway in and out of local authority, education etc.

Embed the call to action for HV and SN providing national recognition of professional roles and the importance of those roles in the delivery of the Healthy Child Programme – 0-19.

Develop a better understanding and recognition of the roles and responsibilities of all professionals working with children and young people resulting in a more cohesive approach to multi
agency working and improve the outcome for children young people and their families.
Engagement

Consider engaging young people in the School Nurse ambassador programme

Identify areas of the service that can be assessed for You’re welcome status and strive towards achieving this. Also encourage other services to achieve this ie GP, local pharmacies
etc in order to ensure local services are accessible to young people.

Ensure that young people are consulted on service provision including considering having young people of recruitment panels.

Ensure services are robustly evaluated and shaped and to measure when an intervention has provided accessible and user friendly services and assess positive outcomes.
Case studies
Shropshire 0-19 Services – Health visitors and school nurses attend continence training sessions/workshops with other health professionals such as a Clinical Psychologist. This aids toileting and tackles any
constipation issues before they become a real problem however, consistent advice and support can be transferred from the health visitor to the school nurse in an effective way. For example a 5 year old was
soiling at school and the work that the HV had commenced was passed to SN to continue and this appeared expedited resolution of his issue in conjunction with the Telford Constipation Service.
School nurses use power-point and interactive assemblies for Years 6 and 7 to address school transitional anxiety. We have “Crucial Crew” - a group session for all Year 6s in Telford which has many different
professionals aiding transitional phase including Electric Companies, Fire Service, Police and School Nurses, the latter providing constructive advice in a game format addressing any anxieties with Primary to
Secondary school transition.
The Bridge Foundation - The Stepping Up project is delivered by a partnership of five Bristol voluntary organisations and provides specialist support to vulnerable children/young people before, during and after
the period of their transition from primary to secondary school. The Project meets the emotional, physical and social needs of young people through 1:1counselling, sports / creative groups: 1:1 year long
mentoring for children living in families with substance misuse issues; and an intensive environmental group programme and 3 day summer residential. The young people entering the Stepping Up programme
frequently have complex or troubled family situations, involving loss, frequent change, relationship breakdown and/or disrupted attachments. Once in secondary school, without support, this can lead to poor
attendance, disruptive behaviour and lower attainment. Support begins in year 6 and continues into the first term in secondary school. Further places are available for children whose difficulties come to the
schools attention in year 7.
A high importance is placed on partnership working – within the Stepping up partnership, between the project and the schools and importantly with parents. The project has involvement with most parents at the
Primary school stage and continuing into the secondary school. Many of those parents feel more confident in their contact with school and consequently have a greater involvement in their child’s educational
progress. We have completed the first full year of activities and are encouraged by reported outcomes. For example; attendance of children participating in Stepping Up increased from 66% in year 6 to 88% in
year 7. The ongoing needs of each child/ family are considered at the end of Stepping Up involvement. The secondary school continues to offer appropriate support; young people can have the opportunity to
attend other sports or creative activities and children attending last year’s residential continue to meet as a peer group.
Coram Project Coram Life Education (CLE) Supporting Schools – working in Lancashire primary schools following a review of the school’s PSHE policy. The intention of the programmes was
to build resilience of children as they moved to adolescence so they could make positive assertive choices in their lives and because they are based in a holistic framework address all
aspects of health and wellbeing including relationships with others personal confidence etc.
