Principles of Good. Transitions1 ARC. Scottish Transitions. Forum. Scotland. For Young People with Additional Support Needs

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1 Scottish Transitions Forum Transitions1 # Principles of Good For Young People with Additional Support Needs April 2013 Inside: Top nine problems with transitions p.4 What is the Scottish Transitions Forum? p.7 Solutions to the top 9 transitions problems p.8-26 Next steps p.27 Foot Notes p ARC Scotland Supporting Excellence

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3 3 SCOTTISH TRANSITIONS FORUM April 2013 Editor Scott Read Development Worker ARC Scotland (0131) org.uk ARC Scotland Supporting Excellence Websites: Unit 12 Hardengreen Business Centre Eskbank, Dalkeith, Midlothian EH22 3NX The period of planning for young people with additional support needs (such as a disability, Autism, Deaf/blindness, mental health, emotional behavioural issues, bullying, exceptional health care needs amongst many others), who are making the transition to young adult life can be one that is characterised with disappointments, distress and disillusionment due to the many pitfalls this process is traditionally characterised by. Professionals and partner agencies refer to this process as transition planning or the transitions process. Young people moving through transitions are not a homogenous group and come from a wide range of different circumstances. Some may live in families; others may live with foster carers, kin ship carers or in residential or community settings. No matter the circumstances, all young people with additional support needs have a right to individualised support, to express their views and be part of deciding their own future and the support and care they will need. This document has been developed by members of the Scottish Transitions Forum (ARC Scotland). Our aim is to inform policy and to fundamentally change the way we do things in Scotland in the area of youth transitions, from the top down and the bottom up. We need to help young people and their carers achieve positive outcomes through greater Personalisation, independence, choice and control of the transitions process. A new way of working needs to be embedded in legal frameworks, policy decisions, good practice guidelines, monitoring mechanisms, work culture and funding and investment policy. This then needs implemented at a local level. NEXT STEPS If you agree with the contents of this document and wish to help improve transitions services for children and young people with additional support needs please join the forum as a member by using the contact details in the grey box above. This document will be reviewed and updated on a regular basis against new and existing evidence as it emerges from cross sector Practice, Policy and Academia and other sources with the aim to release an updated version in The forum, in association with Scottish Transitions Forum members, will be working to create an evaluation tool based on this document to help evaluate and improve Transitions services across Scotland and to build on these principles for future versions of the document.

4 SCOTTISH TRANSITIONS FORUM April THE FORUM The Scottish Transitions Forum, facilitated by ARC Scotland,is made up of a diverse mix of members from all over Scotland. The Scottish Transitions Forum aims to improve the experience of people with additional support needs. Particularly those with high support needs, as they go through life transitions. The forum has a focus on the transition of young people from school or college to adult life. We achieve our aims by through the Forum facilitated meetings and other forums. Involving and consulting with people with additional support needs and for their views to influence and guide the work of the forum demonstrated by the ongoing video project as shown throughout the videos on our website. Working collectively to raise awareness, inform and influence approaches to transitions for people with additional support needs at a local and national level. The Scottish Transitions Forum began in I t now has over 200 members that meet every 3 to 4 months in either Glasgow or Edinburgh. The membership of the forum consists of a wide range of individuals. Membership of the Scottish Transitions Forum is open to anyone who is committed to improving the transitions for young people with additional support needs. TO LEARN MORE ABOUT US AND THE FORUM PLEASE VISIT OUR WEBSITE AT Bringing together people working in transitions for people with additional support needs The forum has over 200 members from across the whole of Scotland Identifying and sharing good practice, learning and resources- This is done through the Forum meetings and there will be evaluation tool available soon. Generating new ideas, challenging our thinking and improving our work practice This happens The forum membership. The Forum has been running since Since then it has grown to include over 200 members from various sectors across Scotland.

5 5 SCOTTISH TRANSITIONS FORUM April THE BIG The Scottish Transitions Forum has identified 9 key problems (and corresponding solutions) faced by young people in transition and their carers in Scotland. We have called these THE BIG 9.

