Transitions between services

What this means

Transitions between services are times when people move from one part of the system to another – for example, between child and adult services, or between health and social care. There are likely to be different policies and procedures between the two points, and sometimes different legal frameworks too. Transitions are particular pinch-points, when cracks in the system can be big enough for people to fall through. All this can come at a time of particular stress. As one group member put it:

For many, the first contact with social care is from a position of distress, and having to then negotiate a way through the somewhat labyrinthine system causes further distress.

Why are transitions such as between hospital and home such an important point to consider?

In these videos, Susan Bruce and Laura Collins reflect on why transitions between hospital and home are an important point to consider:

The key to improved transitions is usually partnership working. This requires trust and time, sharing of vulnerabilities, and the reduction of professional defensiveness.

Let’s take away the walls.

The research

Supported and timely transitions can make a huge positive difference in people’s lives. For instance, looking at the evidence on looked after young people, research suggests that the most influential factor on improving outcomes for care experienced young people is that they are at an older age when leaving care and moving into independent living, with their transition being supported over the longer term (Lee Lough Dennell et al., 2022; Dixon et al., 2020; Stein, 2012).

Transitional safeguarding – where children’s and adults’ safeguarding work together with each other and the wider networks in a young person’s life - similarly frames transition as a journey and not an event (Office of the Chief Social Worker et al., 2021). The group shared a positive example of transitions for young people in Wales, where the Welsh government provided a guaranteed income to young people leaving care for two years.

Werner et al. (2019), when looking at transitions from hospital to home for older adults, found the following important factors in determining whether the transition would be a success:

1. Recognition that the hospital-to-home transition was complex, could unfold over several months and required substantial investment and effort. This includes effort from the older adult and any informal carers.
2. Providing comprehensive information at the point of discharge, including on new routines, self-care, and any financial support the person and carers may be entitled to.
3. Discussing how a person lived their life before going into hospital, how these routines might be maintained, re-established, or changed.
4. A realistic understanding of the capacity someone has for self-care, how this may fluctuate (and, in some cases, deteriorate over time), and support to manage this.

In another study, Oyesanya et al. (2021) looked at younger patients with traumatic brain injury and how they experienced the hospital-to-home transition; similar themes were found, with this study describing the process as a ‘negotiation’ rather than an event. However, it also noted that, from the hospital’s point of view, there could be a ‘no news is good news’ approach - where if people did not ‘bounce back’ [to hospital], it was assumed that the transition was successful, without considering any other wellbeing factors.

Research into the experiences of people with learning disabilities and/or autistic people in long-stay hospitals has highlighted several barriers to transitioning into living in the community. These include seeing people as ‘labels’ or diagnoses rather than people, a lack of staff knowledge regarding community support options, and delays in planning and coordinating discharge (Glasby et al., 2023).

The recognition of complexity, clear information and planning, discussion of routines and a realistic understanding of people’s capacity for self-care – all mentioned in the Werner et al. (2019) research as key to older people transitioning out of hospital – are, therefore, also highly relevant in these circumstances.

Because hospital discharge is a point where health and social care meet, it is a time when services need to work together. Information sharing is key; this also supports efficiency and person-centred working, as somebody does not have to constantly repeat their story (and potentially re-live their trauma). For example, patient passports have been used in healthcare settings, which were originally developed for people with a learning disability. The Centre for Excellence for Information Sharing (2015), when evaluating how Integrated Digital Care Records had been used in the NHS, found they supported efficiency and smoother transitions, where ‘Practitioners recognise the benefits that shared access to one view of the patient/citizen care record brings, particularly for processes such as hospital discharge and in supporting integrated teams - for example, GPs, social workers and community staff working together in multi-disciplinary teams‘ (p.11).

A care record has been piloted in Wirral, which also ensured social care information is an equal part of that record. It was developed specifically to bring together data from different health and social care organisations, and to reduce the duplication of information. A similar approach has now been adopted across Greater Manchester, which not only brings together health and social care information, but also information from across all ten Greater Manchester boroughs.

Nevertheless, challenges interpreting the law on data sharing remain, and the Centre for Excellence for Information Sharing (2015) also found a technological solution such as a digital care record did not mean other aspects of partnership working – such as senior management collaboration - were any less important.

What you can do

For everyone: Supporting people with successful transitions is about collaboration and partnership. If you are in direct practice, or in a leadership role, making the mental shift into thinking that transitions are a negotiation, or a process, rather than an event, is vital.

If you are in direct practice: One key action you can take on transitions is to be clear on information sharing, and how effective and efficient this is, particularly at transition points. (There is a guide to Information Sharing in Social Care from NHS England, which you may also find useful.)

The Information Sharing Every Day project (from the NHS in Hertfordshire) has ‘Seven golden rules’ for information sharing:

1. Remember that the Data Protection Act 2018 is not a barrier to sharing information, but provides a framework to ensure that personal information about people is shared appropriately.
2. Be open and honest with the person (and/or their family where appropriate) from the outset about why, what, how, and with whom, information will, or could be shared, and seek their agreement unless it is unsafe or inappropriate to do so.
3. Seek advice if you are in any doubt, without, where possible, disclosing the identity of the person.
4. Share with consent where appropriate and, where possible, respect the wishes of those who do not consent to share confidential information. You may still share information without consent if, in your
   judgement, that lack of consent can be overridden in the public interest. If the person (or someone else) is at risk, sharing information may be justified without consent, although it is good practice to tell the person you will be sharing information without their consent (as long as that, in itself, doesn’t increase risk). You will need to base your judgement on the facts as presented.
5. Consider safety and wellbeing: Base your information-sharing decisions on considerations of the safety and wellbeing of the person and others who may be affected by their actions.
6. Necessary, proportionate, relevant, accurate, timely and secure: Ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who
   need to have it, is accurate and up-to-date, is shared in a timely fashion, and is shared securely.
7. Keep a record of your decision and the reasons for it – whether it is to share information or not. If you decide to share, then record what you have shared, with whom and for what purpose.

You may consider how confident you feel in information-sharing practice, and speak to your supervisor for areas to work on.

If you are in senior management: Directing resources into transition points, raising awareness of successful transitions as fundamental to people’s wellbeing, alongside positive partnership with senior leaders in health and social care, are all key to improving transition experiences for people.

Working with ‘place-based partners’, with points of action to take, is covered in detail in this briefing using information from Think Local Act Personal.

In terms of information sharing, The Centre for Excellence in Information Sharing (2015) has argued that the following are key at the leadership level:

• Having information sharing agreements and local protocols in place (including templates), so everyone is clear about what they can share. This also has the effect of helping to build up trust and relationships across professional boundaries.
• Building relationships at all levels – often starting with a group of committed people and working from there.
• Implementing a communication plan, setting out frequent and clear communication about information-sharing with staff, with information provided directly to people with care and support needs.
• Providing training on information-sharing and embedding this into the induction process.

Further information

Watch

An older person and a social worker discuss care coordination and the evidence around it, particularly thinking about improved relationships across health and social care.

This video from SCIE interviews young people who move from child to adult mental health services about their experiences, and features a service in Sheffield attempting to address this.

Read

The National Institute for Health and Care Excellence has guidance on transitions between children’s and adults’ services and inpatient setting to community or care home settings.

SCIE has a report highlighting good practice in hospital discharge and preventing unnecessary admissions.

Watch and read

The University of Birmingham’s Why Are We Stuck In Hospital? project has videos and top tips to support people with learning disabilities and/or autistic people with their transition to life outside long-stay hospitals.