Dr Reza Zaidi and Dr Fulya Mehta: Squaring the Circle in Transitional Diabetes Care

When one discusses transition of young people from paediatric to adult diabetes care, two words spring to mind instantly: change and challenge.

Undoubtedly, across the entire age-spectrum of people living with a long-term condition such as diabetes, this a unique phase of vulnerability that witnesses change on multiple fronts in quick succession, if not simultaneous. Anatomically, young people go through developing maturity and a post-puberty phase. Growing independence, adopting new relationships, along with geographical relocation, shine the light on numerous social amendments.

Furthermore, a change of healthcare providers, in conjunction with different funding streams, disrupts the continuity of care and long-lasting relationships with young people during this time. As a result, some of the most challenging healthcare outcomes are observed in young adults with diabetes. A drop in engagement with clinical services, high admission rates with diabetes-related emergencies and a reduction in target outcome achievement are some of the outcomes encountered. These challenges are further compounded by a lack of robust research and evidence for an ‘ideal transition service model’, while general principles of good service delivery exist.

For far too long, healthcare professionals have been trying to crack the ‘transition-conundrum’ while focusing solely on service delivery designed by ‘healthcare experts.’ Unfortunately, young people living with diabetes are often not utilised in service design, thus resulting in a very ‘top down’ approach in this process. Adolescents and young adults possess the freedom of uninhibited thinking and can generate innovative feedback and ideas. Examples of this include offering self-management advice and peer-support and, consequently, embedding this into education programmes and delivery of standard care. Exemplar transition models have also made strides to improve approachability of young people to their healthcare teams, their preparedness while navigating through life and healthcare, and to address psycho-social needs. Additionally, the success of transition hugely depends on clear communication and professional relationships between healthcare professionals in paediatric, young adult and primary care.

In Liverpool, transition care in diabetes is delivered between 2 large, teaching hospital trusts, roughly 5 miles apart – Alder Hey Children’s Hospital and Liverpool University Hospitals NHS Foundation Trust. The defined transition period is 17-19 years of age, with monthly, joint multi-disciplinary clinics, involving paediatric and adult teams, held in Alder Hey Children’s Hospital. Individuals are expected to see their prospective adult care teams up to 4 times prior to transfer of care, thereby increasing their familiarity. Throughout this process, alongside the clinical care given to young people, their readiness to transition through healthcare, geography and educational and vocational changes is checked.

A nationally adopted but amended readiness tool (Ready, Steady, Go) is utilised at specified checkpoints for this. Psychological needs are addressed, continuity of funding for diabetes-related technology is ensured and correspondence is communicated in a timely manner to ensure a seamless handover.

Young people and their carers are reassured of continued support in young adult care, which shares the same principles of care they have received from their paediatricians. Most importantly, they are invited for their views and feedback to improve the experience and influence service design. Furthermore, young adult diabetes care at Liverpool University Hospitals is designed to mirror the paediatric diabetes clinics as much as possible, within the constraints of workforce and funding availability. In addition, primary care colleagues looking after a large university student population have been involved in the care pathways to ensure effective referrals to young adult diabetes clinics and offer of support out of hours.

Outcomes resulting from the Liverpool experience have shown consistent reductions in median HbA1c and hospital admissions with diabetes-related emergencies for this population. Significant increases in clinic attendance, uptake of technology and patient satisfaction have been observed. Through the partnership with primary care colleagues, there has been a substantial increase in the referrals and overall service population.

While this is an illustration of an area where transition care has been successful, on a national level we observe a wide variation in outcome delivery. NHS England has embarked on a couple of ventures to examine, improve and implement transitional care delivery in diabetes, via the National Transition and Young Adult Pilot Programme and CYA GIRFT process. Through these, the aspiration is to shine further light on successful aspects of models, rationale for variation of care and strategies to implement efficient quality improvement.

But in the end, as in any challenging area in healthcare, a great deal will depend on the vision of clinical leadership, who will need to change the lens when confronting the ‘transition-conundrum.’ As the saying goes – ‘Change the way you look at things and the things you look at change.’

Additional reading

Zaidi R. Transitional care in diabetes: a quest for the Holy Grail. Practical Diabetes. 2021; 38: 31-35a

Zaidi R, Spence M, Manoharan K et al (2019) Improving outcomes for young adults with diabetes in Liverpool. Diabetes Care for Children & Young People 9: DCCYP44