6 1 Person Centred approaches are often lacking or inconsistent 2 Lack of the voice of the young person in transition planning 3 Planning starts too late 4 Lack of support for future transitions. 5 Lack of information for young people and their carers 6 Confusing legislative and policy framework. 7 Support is not coordinated between services 8 Too many young people are not regarded as eligible for support. 9 Confusing Language

7 7 SCOTTISH TRANSITIONS FORUM April 2013 CONTENTS PAGE 4 THE FORUM Information about how the forum is set up. PAGE 9 PROBLEM 1 Person-Centred approaches to transition planning are often lacking or inconsistent and there are too many plans. PAGE 12 PROBLEM 2 Lack of the voice of the young person in transition planning. PAGE 13 PROBLEM 3 Planning start too late. PAGE 15 PROBLEM 4 Lack of the voice of the young person in transition planning PAGE 17 PROBLEM 5 Lack of information for young people and their carers. PAGE 19 PROBLEM 6 Confusing legislative and policy framework. PAGE 21 PROBLEM 7 Support is not coordinated between services PAGE 25 PROBLEM 8 Too many young people are not regarded as eligible for support PAGE 27 PROBLEM 9 Confusing language. PAGE 28 NEXT STEPS What are the next steps for the forum?

8 SCOTTISH TRANSITIONS FORUM April The most recent review of the transitions process, the Doran Review (2012) states: Effective management of transitions from one stage of education to another and on to life after school is a key component to effectively meeting the needs of all children and young people. It is crucial when considering any changes for those children and young people with complex additional support needs. The review regularly heard concerns about all transitions including; into school, from primary to secondary, from one kind of school to another and particularly from school to adult services. Adequate time for planning and preparation, full involvement of the child and family and coordination of professionals were identified as contributing to successful transitions. When any of these are not properly addressed problems arise. By far the greatest concern for parents was about the move to adult services and the fear of the young person falling into a black hole where there was no direct accountability for continuing services. References: Throughout this document we referred to relevant policy, legislation, guidance and research and are indicated by a bracketed number (#). These are found on page 29. You can find up-to-date and interactive information, such as videos and presentations on our website. This is version #1 of the principles of good transitions document. The content is Copyright (all rights reserved) 2013.

9 PROBLEM 1- PERSON-CENTRED APPROACHES TO TRANSITION PLANNING ARE OFTEN LACKING OR INCONSISTENT AND THERE ARE TOO MANY PLANS Person centred approaches are not routinely used in transition planning. Indeed, there is no shared definition between professional groups about what Person Centred Planning actually means.. Problem The holistic approach offered by Person Centred Planning in its truest sense often does not fit well within the culture of the education sector. The education and further education sectors predominantly seek outcomes related to education and employment. (1) There is also a lack of consonance between different legal/policy agendas in adult and children services, such as, Adult Health and Social Care Act linking with Children services and following personalisation and person centred planning values and principles. There is recognition of personalised approaches within the integration of health and social care 20/20 agenda. This agenda uses terms such as coproduction and co design (2) rather than personalisation, however it seems to be a professional as much as a post code lottery as personalisation in these two areas is not standard, with inconsistencies across Local Authorities and professionals. This personalised and outcome based way of assessing is being embodied to some extent in the Children and Young People Bill, under the idea of Wellbeing. Outcome based assessment is not simply a way of obtaining a diagnostic label highlighting support needs to access services it is also a way of celebrating strengths. Some professionals regard Person Centred Planning as too time consuming and believe it raises expectations unrealistically, which cannot then be met. Throughout a person with additional support needs lifetime there can be a large amount of assessments and plans constructed. Each time a family/care giver or a person who uses services has to retell their story to any number of professionals. Not only is this frustrating for those involved it is also a duplication of resources and effort on behalf of professional teams.

10 ALL YOUNG PEOPLE SHOULD HAVE ACCESS TO PERSON CENTRED PLANNING IN ITS TRUEST SENSE OR SIMILAR INPUT IF THEY WANT IT. Solutions Person Centred Planning approaches have been legislated for in England, such as in the Department of Health policy guidance 3. It is well supported and evidenced as a positive method of working such as the Big Plan evaluation, the work of Helen Sanderson Associates (4) and the Edinburgh Development Group. Person centred approaches should be used to ensure that the young persons views are at the centre of any outcome led assessment and subsequent support plan. The 3rd sector have developed and use Person Centred Planning to great effect in planning services for adults and young people, using these principles to achieve support that is centred around individuals, long before the advent of co-production, codesign and integration approaches. Policy and legislative teams and partner agencies should use the good practice developed around these principles to inform future work within children and adult health and social care areas. All young people should have access to Person Centred Planning (in its truest sense of MAPS, PATHS, the Big Plan etc.) Legislation should place a duty on Local Authorities, similar to that in England, to ensure that there is opportunities to access different ways of planning independently of the social care statutory system, such as person centred planning in its truest sense. Other planning tools if person centred planning approaches do not fit the individual should be available. These plans, whatever their nature, should link to the principles of Personalisation, choice and control as represented by the Social Care Self Directed Support Act (2013). The cost involved is a preventative spend to save (5) approach, as planning at this stage will prevent more complications and related costs at a later date. The use of Person Centred Planning should help young people to be empowered about their future. Helping them to have a better idea of whole person focussed outcomes they want to achieve via the transitions planning meeting. This approach links well with Curriculum for Excellence and Getting it Right for Every Child and wellbeing agenda within the Children and Young People Bill. Out-with Person Centred Planning, young people should have one plan which links to the Child s Plan (6) (one single plan). The plan should: Embody the philosophy of Person Centred Planning by being person centred (7). Be the property of the young person. This will help in the sharing of information with other agencies. Focus on positive risk enablement rather than risk adverse management culture, where safeguarding is a concern.

