NHS England – Delivering Safe and Robust Transition to Adult Services

Dr Jacqueline Cornish,National Clinical Director Children YP & Transition to Adulthood

Patricia Morris, Director, NHSIQ

NHS EXPO – March 4th 2014

NHS Outcomes FrameworkNCD Children, YP and Transition - Objectives

Preventing people from dying prematurely

Reducing avoidable deaths – perinatal/congenital/infant,

acquired natural causes, injury, RTA, childhood cancers

Reducing time spent in hospital LTC unplanned hospitalisation

asthma, diabetes , epilepsy

Enhancing quality of life for people with long-term conditions

Emergency admissions for

conditions not usually requiring hospitalisation, improving recovery

from injuries & trauma, rehab

Helping people to recover from episodes of ill health or following

injury

Improving Children, YP and Families experience of

healthcare (GP, OOH’s, A&E, acute IP care, end of life care)

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and

protecting them from avoidable harm

Harm due to ‘failure to monitor’, delivering safe care to children

in acute settingsMedication errors, infections

Additional Objectives • Generic Service Specification’s - embedded in all NHS commissioning

structures for consistent approach to Transition to adult services

• Mental Health on a par with physical health, measurable progress towards parity of esteem, roll out of CYP IAPT programme, 60% by 2015

• Acutely sick child – support Urgent and Emergency Care Review through Primary/Secondary Care Interface, OOH services, appropriate workforce needs assessment to deliver care in community when appropriate

• LTC’s, Disability and Palliative Care in children – support and develop integrated care pathways, and enhanced community nurse support

• PbR – Lead commissioning support of tariff for directly and CCG commissioned services for CYP and Fetal Medicine, ? More BPT’s

• Work with DH, DfE, & PHE to support NHS England response to Pledge

• Identifying and addressing inequalities in vulnerable children: looked after, adopted, travellers, those in criminal justice system

Transition to Adult Services for Young People with Long Term

Conditions, Mental Health Problems, SEN and Learning Disability

A continuity of care along an appropriate time course

“The transition to adulthood is becoming more complex, longer and more risky. It is a time when young people enter a new and exciting world with new rights – and responsibilities, including legal. It is also the time when they take decisions that will affect the rest of their lives.” Social Exclusion Unit ,2005,

Transitions: Young adults with complex needs

Current Health Service

Paediatric services and paediatricians

Adult services and adult physicians

Primary Care and General Practitioners

Why is transition important?

Who is this person?Do they know

anything?Doubt I’ll be back….

How do we get back to Childrens services?

That’s NOT what the Paediatric team said!!

Semi-intelligent comment about patients

care

If only I knew what the Paediatric team said!

Why do young adults need a different approach?

• Three great transitions: work to school, home to independent living, parented to becoming independent/a parent

• The brain is still changing - up to 25 yrs to full development• Mental Health in adolescents is deteriorating - and incidence

rises from 1:10 in children to 1:6 in adults• Learning Disability & SEN - uncertain transition services• Patterns of service use and access develop early in life, so

how young people experience services when they first use them will affect engagement as adults

• Avoid crisis presentation & family, school, college, work issues

We know what young people want ..

We know what young people want ..

• To be listened to and understood• To be taken seriously• A well planned service where the transition and discharge

arrangements happen smoothly , it shouldn’t be left to us or our families to manage it

• Flexible services focused on developmental age rather than chronological age and on our individual needs

• Choice , information and advice to help us make informed choices about our care and to help us move on

• Honesty about what can and cant be kept confidential• Continuity of care – it take time to build relationships • We shouldn’t have to fight for our rights

Suggested Transition Philosophy

“Paediatric and adult health care professionals need to provide developmentally appropriate health care for adolescents and young adults

with long term physical and medical conditions addressing medical, psychosocial and educational/vocational needs working

together when necessary to support continuity of care“

Recognised Phases of Transition

• Timely preparation started within paediatric services

• Actively managed and co-ordinated transfers between paediatric and adult services

• On-going developmentally appropriate support from adult receiving services

Paediatric

care

Adolescent care

Transfer

Young adult care Adult

care

The “Pull”

Supporting transfer to adult services

The “Push”

Four very simple questions for young people

What happened to you in the past? Evidence that the patient has been given a treatment summary

How does this affect your life now?Evidence that an holistic needs assessment has been offered

What help do you need in the future?Evidence that an agreed care plan exists

How will you know you are getting the best care?Measurement of: One or two key disease related health / wellbeing indicatorsYoung person ‘friendly’ characteristics of the service

Transition – Young People with poor Mental Health - a distinct group

• There are wide variations in the way transitions from CAMHS to adult services are handled, yet much published literature

• The Government’s mental health strategy – “No health without mental health : a cross-government mental health outcomes strategy for people of all ages”, published in February 2011, states that care and support for young people going through transition needs to be age and developmentally appropriate, involving careful planning to avoid unnecessary disruptions in care. The strategy also confirms that services can improve transition, by :

o planning for transition early, listening to young people and improving their self efficacy;

o providing appropriate and accessible information and advice so that young people can exercise choice effectively and participate in decisions about which adult and other services they receive; and

o focusing on outcomes and improving joint commissioning, to promote flexible services based on developmental needs.

