The Thames Valley Strategic Clinical Network Transition Project

The Thames Valley Strategic Clinical Network Transition Project Achievements across the Network, resources and tools Polly Schofield Lead Nurse for Transition (SCN) Royal Berkshire NHS Foundation Trust

The national picture Key national Documents Key Recommendations 1. NICE Guidelines for Transition from children’s to adult services (DRAFT, 2015) Ø Transition Key Worker 2. Care Quality Commission Review into Transition: ‘From the Pond into the sea’ (2014) 3. NHS England (DRAFT): Generic Service Specification for Transition Ø Documented transition plan Ø Transition communication tool Ø Information about the provider’s transition service / pathway Ø Engage young people in developing service Ø Transition Policy Ø Transition database Ø DNA tracking and FU procedures for 13 -25 year olds 2 NHS | Presentation: Transition Event December 2015

The Reading Transition Project 1. Project outcomes align with national recommendations (NICE Guidelines February 2016, CQC review, 2014, Generic service specification for transition) 2. Transition pathway mapping and data analysis 3. Patient and parent survey 4. Identified transition Lead Clinician 5. Set up Transition Steering Group 6. Trust Transition Policy 7. ‘Ready Steady Go’ pilot 8. Develop Transfer Clinics 9. Develop links with external services (SEND Joint Implementation Group) 3 NHS | Presentation: Transition Event December 2015

Network Transition Nurse: Katie King Objective: Develop and deliver teaching sessions for clinicians across the Thames valley: - The importance of getting transition right for young people The RSG programme, what, why, how How you could set up RSG in your organisation Uptake of training so far: Oxford UH x 15 Wexham Park x 3 Milton Keynes x 1 Buckinghamshire x 2 diabetes rheumatology oncology (late effects) community paeds cardiac cleft surgeons, general paeds orthopedics Diabetes General paeds Diabetes endocrinology Children’s Therapies 4 NHS | Presentation: Transition Event December 2015

Developing a ‘Transition Toolkit’ 5 NHS | Presentation: Transition Event December 2015

Transition Toolkit http: //tvscn. nhs. uk/networks/maternity-and-childrens/children/transition-childrenadult-health-services/ Policy and Guidelines • Skeleton Transition Policy • Transitions Steering Group: Terms of Reference • Transition: Professional’s Handover Document 6 NHS | Presentation: Transition Event December 2015

Transition Toolkit http: //tvscn. nhs. uk/networks/maternity-and-childrens/children/transition-childrenadult-health-services/ Pathway • Generic Transition Pathway 7 NHS | Presentation: Transition Event December 2015

Transition Toolkit http: //tvscn. nhs. uk/networks/maternity-and-childrens/children/transition-childrenadult-health-services/ Ready Steady Go • RSG Documents • RSG Train the Trainer Slides • Ready Steady Go FAQs • RBFT Easy Read (awaiting Southampton version) 8 NHS | Presentation: Transition Event December 2015

Transition Toolkit http: //tvscn. nhs. uk/networks/maternity-and-childrens/children/transition-childrenadult-health-services/ Signposting and advice • Transition: Signposting Tool • Ask 3 Questions • Mental Capacity Act: ‘Making decisions’ leaflet 9 NHS | Presentation: Transition Event December 2015

Transition Toolkit http: //tvscn. nhs. uk/networks/maternity-and-childrens/children/transition-childrenadult-health-services/ Patient satisfaction • Picker Institute: Transition survey overview and contact details • RBFT Benchmarking questionnaire 10 NHS | Presentation: Transition Event December 2015

Transition Toolkit: young people with lifelimiting illnesses. Helen and Douglas House: Transition and Beyond Toolkit • Helen & Douglas House staff come across a number of complexities where children mature into adults at different times. • This toolkit will equip clinical staff with an understanding of the process of transition for young people with life-limiting illnesses. • It covers physical, social and emotional development, including aspects of legal and social norms that can impact upon a young person’s decision making. • Available at: http: //www. helenanddouglas. org. uk/ 11 NHS | Presentation: Transition Event December 2015

Thank you Polly Schofield email: polly. schofield@royalberkshire. nhs. uk mobile: 07908548864 Transition Toolkit: TVSCN Children's and Maternity website http: //tvscn. nhs. uk/networks/maternity-andchildrens/children/transition-children-adult-health-services/