11 Make clear to the individual and their family about what financial and other help they can get at the start of the process, including self directed support options (8). Be accessible and easily understood by those it is written about (9). Involve the whole family/care givers wherever possible. We acknowledge this may throw up barriers for Looked After Children due to the corporate parenting approach. Acknowledge that there are many ways to carry out an assessment and that not all of them are through written forms of communication. To be person centred means to communicate in a way that the person understands. Engage all appropriate agencies, including the third sector in the planning of the post school arrangements (10). Professional input should always focus on the needs and wishes of the young person and their family and not be something that monopolises the transition experience i.e. is truly co-productive (11). Adult services should adopt the Children and Young Persons assessment as evidence for service provision against adult services eligibility criteria as a need that is already well evidenced, especially if a short breaks or respite assessment or previous social care assessment has been carried out. This plan should be an integral part of adult service outcome based assessments (12). This will link into a suggested direction of travel from the Children and Young People Bill. (Compare to problem point 8) Be adaptable and change to circumstances as they arise throughout the transitions process. Where a more in depth person centred plan (i.e. MAP or PATH process) is wanted to help the young person and their family to plan for the future this should be facilitated by a trained planner who is operating externally to health, education and social care (3rd party individual) to prevent conflicts of interest. ACTION 1 To liaise with partner agencies, local authorities and national government to adapt work practice, philosophy, legislation and policy to include these recommendations. Ensure they take on board these recommendations. I nvolving them into transitions pathways and day-to-day practice and that the difference is evaluated.

12 SCOTTISH TRANSITIONS FORUM April PROBLEM 2 - LACK OF THE VOICE OF THE YOUNG PERSON IN TRANSITION PLANNING. Too often the voice of the young person who is undergoing the transitions process go unheard. Problem Solution The views of the child/young Advocacy (13) or similar representation should be offered person undergoing outcome based assessment are often to everyone who needs it. missed. Advocacy, if they wish This offer should be made at to access it, is not routinely the start of the transitions available, even though there process. This is especially relevant for those involved with is a legislative requirement that the child s view must be the Looked After Child system considered (Education (ASL) or other legal situation (such (Scotland) Act), the Children as Guardianship). (Scotland) Act 1995 and the UNRC). Within transition planning meetings there tends to Role (Problem point 7) who The use of the Key Worker be an over involvement of the could be a parent or kinship professional voice that can carer (if the young person over shadow the views of the wants this), will also help to young person. make the planning process more young person focussed. The keyworker model may be considered an extension of Advocacy or similar representation should be offered to everyone who needs it at the the advocate role or become adopted as a model for its primary focus. Legislation needs to be considered to develop principles and minimum standards of Advocacy. Consideration needs to be given to the differing communication styles of young people. Staff will need to be better trained to ensure full involvement of young people in their planning process. ACTION 2 To liaise with partner agencies, local authorities and national government to adapt work practice, philosophy, legislation and policy to include these recommendations. start of the transitions process.

