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What constitutes successful commissioning of transition

from children’s to adult services for young people with long-term conditions, and what are the challenges? An interview

study

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2017-000085

Article Type: Original article

Date Submitted by the Author: 17-May-2017

Complete List of Authors: Kolehmainen, Niina; Newcastle University, ; Newcastle Upon Tyne Hospitals NHS Foundation Trust, McCafferty, Sara; Newcastle University Maniatopoulos, Gregory; Newcastle University Vale, Luke; Newcastle University Le-Couteur, Ann; Newcastle University; Northumberland, Tyne & Wear NHS Trust Colver, Allan; Newcastle University

Keywords: Health services research, Health Economics, General Paediatrics, Qualitative research

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BMJ Paediatrics Open on June 15, 2020 by guest. P

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Title:

What constitutes successful commissioning of transition from children’s to adults’ services

for young people with long-term conditions, and what are the challenges? An interview study

Authors: Kolehmainen N, McCafferty S, Maniatopoulos G, Vale L, Le Couteur A, Colver A;

on behalf of the Transition Collaborative Group*

WHAT THE ARTICLE ADDS:

What is known about the subject:

• Young people with long-term conditions who transition from children’s to adults’

services have negative experiences of healthcare, and poor health and social

outcomes.

• Despite policy and guidance, the transition process remains fragmented and is a key

risk period for poor clinical outcome.

• Quality of transition can be affected by commissioning, i.e. how services are planned,

contracted and monitored, but there is a paucity of evidence about commissioning for

transition.

What this study adds:

• Commissioners and providers thought successful transition is personalised, co-

ordinated, and collaborative with focus on broad life outcomes, and actualised

through building pathways and universal services.

• Challenges to commissioning for successful transition include inconsistent national

guidance, fragmented resources, incompatible local processes, lack of clear

outcomes, and professional roles and relationships.

• Recommendations include focus on co-ordinated pathways for this population,

engaging generalist community providers from early on, and identifying core

transition outcomes for commissioning and monitoring.

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Title: What constitutes successful commissioning of transition from children’s to adults’

services for young people with long-term conditions, and what are the challenges? An

interview study

ABSTRACT

Objective: We explored what constitutes successful commissioning for transition, and what

are the challenges of commissioning for transition. We aimed: 1) to identify explicit and

implicit organisational structures, processes and relationships which drive commissioning

around transition; 2) to identify challenges faced by commissioners; and 3) to develop a

conceptual model of commissioning for transition.

Design: A qualitative interview study.

Setting: Commissioning and provider organisations across primary and secondary care, and

third sector in England, UK.

Participants: Representatives (n=7) from clinical commissioning groups, health and

wellbeing boards, and local authorities which commission national health services (NHS) for

transition from children’s to adults’ services in England; NHS directors, general practitioners,

and senior clinicians (n=10); and front line NHS and third sector providers (n=6).

Results: Both commissioners and providers thought successful transition is personalised, co-

ordinated, and collaborative with a focus on broad life outcomes, and actualised through

building pathways and universal services. A multitude of challenges were described in

commissioning for transition, ranging from inconsistent national guidance, fragmented

resources, incompatible local processes, lack of clear outcomes, and professional roles and

relationships. No single, specific process of commissioning for transition emerged;—instead

complex, multi-layered, interactive processes were described.

Conclusions: The findings indicate a need to consider more explicitly the impact of national

policies and funding streams on commissioning for transition. Commissioners need to

require care pathways that enable integrated provision for this population, and seek ways to

ensure generalist community providers engage with children with long-term conditions from

early on. Future research is needed to identify a core set of specific, meaningful transition

outcomes that can be commissioned, measured, and monitored.

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interview study

INTRODUCTION

In the UK, more than 25,000 young people with long-term conditions transition from

children’s to adults’ services every year.1 Many of them have negative experiences of

healthcare during transition and poor health and social outcomes following transition.

