Mental health service transitions for young people

Planning and practice in transition: How to support effective transitions

In the sections that follow, some of the possible barriers to service transitions are described, and suggestions about how to address these are made. This is followed by a section exploring how to facilitate different professional groups working well together to support young people. The following are key to effectively supporting young people in transition:

• Start early: the SCIE advisory group considered that plans for transitions should start at least six months before transition.Young people want to prepare for transition, and to be given early notice of changes.
• Involve the family: family members should also be involved early on where this is possible and helpful. All services, and not just CAMHS, need to think about the family and how to acknowledge the important role that family and friends can have in understanding and supporting young people.
• Give timely and accurate information and be sensitive to feelings: young people often feel that they do not receive accurate information at the right time for them. The practice enquiry contains distressing accounts: one young person was not told that their key worker was changing, another was transferred from one service to another but not told about it, and another did not have the reasons for being compulsorily detained in hospital explained. Some young people said that professionals demonstrated a lack of sensitivity about their mental illness and traumatic events in their past.
• Assess needs and make multi-agency plans which centre on the young person: explain clearly what will happen and what support they will receive. Consider holding a multi-agency planning meeting (sometimes known as a transition clinic) involving the young person and relevant staff to share information and make plans.
• Ensure that assessments are co-ordinated: include an overview of the young person's life, issues, strengths and aspirations and ask them for their views. Try to increase the input from education services by making links with schools, colleges and teachers, who are often are not involved. Many young people make multiple service transitions, so it is important consider how to incorporate these.
• Use care planning models that involve and empower the young person: you may be using specific models of care planning, such as the CPA, personal health and wellbeing plans, along with 'stay well' plans. The practice enquiry suggests that the principles of personalisation for adult services (e.g. personal budgets) could be applied to children and young people, enabling them to have more control over their care. For some young people who don't have a clear ongoing need for secondary services, it may be appropriate to think about targeted support options rather than 'care pathways' (e.g. information for young people about what to do if they need future support).
• Think about the different professionals who might need to be involved and establish links with them, including  key professionals, primary care staff (including GPs) and joint staff. Consider how to build informal peer networks and use mentoring and advocates as well as links with non-statutory agencies (e.g. supported housing services).
• Develop flexible ways of working as much as possible - for example, look for opportunities to offer support that can be stepped up or down according to current need, and that doesn't taper off suddenly. Offer a period when young people stay 'on the books' even if they don't need a service at that moment, to ensure that their discharge from the service, or transition elsewhere, is successful. Offer support via 'assertive outreach' methods for those young people who need this.