Transition: Please mind the gap!
Gareth Llewelyn is Consultant Neurologist at the Royal Gwent Hospital, Newport.
To Cite: Thomas R., Llewelyn G. ACNR 2016; 16 (1).
Conflict of interest statement:
Rhys Thomas has declared no conflicts of interest. He has received speaker fees from UCB and Eisai and honoraria from Sanofi. He is treasurer of the ABNT but the views expressed in this article are those of the author and not of the ABN.
Gareth Llewelyn has no conflicts to declare, other than that he is a member of the Royal College of Physicians’ Young Adult and Adolescent Steering Group (YAASG) which was established to look at issues relating to transition.
Correspondence to: Rhys H Thomas, Department of Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW.
The ABN meeting in Brighton this year is themed on the ‘Seven Ages of Man’. This phrase, describing a monologue from Shakespeare’s ‘As You Like It’, poetically portrays moving between the formative eras of life. Robert Smirke (1796) based his matched paintings on this: the infant; the schoolboy; the lover; the soldier; the justice; the pantaloons; and the old age.
A football club is said to be in ‘transition’ often when there has been a run of poor form, a change in manager, and the jury is still out on the sweeping changes at the club. It clearly describes the uncertainty, the flux, and suggests progression from one state to another. Within sporting parlance, it is used euphemistically – and that club may remain in the doldrums fighting a relegation battle before another manager is proffered that poisoned chalice and the ‘transition’ starts again. Transition is a time of uncertainty.
The World Bank identified the key adolescent transitions as: from dependent child to autonomous adult; from primary to secondary and later education; from education into the workforce; transition into responsible and productive citizenship; transitions in health from dependent recipients of children’s healthcare to adults responsible for their own healthcare. Within a healthcare setting a transition clinic is normally a one of or series of joint clinics where the paediatrician and adult physician meet with the patient and their family. This provides an opportunity to reassess diagnosis, treatment aims and to get a timely second opinion. A double handed Consultant clinic allows one to speak to the family (alone) and another to speak to the young adult (also on their own).
There are a whole host of neurological disorders that span childhood-adulthood and yet in the UK the transition clinic is most likely to be in place to help people with epilepsy. So, is there a crisis in transitional neurology clinics in the UK? What is the state of play?
“In XXX, [attending transition clinics] does not happen. Trainees would have to actively seek this experience. A formal transition clinic has only recently been established in XXX although historically the XXX specialist did it for his clinic.”
Anonymous feedback from an ABN Trainee Regional Rep
When representatives for adult neurology trainees in each region were asked to identify their experiences of transition clinics and the training opportunities available to them locally there were some singular comments. At best trainees either attended transition clinics when attending epilepsy clinics, or on an ad hoc basis – perhaps because the trainee was motivated. One region was also able to offer a transitional headache clinic. There was a general feeling that the Consultants were happy for trainees to attend and were often supportive, but that opportunities were limited to a clinic or two every three months only during selected blocks of training. There was a region where a service existed but no one could ever remember a trainee attending. Some trainees were using an elective block to attend paediatric clinics and used this experience to meet their training needs. There was also a concern that people thought they were getting transitional clinic experiences, but they were not. ‘We just see paediatric cases as new cases in the epilepsy clinic’ for example. Furthermore there are some practical barriers to trainees’ attendance at transition clinics. A frustrated trainee working adjacent to a major paediatric centre was prevented from accessing opportunities there by the bureaucratic burden of a mountain of paperwork.
“Generally, like many places there is a lot of pressure on neurology trainees for service commitment and stroke rotas and in this sort of climate the opportunity to do innovative useful stuff can be limited.”
Anonymous feedback from an ABN Trainee Regional Rep
Why is this important? Younger adults reported greater dissatisfaction with NHS services than older adults. The risks are greater than poor service configuration: a BMJ study found that 35% of young renal transplant recipients had lost their transplants by 36 months after transfer to adult renal care.1 Recognising this problem, the Royal College of Physicians in 2015 as part of the ‘Future Hospitals Programme’ put together the ‘Young adults and adolescents transition project.’ This project aims to “improve the quality of care for young adults and adolescents with long-term and complex conditions as they transition from paediatric to adult services.” The first stage is a review of current services (as above) and the second is a platform to showcase the best of current practice. Examples of good practice can be gleaned from the RCP acute care toolkit.2
Do we need standards for what determines a transition clinic? What is the minimum involvement we need as trainees? The next time we need to think about transition may be as a junior Consultant when we are helping to shape services. The best way to ‘mind the gap’ between paediatric and adult services is by ensuring that trainees from both backgrounds get sufficient exposure to transition clinics. We have a lot to learn from each other and it is time to shine the spotlight of adolescent services to ensure that young adults get the support they need to navigate the next stage in the NHS.
- Harden PN, Walsh G, Bandler N, Bradley S, Lonsdale D, Taylor J, Marks SD. Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure. 2012;344:e3718.
- Acute Care Toolkit www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-13-acute-care-adolescents-and-young-adults
Royal College of Physicians: Young adults and adolescents transition project www.rcplondon.ac.uk/projects/young-adults-and-adolescents-transition-project
Young Person’s Health Special Interest Group