Pages: 40 - 46
Article topics: Disability, General practice, Interface, Paediatrics
This article examines the transition process from paediatric to adult healthcare for young people with complex medical needs, focusing on how to increase the involvement of general practice. Poorly managed transitions can lead to increased morbidity and mortality in young adults. Guidelines, including those from the Care Quality Commission (CQC, 2014) and the National Institute for Health and Care Excellence (NICE, 2023), recommend greater involvement of general practice in the transition process, yet limited guidance is offered on implementation. To identify opportunities to improve the transition process, an audit within a specific region was conducted to assess current practices. This identified a small cohort of patients undergoing transition. Based on these findings and consultations with stakeholders, a series of targeted interventions were developed. These included using a dedicated SNOMED code to track transition, use of care coordinators to address additional vulnerabilities, and implementation of a ‘Transition on a page’ document to streamline communication between general practice and secondary care. Although several challenges prevented a pilot from proceeding as planned, the proposals were approved by the local integrated care board (ICB) and disseminated by clinical governance leads to all general practice staff for ongoing embedding. The hospital transition team will review implementation to assess impact. This project highlights a nationwide issue requiring further action to establish effective transition practices across healthcare settings.