Priority 4: Develop the all age autism specialist support offer

Commission and deliver a coordinated and personalised offer of support for autistic people across all levels of need, promoting early intervention and enabling people to navigate this offer as their needs change. This includes redesigning the autism diagnostic pathway and focussing on all age pathways to better support transition from children’s services to adult services.

This objective is about ensuring that autistic people (or people who think they have autism) are able to access the right level of support at the time they need it. It aims to ensure the offer of support is based on what they say they need to live a good life and not about ‘fitting’ them into to services that aren’t suitable or accessible to them. We want to support autistic people when they need it rather than leave them until their needs escalate. The offer will promote early intervention and prevention, with the ability to escalate where required to specialist assessment, treatment and crisis support services. Capacity and capability to diagnose autism and adjust support plans appropriately will be built across services. A key principle in delivering this objective is the ability of front line staff from health, social care and education to work together to solve problems and arrive at pragmatic solutions supported by integrated teams and budgets.

I statements

  • I am in control of planning my care and support.
  • I can access specialist support to help me to understand my autism and support me with my social, communication, sensory and emotional wellbeing.
  • The support available to me to help with my autism is easy to understand and I have someone I can contact to help me get the right support when I need it.
  •  My support is coordinated, co-operative and works well together.
  • I feel safe, I can live the life I want and I am supported to manage any risks.
  • I can plan ahead and get extra help and support when my needs change and before I am in crisis.
  •  I am supported to manage my mental health so that I don’t need to be admitted to hospital.  

What we will do

4.1 Redesign the neurodevelopmental diagnostic pathway to address length of wait for diagnosis and ensure the pathway is co-produced with people and families on the waiting list in order to deliver the support they require to meet social, communication, sensory and emotional needs while awaiting a diagnosis. Build capacity and capability across existing services that work with children and adults, to support and undertake diagnosis.

4.2 Clarify where responsibility sits within social care and health services for care coordination for autistic people with no learning disability so that people do not fall between services. This will include clarifying responsibilities for transition from children's services to adult services.

4.3 Develop a “Keyworker” role which will remain a contact point for autistic people and families to help them to navigate the system and access extra support when they need it, including at times of transition between children’s and adult services.

4.4 Develop an offer of specialist assessment and treatment in the community for autistic people with more complex needs. This will include a holistic assessment of needs and functioning and the development of an individual autism profile which will inform care and support plans. The service will deliver appropriate therapeutic interventions as well as provide a source of specialist advice for parents and care workers when changes to care and support plans are required.

4.5 Provide specialist and ongoing outreach support to autistic people who are in the criminal justice system or at risk of developing criminal behaviours to avoid them entering the criminal justice system or becoming victims of exploitation.

4.6 Ensure that the needs of autistic people are appropriately met within the development of New Care Models for mental health, eating disorders and CAMHS

4.7 Clarify the pathway and offer of support for autistic people at risk of mental health crisis in order to prevent admission to hospital.

4.8 Coordinate transitions from inpatient and other settings and ensure that inpatient settings are sensory friendly and meet the needs of people with autism