Furthermore, despite 20 years of policy and guidance, the improvements in transition are

limited. The process remains fragmented and is a key risk period for poor clinical

outcomes.2-6

Long-term conditions in young people refer to conditions which cannot be cured with current

interventions but which can be managed. These include, e.g. diabetes, asthma, and

developmental disabilities. The transition of young people with long-term conditions from

children’s to adults’ services can be affected by a range of factors. One of them is

commissioning,7 8 the process by which public services are planned, contracted and

monitored. There is currently a paucity of peer-reviewed evidence about commissioning for

transition; our systematic review found no published papers (Supplement S1).

The present study is the first to contribute evidence about commissioning for transition, and

through that to inform practice and guidance on commissioning for transition. The study

explored what constitutes successful commissioning for transition, and what are the

challenges of commissioning for transition. The objectives were: 1) to identify the explicit and


around transition; 2) to identify the challenges faced by commissioners; and 3) to develop a


METHODS

This was an interview study within a 5-year Transition Research Programme funded by the

National Institute for Health Research (RP-PG-0610-10112) to generate evidence for

commissioning and provision of better transition for young people with long-term conditions.

This interview study received ethics approval from the Newcastle University Faculty of

Medical Sciences Ethics Committee (ref: 00767/2014).

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Setting, sample and recruitment

Interviewees were sampled using purposive and snowball sampling from two areas in the

North of England and from national leaders across England, including from: clinical

commissioning groups, health and wellbeing boards, and local authorities which commission

national health services (NHS) transition from children’s to adults’ services in England; NHS

directors, general practitioners, and senior clinicians with roles relevant to transition; and

front line NHS and third sector providers. First, the study steering group nominated potential

interviewees; the nominees were then considered for participation based on their job title;

those selected were emailed a letter inviting them to participate; and if no response was

received then up to three follow-up attempts were made by telephone. Interviewees who

were approached were also invited to nominate further interviewees, and recruitment

continued until new data no longer added content. We anticipated that around 25 interviews

would result in sufficient coverage of a range of views across contexts. Informed written

consents were taken.

Data collection

The interview schedule was based on modified critical incidence technique,9 informed by

grey literature (Supplement S1) and conversations with the research team and the steering

group. The interview schedule (Table 1) was designed to encourage participants to reflect on

successful and unsuccessful practices for commissioning in the context of transition, and to

cover perceptions of (i) the organisational structures, processes, relationships, barriers and

facilitators related to commissioning, and (ii) the relative influence of policy drivers,

relationships with providers, and external influences. SMC, a researcher with PhD in

healthcare commissioning, conducted the interviews either face-to-face in interviewee’s

chosen setting or by telephone. Interviewees had no prior knowledge of or relationship with

the interviewer. The interviews lasted 60-90 minutes and were conducted 04/2014-08/2014,

audio-recorded verbatim, and later transcribed.

Table 1. Interview Schedule

Background/ Context

1 Can you tell me what you understand by the term ‘transfer’ or transition’ in health care? How would you define a “successful transition”?

2 Can you tell me about your role and: a. How you are or have been involved in transition? b. How you are or have been involved in commissioning?

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Successful Commissioning Outcomes

3 Can you describe an example of when transition or commissioning for it has been undertaken successfully? (Outcomes)

Successful Commissioning Activities/Processes

4 With respect to the example shared can you describe the activities, actions or processes that were undertaken to achieve this outcome?

Unsuccessful Commissioning Outcomes

5 Can you describe an example of when transition or commissioning for it has been undertaken unsuccessfully? (Outcomes)

Unsuccessful Commissioning Activities/Processes

6 With respect to the example shared can you describe the activities, actions or processes that were undertaken which resulted in this outcome?

Any other points

7 Are there any other issues which you consider to be relevant that you would like to discuss?

Data analysis

The transcripts were analysed using framework analysis.10 An initial conceptual framework

based on literature and researchers’ experiential knowledge was expanded and modified in

iterative cycles using themes emerging from the data. This produced a cumulative, refined

framework that integrated the initial conceptual framework and the study results. The specific

steps were as follows. Familiarisation: two researchers (GM, NK) developed an initial sense

of the data by reading through a sample of transcripts. Identifying the initial coding

framework: three researchers (GM, NK, SMC) independently recorded their impressions and

deductive themes. GM and NK discussed these impressions, related them to their previous

knowledge and expertise, and agreed the initial conceptual framework. This process was

repeated for six rounds, with the two researchers reading further transcripts between each

