Transition in healthcare
Moving from children to adults
TOP TIP – please refer all on treatment and recently finished patients aged 15 and over to the TYA MDT for a formal transition discussion and plan.
Transition from paediatric to adult cancer services is a highly individualised process, influenced by the patient's diagnosis, treatment stage, and the availability of Teenage and Young Adult (TYA) services. There is no single pathway and the age of transition may vary accordingly.
Despite this variability, it is essential to adhere to core principles of care and follow both national and local policies to ensure safe and effective transitions. Relevant national frameworks should be consulted to guide service design and delivery. Most hospitals and cancer services will have local action plans to support this process.
Additionally, Paediatric Oncology Shared Care Units (POSCUs) and Designated Hospitals (DHs) typically have transition nurses who play a key role in supporting both patients and professionals throughout the transition journey.
Key Transition Metrics
To ensure quality and consistency, transition planning should include:
- Agreed age at transition and correct place in the patient journey
- Transition readiness assessments completed
- Joint paediatric–adult MDT meetings held
- Individualised transition plan in place
- Patient and family aware of plans
- Follow-up adherence post-transition
- Plans in place for any unplanned care episodes during transition
Professionals should refer to relevant frameworks such as:
- NICE Guidelines for Children and Young People with Cancer
- Together for Short Lives Pathway and Standards Framework (2023)
- Royal College of Paediatrics and Child Health: Facing the Future Standards for Ongoing Health Needs (2022)
- A report published by the National Confidential Enquiry into Patient Outcome and Death (2023)
Transition tools:
Transition nurses:
- Anna Brace - Roald Dahl Transition Nurse Specialist - Colchester (ESNEFT) - lhbookings@havenshospices.org.uk
- Gill Read - Transition Sister - Ipswich (ESNEFT) - gill.read@esneft.nhs.uk
- Sarah Cassels - Lead Transition Practitioner - NNUH - Transition@nnuh.nhs.uk
- Kristie Foreman - Transition Sister - KL - paediatrictransition@qehkl.nhs.uk
- JP Rhodes Transition Nurse - NWAFT - nwangliaft.healthcaretransition@nhs.net
- Sonia O'Leary - Associate Director Children's services - KEECH - soleary@keech.org.uk
- Vanessa Gates - Transition Sister - KEECH - vanessa.gates@keech.org.uk
- Lauren Summers - Transition Sister - Little Havens Hopsice - lhbookings@havenshospices.org.uk
- Tracy Whitwell - Transition and SEND Lead Nurse - Cambridge Childrens Community Nursing Team - CCS-TR.CCNCambridge@nhs.net
- Lisa Rafferty - Transition Sister - Bedford Hopsital - lisa.rafferty4@nhs.net
- Lorraine Rodwell - Transition Lead - EACH - Lorraine.rodwell@each.org.uk
- Hannah Willis - Paediatric Matron and Transition Lead - James Paget Hospital - hannah.willis@jpaget.nhs.uk
Moving from TYA to adults
Under review
