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Meeting the needs of young people in hospital
  1. Donald Payne1,2
  1. 1School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
  2. 2Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia
  1. Correspondence to Dr Donald Payne, Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital, Roberts Road, Subiaco, Western Australia 6008, Australia; donald.payne{at}health.wa.gov.au

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Adolescent and young adult (AYA) health has been on the agenda for some time,1 with no shortage of reports and guidelines highlighting the importance of developing clinical services for young people.2–6 However, these recommendations are yet to be translated into established clinical practice, with a culture of young people's health embedded in every health service. Common causes of morbidity among young people include mental health problems, drug and alcohol misuse, injuries (intentional and non-intentional), and sexual health problems.7 In addition, the number of adolescents and young adults growing up with chronic diseases of childhood continues to increase, placing pressure on both paediatric and adult services.8 There are compelling reasons to increase the focus on young people's health as this is a group for whom improvements in outcomes have not matched those seen among other age groups (eg, the under-5s and the elderly).7 Investment in young people's health is required to address this imbalance and to consolidate the improvements in outcomes that have resulted from previous investment in early childhood. A greater focus on young people will also address many of the health behaviours that determine key outcomes in later life, thus reducing pressure on health service use by older adults.9 ,10 For hospital-based clinicians wishing to establish AYA services, how should they proceed and what might such services look like? This article provides some suggestions.

Adapt to your hospital environment

The scope of any AYA service that clinicians provide will depend on where they work; for example, in a general, children's, adult or subspecialist hospital. General hospitals would seem best suited to developing AYA services as they manage patients across the whole AYA age range (10–24 years). In contrast, clinicians in specialist children's or adult hospitals are frequently faced with having to convince hospital managers that young people's health constitutes part of their core business.11 ,12 However, those working in general hospitals still face challenges as they seek to advocate on behalf of young people and negotiate arrangements which fall outside the traditional domains of paediatric and adult medicine.

Clinicians with an interest in AYA health often describe their role as that of a general physician with specific expertise in working with a group of patients who frequently have complex needs. Rather than attempting to see every young person aged between 10 and 24 years, their primary responsibility lies in leading the development of quality clinical services for young people. Specific roles include providing consultation, advice, support and training for other clinicians, specialist services for specific patient groups (eg, those with eating disorders, chronic fatigue and pain syndromes, medically unexplained symptoms, gender identity disorder) and, above all, clinical leadership—encompassing teaching, research, advocacy and policy development (box 1). Alongside this generalist model, there are physicians in subspecialty fields with a strong AYA focus. Of these, oncology has led the way driven by a number of factors, including publication of data highlighting poor outcomes among young people, and advocacy from both professionals and support groups.13 ,14

Box 1

Specific roles and skills for clinicians leading the development of Adolescent and young adult (AYA) services

  • advocate for the development of high quality health services for young people

  • highlight the patterns of morbidity affecting young people, the determinants of health and the influence of exploratory and health-risk behaviours

  • provide a clinical service for the assessment and management of young people with complex medical needs

  • provide a consultative service to assist colleagues in their management of young people

  • lead and work as part of a multidisciplinary team

  • develop and promote services to facilitate transition from paediatric to adult care for young people with chronic illness

  • develop and promote specific AYA services in the following areas

    • mental health

    • sexual health

    • drug and alcohol use

    • disability

    • at-risk and marginalised young people

  • develop health policies and procedures for young people

  • participate in teaching and training for a variety of audiences

  • engage in, foster and encourage research

Other subspecialties, including but not limited to respiratory medicine, endocrinology, cardiology, haematology and rheumatology, have recognised the need to develop dedicated AYA services as a consequence of the increasing number of young people with chronic illness transitioning from paediatric to adult care.

With the increased emphasis on AYA health in medical student and postgraduate training programmes,15 ,16 it is anticipated that doctors in training, newly appointed consultants and those commissioning hospital-based services will become more aware of this area of need. Many current AYA services have developed as a consequence of the interests of individual clinicians and the often unconventional training pathways they have followed. Sustainable, comprehensive provision of AYA services needs to be underpinned by a supportive system, rather than the drive and advocacy of a few individuals.

