Transition Toolkit Andrew Clarke Quality Improvement Manager Children & Young Peoples Mental Health Clinical Network Yorkshire & the Humber

Drivers of NHS England priorities Set out 3 gaps: care & quality, funding & efficiency, health & wellbeing Authored by six national NHS bodies Clear list of national priorities for 2016/17 and longer-term challenges for local systems

CYP are embedded in key programmes in NHS England Mental health access and waits: programme of transformation of CYP mental health services is underway Cancer: Independent taskforce made specific for children, teenagers and young adults Learning disabilities: aim to reduce inpatient admissions for those with LD/autism applies to children and complements EHCP Long-term conditions: Work underway to support improvements in diabetes and asthma care for CYP Urgent & Emergency Care: CYP one of the ‘lenses’ through which the proposed new model of care will be viewed. Genomics: The Genome project will enable conclusive diagnosis in some rare childhood diseases, and allow treatment to be tailored NHS England business plan, 2016/17 Specialised Commissioning developing leading edge science and innovation to enable patients with rare diseases to be treated most effectively New care models: Working with interested vanguards, UEC and acute care collaboration vanguards to support focus on CYP

NHS England’s activity in 2016/17 is set out in three broad themes Promoting mental and physical well being Improving quality of services Developing future models of care Transforming mental health services for children and young people Improving asthma, diabetes and epilepsy care and supporting children with long term conditions Improving care for children with special educational needs Supporting vanguard sites and local areas working to transform models of care for CYP Emerging work on childhood obesity Specific patient safety work including still birth reduction Improving acute care for children and young people Safeguarding Improving child death process & identification of preventable factors Improving CYP experience of care Health Inequalities Improving transition from paediatric to adult services

Why transition? “Services will be integrated and care will be coordinated around the individual, with an optimal experience of transition to adult services for those young people who require ongoing health and care in adult life.” “We have put the interests of a system that is no longer fit for purpose above the interests of the people it is supposed to serve. The system is fragmented, confusing, sometimes frightening and desperately difficult to navigate.” 2013 2014 “Services will work together to make the transition in and out of services, and between different services as smooth as possible” 2014/15

Transition in Y&H Providers and Commissioners across Y&H identified Transition as a priority. Clinical Network established a working group and T&F group to solve the issue of Transition. Transition was happening but it all needed to be brought together.

http://www.yhscn.nhs.uk/Transition.php

In March 2015 the Y&H Strategic Clinical Network for Children established a Task and Finish Group (T&FG) for Transition as part of its work programme. The priorities for this work were: Developing an evidenced based, systematic approach to the provision of transitional systems for C&YP to adult care. To support collaborative working in order to respond and meet the needs of CYP as they transition from children’s to adult services To seek to provide a generic approach to transition which can be used by all Providers and Commissioners to improve quality of care and develop a patient centred approach. To improve outcomes and experience for C&YP transitioning from children’s to adult services. The T&FG brought together commissioners and providers across Y&H to provide and promote a coordinated approach between and within whole health communities including, NHS, health and social care, local authorities, voluntary organisations and other appropriate stakeholder organisations to support the delivery of Young People Friendly (YPF) transitional care. The outcomes from this work have included: Identifying of the priorities for transition across the region. Identifying issues, challenges and barriers for transition across the region. Exploring integrated, whole system pathways for transition. The development of evidenced based guidance for commissioners and toolkit for Providers. The T&FG have developed a generic toolkit and guidance for transition which can be used by Providers and Commissioners to provide evidence based high quality care and improve outcomes for children, young people (CYP) and their families.

Transition Toolkit for Providers This toolkit is aimed at provider organisations who are looking to; •work internally to improve services •work with commissioners to improve existing or develop new services

Transition Toolkit for Providers This toolkit is aimed at provider organisations who are looking to; •work internally to improve services •work with commissioners to improve existing or develop new services

Transition Guidance for Commissioners This Guidance is aimed at commissioners of services who are looking to scope potential service design and or work with their provider organisations to: