Transition from children’s to adult services – early and comprehensive identification
Version 1: Published March 2015
The Care Act 2014 places a duty on local authorities to conduct transition assessments for children, children’s carers and young carers where there is a likely need for care and support after the child in question turns 18 and a transition assessment would be of ‘significant benefit’ (see below). This resource should be read in conjunction with the statutory guidance underpinning the Act,  in particular chapter 16: ‘Transition to adult care and support’.
The guidance states that in order to fully meet these duties, local authorities should consider how they can identify young people and carers who are not receiving children’s services but are nevertheless likely to have care and support needs as adults. They should consider how to establish mechanisms to identify young people as early as possible in order to plan for or prevent the development of care and support needs and thereby fulfil their duty relating to ‘significant benefit’ and the timing of assessments.
Comprehensive identification may also involve building new links with children’s services and schools to ensure that young carers and parent carers receive transition assessments. The Children and Families Act 2014 has added new duties to the Children Act 1989 to assess young carers and establish whether they are ‘children in need’ and to assess parent carers of disabled children and consider what support they may need under section 17 of the Children Act 1989. This should lead to more comprehensive identification of young carers and parent carers on which to build a transition strategy. Transition for these groups is discussed in more detail in SCIE guidance on transition for young carers and adult carers.
Examples of groups that are more difficult to identify are set out in the Care Act statutory guidance as follows:
- those with degenerative conditions
- those whose needs have been largely met by their educational institution, but who, once they leave, will require their needs to be met in some other way (e.g. those with autism)
- those detained in the youth justice system who will move to adult custodial services
- young carers whose parents have needs below the local authority’s eligibility threshold but who may nevertheless require advice or support to fulfil their potential (e.g. a child with deaf parents who is undertaking communication support)
- young people and young carers receiving child and adolescent mental health services (CAMHS) who may also require care and support as adults even if they did not receive children’s services from their local authority.
This document looks at what some authorities are doing in practice and considers some of the principles behind that practice which align with the Care Act 2014. It looks at mental health transitions and considers what can be learnt from current practice and applied to identifying the seldom heard groups mentioned above.
Both the Children and Families Act 2014 and the Care Act 2014 deal with support for young people with care and support needs preparing for adulthood. These two pieces of legislation now provide the context in which transition practice occurs.
Nothing about us without us: co-production and power-sharing in effective service planning
It is well understood that in order to produce a quality service that meets the requirements of people who use that service, those same people have to be involved in practice. Evidence from work on social care governance  and co-production in social care  points to many examples of how and where this works. The defining principles of co-production are:
These principles both define and measure what we have achieved and can achieve. The Care Act 2014 and the Children and Families Act 2014 capture the principles of personalisation, inclusion, participation and co-production in law.
The early identification of young people who are likely to have care and support needs as adults involves considering where they may be located, their existing networks and what they have to tell us of their experience.
Early identification and ‘significant benefit’
Practice suggests that many young people who come to the attention of adult social care at or post-18 are already known to children’s services.
The Education, Health and Care (EHC) plan introduced by the Children and Families Act 2014 aims to ensure that professionals work together to support children with special educational needs and that information is shared between them. This is a consistent theme in much of social care practice. The early identification of young people likely to be in need of care and support as an adult can effectively begin with:
- monitoring Education, Health and Care plans
- thinking ‘whole family’ 
- building relationships with young people and their families
- building relationships with other professionals.
Such practice is already in place in some councils, which are, for example, strengthening pathways to care for specific groups of young people, including young carers. However, those working in adult social care need to consider how best to identify the other groups mentioned above, including:
- looked-after children
- young people with specific needs placed in educational establishments out of borough
- young people receiving CAMHS
- young people with life-threatening illnesses as they move from child to adult service provision.
Strategic planning and leadership at all levels, together with strong governance and clear responsibilities, are required to shift practice to make it both effective and compliant. Senior managers in social services will need to make decisions about workforce requirements and the deployment of resources, along with information systems that best support this, taking into account at all times the views of people who receive services in order to meet the requirements of the Care Act 2014.
In current practice, some authorities may wait until people reach the age of 17½ or even 19 to make an assessment, as situations during these years are often subject to change and they want to avoid performing two assessments. The assessment of young people with a life-threatening or life-limiting condition may not happen until they have reached 18 or 19 years old, if at all. Under the Care Act this will not be routinely acceptable. However, unless a young person or carer is identified early enough and assessed, the authority may be falling short in their duty in relation to ‘significant benefit’. This is because in failing to identify the person or delaying the transition assessment, the authority may not have time to put services in place, or the benefit to the person of transition planning may be reduced. This can result in care and support that do not best meet the young person’s or carer’s needs – and sometimes a greater financial cost to the local authority than if transition had been planned properly in advance.
Much of the evidence that supports good transitions into adulthood points to effective planning and relationships built with a young person and their family. The transition assessment required under the Care Act does not mean duplication of effort, as it can be adjusted if circumstances change or there is new information. Assessments can also be joined with those of other agencies (for example, a review or re-assessment under children’s legislation), or be combined with another person where appropriate (for example, a parent carer also transitioning to the adult statute).
Building good relationships with young people and their families
Apart from attending meetings at schools and academies where young people are likely to be making a transition to adult social care, transition teams build relationships at the schools and academies. These relationships are built over time and through regular contact. An example of this is the work of the transition team in Hampshire who attend open days and coffee mornings at schools and link with youth support services and post-16 special educational needs services. They have also created a full-time post to concentrate on young people who have been referred for an Education, Health and Care plan but have previously not been known to social care.
Engaging with black and minority ethnic families
The decision to identify and specifically engage with black and minority ethnic (BME) families will need to be taken at the local level, depending on demographic and other issues such as those set out in a Joint Strategic Needs Assessment. For authorities such as Newham, where more than 200 languages are spoken and where the demographic profile suggests that there are significant numbers of young people, this may be an issue to focus on in relation to early identification, applying the principles of equality, diversity, accessibility and reciprocity.
Another local authority (Stoke City Council) currently undertakes to reach BME families through local teams, which include housing teams, leisure services and those based at children’s centres, nurseries and schools. Its ‘early help assessment’ process identifies additional needs and refers people on to a more focused level of service. A proportion of referrals into ‘Aiming High’ (a programme taking its name from the ten-year strategy for young people to achieve the best possible outcomes ) are made from general settings and within these some BME young people may be identified. (Stoke-on-Trent practice example)
Regular meetings and forums
Authorities such as Stoke City Council, Newham and Hampshire have transition forums that meet every month with partners from education, post-16 specialist learning providers, health providers and children’s and adult social care services to discuss young people when they turn 17. This provides a network that ensures that young people approaching transition are identified and solutions for specific individuals are discussed. Stoke City Council, for example, refers issues from its transition forum to its special educational needs and disabilities (SEND) reform board. This is a strategic overarching partnership where parents from the Aiming High Together parent forum (see below) have a presence. The local authority also actively supports social care discussions between children’s and adults’ social workers regarding young people aged between 14 and 16 where early co-working results in key joint decisions about the best interests of the young person and their family.
Stoke also runs a parent forum for and by parents who have disabled children and young adults. By organising workshops and participating in a wider engagement process, this group acts as a communication channel for commissioning processes. It is also involved in the special educational needs reforms and the local offer as well as the whole-life disability approach adopted by Stoke. A local offer is a requirement on the local authority to provide information on what services children, young people and their families can expect from a range of local agencies, including education, health and social care.
Newham, Hampshire and Stoke City Council also hold monthly transition forums attended by partners, voluntary groups, health, further education and other learning providers. This regular network shares information on young people over the age of 17 and is an opportunity to identify those likely to have care and support needs. In relation to the groups of people who are difficult to identify, mentioned in the guidance (see above), in order to discuss and identify people from these groups such forums will need to include the professionals who work with them. The appropriate professionals to invite will vary between areas depending on local systems and population characteristics. Practice in the East Midlands, for example, suggests that children’s community nurses, children’s hospice staff and specialist residential establishments are being invited to forums in order to reach those young people with degenerative conditions likely to need adult care and support.
Proactive early identification
Under the Care Act 2014 it is the responsibility of the local authority to proactively identify such young people and carry out an appropriate assessment.
Early identification and assessments that build on a person’s strengths and what they do well, give local authorities an opportunity to put in place enabling services that will help young people to become more independent as they move into adulthood.
Stoke City Council has continued to support an ‘Aiming High’ programme that has allowed approximately 400 children and young people to access short breaks. The majority of them have no social worker and the early help assessment process helps Stoke to identify young people who do not receive statutory children’s services but may nevertheless have care and support needs as adults and so require a transition assessment.
Newham identifies young people through open house events, parent co-production forums and a tracking list that details young people open to children’s and adult social care, young and parent carers as well as their siblings.
Information technology (IT) systems that ‘talk to each other’
Many authorities have different systems to record adult information and to record children’s information. They may then need access to basic primary health care information or information from the education sector. Some authorities do the ‘joining up’ through one person – for example, a transition worker based in adult services who has access to both systems as well as to the basic primary health care record. The transition team or worker is thus able to monitor and potentially identify young people likely to have care and support needs as adults.
Some authorities are considering investing in one system for recording information about children, adults and carers with support needs. This could be a joined-up information system that would interface with health and education and make it possible to support a whole-family approach  to assessment. It would also support the monitoring of difficult-to-identify groups by bringing the information together.
The advantage of having an IT system with a standard integration protocol means that systems used by the local authority can talk to systems used by GPs, for example. This involves locality-wide, information-sharing agreements as in the case of Liverpool City Council (see below) and means that professionals will be able to see basic information such as the existence of care packages but not more sensitive information.
Practice example: Liverpool
Liverpool’s children social care service moved to an integrated system (called ‘CAPITA 1’) in 2004 while the adult social care service continued to use an in-house information management system. The advantage of this for adult services at the time was flexibility and the capacity to manage the system. The disadvantage was that it was too localised. Liverpool decided to move to an integrated system so that both adults’ and children’s departments would use the same information and the system would be able to access both education and health information through a standard integration protocol. This decision was influenced by the practice of thinking about the whole family as it was felt that an integrated IT system would better support this approach in social care. Liverpool puts the cost of this initiative to in excess of £1.5 million. Adult services will move first and children’s services will follow in May 2015. There is a city-wide agreement about information-sharing and levels of access to information. Liverpool has also built in an evaluation using a system of metrics that enables it to assess how many cases are opened, how long cases are held, and what the impact is on the people who use the service. Data will be gathered prior to implementation and again a year later.
Any IT system can only be as good as the people who use it. Therefore, joining up the thinking around the child or young person in relation to the adult (often parent) and the family is as necessary and relevant now under the Care Act 2014 and the Children and Families Act 2014 as ever before. (The Care Act and Whole-Family Approaches) 
Identifying young carers
Some local authorities such as Newham are monitoring the siblings of children with complex needs in relation to any care being given so that they can identify potential young carers. They have compiled a young carers list (those aged 14–25) and these young people are offered assessments as well as referral on to commissioned services. A transition assessment can be offered to those young people approaching 18. Also, their young people’s service works consistently with schools on how to identify and support young carers. (See Young carer transition in practice under the Care Act 2014)
Similarly, during adult social care needs assessment, assessors in Newham are encouraged to identify those who may be caring for the adult they are assessing, including young carers. This is a requirement under the Care Act 2014 as set out in the Care and Support (Assessment) Regulations 2014. 
Newham has rolled out carers training for adult social care staff and this includes the identification of young carers. A good part of this training is delivered by carers and commissioned organisations and this now ties in effectively with the new duty to identify a young carer while undertaking an assessment and the parallel scenario of assessing a child with a disability.
Another example of the identification of young carers is the Young Carers Pathway in Liverpool, which brings together assessment processes for adults and children to allow the early identification of and intervention for young people’s additional needs – some of which may be related to taking on a caring role.
Example of a young carer identified through an assessment of an adult
Liverpool City Council, Merseycare and Barnardo’s have a joint statutory assessment protocol, which states that adult social care workers should undertake the young carer’s assessment as part of support to the adult. The following is an example of how this has worked.
Adel lives alone with her mother who has a diagnosis of paranoid personality disorder and epilepsy. Following an assessment of Adel’s mother, the community psychiatric nurse (CPN) identified Adel as a young carer and a child in need and therefore a young carer’s assessment was completed by the CPN. Adel was found to provide a significant level of care for her mother, including supervision, medication, shopping, dealing with finances, domestic tasks and interpreting on a daily basis.
Adel was referred to Barnardo’s Young Carers project and joined-up work was completed with the CPN, family support worker and children’s social worker as to how best to support the whole family. The young carer’s assessment used at Barnardo’s measures the impact of caring (MACA-PANOC). Following support being put in place, further assessments showed that the impact of caring on Adel had decreased.
As stated previously, the Care Act 2014 and statutory guidance now specify that adult services must identify children in the household they are assessing, consider whether they are young carers and if they are, whether they are children in need. The shift from protocol in practice, to duty under the Care Act, is one that local authorities will be taking note of.
Mental health transitions
The issue around the transition from Child and Adolescent Mental Health Services (CAMHS) to adult services is multi-faceted. Young people with mental health problems who are approaching the age of 18 are discussed in detail and recommendations are made based on the available evidence in Mental health service transitions for young adults (SCIE, 2011).
The following practice example is of current transition practice in a mental health setting in Merseyside.
Beverly is 17 and a half years old. She has an extended history of CAMHS involvement, a high risk of harm to self and others and was an informal patient on a young person’s acute ward. Children’s social care became her corporate parents under section 47 of the Children Act 1989 and then section 20. She was removed from her parents due to sexual grooming and placed out of area for safety reasons. Her placement was tri-funded by health, education and social care in a registered children’s home that buys in psychology and psychiatry for residents.
A transition review identified the need for continuing care, with the placement to continue out of area. Beverly was assessed jointly by an adult community mental health (ACMH) social worker and ACMH nurse. The placement was happy to keep Beverly with them; however, there was no plan for stepped-down care and this had to be reviewed.
The transition issues were as follows:
- The young person was ‘sent to placement’ out of area.
- The young person has now settled after a very complicated and traumatic childhood and so chooses to remain in the area.
- At age 18 there is no agreement that an out-of-area placement would be funded. Nonetheless, under current legislation (Children and Families Act, 2014), local authority responsibility extends to young people up to the age of 25.
Beverly’s joint transition assessment led to an agreement to continue funding the out-of-area placement in line with her desired outcomes. Adult mental health services will continue to be involved.
The issue for adult services initially is that Beverly is not subject to any aftercare under section 117 of the Mental Health Act 1983 or similar, as she has never been sectioned nor does she have a learning difficulty. Mental health can be an issue as young people cannot attract a diagnosis of psychiatric disorder until the age of 18, adding another layer of complexity to transition planning.
The key components that triggered a transition assessment in relation to Beverly were:
- an awareness of the young person to begin with (early identification)
- understanding the context of children and adult mental health services in Merseyside
- established relationships and a clear understanding of each other’s roles.
The service model in this case identified a key role – a mental health transitions worker with a nurse/social work background. The person in this role takes responsibility for identification and the transition assessment. A clear understanding of roles is important particularly where services have been restructured and staff have taken on different roles.
Transition requires a coordinated approach, which involves key professionals from education, health, social care and commissioning. The critical point of early identification and transition assessment in Beverly’s case was that it allowed enough time for planning.
John is 17 years old and has learning difficulties and a diagnosis of autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD).
He attended a school for special educational needs due to his ASD diagnosis.
There was extended involvement with CAMHS due to the presentation of challenging behaviour, where John was deemed a risk to himself and others. There was a significant maternal family history of mental illness, resulting in John being placed with his maternal grandmother due to his mother’s mental health difficulties. John was also a carer for his mother as a very young child.
John was recognised as a child in need and placed in supported accommodation at age 17. This subsequently broke down and he returned to live with his grandmother.
A transition assessment was conducted and the following issues were identified:
- John has been supported by CAMHS as a child/young person, having received an assertive outreach approach to his needs and his family’s needs. As a young adult he was reluctant to engage with services, which resulted in him being discharged from CAMHS and then referred back when in crisis.
- He does not meet the criteria for adult mental health services – there is no diagnosis of mental health problems.
- He is recognised as having a moderate learning difficulty but adult learning disability service criteria suggest that he would not have access to any of its services.
- He is able to access an ADHD review, which is offered by adult mental health services, but this would be to review medication.
- John has become involved in anti-social behaviour and is now known to the police and youth offending services, which complicates the outcome and potential perception of his risk to others.
