Working together around a young person
How adults across home, school, community and services join up so concerns are not lost and families get support to find their way through the system together.
Why the current system has no return journey
A young person may spend more time with a youth worker, community organisation or other trusted adult than with council or NHS services. These adults may notice changes, strengths and pressures that do not appear in official records.
Too often, information moves into formal services but does not come back out. Families and trusted adults are left without a clear picture of what is happening, while services may make decisions without the context that could help them understand the young person better.
Share information only when it is necessary, appropriate and safe. Where possible, make sure children, young people and families understand what is being shared, who it is being shared with and why.
What this chapter holds
Six ways adults, families and services can work together around a young person.
When services work separately, children can get lost in the gaps.
Where possible, bring young people, families and the adults supporting them into the same conversation. Set clear ground rules and ensure someone is there to hold the discussion fairly.
The aim is not to decide who is the expert. Everyone brings knowledge. Young people know their own lives. Families know their child. Community workers may see what services do not. Professionals bring their own specialist knowledge.
For a format you can adapt, see Family Group Conferencing below.
Regular, low-pressure contact from a trusted adult can build trust and reveal context that is easy to miss in a short appointment.
When a council or NHS service is making an important decision, ask: what are the adults around this young person seeing that our records do not show?
This does not mean sharing everything. It means listening to relevant, factual information from people who know the young person well.
A handover does not end with “referred”.
A clear handover includes:
- What will happen next.
- Who is responsible.
- When the family can expect an update.
- How to ask for progress if they do not hear anything.
The research calls for a named key worker for every child. Until that is consistently in place, the adult holding the relationship can help keep the loop closed.
When you refer or hand over, put a follow-up date in your diary. Use it to ask what happened, check whether the family has heard anything, and share any relevant changes you have noticed.
Community workers often see important things that need to reach council or NHS decision-making.
A short, structured note can make this easier to act on:
- The situation: What has happened?
- The background: What is important to understand?
- What you are noticing: What may be affecting the young person?
- What you are asking for: What support, decision or response is needed?
Keep it fair, factual and brief enough to be read. Separate what you know from what you think. Include only information that is relevant and appropriate to share.
Many families in our research described SEND, mental health and education systems as a maze. They were expected to understand processes, complete paperwork, chase updates and coordinate different services while also supporting their child.
Families have valuable knowledge about their own child. The system is not always easy to navigate.
Support can include:
- Clear guides to key pathways.
- Templates for writing to schools and health services.
- Help preparing for meetings.
- Routes to independent advocates, including for children and young people with SEND.
The adult’s job is to help a family understand how the system works, not to take over or speak for them without their involvement.
Open-to-all services often reach families who already know how to find and use them. Other families may be better reached through trusted community relationships.
If a family has not taken up council or NHS support, do not assume they do not care. They may have had difficult experiences, may not trust the service, or may not feel ready.
Keep the relationship open. Be a bridge when and if the family wants one.
The return journey: keeping families in the loop
The tools above help relevant information move from families and community into services. The return journey matters too: services need to communicate clearly back to families.
Send short, regular and jargon-free updates. Use four headings:
- What support is being given
- What we have noticed
- What is helping
- What we can do next
Keep updates focused on progress. Describe behaviour as context, not character. For example: “Finds the noisy start of the day difficult”, not “Disruptive in the mornings”.
Use a rhythm the family can rely on.
Name one school or service contact and one community link person. Give both names to the family in writing.
Staff change. The relationship does not have to disappear with them. If a named person leaves, tell the family who the new contact is before they have to chase for that information.
At the top of each update, include one clear line:
- Green: Settled. Support is working.
- Amber: Some concerns or wobbles. We are watching closely.
- Red: A conversation is needed this week.
Families told us they want to see progress quickly, before reading the detail. Always explain why the light is green, amber or red, and what will happen next.
- This fortnight at a glance: green / amber / red, and why.
- What support is being given.
- What we noticed (context, not labels).
- What is helping.
- What can we do to support? And one question for you.
- Your named contact here is: [name, role, how to reach them].
A family-led way to make a plan together
This approach helps families, young people and professionals make decisions together, with the family’s voice at the centre.
Formal name: Family Group Conferencing.
What it is. A family-led decision-making meeting used in UK children's social care. A coordinator helps the family prepare, professionals share information at the start, then the family has private family time to make a plan. The professionals come back at the end and respond to the plan.
Why it fits here. The most established structure for families genuinely leading, fitting the family-expertise principle named throughout the toolkit. Worth borrowing the structure even when you cannot run a full formal FGC.
Put joined-up support into practice
Choose the step that fits your role and the support around the young person.
Follow up after a referral
After your next referral, set a reminder to ask what happened and what support is now in place.
Write a clear handover
Use four short parts: what is happening, relevant background, what you have noticed and what you are asking for.
Bring people together
Where possible, create a conversation where the young person, family and relevant adults can agree what support happens next.