Growing up: the role of the Royal College of Physicians

Background

Adolescence is a time of adoption of health-promoting and health-risking behaviours, both of which have the potential to influence future adult health and ill-health. Adolescents have specific health needs related to their developmental status, which in turn need to be acknowledged and appropriately addressed by healthcare providers. While the developmental stage of adolescence commences within the paediatric arena, neuroscientific advances reveal that adolescent brain development continues into the mid twenties,¹ which places adult healthcare in a pivotal role. Psychosocial adolescent development likewise continues into the twenties. In the UK, 80% of young men aged 18–24 years are still living in the parental home.² The evidence suggests that 41.6% of young adults (18–30-year-olds) do not self-classify themselves as adults.³ Although ‘young adults’ may have similar logical competencies as older adults, their different psychosocial status influences their decision-making and risk-taking. There is therefore a need to adopt a developmentally appropriate approach in adult care whenever adolescents and young adults are encountered.

Epidemiology

The number of adolescents aged 10–19 living in the UK has increased by more than 11% since 1995 to around 7.6 million today;² 16–24-year-olds account for 12% of the resident UK population.² The perception may be that members of these groups are young, fit and healthy, but their use of health services is significant. Between 1996 and 2010, emergency admissions among the 16–19-year-old age group increased by a dramatic 43%.² Hospital admissions among 10–19-year-olds for diabetes, asthma and epilepsy, the three most common long-term conditions affecting young people, have increased by over 26% over the past eight years.² In adolescent-onset cancer, mortality rates have failed to see the improvements observed in childhood and adult cancer.⁴ Although new diagnoses of chlamydia have shown a marginal decrease since 2008, this, along with other sexually transmitted infections, remains a significant public health issue for 16–24-year-old men and women in the UK.²

For young people with childhood-onset long-term conditions, the event of transfer to adult care can be associated with significant morbidity. Graft loss and/or rejection-related mortality for adolescent and young adult transplant recipients is reported to be worse than for any other age-group.⁵ Similarly, there is an increased rate of hospitalisation post-transfer reported in diabetes.⁶ Loss to and/or lack of follow-up following transfer to adult services have been reported in several conditions,^7,8 which leads to serious health consequences at great personal and societal cost. Reasons for lapses of care post transfer to adult services include lack of availability of adult specialist care, young people presuming cure, lack of health and disease literacy – an integral component of effective transition – and psychological reasons, all of which could be addressed with effective multidisciplinary transitional care to young adult healthcare.

With medical advances, more young people with childhood-onset conditions are surviving into adulthood. These include those with inherited metabolic disease, muscular dystrophy and certain types of congenital heart disease. Specific adult services for such conditions (including palliative care) are at varying stages of development in the UK. With continuing medical and technological advances, effective planning involving both paediatric and adult care providers, including physicians, from a range of disciplines will be vital to ensure that developmentally appropriate service provision keeps pace with survival rates. For many conditions, there will also be young people diagnosed in late adolescence and young adulthood who have never experienced paediatric care, further highlighting the importance of ensuring the provision of care that is appropriate to age and developmental stage, beyond the event of transfer to adult services.

Current adolescent and young adult healthcare

Paediatric and adult healthcare are two very dissimilar systems with different cultures of care, and therein lies the challenge of transition irrespective of the specific disease. Acknowledging these differences as professionals⁹ and preparing young people and their families for them is vital. This entails collaboration across the paediatric and adult interface so that both services are aware of each other's provision. Despite high levels of overall satisfaction, young adults report a poorer experience of care than older adults according to UK survey data.¹⁰ In a recent editorial entitled Young adults are worse off than adolescents, the changes in healthcare utilisation and their negative impact on the health of young adults were highlighted.¹¹ Although US-based data were presented, the increased emergency admission rate observed in the UK for the 16–19 age group in the UK may reflect similar factors at play.² The ‘You're welcome’ quality criteria for young-person-friendly services,¹² endorsed by the World Health Organisation and now revised for use in secondary and tertiary hospital-based services, is a much-needed set of quality indicators. These will prove useful in objective assessment of health service provision for this age group.

There is a growing body of evidence to support the development of young adult healthcare services for the 16–25-year-old age group. Young adult clinics were identified as a key strategy of successful transition programmes in a recent systematic review.¹³ Bent et al reported that a young adult multidisciplinary team approach for young people with disabilities cost no more to implement than an ad hoc approach and was actually more likely to enhance participation of involved young people in society.¹⁴ Several specialties are already recognising the young adult age group as needing more innovative ways to access services, reflected by the current NHS Kidney Care Supporting young adults with renal disease project.¹⁵ The young adult clinic concept is particularly appropriate to address the discrepancy between average age and/or case mix of patients between paediatric and adult clinics, and potentially facilitates uninterrupted service provision of age and developmentally appropriate care alongside the other key adolescent transitions, such as vocation, independent living, etc. Finally, young adult clinics can facilitate adolescent healthcare provision within adult services and potential paediatric–adult collaboration in terms of clinical service, education and training, research and the process of transition.

Training issues

Until the launch of the Department of Health-funded e-learning Adolescent Health Project,¹⁶ there was no formal adolescent health training outside mental health in the UK. Acknowledging the reported unmet adolescent health training needs of paediatric professionals,¹⁷ Okumura et al reported that adult physicians were more likely than paediatricians to report that insufficient training limited their ability to provide care for young people with chronic conditions.¹⁸ The time is therefore ripe for joint Royal College training initiatives, particularly with respect to the core topics of relevance to any specialist encountering young people in adult services (see Box 1).

Box 1.

Core modules in adolescent health for adult specialty training programmes.