discussion round. The discussions consisted of the researchers talking through the emerging

issues, themes and relationships, and agreeing themes, codes and relationships which were

added to the framework. Indexing: Once the framework became stable (i.e. few

modifications were required on each round), GM used it to ‘index’ the remaining transcripts

one by one. This involved ‘sifting and sorting’ the remaining data and allocating these into

the coding framework. The researcher took notes of any changes to the framework and

issues, and these were discussed with NK. This process was repeated until all data were

indexed and the final framework agreed. Charting: Data from the transcripts were

summarised according to the themes and codes (‘categories’) to reduce the data while

carefully retaining the original meanings. References to illustrative quotations were tagged

and managed using Microsoft Word and NVivo10.

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Quality assurance

We employed recognised quality assurance techniques11 to ensure credibility, transferability,

dependability and confirmability (Table 2).

Table 2. Quality assurance techniques employed

Credibility � During the data collection, contact was established through

demonstrated interest in the responses, attentive listening,

understanding and respect for what the participant says 12

� The sequencing and posing of questions was carefully considered,

and was dynamic so that the questions promoted positive interaction

between the participant and the interviewer and stimulated the

participant to share their experiences and points of view 12

� All interviews included an opportunity for participants to comment on

any topic covered in the interview, or any new topic which they felt

was relevant12-15

� Triangulation: accounts between participants were compared and

contrasted

� Member-checking: the themes and their content were shared and

discussed with the study steering group

� Frequent de-briefing: study progress, methods, emerging themes and

any issues were reported to and scrutinised by the research

programme senior team at regular intervals

Transferability � The sampling frame and criteria (see Methods), and the key

population characteristics (see Results) were clearly recorded and

reported

Dependability

and

confirmability

� To allow a nuanced, multifaceted analysis and reconciliation of any

tensions in the coding and concepts, researchers from different

disciplinary backgrounds with different expertise contributed to the

data analysis, including: GM sociology; NK behaviour change, NHS

practice in long-term conditions; SMC commissioning, health

economics; AC paediatrics; ALC child and adolescent psychiatry; LV

health economics; and DR (in acknowledgements) NHS management

� Involvement of several researchers with different viewpoints and

expertise also helped to ensure that the framework was adapted to

reflect the data rather than making the data ‘fit’ the framework

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� Involvement of new researchers (GM, NK) in the data analysis

encouraged further peer examination through critical discussion

� Audit trail: researchers kept field notes (SMC) and a logbook of data

analysis (GM, NK), and established an electronic data analysis and

synthesis trail of the development of the themes

RESULTS

Forty six interviewees were approached; 29 agreed to participate. The participants covered a

range of roles across the target population (Table 3).

Table 3: Summary description of the participants

Coverage Participant role Organisation(s)

Regional Commissioners at different levels of

seniority, and related managers (n=8)

Health and social care

commissioning organisations,

including local authorities,

commissioning support units and

clinical commissioning groups

NHS director (n=1)

NHS clinicians (n=2)

General practitioners (n=3)

NHS

Transition planning workforce (n=2)

Transition managers, co-ordinators (n=2)

Local authority

National Clinical leaders (n=5) NHS, and NHS England

Voluntary sector leaders (n=2) Charities providing care

Successful transition

While no single definition of successful transition emerged, some key characteristics were

described (Table 4). These included that transition should: (i) be personalised, (ii) be

planned, co-ordinated and collaborative, (iii) focus on broad developmental and life

outcomes, (iv) build pathways from children’s services to adults’ services rather than just rely

on individual, single solutions, (v) ensure co-ordination and continuity of relationships and

knowledge across sectors and life domains rather than just transfer young people from one

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service to another, and (vi) use universal services such as general practitioners where

possible with tailored enhanced support as required.

Table 4. Selected quotes about perceived characteristics of successful transition

Personalised, planned, co-ordinated, collaborative with focused on broad

developmental and life outcomes:

“(�) what all the legislation is telling us, and all the national direction is about, is about

personalisation. (�) [in current practice] we keep on just focusing on the here and now.