Involve and engage the right people

AYA services often appear to be promoted by those trained in paediatrics rather than adult medicine. If this area is to expand beyond a few niche centres of excellence into a hospital-wide culture of young people's health, it is essential that adult medicine training programmes embrace AYA health and that clinical and academic leadership in this area is valued.8 ,17 As adult services increasingly focus on the needs of the elderly, it is vital to highlight the burden of illness among young people and to demonstrate the value of AYA services. One way to raise awareness is to collect relevant data. The traditional age ranges of 0–14 and 15–44 years are guaranteed to reduce the visibility of young people in hospital. In contrast, collecting and reporting data on those aged 10–14, 15–19 and 20–24 years will provide information on absolute numbers and trends in healthcare use. This practice is now becoming more widespread, with a number of organisations and publications advocating this approach.18–20

It is also essential to highlight the difficulties that may arise when suitable services are lacking. These include the poor outcomes reported among young people with chronic illness (eg, congenital heart disease, post-transplant) during the transition from paediatric to adult care.21–23 The identification and acknowledgement of poor outcomes among young people with cancer has been a key factor in the development of AYA oncology services.14 A challenge for advocates of AYA health is to add to this evidence base by reporting data demonstrating improved outcomes as a result of their involvement.

Accurate data are also essential to attract the attention of hospital managers, politicians and those commissioning hospital-based services. Demonstration of improvements in outcomes such as reductions in emergency department visits, unplanned hospital admissions and length of stay, with the associated cost savings, will be of great value to clinicians wishing to develop services. The use of hospital-wide systems to collect data (or setting up of new systems) is essential. The major requirement is for these to be accurate rather than complex. Simple, well-presented data can deliver a powerful message.3 ,11

Youth participation

Young people's participation in the design and delivery of clinical services is vital and has been championed by the Royal College of Paediatrics and Child Health (RCPCH) and the Department of Health (DH) in England.2 ,24 With the participation of a broad range of young people, DH has produced a list of criteria, ‘You're welcome’, to guide the development of youth-friendly clinical services (box 2).2 These criteria illustrate the importance of the environment in which young people are treated, the need for them to be involved in their care and the issues that concern them. The last include mental health, drug and alcohol use, and sexual health and extend beyond the primary reason for presentation to hospital.25 However, the most important aspect of services for young people relates to the attributes of the staff providing the service—their skills, attitudes and values.26 ,27 As well as medical, nursing and allied health staff, this applies to all members of the team with whom young people interact—including reception and administrative staff, hospital cleaners and security personnel (Professor Susan Sawyer, personal communication). Thus, in developing AYA services, there are gains to be made in influencing the culture of the hospital and the training of staff, alongside the design and building of specific clinical and non-clinical areas for young people. Many hospitals have established a youth advisory committee to guide the development of AYA services, which provides a visible outlet for young people to participate in a meaningful way.

Box 2

You're Welcome criteria2

  • accessibility

  • publicity*

  • confidentiality and consent

  • environment

  • staff training, skills, attitudes and values

  • joined-up working†

  • young people's involvement in monitoring and evaluation of patient experience

  • health issues for young people

  • sexual and reproductive health services

  • specialist child and adolescent mental health services

*This refers to the need to publicise and raise awareness of services available for young people, thus enhancing access to services.

†This refers to the need to provide information about other relevant services for young people and promote colocation of services, where possible.

Leadership in AYA health

Developing a new service requires leadership.3 In Australasia, the Royal Australasian College of Physicians is in the process of endeavouring to establish a recognised specialty of Adolescent and Young Adult Medicine (AYAM).15 It is hoped that recognition will be achieved within the next few years, with the aim that trainees who have completed basic training in either paediatrics or adult medicine will be eligible to undertake advanced training in AYAM.

In contrast, the RCPCH has no plans to develop a specialty of AYAM, although trainees can undertake a special study module in adolescent health.16 A special interest group has been formed and an online training resource developed.28 ,29 The Royal College of Physicians, the UK college responsible for training adult physicians, has no requirements or modules in AYA health, although discussions are underway.8 ,17

In the USA and Canada, AYAM is a recognised specialty. Is there a need for other countries to follow their lead? In this author's opinion, the answer is yes. This is a view supported by the 2010 Kennedy report into children's and young people's health services which states that ‘there should be a cadre of professionals who are trained in both paediatrics and the care of young adults. Government, employers and professional groups should work together in order to ensure that such a cadre is established and receives appropriate training’.3 Without specialist recognition, progress in developing AYA services will continue to be slow. To those who would suggest that this is another example of the ever-increasing subspecialisation of clinicians, there is a counter-argument, already referred to above: that this constitutes the recognition of the need for generalists with specific expertise in working with a group of patients who often have complex needs and for whom improvements in health outcomes have not kept up with those seen among other groups.7 

The challenge

Advocates of young people's health must continue to take every available opportunity to highlight the need for AYA services and to strengthen the existing evidence base. The key challenge will be to engage positively with health service administrators, training organisations and government ministers to allow them to appreciate the significant improvements in health outcomes that can be achieved. This will result in the message of advocacy being delivered by those with the influence to make these changes a reality.

Acknowledgments

Thanks to Dr Andrew Kennedy and Dr Lee Hudson for their comments on earlier drafts of this article.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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