13 PROBLEM 3 - PLANNING STARTS TOO LATE The Education (Additional Support for Learning) (Scotland) Act 2009 states transitions planning should begin at least one year before a young person is due to leave school. Problem Despite this legislative requirement, many young people with additional support needs still do not have plans in place when they leave school. Starting at age 14 is referred to in recent guidance in Post 16 Transitions: Policy and Practice Framework (2012) but frequently not done (14). There are differing views about early intervention in the transition planning process. Some families are already considering this future direction by the time they have moved from primary to secondary school, whereas some professionals believe planning at 14 years is too early and could possibly lead to duplication of work. There are concerns from Looked After Children Services that this early start could result in pushing out the young person from services too early. Solution It has been demonstrated in pioneering projects, current research and government review (15) that early intervention has a very positive effect on future life planning and resulting positive destinations. All young people with additional support needs should have the opportunity to begin planning for transition to young adulthood when this is deemed appropriate but at the very minimum 14 years old. This earlier start should be legislated for in the Education (Additional Support for Learning) (Scotland) Act (16). This earlier start can mean the commencement of lowlevel interventions around transitions such as information sharing, benefit knowledge and up skilling of those involved (17). This should represent the start of an increase in joined up planning activity and should mean that young people and their carers meet with the professionals and partner agencies involved to have a low level discussion around the whole process. This is also the time to discuss future life planning, benefit changes, potential person centred planning opportunities if wanted and to provide information about what choices and resources are available as the transition process continues. This is also a time to start to establish an early indicative budget to help to plan under. Plans begun at an earlier date should be regularly checked/ updated by the Named Person or Lead Professional. This is because the young persons needs and aspirations can change and complacency can lead to negative outcomes for the young person. The commencement of early planning in transitions at this stage is to ensure that the Looked After Children, or any child, has all the information they need. This means the process of future planning can start with an understanding of what a corporate parent (18) may be and to provide the young person with the option to choose a key worker if they so wish.

14 SCOTTISH TRANSITIONS FORUM April ACTION 3 To liaise with the education (additional support for learning) (Scotland) act advisory group to include a recommendation that transitions planning should begin as stated at 14 and link to the responsibilities of the named person and lead professional as being legislated for by the children and young persons bill team. ACTION 4 All young people with additional To engage with and work alongside local authority and partner agencies to ensure they take on board these recommendations. I nvolving them into transitions pathways and day- to- day practice and that the difference is evaluated. support needs should have the opportunity to begin planning for transition to young adulthood when this is deemed appropriate, but at the very minimum 14 years old.

15 15 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 4 - LACK OF SUPPORT FOR LATER TRANSITIONS Problem There are mixed approaches of engaging appropriate agencies and Third Sector Organisations in planning for post school arrangements. Post 16 transitions are often treated as a leaving school event rather than an ongoing process lasting several years that often include several transitions throughout life. As a result, support for subsequent transitions is often lacking (19). Whereas it has been acknowledged in the upcoming Children and Young People Bill that Looked after Children require on-going support until they are 25. Situations also occur when diagnosis emerge late or very close to school leaving age, for instance Asperger s or Autistic Spectrum diagnosis. This can affect the success of subsequent college and university placements.

16 SCOTTISH TRANSITIONS FORUM April Solution All young people with additional support needs should have support to plan transitions up to their 25th birthday (20). This should be reflected in the role of the Named Person, Lead Professional and Key Worker continuing up to 25 as detailed within the Children and Young Peoples Bill. This, however, may clash with the Children s (Scotland) Act 1995 if a parent is a key worker and interfere with parental rights and responsibilities till the age of 18. This would extend the input via a Key Worker role a parent would have up until the 25th birthday. Those who have a late diagnosis should be able to access a fast track planning process and the ASL codes of practice should reflect this as a duty. This planning should be integrated within college and university Learning Disability Services, such as student support through policy such as Partnership Matters. ACTION 5 To engage with the Children and Young Peoples Bill team to ensure there is fair representation of expectation of support for both Looked After Children and all others with additional support needs up to 25 years of age. ACTION 6 To recommend a review of the links between children and adult policy and legislation to National Government and for National Government to publish these reviews and future policy information in easy to understand language, including a clear outline of long-term goals. ACTION 7 All young people with additional support needs should have support to plan transitions up to their 25th birthday. To ensure the definitions of the Named Person and Lead Professional fit within the roles required for transitions planning and to work with Partner agencies, Local and National Government to aim for national understanding.

17 17 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 5 - LACK OF INFORMATION FOR YOUNG PEOPLE AND THEIR CARERS Despite legislative requirements, young people and their families are not routinely provided with accessible information that informs them about what they should expect and are entitled to during the transitions process. Information is not always clear for everyone. Not only this is sometimes not based on information that would be the most useful. Problems Further to this, many local authorities do not provide clear and accessible information around the provision of information detailing what support services are available to individuals going through the transitions process (27). There is also a duty from the Equality Act (2010) to provide equitable information. It is concerning there are still areas where this isn t happening, as it is an infringement of this above duty and human right. Solutions Good information resources are available (e.g. Enquire, Autism Tool box, Moving On Transitions Workbook (21), English as a second Language resources) and these avenues need to be funded and continually developed to their fullest potential if this lack of information is to be overcome. There should be accessible information, which is inclusive of young peoples personalised communication needs (such as, audio video, assistive technologies, board maker), for young people and families that clearly shows what support they are entitled to in the transition period, how they can access it and that covers all options that are available to them. This should include clear information about their statutory rights, including those relating to the upcoming Children and Young People Bill and other relevant transitions legislation such as, the Education (Additional Support for Learning) (Scotland) Act, Children s Act, Adult Health and Social Care Act, Health, Protection of Vulnerable Adults, Guardianship and Social Care (Self Directed Support) (Scotland) Act amongst others. At local level there should also be good clear quality