What we should be doing is (�) predict what the needs will be in the future (�)”

(Commissioner/related manager 1, Regional)

“(�.) a smooth journey and needs met. (�) the much wider picture. So your health needs

will impact on your employment outcomes or your education (�) and what you do with your

aspirations within your community (�)” (Member 1 of transition planning workforce,

Regional)

“(�) I think successful transition (�) has to be addressed and introduced as a concept at

the age of 14+ school review (�) then the families, and the young people, and the

professionals begin, hopefully, to develop some type of joint work between them. (�)”.

(Voluntary sector leader, National)

Builds pathways, ensures continuity, and uses universal services:

“(�) if the systems were right, so if you had children’s services interfaced properly into adult

services there was a clear pathway (�) children would just sort of flow through (�)”


“(�) a successful transition is where the person undergoing transition has the change of

care seamlessly, without any interruption in their therapeutic relationship, in their treatment

strategy, and in their engagement. (�) the aspects of continuity, information continuity,

relational continuity, therapeutic continuity.” (NHS clinical leader 1, National)

“(�) this concept of universal (�) you might have somebody who’s complex and needs

[Children and Adolescent Mental Health Services] and learning disability team or whatever,

and has some physical needs as well. But still can access the already commissioned

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services. And if they interfaced well then the transition could be seamless and wouldn’t need

active commissioning. (�)” (Commissioner/related manager 1, Regional)

Challenges to commissioning

Four meta-themes related to challenges in commissioning for transition emerged: 1) The

broad context: legislation, policy and wider life transitions; 2) Commissioning structures,

processes, pathways and relationships; 3) Service-level co-ordination, sign-posting, and

relational support; and 4) Outcomes and contract evaluation.

The broad context: legislation, policy and wider life transitions

Participants discussed a range of features related to national legislation, and national and

local policies that they perceived to influence commissioning and healthcare. One common

theme was service eligibility. Participants described problems in relation to the criteria

commonly used for service eligibility, including age, severity, and diagnosis. Inconsistencies

within and between sectors in cut-offs created challenges for effective commissioning.

“(�) some services will say, “We go up to 16”, some go up to 18, some go up to your 19th

birthday, some go up to 25, and some are lifelong (�) depending on who you are and what

service you’re dealing with depends on what, even age group, you’re dealing with in terms of

transition.” (Commissioner/related manager 2, Regional)

“(�) mental health conditions that children suffer from do not actually make the grade for

adult mental health services. (�)” (Clinical leader, National)

Participants also consistently highlighted that young people’s lives and transitions are wider

than the prescribed service remits, and described challenges stemming from a reductionist

approach which requires partitioning the wider life to public sector remits.

“(�) [the Government] send guidance on what they think a health need is and what an

education need is, or a social care need is, which again creates barriers. So, for instance, if

you are peg-fed when you’re at home you could say that’s a healthcare need because you

need to be fed to live. While you’re at school, school are responsible for making sure you

can access education; you can’t access education if you’re hungry; so is it then [education’s]

responsibility to feed you? (�)” (Commissioner/related manager 4, Regional).

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Legislation that requires more co-ordinated public services was hoped to address the

segmentation; but participants also expected the impact of any legislation to be hampered by

fragmented resource allocation.

“(�) Government, is saying, “Well we need to go through to 25” that’s fine, but as long as

there’s an 18-year-old cut-off and there isn’t the funding� the world isn’t going to change.”


Some participants suggested that joint commissioner posts, funded together by health and

local authority, could facilitate positive arrangements.

“(�) my role (�) it’s half funded by the local authority (�) I think the principle of a joint post

is good, (�) children in education, there’s links to social care; it’s all a very interlinked (�) [I

resolve funding disputes] particularly between the local authority and the [health] about

health need or a social need, and who should pay (�)” (Commissioner/related manager 4,

Regional)

But others expressed a belief that transition is not a Government or commissioning priority,

and there is limited willingness to allocate resources for transition.

“(�) whilst we’re aware that [transition] is an issue, we’re also acutely aware that there are

bigger issues at stake (�) you tend to find that the big issues, like the fact that we’re about,

potentially, about £8 million short in terms of budget this year is much more of a priority than

transition (�)” (Commissioner/related manager 5, Regional)

Commissioning structures, processes, pathways and relationships

Overall, participants described that the multitude of local structures, processes, and

agencies involved in commissioning and provision created a major challenge.

