Reviewing the multidisciplinary team

  • The Circle of Support is the group of people: professionals, friends and family, who are there to help the young person. Professionals should list the multidisciplinary team of professionals in the young person's Circle of Support and identify someone to take over when the young person transitions to Adult Services.
  • Professionals should identify a Transition Keyworker, and if three or more specialties are involved, a Lead Consultant, to support the young person and co-ordinate their transition. 
  • The GP is often the only source of continuity between children’s and adult healthcare provision and has a significant role in the ongoing management of many long term conditions.


  1. All young people with long term conditions who are supported by three or more specialist medical services have a clearly identified Lead Consultant identified before their 15th birthday
  2. Young people of transition age (14 – 25 years) with long term conditions have access to a named professional, working in a key-working capacity, to support them through transition
  3. The young person’s GP is actively involved in the young person’s transition including routine prescriptions, reviews for minor illnesses, and planning the young person’s route into urgent care: at the latest from their 15th birthday

Frequently asked questions

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