18 SCOTTISH TRANSITIONS FORUM April There should be accessible information, which is inclusive of young peoples personalised communication needs. information about the services available to individuals to help support them in adult life, such as work experience, further education options, travel, housing and other information that impacts on rest of life planning. This is already a duty under the Equality Act (2010) and failure to provide this information is failure to uphold this duty, it is also discussed in article 17 the right to information in the UNRC (22). The Health and Social Care (Self Directed Support) Act (2013) requires each local authority to make this information available about SDS options. This approach needs to be inclusive of transitions planning options in guidance. The information provided should give accessible information that is relevant to carers and young people s individual needs, rather than being developed to meet statutory led concerns. There also needs to be an easily accessible (co-produced) national database of services available to individuals. This would link with self-directed support ideals and the recommendation within the Doran Review (23) to map further education and training provision. Young people and their families should also have access to information about benefits that they and the young person are entitled to once they become an adult at 16 (24). This would be a useful service for schools to provide in partnership with DWP at the start of the transitions process. ACTION 8 To engage with Education and other partner agencies to explore information accessibility within school environments. To coproduce with user of services and partner agencies information sources required that are service user led and relevant to their needs. ACTION 9 To continue to explore the development of a national resource database through open source software such as ALISS. org. with partner agencies Local and National Government that will ensure equity of access and representation for all. ACTION 10 To engage with relevant Partner Agencies, Local Authorities and National Government bodies to create a National Resource Database in line with Self Directed Support principles of all services across Scotland to provide better outcome planning for individuals.

19 19 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 6 - CONFUSING LEGISLATIVE AND POLICY FRAMEWORK There should be a team, or dedicated person, at national level to review Legislation and Law can be a confusing minefield. A clearer understanding for those in transitions is vital to help smooth transitions. and explore how current policy and legislation interlink to provide smoother and clearer transitions pathways. Problem The policy and legislative framework surrounding transitions offer a positive framework to improve young people s experience. However new initiatives sit on top of older policy and legislation without clarity about how they link together. Older policy and legislation was created in times of different social drivers and often do not focus on the right to an independent life. Conflicting messages and outdated work practices can combine to cause confusion amongst professionals, young people and families. It also adds to inconsistent application of policy across the country. Professionals and partner agencies continue to feel as though Civil Servant and Committee Teams work in isolation to one another in creating new drivers and law that impacts on young people in transition. This is partly due to the large amount of guidance and policy that is generated by Policy and Legislation teams and lack of strategic knowledge of professionals around how this interrelates. The Health and Social Care (Self Directed Support) (Scotland) Act has the potential to have a significant impact on young peoples experience of transition, however there is currently a lack of awareness and understanding about how this will link with education and health care budgets. There is also a lack of understanding in local authorities, families and young people about how Self

20 SCOTTISH TRANSITIONS FORUM April Directed Support can be used as a tool to create positive future outcomes that do not fit within traditional service provision. They should develop briefings that clearly indicate links throughout the policy and legislative environment not just the area of concern. These briefings should be simple The culture change represented by the integration of health and social care enough for layman to understand such as by those undergoing the transitions process. and co- production agendas seems to not be filtering down into the larger work force creating barriers to the joint working that is key in transitions. These agendas should inform Continuing Professional Development and professional competencies of partner agencies involved in The team should review all policy and legislative proposals especially between children and families and adult services legislation. Traditionally looking at both of these areas over the transitions period has been outside the scope of any review in the transitions process (25) recent times (26). National Solution There should be a team, or dedicated person, at national level to review and explore how current policy and legislation interlink to provide smoother and clearer transitions pathways. They should help it make sense to those in the professional fields and agencies in the third sector. Government should review this. Training for staff should include an understanding of the policy and legislative background affecting all aspects of transition and not solely their own professional area. These CPD implications should include improving awareness of everyone s role in the process and include The policy work needs to be more joined up. The Scottish Executive and Government should ensure this takes place. information around the differences in professional cultures and include innovative and aspirational learning being taught in contemporary institutions for newly qualified staff. This would link into the Integration agenda. ACTION 11 To explore with partner agencies the development of Continued Professional Development for those working in the field of transitions capturing the future direction of travel in line with upcoming National Government policy and service user led co- production approaches. ACTION 12 To recommend to National Government and Local Authorities that a team be set up to explore the links between policy and legislation areas across health, education and social care. This team should provide guidance and audit functionality of National and Local Government policy and legislation and create accessible information around these areas.