“(�) with CCGs [Clinical Commissioning Groups] and commissioning support, with NHS

England having their role, with public health being in the council, with the different bits of the

council, the education bit and the care bit. (�) Responsibility, process, who to talk to, who,

who is doing what. (�)” (Commissioner/related manager 4, Regional)

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Other challenges repeatedly described were that the services for children and adults are

commissioned separately and on different organising principles, including differences in

clinician roles.

“(�) [in transition] the paediatrician is referring to an adult respiratory doctor, an adult

gastroenterologist and an adult neurologist to replace [the paediatrician] (�). [who] may

have dipped in and out of the paediatric specialities in those areas (�).” (NHS clinician 2,

Regional)

These differences resulted in “the gap”, a situation where there was no clear destination for

the young person to transfer to. Commonly described approaches to fill the gaps were the

use of personalised, tailored solutions for individuals and personalised budgets. In contrast,

examples of proactive commissioning of pathways for populations were rare, and some

explicitly recognised this.

“(�) the way that commissioning works currently is that (�) usually the providers identify

gaps and they’re then asked to fill those gaps within, usually within the resource or

something you get a little bit of extra resource to do that. Erm, but that’s not the same as

commissioning a full pathway from start to finish.(�)” (NHS Director 1, Regional)

Commissioning successfully without gaps was perceived to be greatly facilitated by effective

relationships and communication that fostered trust and good faith across stakeholders.

“(�) we had a very good commissioning team at the time (�) [the commissioners] worked in

the same building. So they had a very good understanding of transition and the gaps (�) the

children’s commissioner worked alongside the adult commissioner (�) once we’d

established that good relationship with the adult commissioners we’ve built on that year in

year out.” (Voluntary sector leader, National)

Service-level co-ordination, sign-posting and relational support

Co-ordination, sign-posting, and relational support were consistently discussed as central to

successful transition. Proposals for commissioning solutions to achieve these focused on

enabling young people to self-manage their condition and care with support of a nominated

professional. One common proposal was to involve general practitioners (GPs) more

proactively from early on, alongside paediatricians.

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“(�) parents build up great relationships with these paediatricians and so, if they’ve got, any

queries, regardless of whether it’s associated to that child’s disability or not, obviously

they’re going to ring the person who knows them best and is, kind of, in charge of their care.

So for me that’s a really big risk for transition because you’ve had this brilliant service from

this one particular person, for the whole of your child’s life, and when they’re approaching

transition there’s no equivalent (�)” (Commissioner/related manager 9, Regional)

“(�) I think we need to involve the GPs from very much earlier on. (�) maybe if you

involved the GP, gives the confidence to the families as well. (�)” (NHS clinician 3,

Regional)

Other proposals, for improving transition, included use of specialist nurses and other

community clinicians, and the creation of ‘transition workers’.

“(�) identifying the children and young people at around [age] 14, 15 then the transition

workers will introduce themselves and begin to get that process in place (�)” (General

practitioner 1, Regional)

Outcomes and contract evaluation

Participants emphasised that transitions should be outcomes focused and these outcomes

should be considered broadly across life domains. However, participants’ accounts lacked

specific examples of outcomes-based commissioning. Instead, they conveyed difficulties in

specifying outcomes, and some participants explicitly said it was difficult to identify clear,

shared values and outcomes for commissioning for transition.

“(�) outcomes based commissioning (�) with health, I mean outcomes are so often, you

know, they’re not, (�) it depends on how you determine or define the outcomes (�) it is

very difficult to (�) I think everyone, yeah, sort of talks around outcomes based

commissioning as a good idea and it is better than kind of just throughput. Erm, erm but, er,

(�) it still feels a bit too hard to do and there isn’t this kind of universal understanding of

what that is and what it means, let alone how you measure it.” (Commissioner/related

manager 11, Regional)

“(�) it is so complicated and it’s so multiagency (�) we don’t have a shared value base of

what we’re trying to achieve with young people and their families. (�) commissioning circles,

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lovely things they are, but they don’t mean anything to young people and their families.

