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← Paediatrics and child health indexChapter sections
Purpose and principlesIndications, selection and cautionsAssessment before treatmentTreatment approachComplications, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Transition to adult services

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Unsafe gap during transfer

Running out of essential medicine or nutrition, failed equipment, absent emergency plan, unresolved safeguarding risk or no adult clinician accepting a high-risk condition can cause immediate harm around service transfer.

Action: Stabilise the urgent clinical need, identify the current accountable paediatric and proposed adult teams, provide a time-limited bridging plan with prescriptions and contacts, document responsibility explicitly and escalate organisational barriers through senior clinical governance.

Purpose and principles

Prepare young people with disability for adult healthcare through developmentally appropriate, person-centred planning, supported self-management, explicit transfer of clinical responsibility and coordination of equipment, medicines, education and social support.

Good transition supports an emerging adult identity rather than simply moving records on a birthday. Planning begins in early adolescence or at a developmentally appropriate point and is reviewed over several years. The young person defines goals for health, relationships, education, work, housing, mobility and community life. Families remain important, while clinicians progressively create space for private discussion and supported autonomy.

Readiness is task specific. A young person may understand symptoms but not arrange transport, or manage tablets but not recognise an emergency. Teach one skill at a time, provide accessible written or digital prompts and practise with real appointments. For those who will continue to need extensive support, transition still matters: adult teams need to know communication, baseline physiology, pain behaviour, best-interest processes and how supporters facilitate rather than replace the person's voice.

Capacity is assessed for the particular decision at the time after all practicable support. Reaching 16 changes relevant legal frameworks, but disability or parental concern does not by itself establish incapacity. Explain confidentiality and its safety limits. Share information with consent when possible, and use lawful best-interest or safeguarding routes when required. Document how the young person participated and which communication adjustments enabled the assessment.

Indications, selection and cautions

Transition readiness

Assess knowledge, practical skills, communication, confidence and support for each healthcare task rather than using age as a proxy.

Service-interface risk

Different eligibility rules, commissioning and referral thresholds can leave therapies, equipment or specialist surveillance without an adult owner.

Emerging autonomy

The young person may want private discussion and different information-sharing boundaries while still relying heavily on family support.

Disengagement signal

Missed appointments may reflect inaccessible systems, transport, anxiety or competing life demands rather than a considered refusal of care.

Carer role change

Parents may move from directing paediatric care to supporting decisions, advocacy and daily tasks under adult legal frameworks.

Red flags requiring action

  • A young person approaching transfer without an identified adult team, named coordinator or shared clinical summary is at high risk of loss to follow-up.
  • Essential prescriptions, gastrostomy supplies, ventilation consumables or wheelchair support ending at an age boundary requires urgent continuity planning.
  • Deteriorating adherence, repeated missed appointments or unplanned admission may indicate inaccessible communication, mental distress, coercion or a failing transition pathway.

Assessment before treatment

  1. 01
    Person-centred transition assessmentFirst step
    Why
    Identify aspirations, strengths, support needs and barriers across adult life domains.
    Interpretation and limitations
    Priorities belong to the young person and should determine actions rather than a generic age-based checklist alone.
  2. 02
    Task-specific self-management review
    Why
    Measure ability and support for medicines, appointments, emergencies and supplies.
    Interpretation and limitations
    Skills may be independent, prompted or delegated; record the reliable arrangement for each task and its next learning goal.
  3. 03
    Decision-specific capacity assessment
    Why
    Determine whether the young person can make a particular decision with support.
    Interpretation and limitations
    Capacity cannot be inferred from diagnosis or one difficult choice; optimise communication and document understanding, retention, weighing and expression.
  4. 04
    Transfer readiness audit
    Why
    Confirm adult acceptance, records, prescriptions, equipment and emergency continuity.
    Interpretation and limitations
    Any unowned critical action requires a named professional and deadline before paediatric responsibility ends.

Treatment approach

01Early planningBuild adult-life goals into healthcareFirst stepThe young person enters adolescence or a service-specific transition pathway.+
  1. 1Identify a named worker and map every current service and dependency.
  2. 2Ask the young person about health, relationships, education and independence goals.
  3. 3Assess communication, self-management and family support task by task.
  4. 4Create a written action plan with annual or more frequent review.
02Preparation phasePractise skills and resolve service gapsTransfer is approaching within the locally agreed planning horizon.+
  1. 1Teach appointment, medicine, supply and emergency skills using accessible methods.
  2. 2Explain consent, confidentiality and adult service structure directly.
  3. 3

Complications, monitoring and follow-up

  • Review the transition action plan at least annually and after major health, education, housing or family change.
  • Track readiness for each self-management task using observed performance rather than a single total score.
  • Confirm referral acceptance, first adult appointment and urgent contact details before the planned transfer date.
  • Reconcile medicines and ownership of blood tests, imaging and device surveillance during joint handover.
  • Audit continuity of wheelchair, orthotic, continence, nutrition, respiratory and communication supplies across commissioning boundaries.
  • Follow up missed adult appointments proactively when the condition creates substantial risk from disengagement.
  • Ask the young person whether privacy, accessibility and involvement improved after transfer and use feedback to repair the pathway.