21 21 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 7 - SUPPORT IS NOT COORDINATED BETWEEN SERVICES (27) Partnership working between education/adult/health/children s services and the voluntary sector exists, however, organisations in transitions pathways can be unsure of each other s roles and often don t actively engage with one another. Problem Each specialism is under different policy and legislative pressures and some professionals know little about the roles of other professionals. This lack of professional interdisciplinary knowledge can cause problems in correct referrals, continuity of health care, can lead to lack of coordinated support, incorrect support provision and other issues that traditionally characterise negative side of the transitions process when a young person has more than one professional involved. There is also no shared understanding about what different terms used by professionals may actually mean (see problem 9). Joint training for staff should be a matter for workforce development and CPD requirements. A family need all the help they can get from coordinated services at this time. It is also important to remember that families have been maintaining a lot of effort to get to this point and coordinated support helps to everyone not just those going through the process.

22 Solution Education should take the lead in coordinating services as under the Education (Additional Support for Learning) (Scotland) Act as it is the responsibility of a schools Named Person to coordinate young peoples transition initially (see below). This role is not fully realised in some education departments in Scotland even though it is a duty. There should be accountability for this as suggested under the Named Person duties (see below). There should be a dedicated Transitions Team in every Local Authority (28). The team may consist of other professions than solely social work. One model is to develop a Multi-Agency Specialist Team similar to work that is underway in Kent (29). A similar model is tentatively suggested in the Post 16 Transitions policy document that suggests there is a dedicated team in each school. This team should work with young people between the ages of 14 to 25 years in line with the Children and Young People Bills suggested age range for Looked after Children. There should be a key worker (30) available to all young people who need them Education should take the lead in coordinating services as under the Education (Additional Support for Learning) (Scotland) Act as it is the responsibility of schools Named Person to coordinate young peoples transition initially. over the transitions period. This also ensures someone The young person should with a good relationship to be able to choose their key the young person is involved worker. The parent(s) are often in the process. This is conceived as a very different role the primary positive influence and voice for the young from the Named Person/Lead person although Looked After Professional/Corporate Parent and other young people may as the concerns are very different (see below) but may experience this differently. link into an advocacy role. The key worker would fill this role of positive parent, There should be a shared which is potentially missing, understanding amongst professionals, young people and for the looked after child. Someone s relative/kinship their families about what the carer or parent may fill the Key Worker does. key worker role if they and the child agrees but it is usually better to have a professional involved as there can be tension between parents and young person s wishes and the key worker can also support the parent. These tensions should be discussed in the early stages of planning (See Problem Point 3 above).

23 There should be a dedicated Transitions Team in every Local Authority. At various times in their childhood and adolescence most young people will experience needs which require to be brought to the attention of either or both of the universal services. The key worker should: Know the young person and their family Be aware of the different children and families and adult services and health systems, processes and assessment protocols. This may require up skilling of some carers, for this reason transitions should begin as stated at 14 to provide the assimilation of this knowledge. Approach professionals that are involved in the transitions process in a measured way and source appropriate support for a young person when it is needed. Facilitate the planning of the young persons transfer to adult services. Continue to be involved once the young person has transferred to adult services or if being sign posted to other services. At various times in their childhood and adolescence most young people will experience needs which require to be brought to the attention of either or both of the universal services. To facilitate a timely, appropriate, and proportionate response to these emerging needs, a named contact known as the Named Person has been developed. (31) The Named Person should be available to anyone who

