Across South East London Integrated Care System (SEL ICS), autistic adults are routinely falling into the gaps between mental health services, learning disability teams, primary care, and social care. Despite strong diagnostic pathways in most boroughs, very few services exist for autistic adults post-diagnosis - a gap repeatedly highlighted in SEL ICS-wide mapping of provision.
Two groups are particularly underserved:
Without appropriate early support, individuals often deteriorate until they reach crisis, placing pressure on emergency mental health services, acute care, social care and even the criminal justice system. The ICS identified this as a strategic priority: improve quality of life, reduce escalations, and prevent avoidable harm.
But designing a preventative service for a heterogeneous group of residents, across six boroughs with differing population needs, required a shared vision, clarity on outcomes, and coordinated planning. This is why SEL ICS needed support to turn fragmented evidence into a practical, human-centred service model.
The South East London All Age Autism Strategic Framework sets out a bold vision: autistic people should be able to live happier, healthier, longer lives through access to inclusive, needs-led support close to home.
The framework identifies several system challenges that directly relate to the need for a Community Autism Team, including:
Stakeholders across the ICS including provider trusts, commissioners, and clinical leads agreed that to address these gaps, SEL ICS needed a Tier 2 offer: a community service focused on early intervention and autism-specific expertise, sitting between universal provision and crisis care.
Example cases shared during the workshops illustrated the impact of the gap:
These individuals and many like them need autism-informed, coordinated, multidisciplinary support, and currently have nowhere to turn.
We began by grounding all stakeholders in the evidence: the needs analysis, the strategic framework, the experiences of autistic adults, and the current service landscape across SEL ICS. These shared inputs allowed the group to define the problem together and agree what success should look like.
A further workshop focused on building alignment and updating assumptions, setting the stage for collaborative design.
Through problem-mapping exercises, we explored how gaps in service provision leave autistic adults unsupported. Stakeholders openly discussed constraints—financial, structural, operational—and articulated a collective aim: prevent escalation by intervening earlier and more effectively.
Codesign workshops brought the emerging model into focus. Together with commissioners and provider teams, we drafted and iterated the core elements of the service specification:
Clear discharge pathways to Tier 1 services, mainstream provision, or higher-need teams (e.g., Transforming Care).
This phase also surfaced essential system-wide questions—such as how to support people with multiple neurodevelopmental needs or how to ensure the team could provide training and consultative support to mainstream services—which shaped recommendations for the next stage of service development.
Working collaboratively, we produced a user journey from referral to discharge, capturing how residents, families, and professionals would experience the service. This map became a shared reference point for decision-making and market engagement planning.
A consistent message across boroughs was the need for parity of access while respecting local context. Workshops enabled honest discussion about resource differences and operational realities. The emerging model balances consistency with local flexibility—ensuring all autistic adults can access a core offer while allowing place-based adaptation.
The lived-experience cases shared were not edge scenarios—they were everyday examples of people missing out on timely support. The system recognises that without early intervention, the personal, financial and societal consequences are significant.
Defining the middle tier—between universal support and crisis care—created alignment across providers, commissioners and clinicians. Without this shared understanding, service development would have remained fragmented.
Autistic adults and their families often experience a cycle of being assessed, signposted, and then left without sustained help. The proposed Community Autism Team (CAT) emphasises continuity, trust-building, and autism-informed approaches—qualities repeatedly identified as essential.
Every borough wants an offer that is both fair and feasible. Designing a consistent core model—while enabling local tailoring—respects the reality of six boroughs working as one system.
By involving stakeholders early, decisions were owned collectively, not imposed. This built trust, reduced friction, and ensured the emerging model was realistic for those who would ultimately deliver it.
The workshops resulted in a clear, collaborative foundation for SEL ICS’ new Community Autism Team:
As SEL ICS moves into the next stage, further co-production with autistic adults, development of pathways, and market engagement, the programme is starting from a position of alignment, clarity and confidence.
Most importantly, this work lays the groundwork for a service that:
By designing collaboratively and centring autistic people’s needs, SEL ICS is building a compassionate and preventative model of community support—one that has the potential to transform experiences and outcomes for thousands of residents.
If you’re grappling with unmet need, fragmented pathways, or pressure on crisis services, we can help you co-design a clear, evidence-led model that works for your system and the people it serves.