With one strategy concentrating on adults, the other on children, there is a risk that young people and their families in adolescence, or at the transition stage between the two sets of services, will fall between the two strategies.
Role of the Transition Partnership
When designing and managing the transition processes the role of the partnership will be to interlink pathways, requiring coordinated working across the sectors and professional disciplines.
End of Life Care Strategy
Key themes of the adult EOLCS:
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The challenges of end of life care, including people’s preferences at the end of life and changing demographics
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Death, dying and society, including the need to promote greater public awareness and discussion on issues around death and dying
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Care delivery, which includes a care pathway for the end of life (see below)
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The importance of measurement and research in end of life care, including development of quality standards against which primary care trusts (PCTs) and providers can assess themselves and be assessed by regulators.
The end of life care pathway
The End of Life Care Strategy proposes a step by step end of life care pathway. It is vital that this pathway is integrated with those developed for the NHS Next Stage Review led by Lord Darzi.
As part of the Review, each strategic health authority has produced a series of care pathways, including one for each of end of life care, children’s services and long term conditions. When designing and managing transition processes, all of these pathways will need to be considered and interlinked, requiring coordinated working across the sectors and professional disciplines. ACT’s transition care pathway will be a particularly useful resource for this process.
Opportunities
Between them, the two strategies offer vital support and opportunities to improve the lives and choices young people and their families receive during the transition process.
Linking services
For effective transition, services will need to agree how the single point of access works with the young person’s key worker. Both strategies call for 24/7 access to services during the end of life phase, and this is a further reason for ensuring there is coordination between the children’s and adults providers to meet that need.
Both the adult's and children's strategies present clear opportunities for linking services. Better Care: Better Lives, for example, recommends the use of a key worker with responsibility and authority for negotiating and arranging packages of care for the child and their family and a transition support worker or lead worker to oversee their transition and linking with the receiving adult service(s). This role is reflected in the adult strategy’s recommendation for individuals to have a single point of access through which to reach services.
Care planning
A central component of all end of life care and highlighted in both strategies, there are particular potential implications to care planning for staff working with young people and their families during the transition phase.
In some instances, the young person’s family may have been more heavily involved in steering the care planning than adult services may be used to. This may require staff to manage ascertaining the views of the young person themselves using slightly different techniques than with somebody who has only been involved with adult services. This may impact on staff’s training needs and identifying opportunities for training links between local children’s and adult teams would be useful.