CLE delivered lessons for children at Years 1 and 2 (Key Stage 1) and Years 3, 4, 5 and 6 (Key Stage 2) about how the body works and how to keep physically and emotionally healthy and
safe. The specially-trained educators provided lessons which were fun, using active learning strategies and innovative teaching techniques including songs, brain games and role play,
which are evidenced to be memorable year on year. Evaluation (pupil questionnaire) found a 100% positive response to ‘not smoking’ and the dangers of alcohol putting them in the 1st
percentile in Lancashire. The School was one of the first schools in Lancashire to gain National Healthy School Status and the school’s strength in drug and alcohol awareness was
recognised in its Ofsted report.
Acknowledgements
Betsy Allen
Professional Lead for School Nursing, Devon
Integrated Children’s Services
Virgin Care Limited
Catherine Ashton
Julie Bulmer
Locala Community Partnerships
David Burton
Coram Life Education
Mary Dillon-Hanley
Central London Community Healthcare Trust
Beverley Evans
Health Transition Lead for Young People with
Complex Physical Health Needs
Ealing ICD
Diane Evans
Clinical Lead – School Nursing
Walsall Healthcare NHS Trust
Heidi Ferrier-Hixon
Lead Nurse – Universal Plus School Nursing
Team
Sandwell and West Birmingham NHS Trust
Glenda Bestford
Public Health School Nurse Team Lead
Newcastle Upon Tyne Hospitals NHS Foundation
Trust
Frances Fox
Director
The Bridge Foundation
Sue Garland
Service Lead – School Nursing
Staffordshire and Stoke-on-Trent Partnership
Trust
Jo Gregg
Jenny Hallsworth
Lancashire Care NHS Trust
Julie Hughes
Royal Berkshire NHS Trust
Carrie James
Health Transition Case Manager
Walsall Healthcare NHS Trust
Ceri Anwen James-Ellis
Senior Lecturer (Faculty of Education, Health
and Community)
Liverpool John Moores University
Ros Jagoe
Specialist Community Public Health Nurse
(School Nurse)
Shropshire Community Health NHS Trust
Annemarie Kennedy
Coventry and Warwickshire Partnership NHS
Trust
Kath Lancaster
Orla McAlinden
Lecturer in Children and Young People’s
Nursing
Queens University Belfast
Helen Molloy
Blackpool, Fylde and Wyre Hospitals NHS
Foundation Trust
E Owen
Farhaj Parthan
Quality Improvement Lead – Young People
and Transition into Adulthood
NHS England
Rachel Osborne
Shropshire Community Health NHS Trust
Getting it right for children, young people and families: Maximising the contribution of
school nursing team: Vision and call to action Department of Health, 2012
Healthy Child Programme: From 5-19 years old, Department of Health and
Department for Children, Families and Schools, 2009
Getting the right start: National Service Framework for Children: Standard for
Hospital Services Department of Health, 2003
Transition: Moving on well: A good practice guide for professionals and their partners
on transition planning for young people with complex needs or a disability,
Department of Health, 2008
Think transition: Developing the essential link between paediatric and adult care,
Royal College of Physicians of Edinburgh, 2008
Nursing and Midwifery Council, Consent
Claire Robson
Public Health England
Kerry Rose
South Warwickshire NHS Foundation Trust
Jackie Ruddy
Coventry and Warwickshire Partnership NHS
Trust
Lynne Schuller
Clinical Lead, Healthy Child Programme 5-19
Rotherham, Doncaster and South Humber
NHS Foundation Trust
Carla Williams
SCPHN Student
Sandwell and Birmingham NHS Trust
Sheila Thomas
Acting Matron/Team Leader – School Health
Sandwell and Birmingham Hospitals NHS Trust
Secretariat
Ruth Cohen, Clinical Lead for School Health, Barts Health NHS Trust
Wendy Nicholson, Professional Officer – School and Community Nursing, Department of Health
Fiona Hill, PA to Professional Officer – School and Community Nursing, Department of Health
Lost in Transition: moving young people between child and adult health services,
Royal College of Nursing, 2013
Transition: Getting it right for young people: Improving the transition of young people
with long term conditions, Department of Health, 2007
Sharon Poole
Registered Nurse – Student Public Health
Nurse
Worcestershire Health and Care Trust
Frances Walsh
SCPHN Student
South Warwickshire NHS Foundation Trust
References and Resources
Lisa Worth
Gillick Competency and Fraser Guidelines, NSPCC, 2014
Working Together to Safeguard Children: A guide to inter-agency working to
safeguard and promote the welfare of children, HM Government , 2013
Children and Families Bill 2013, Department for Education, 2013
Compassion in practice: Nursing, Midwifery and Care Staff: Our Vision and Strategy
Resilience in the face of adversity: Protective factors and resistance to psychiatric
disorder. Rutter, M. 1985