Redesigning Transitions: A Person-Centred Approach

CASE STUDIES

At a Glance…

As part of Stockton-on-Tees Borough Council’s “Powering Our Futures” transformation programme, Peopletoo was commissioned to undertake a comprehensive diagnostic review of transitions from Children’s to Adult Social Care. The review responded to local and national concerns about inconsistent planning, insufficient accommodation, and lack of joined-up working across Children’s and Adult Social Care. Through extensive engagement, case reviews and pathway mapping, Peopletoo identified the strengths, challenges, and opportunities to co-design a sustainable, person-centred model for transition that improves outcomes and value for money.

The Challenge

Stockton Council recognised that transitions to adulthood were not consistently well-managed across the system. Key issues included:

Late identification and planning: Young people were often coming to the attention of adult services too late, limiting the time available for effective transition planning.
Fragmented pathways: There was no consistent or shared practice guidance across teams; referral processes varied, and expectations were unclear.
Sufficiency and market gaps: There was a lack of suitable accommodation and services for young adults aged 16–18, with providers often only accepting clients aged 18+, contributing to crisis placements.
Workforce and training gaps: Frontline staff had variable confidence in applying Care Act or Mental Capacity Act principles, with limited joint training opportunities.
Data and intelligence limitations: The council lacked a comprehensive dataset to track transitions demand, outcomes, or service costs, undermining commissioning and future planning.
Inconsistent voice and advocacy: Young people’s voices were often secondary to their families’, and access to advocacy services was limited or not embedded.

The council needed a whole-system review to identify root causes and set a new direction for delivering better transitions for young people and their families.

Our Approach & Delivery

Peopletoo adopted a system-wide diagnostic approach, structured around national best practice and the unique local context. Key activities included:

Stakeholder engagement: Over 40 stakeholders across Children’s and Adults’ services, commissioning, education, housing and health were consulted via workshops, interviews, and surveys.
Case file reviews: Multi-agency reviews of real transition cases identified variations in planning, quality of referrals, and communication across teams.
Pathway and process mapping: “As-is” mapping highlighted a lack of consistency in referral triggers, assessment timing, and use of transitional tools like EHC plans or LCS forms.
Practice benchmarking: We assessed Stockton’s current performance against national standards from the SEND Code of Practice, Care Act, NICE, and CQC/Ofsted findings.
Commissioning diagnostic: A review of commissioning roles, data use, sufficiency planning, and market shaping was undertaken, with detailed recommendations for aligning Children’s and Adults’ commissioning strategies.
Co-production insights: Through feedback from young people, carers, and services such as Vision 25 and supported internship providers, we identified practical ways to improve engagement and information accessibility.

The Impact

Outcomes Achieved

Peopletoo’s review delivered a robust evidence base and clear strategic direction for Stockton-on-Tees Borough Council:

Strategic clarity: Developed a clear set of goals and a draft vision for transitions focused on person-centred planning, coordination, and independence.
System-wide recommendations: Provided 12 pillars of good practice with tailored actions for improvement—covering early planning, advocacy, housing, employment, health continuity, and co-production.
Enhanced commissioning insight: Identified gaps in market sufficiency and proposed updates to Market Position Statements and data-sharing protocols across directorates.
Improved governance and process: Recommended the development of joint practice guidance, named worker pathways, and standard referral tools to reduce variability and duplication.
Informed decision-making: Enabled the council to proceed to Phase 2 of the transformation programme with a comprehensive understanding of current challenges, good practice, and options for redesigning transitions support.
Cultural shift: Created momentum among professionals across both Children’s and Adults’ services, with a stronger shared commitment to earlier planning and young people’s voice.