‘Everybody’s business’: transition and the role of adult physicians

Abstract

-The outcome of transition from paediatric to adult care is often judged by what happens after transfer. Young people at the point of transfer are reported to have low levels of knowledge and independence. These observations could be interpreted in one of two ways: either that the transition process before transfer is inadequate or that the transition process needs to continue into young adulthood and therefore adult care. The second interpretation is further supported by brain development continuing into the third decade. There is also growing evidence for the effectiveness of young adult clinics in the process of transition. To optimise transition, adult physicians need not only to work with paediatricians to achieve continuity during transfer, but also to look critically at their service as to how it can be changed to meet the needs of young people. In addition, they need to develop knowledge, skills and attitudes to communicate effectively and address a young person's developmental and health needs.KEY WORDS: transition, adolescents, young adults, age appropriate care Introduction Transition has been described as 'a multi-faceted, active process that attends to the medical, psychosocial and educational/vocational needs of adolescents as they move from child-centred to adult-orientated care' . 1 There is evidence that optimal transition is not being achieved for a significant proportion of young people. The recent report from the Children and Young People's Health Outcome Forum (CYPHOF) states that transition services in the UK need to adopt 'an approach combining both a pull (from adult care) as well as a push (from paediatrics)' . 2 Adult physicians need to know how to 'pull' effectively to provide a service that meets the needs of young people transferring into their care (Fig 1). Transition does not end at transferTransition is a process and, although most literature focuses on the process up to transfer to adult services, it is after transfer that outcomes of transition are judged. Studies have shown that young people drift away from adult care and suffer deteriorating health. We suggest that it is time to focus on the transition process continuing beyond transfer, into young adulthood. This approach is further supported by evidence from neuroscience that the brain continues to develop into the third decade, with implications on thought processing and risk taking. 3 The extension of transition into young adulthood allows additional time for young people to become autonomous in their healthcare and achieve their full adult potential, the latter potentially delayed or disrupted by growing up with a chronic condition. Adult physicians need not only to aim for continuity of care with paediatric colleagues, but also to adapt their skills and services to meet the young person's changing needs. Working with paediatriciansA recent survey of paediatric and adult gastroenterologists found differing perceptions of whether young people were prepared at the time of transfer; the main areas of concern were la...

Young adults as users of adult healthcare: experiences of young adults with complex or life-limiting conditions

“…How adult health services can, or should, respond to the specifi c needs of young adults has begun to be discussed, driven both by evidence of poor health outcomes among young adults compared with adolescents 8,9 and, for those with long-term conditions diagnosed in childhood, by evidence regarding the risks to health outcomes associated with the transfer from paediatric to adult healthcare. 10 With respect to this latter population, this discussion is a welcome development. Explanations for 'poor transitions' have typically related to inadequacies in transition planning and preparation in paediatrics.…”

“…Until recently, little consideration has been given to whether the settings into which these patients transfer are appropriate or take adequate account of their developmental stage. 10,11 This is evident in the (relative) lack of attention in guidance on transition (both national policy and specifi c to conditions) in terms of what adult healthcare teams/settings should do to ensure a successful transfer from paediatrics.…”

Adolescents and young adults on the acute medical unit: how might we do it better?

“…22 Where previously their care will have been provided by a stable team with whom they had a long-term relationship, they may be confronted by staff who not only are unknown to them, but may have limited experience in managing their condition. Pathways for care that were previously clear may need renegotiation, with resulting confusion and frustration.…”

“…Many paediatric teams now actively 'transition' patients from paediatric to adult services, 22 but there is frequently a gap concerning what happens to patients who require emergency adult admission during the transition process. Being aware of how local transition programmes function can, in itself, be extremely useful, because many have identifi ed team leads, records of care plans and agreed pathways for follow-up.…”

‘Part of the problem, part of the solution’ – adult physicians’ role in adolescent and young adult health

“…8 However, the blame for some young people suffering deterioration in health and getting lost to follow up following transfer is often laid firmly at our door. 9 The benefit of being part of the problem is that we are also part of the solution. Since 2010, the Young Adult and Adolescent Steering Group at the Royal College of Physicians (RCP), with representatives from all specialist societies, have focused the RCP's efforts in improving the care of young people accessing adult services.…”