DH Policy on transition

Working to Define a GENERIC Service Specification for Transition

Diabetes Chronic renal failure

Cancer

Since 1st April 2013.....

New commissioning landscape:

• 212 clinical commissioning groups (CCGs)• Local authorities• Public Health England• NHS England direct commissioning

responsibilitiesPrimary CarePublic Health and ScreeningArmed Forces HealthOffender HealthSpecialised Commissioning

NHS England Board

Direct Commissioning Committee

Clinical Priorities Advisory Group

Specialised Commissioning Oversight Group

Women & Children's Programme of Care Board

Cancer & Blood Programme of Care Board

Internal MedicineProgramme of Care Board

Mental Health Programme of Care Board

TraumaProgramme of Care Board

CRGs CRGs CRGs CRGs CRGs

Patient and carer voice on CRGs

• Designed to provide objective input on needs of patients and carers using the services, critical in Transition

• Inform service planning, redesign and specification with patient perspective

• Four places on each CRG for patient and carer members

• Will involve recruiting up to 300 members

• Work of CRGs should also be informed by patient insights and perspectives received via the area teams, and from wider stakeholders for each group

Generic Paediatric Service Specification

• Safeguarding• Patient safety, medicine’s guidelines• Patient experience• Patient/user/public

involvement/engagement• Clinical effectiveness• Child-appropriate environment• Access• Staffing• Family support• Transition to adult services• Networks – strengthening of SCN’s and

ODN’s• Applicability for CCG’s? Primary

Care?

A generic paediatric service specification should ensure a consistent approach for all in-patient services where children are cared for, perhaps in Primary Care too.

Children’s & Young People’s Services in the NHS land • Opportunity - Uniform commissioning – Direct and CCG

National process with national engagement More equity, resulting in secure systems for delivery High level input from NHS

• Challenge - Service re-design moving towards integration Precise definitions of levels of skills and workforce needed Whole pathway approach with appropriate Transition to Adult Services Absolute clarity in Service Specifications

• Conundrum - To link all the parts of service pathways from Primary to Secondary & Tertiary care, working with CCGs to commission a care continuum with SCN support.

Children’s & Young People’s Services in the NHS England Solution - Specific NHS England Work Programmes

SCN Work Programmes – support to achieve local & national priorities

Pathfinder Working Groups – e.g. developing guidelines from CRG’s for the CCG commissioned elements of the disability/rehabilitation pathway, paediatric diabetes, LTV, Anomaly Scan CHD detection

Working Relationships – Close working vital with:Commissioning bodies - CRG’s, W&C POC, CCG’s, AT’s, LA

CYP Health Outcomes Forum, Office of the Children’s CommissionerChildren’s Health and Wellbeing Partnership Royal Colleges including RCPCH, RCN, RCGP, RCM, RCOGDH and DfE, PHE, HEE, NICE, CQC, Monitor, Charitable Sector

• To share learning from existing good practice – successes, challenges

and barriers to implementing clinically and patient designed Transition models

• To define the critical elements of an effective Transition model

• Using the above, develop a Generic Service Specification as a commissioning template, onto which all specialised and complex services can be added, with separate consideration of CAMHS, and young people with SEN and Learning Disability

• Start to consider measurable outcome indicators against which successful Transition plans can be commissioned and monitored

• Work with CRG’s, SCN’s and AT’s to identify partners, LA & others

4 Work Streams established with significant progress to date:

Specialised Service Specification work-• A Transition Insert now completed• The next stages needed to enter 2014/15 contracts :

-Sent to relevant CRGs for comment & feedback - Finance implications checked by Finance Team-Re-considered by the Women’s & Children’s POC Board-Submitted to the Clinical Priorities Advisory Group-Public consultation if required-Any changes considered and made-Submitted to Specialised Services Operational Group-Finalised and inserted into all CYP specialist service specs.

TRANSITION – Where are we now?

Engagement of CCGs

• Event planned on 2 April 2014 led by NCDs (Dr Jackie Cornish & Dr Catherine Calderwood)

• Audience of circa 200 expected

• Delegates drawn from CCG Leads for CYP, Maternity, CAHMS, Primary Care & SCNs

• Focus on collaborative dialogue to deliver both national agenda and local priorities by working together.

• Excellent opportunity to engage.

CAMHS Transition

• Expert clinical group established

• Generic service specification reviewed to ensure needs of this group identified

• Youth Forum and the voice of patients involved

• Excellent progress in this work stream.

Learning Disability & SEND Transition

• Same approach as for CAMHS

• Department of Education & Council for the Disabled Child involved, together with many other agencies and NCD for Learning Disability

• Development of service specification now underway in partnership with commissioners

• Real commitment by all involved partners

Key Messages to date…..

• Significant overall progress already made

• Expert advice and commitment from senior stakeholders

• Innovative and transformational opportunities to achieve tangible improvements for patients during Transition through robust commissioning routes

• Linked to other key initiatives (e.g. Peer Review, NICE)

• Endorsed and supported as part of NHS policy, and NHS England priorities through The Mandate

• Strong support from patients & their carers.