24 SCOTTISH TRANSITIONS FORUM April requires one, up to the age of 25. The primary responsibility of the role is to look out for the needs of the child, including monitoring progress and development and responding to emerging concerns. The named person is the one who coordinates other professionals and who people contact for information sharing. The Named Person should have a duty to be accountable for information sharing with other agencies and a further duty and accountability for calling timely and responsive transitions meetings. At the transitions stage the Named Person will be a member of the education faculty and therefore dovetails with the Education (Additional Support for Learning) (Scotland) Act codes of practice and guidance. When individuals with additional needs require support from more than one agency or service a Lead Professional is nominated. They take on the responsibility and duties of the Named Person and ensures the support provided by various services and agencies is coordinated at the point of delivery and that the child and family experience a seamless, multi-agency service which effectively addresses the child s needs and concerns. The Lead Professional is also responsible for coordinating assessments and the different time scales of the process. The Key Worker works closely with the Named Person/Lead Professional to ensure that the young person s needs are fully represented. Partner agencies and all key individuals in the transitions process should meet to discuss, coproduce, codesign, codeliver and co-assess (32) a transitions pathway in their local authority. Joint working should be something that is built into National and local authority considerations and work forces combining the work of the third sector in these areas. Effective evaluation in this area combined with up to date multidisciplinary training in these areas should be the norm not the exception. This should help to remove a lack of understanding amongst professionals and partner agencies of each other s roles. This group will include everyone who is involved within the transitions pathway and not solely limited to health, social work and education. The transitions pathway should be established and subject to review. ACTION 13 The forum will explore how the self directed support and Personalisation agenda can be applied within health and education (and social care even though this is covered by Self Directed Support Act) in terms of personalised budgets (such as the Personalised Care Budgets being trialled in England) and personalised education plans. ACTION 14 The Forum, with its partner agencies suggests there should be a national understanding of the different time scales different services work under. These different time scales can be led by different policy and legislation and/or needs. We will engage with colleagues from health, education and partner agencies to explore these areas.

25 25 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 8 - TOO MANY YOUNG PEOPLE ARE NOT REGARDED AS ELIGIBLE FOR SUPPORT. Eligibility criteria are often viewed as something that gate-keeps resources for local authorities rather than something that establishes a level of need. It can be confusing for young people at this time. Especially as they navigate the adult world for the first time. Problem The Doran review mentions the ambiguity of professionals on one hand with the desire to help but are unable to do so because on the other hand eligibility criteria prevent them from being able to offer any council led services or financial aid. There is an inequity across Scotland as individual local authorities decide eligibility criteria. Those who don t meet the eligibility criteria may in the future need services due to not having low-level support that would prevent crisis from occurring. Some families are known to place themselves at risk to get the services they need. To get funding, a worse case scenario is often painted by families as they need services. Services are only available to those who meet at times very strict eligibility criteria geared towards risk management rather than need led access to services. I t must also be recognised that Looked After Children rely on corporate parents (i.e. social work) to ensure they receive support and this is not without its pitfalls given that corporate parents have a dual role of caregivers and gatekeepers of resources. Solution There is no easy solution to this. It is hoped within an early interventionist model (33) eligibility criteria will become less of an important marker for families to receive services from adult services post 16. Early intervention and universal provision of services should ensure adequate support is already in place and prevent the increase in risk as per the Getting it Right policy. As the demand on the eligibility criteria/assessment system is reduced due to the success of the early intervention

26 SCOTTISH TRANSITIONS FORUM April There should be accessible information, which is inclusive of young peoples personalised communication needs. model, more funds should be available to support those with significant additional support needs, such as disability. This may also mean that those who have low-level needs that don t meet eligibility criteria may be prevented from moving into future crisis situations. Eligibility criteria should be designed to ensure they are needs (preventative and rehabilitating) not risk based (risk management and response to crisis) measures. The philosophy and evidence behind eligibility criteria should also be reviewed by Local Authorities and Academia to explore this approach is still fit for purpose. This will ensure that these criteria are adequate in dealing with gate keeping of resources and assessing need. process starts (see Problem 1 and Problem 3). Young people and families should be aware of what services are available to help support them and encouraged where possible to consider the use of the full 4 options in self directed support (i.e. from direct payments, self controlled services to traditional service provision models). Adult services should adopt the Children and Young Persons assessment as evidence for service provision against adult services eligibility criteria as a need that is already well evidenced, especially if a short breaks or respite assessment or previous social care assessment has been carried out. This plan should be an integral part of adult service assessments (34). This will link into a suggested direction of travel from the Children and Young People Bill). (Compare with problem point 8). ACTION 15 To promote the adoption of early indicative budgets under the principles of Getting it Right for Every child in partner agencies, local authority guidance and National Government Legislation and Policy. (Cf with Problem point 1 use of respite and short break assessment to provide early indicative budget). There should be a clear indication of Budget to plan under before the Transitions

27 27 SCOTTISH TRANSITIONS FORUM April 2013 PROBLEM 9 - CONFUSING LANGUAGE Problem Different terms used by different professionals confuse young people and their carers. One term can even mean different things depending on which professional is using it. For example the terms key worker learning disability, disability, learning difficulty and person centred plan can have different meanings between different groups of professionals. Solution There should be a common and agreed frame of reference for language used within the transitions process (35). This should include definitions for Person Centred Plan, Key Worker, and Positive Destination amongst many other phrases in common usage within this field. There should be a common and agreed frame of reference for language used within the transitions process. ACTION 16 A glossary of terms for discussion amongst members of the Scottish Transitions Forum will be made available to forum members via publication on line. This information will be taken from existing policy, guidance and legislation where possible. This will be passed to other partner agencies and National Government for use as standard definitions. To develop with partner agencies a glossary of terminology available to standardise key literature, such as guidance, around the transitions process, which other service providers and legislative guidance teams, may adopt.