- He has never been a looked-after child – and there is no identified aftercare responsibility.
- He has never been an inpatient or on section for a mental health assessment and so there is no responsibility under section 117 of the Mental Health Act 1983.
The transition assessment recommended that John access a youth mental health service that looks to recognise the needs of young people who are no longer on the radar of services but are seen as vulnerable. As there was currently no such service available, the transition worker requested supported lodging and referred ‘the case’ as evidence of the need to develop such a service strategically as part of Commissioning for Quality and Innovation (CQUIN) and as part of market development on the part of the local authority.
Transition from youth justice
The Youth to adult transitions framework states that:
The point of transfer from youth to adult justice services is a critical time for a young person and for the justice professionals who must work to ensure that a young person’s welfare is properly safeguarded and that any risks they pose to the public are minimised. 
This particular group of young people is specifically identified in the Care Act 2014 statutory guidance,  because these young people receive services that traditionally lie in the criminal justice system, but under the Care Act local authorities will be responsible for meeting their care and support needs as adults.
Managers tasked with identifying this group will need to familiarise themselves and their staff with the context in which transition from youth justice occurs locally, for example by building links with youth support services in their locality.
A decision on whether or not a young person has eligible care and support needs can only come after a young person is identified and a transition assessment has been made. If a young person with care and support needs is going to transfer to a prison in another area as an adult, or is going to be released but plans to move to another area on their release, the local authority where they are currently resident should establish their likely destination and make contact with the relevant local authority to involve them in the transition planning.
In order to identify young people who are likely to have care and support needs as adults, it makes sense to be proactive and look for those young people where they are located. For example, young people with degenerative conditions are likely to be known to hospices run by organisations such as Together for Short Lives. Similarly, young people can be identified in the youth justice system, in CAMHS and in special educational establishments out of borough and in borough.
Transition forums are likely to be good at building relationships, but a key focus should always be: Who are the key people who need to be around the table in order for identification to occur and any decision made? For example, just having a representative of ‘health’ is not necessarily adequate, given the broad range of people that health services serve – an occupational therapist is unlikely to be able to discuss transition for people receiving CAMHS.
A joined-up information system will certainly help this process as will a whole-family approach,  for example, ensuring that any carers are identified when assessing someone with care and support needs.
The principles of co-production, building good relationships, whole-family thinking and joined-up information management systems are very much in evidence in some cases, as is the leadership, supervision and governance required to support effective practice. In terms of implementing the new legislation (the Children and Families Act 2014 and the Care Act 2014), we know, to some extent, what works in effective service transitions. The principles underpinning effective mental health transitions, for example, can be said to extend to other service transitions but will require an understanding of the different context (the justice system, for example).
Good practice in transitions to adulthood can evolve to fully realise the vision in both Acts. It will take time, consistency and effective leadership to engage communities and build trust in order to provide the sort of service people require.
Checklist for the identification of seldom heard groups
- Co-produce everything with people who receive services.
- Hold regular meetings with appropriate professionals who work with seldom heard groups.
- Gain knowledge of local networks and commissioners.
- Gain knowledge of the context and roles of other professionals, particularly if there have been changes in organisational structures and personnel.
- Make sure that there is a clear referral process between agencies.
- Adopt a whole-family approach.
- Make sure that there is clear information about services.
- Consider practice that has worked in your locality and whether it is now compliant with the Care Act 2014.
- Department of Health (2014) ‘Care and support statutory guidance: Issued under the Care Act 2014’, London: Department of Health).
- Social Care Institute for Excellence (2011) ‘Social care governance: A workbook based on practice in England’, SCIE Guide 38, London: Social Care Institute for Excellence.
- Social Care Institute for Excellence (2013) ‘Co-production in social care: What it is and how to do it’, London: Social Care Institute for Excellence.
- Department of Health (2014) ‘The Care Act and whole-family approaches’, London: Department of Health.
- HM Government and Department for Children, Schools and Families (2007) ‘Aiming high for young people: A ten year strategy for positive activities’, London: HM Treasury.
- Ministry of Justice and Youth Justice Board (2012) ‘Youth to adult transitions framework: Advice for managing cases which transfer from youth offending teams to probation trusts’, p 5, Youth Justice Board for England and Wales.