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The outside of the Stephanie Marks Diabetes Centre at Saint Peter's Hospital

Having diabetes and transferring to adult diabetes services can make this a difficult and worrying time. The Trust’s Diabetes Transition Service aims to provide help, support and education to enable transition and transfer to adult services to be as straight forward and stress-free as possible and keep young people engaged in their diabetes care.

This process can start from around the age of 16 years and continue until transfer, usually when the young person reaches the age of 19 years. Our service aims to integrate children’s and adult services and provide support for young people until the age of 24 years to empower them to manage their diabetes successfully.

 

Age ranges and clinics

We take a flexible approach to transition which takes into account developmental readiness and links to other social transitions such as leaving school. However, for the purpose of our Transition policy, age ranges and movement through the clinics have been defined as follows:

General Paediatric Diabetes Clinic Up to 17 years of age
Diabetes Transition Clinic (young person) 17 to 19 years of age
Young Adult Service 19 to 25 years of age
Adult Diabetes Service 25 years of age

Our Transition service is introduced to the family and young person at the start of secondary school. Leaflets and materials about the young person’s transition clinic are sent out from early adolescence.

 

Preparation for Transition

We only transfer young people when they have completed growth and puberty and have the necessary skills to function in a young person’s service largely independent of parents and staff e.g. decision-making, communication, self-care, assertiveness. When this is not possible due to cognitive impairment and/or severe disability, appropriate advocacy, preparation and developmentally appropriate care in the young person’s service should be ensured prior to transfer. We approach transfer to transition flexibly and on a patient by patient basis.

Young people are helped to take appropriate responsibility for their diabetes from as early an age as possible by our MDT. Furthermore, we encourage parents/carers help them to do so.

In preparation for young people to be seen independently, we provide continuity of professionals at each visit.

When a young person is ready to move from our general Diabetes clinics into Transition, an appointment is given between 10 to 12 weeks later. The registered GP is kept fully informed within the clinic letter of the plan to transfer to the transition clinic.

We recognise that children and young people with diabetes often need extra help and support to help them cope with their condition especially during this time. All the usual changes are taking place that go along with growing up, puberty, changing schools, exams, starting college or university, decisions on what to do with their life and career. As well as finding a job, starting relationships, moving away from home, learning to drive, and becoming more independent from parents to name but a few.

 

Transition out-patient appointments

We provide the opportunity for the young person to be seen alone for part of each of their clinic appointments and then together with parent/carer as part of the transition process. A ‘Lifestyle questionnaire’ is used to facilitate discussion on specified topics led by the young person such as, lifestyle choices; glycaemic control and accessing further resources.

We provide information to help ensure young people achieve good diabetes control and reduce their risks of developing diabetes associated complications.

Our Diabetes Transition Service provides all aspects of specialist diabetes care and support for young people with both Type 1 and Type 2 Diabetes including:

  • Twice monthly Consultant Transition Clinics
  • Telephone and email follow up
  • Diabetes Specialist Dietitian
  • Clinical Psychology / PLN review if indicated
  • Education and Advice on Sexual Health, Pre-pregnancy, Smoking and Alcohol, Exercise and Weight Loss

 

The Trust’s Diabetes Transition Service is provided by:

Dr Sonali D’Cruz Diabetes Consultant Paediatrician
Dr Sarah Roberts Consultant Diabetologist
Sophie Clarke Paediatric Diabetes Specialist Transition Nurse
Taka Ziwenga Psychiatric Liaison Nurse
Cara Retief Diabetes Specialist Dietitian - Transition & Adults