28 NEXT STEPS SCOTTISH TRANSITIONS FORUM April Along with continually assessing the evidence for this document to release an updated version of it in The Scottish Transitions Forum will also undertake these following actions: 1 & 2 & 4 liaise with partner agencies, local authorities and national government to adapt work practice, philosophy, legislation and policy to include these recommendations ensuring they take on board these recommendations. Involving them into transitions pathways and day-to-day practice and 10 engage with relevant Partner Agencies, Local Authorities and National Government bodies to create a National Resource Database in line with Self Directed Support principles of all services across Scotland to provide better outcome planning for individuals. that the difference is evaluated. 11 explore with partner agencies the development of Continued Professional 3 liaise with the education (additional support for learning) (Scotland) act advisory group to include a recommendation that transitions planning should begin as stated at 14 and link to the responsibilities of the named person and Development for those working in the field of transitions capturing the future direction of travel in line with upcoming National Government policy and service user led co production approaches. lead professional as being legislated for by the children and young persons bill team. 12 recommend to National Government and Local Authorities that a team be set up to explore the links between policy and legislation areas across health, 5 engage with the Children and Young Peoples Bill team to ensure there is fair representation of expectation of support for both Looked After Children and all others with additional support needs up to 25 years of age. education and social care. This team should provide guidance and audit functionality of National and Local Government policy and legislation and create accessible information around these areas. 6 recommend a review of the links between children and adult policy and legislation to National Government and for National Government to publish these reviews and future policy information in easy to understand language, including a clear outline of long-term goals. 13 explore how the self directed support and Personalisation agenda can be applied within health, education and social care (via self directed support Act). In terms of personalised budgets (such as the Personalised Care Budgets being trialled in England) and personalised education plans. 7 ensure the definitions of the Named Person and Lead Professional fit within the roles required for transitions planning and to work with Partner agencies, Local and National Government to aim for national understanding. 14 explore the national understanding of the different time scales different services work under. These different time scales can be led by different policy and legislation and/or needs. We will engage with colleagues from health, education and partner agencies to explore these areas. 8 engage with Education and other partner agencies to explore information accessibility within school environments. To coproduce with user of services and partner agencies information sources required that are service user led and relevant to their needs. 15 promote the adoption of early indicative budgets under the principles of Getting it Right for Every child in partner agencies, local authority guidance and National Government Legislation and Policy. (Cf with Problem point 1 use of respite and short break assessment to provide early indicative budget). 9 continue to explore the development of a national resource database through open source software such as ALISS.org. with partner agencies Local and National Government that will ensure equity of access and representation for all. 16 develop with partner agencies a glossary of terminology available to standardise key literature, such as guidance, around the transitions process, which other service providers and legislative guidance teams, may adopt.

29 29 SCOTTISH TRANSITIONS FORUM April 2013 FOOT NOTES REFERENCES. 1. Transforming Transitions Report 2. Co production of health and well being in Scotland, (2013). 3. Personalisation through Person - Centred Planning. Department of Health. (2010). 4. The emergence of person centered planning as evidence based practice. Journal of integrated care. (2006). 5. As discussed in the Early Intervention Approach and by advocates of this such as the Chief medical Officer (Sir Harry Burns). 6. As discussed in the Children and Young Peoples Bill (2013). 7. As discussed in Opportunities for All, Curriculum for Excellence and GIRFEC. 8. Self directed Support guidance. (2013) 9. As directed by the clear English campaign and under the Equality Act (2010). 10. Education (Additional Support for Learning) (Scotland) Act guidance. 11. Co-production of Health and Social Care (Governance International, 2013). 12. As directed in Getting It Right For Every Child idea of person-centered assessment. 13. As written in the self directed support Act (2013) 14. Post 16 Policy and Guidance Framework (2012) and Opportunities for all (2012). 15. Doran Review, What makes a good life (2009) and Stalker (2011). 16. As also recommended in the Post 16 policy and Framework Guidance (2012) and Opportunities for all (2012). 17. Playback have developed resources. (2008) Are discussed in these are our Bairns 19. Opportunities for all, post 16 education guidance th Birthday with room to increase this is mentioned in Opportunities for all (2012) 21. Available through Playback (