Special situations

Transition is longer than transfer

Years of supported preparation cannot be replaced by one referral letter sent near an age boundary.

Readiness belongs to tasks

A young person may independently take medicine while still needing help to order it or monitor toxicity.

Capacity is not a diagnosis

Learning disability prompts communication support, not an automatic conclusion that every adult decision belongs to parents.

Equipment also transitions

A clinical referral is incomplete if seating, supplies and repair contracts disappear when paediatric commissioning ends.

Missed care needs curiosity

Re-engagement begins by identifying access barriers rather than labelling the young person as non-compliant.

Common pitfalls

  1. 01

    Starting transition only when the paediatric service is ready to discharge.

  2. 02

    Addressing every question to parents while asking the young person to become independent.

  3. 03

    Assuming incapacity from diagnosis without supporting and assessing the specific decision.

  4. 04

    Sending a referral without confirming that the adult service accepted clinical responsibility.

  5. 05

    Allowing essential prescriptions, tests or equipment maintenance to lapse between teams.

  6. 06

    Using one readiness score instead of teaching and verifying practical tasks individually.

  7. 07

    Discharging a high-risk young person immediately after they miss the first adult appointment.

Practice

Two practice questions

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Paediatrics and child healthOriginal SBA

Unsafe transfer date

A young person with home ventilation reaches the local paediatric age boundary, but no adult respiratory team has accepted care and consumable prescriptions expire next month. What should happen?

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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG43 Transition from children's to adults' servicesNamed worker, developmentally appropriate planning, transfer and follow-up.
  • NICE QS140 Transition quality standardPlanning, annual meetings, named coordination and missed-appointment follow-up.
  • Mental Capacity Act 2005 principlesPresumption, practical support, unwise decisions and best-interest principles.
  • NHS England transition to adult services guidanceOperational preparation and continuity across NHS services.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

The transfer package is operational. Adult clinicians accept the referral, urgent routes are known, prescriptions do not lapse, monitoring continues and equipment contracts remain active. A joint clinic or direct professional conversation is valuable for complex risk. Paediatric discharge occurs only when agreed transfer actions are complete or a documented senior bridging plan protects the gap. After the first adult visits, check whether the young person attended, understood the plan and can access advice.

Key points

  • Transition is a planned developmental process; transfer is the particular event when responsibility moves from paediatric to adult services.
  • Start preparation early enough to build skills and resolve service gaps, adapting pace to cognition, condition, family circumstances and local pathways.
  • Use one named worker to coordinate health, education, employment, social care, equipment and community participation.
  • Meet the young person partly alone when appropriate, ask their priorities and provide accessible information about confidentiality, consent and adult-service expectations.
  • Assess self-management by task: knowing medicines, booking appointments, explaining emergencies, ordering supplies and seeking help can develop at different rates.
  • Create a concise portable clinical summary with diagnoses, baseline function, communication, medicines, allergies, devices, emergency plans, safeguarding and key contacts.
  • Confirm adult acceptance, first appointment, prescribing responsibility, equipment maintenance and contingency cover before paediatric discharge.
  • Review attendance and outcomes after transfer and actively re-engage a young person who misses the first adult contacts.
Disagreement about decision-making must prompt assessment of capacity for the specific decision and appropriate support, not automatic transfer of authority to parents.
  • New exploitation, financial control, sexual risk or neglect can emerge as social networks and independence change and requires safeguarding action.
  • A transfer date chosen solely by birthday despite clinical instability or incomplete arrangements should be reconsidered by both services.
    • Refer early to adult teams and negotiate any eligibility mismatch.
  • 4Update the portable clinical summary and contingency arrangements.
    • 03Transfer eventMove responsibility without a clinical gapBoth services and the young person agree that transfer arrangements are ready.+
    1. 1Confirm the accepting clinician, appointment, referral information and urgent contact route.
    2. 2Allocate prescribing, monitoring, equipment and outstanding investigation responsibility explicitly.
    3. 3Use a joint consultation or direct handover for complex risk.
    4. 4Provide the young person and supporters with the final accessible plan.
    04Post-transfer reviewDetect disengagement and repair the pathwayThe young person has attended or missed initial adult-service contacts.+
    1. 1Check attendance, understanding, prescriptions, monitoring and supply continuity.
    2. 2Contact the young person accessibly after a missed critical appointment.
    3. 3Address transport, anxiety, communication and service-design barriers collaboratively.
    4. 4Close paediatric follow-up only when responsibility and safety are clear.