13th February 2018

Transition Care: Getting it right – Making it happen

A collaborative approach between the childrens’ and adult hospices in Surrey to improving Transition Care for young adults with life limiting conditions.

Each intervention forms part of a programme of collaborative work that will cumulatively move towards the aim of remodelling Transition Care Services in Surrey.

This multi-organisational approach involves planning, supporting and delivering care to young adults with life limiting conditions in transition as well as providing education, training and support to further develop the knowledge, skills and awareness of hospice staff in challenges faced by families in transition.

Getting it Right

  1. 6 monthly cross-organisational MDT meetings to triage those aged 17+ with complex and palliative care needs, likely to need adult hospice care.
  2. Annual multi-agency conference with the aim of enhancing a common understanding of the challenges and opportunities in meeting the needs of young adults leaving childrens’ services and entering adult care. Integral workshops to identify responsibilities and requirements needed to create more meaningful partnerships. Key components are opportunities for young adults themselves to speak and help shape their care.
  3. Hospice facilitated education programme with the aim of supporting care staff across all services to realise the 6 Ambitions for Palliative and End of Life Care. Sessions focus on sharing knowledge and skills, to create a cohesive team of experts that can assist young adults to live as actively as possible until the time they need specialised Hospice Care. This joined up approach seeks to deliver wraparound care so often talked about but not always delivered.


The programme has senior level engagement from each hospice and is supported by a memorandum of understanding between the Local Authority and key voluntary transition care organisations across Surrey.

Representatives work directly with the CCG’s End of Life Care group reinforcing the concept that Transition Care is everyone’s business whether working at commissioning level, planning or delivering care.

Evaluations & feedback

“Listening to the young adults themselves talk about their experiences gave great insight into how different outcomes in transition can have lasting effects”

“Its been really interesting to hear the other side of the coin”

“The conference made me reflect on palliative care service provision regardless of diagnosis”

“I now understand better what the reality for service users’ families in the transition process is – what it’s like letting their child become an adult and empowering them”

See the full summary poster here