Mental health service transitions for young people

Working better together: Protocols


Use processes and corresponding paperwork that 'join up' and are consistent across agencies. Formally agreed cross-sector transition protocols have many benefits.

The SCIE research found that while many services have protocols, including transition protocols, agencies differ in their levels of joint working and the ways in which protocols are shared. Some staff, especially in services not directly concerned with transition in mental health, may not know about protocols even where they exist. Sometimes different and confusing protocols exist in different services and sectors.

Staff in the process mapping workshops said that protocols can result in effective practice but must be supported by managers and implemented by staff from all services covered in the protocol. Some staff felt that other mechanisms for sharing information - for example the CPA and Fair Access to Care, can also be effective.

To maximise their effectiveness, protocols should:

Protocols need to cover:

Practice examples

This guide does not include a detailed template of a model protocol, but the NMHDU/NCSS self-assessment tool has a helpful template.

  • The Riverdale Unit in Wakefield is a multi-disciplinary transition service for 17-year-old women in existence since December 2010. This designated unit is within a large (adult) female prison (HMP Newhall) for very vulnerable young women with high rates of self-harm and complex psychopathology, often resulting from multiple traumatic experiences in the past. The transition service involves clear transition arrangements, formalised in a joint protocol between the Unit and the adult mental health provider in the main prison. A protocol in itself is only a first important step, and its implementation needs the participation of all parties involved.

Information systems and information-sharing

SCIEs research indicates that the reasons behind poor partnerships and communication between agencies include:

These difficulties often mean that key professionals cannot access records and track progress across services.

Practice example

  • In Leedsa formal information-sharing agreement between CAMHS and AMHS has been finalised, allowing easier monitoring of young people moving from CAMHS to AMHS located in different trusts.