(Laughter) (�)” (Member of transition planning workforce 3, Regional)

Similarly, contract management based on outcomes, as opposed to activity, was perceived

to be difficult.

“(�) you look at it within the contractual management (�) [Historically] commissioning has

been very much [about] (�) number of contacts, number of review appointments, maybe

even staffing numbers (�) all the kind of rhetoric and theory around commissioning for

outcomes (�) everybody talks about it all the time, but to actually make it meaningful (�) it’s

relatively easy to measure activity; it’s very hard to measure outcomes. (�)”

(Commissioner/related manager 4, North England)

One way participants sought to evaluate outcomes was through generic feedback from

service users, but this too was perceived to have limitations, e.g. providers failing to collect

this data.

Conceptual model of commissioning for transition

While the participants provided rich reflections on key characteristics and challenges related

to commissioning for transition, there was limited discussion about any unique steps related

to commissioning for transition (as opposed to commissioning in general). There was little

evidence of a specific ‘transition process for commissioning transition’. Instead, the accounts

reflected complex and nuanced processes entangled with other local and organisational

structures, processes, and relationships as described above. The summary

conceptualisation of the process of commissioning for transition (Supplement 2) reflects

these complexities and multidirectional relationships.

DISCUSSION

This study found that both commissioners and providers believe transition from children’s to

adults’ services should be personalised, co-ordinated, and collaborative with focus on broad

life outcomes; and that such transitions should be realised through building pathways and

universal services where possible. However, a multitude of challenges were described in

relation to commissioning for such transitions, ranging from Challenges to commissioning for

successful transition include inconsistent national guidance, fragmented resources,

incompatible local processes, lack of clear outcomes, and professional roles and

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relationships. No single, specific process of commissioning for transition emerged—instead


The study used established qualitative methods, with clear quality assurance strategies,

which provide confidence in the findings. The data on commissioning processes specific to

transition were thin. It is possible that this is a true finding, i.e. that there are no steps unique

to commissioning for transition, or that a different elicitation method would have yielded

richer data with a different finding.

This is the first peer-reviewed paper on commissioning for transition. The findings concur

with other stakeholders’ views on the criteria for successful transition and further elaborate

these by identifying some of the barriers to commissioning for such transitions.16 For

example, the findings on fragmentation in funding and the tendency to commission

individual, single solutions as opposed to pathways provide possible explanations for the

“gap” between children’s and adults’ services reported in studies with service users

The findings have a number of implications. These include a need for policy makers to

facilitate joint funding arrangements across sectors and to be aware that using chronological

age as a criterion risks creating barriers to effective commissioning. Commissioners need to

reflect on the tendency to fund single solutions rather than create care pathways, and to

consider incorporating available legislation (such as the Children and Families Act 2014 in

the UK) in service specifications and contract monitoring to encourage more integrated

services. Commissioners may also wish to seek ways to ensure general practitioners or

other community providers are involved with children with long-term conditions from early on

in order to be better placed for co-ordinated adult care.

The extent of difficulties in identifying specific outcomes that should be commissioned,

measured, and monitored indicates a need for research to develop a core set of agreed

transition outcomes with related measures. Previous research, e.g. on benchmarks for

transition16 and on commissioning for long-term conditions,17 as well as guidelines for good

transition practice,18 provide a starting point. There have also been two useful Delphi

exercises 19 20.

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15

REFERENCES (for the main body of the text – for the systematic review see S1)

1. Colver A. How can healthy services contribute most effectively to facilitating successful transition

of young people with complex health needs from childhood to adulthood? In: report to

NIHR: Programme Development Grant. Newcastle: Newcastle University, 2010.

2. Stam H, Hartman EE, Deurloo JA, et al. Young adult patients with a history of pediatric disease:

impact on course of life and transition into adulthood. J Adolesc Health 2006;39(1):4-13.

3. Lyon ME, Kuehl K, McCarter R. Transition to adulthood in congenital heart disease: missed

adolescent milestones. J Adolesc Health 2006;39(1):121-4.

4. Islam Z, Ford T, Kramer T, et al. Mind how you cross the gap! Outcomes for young people who

failed to make the transition from child to adult services: the TRACK study. BJPsych

2016;40(3):142-48.

5. Hovish K, Weaver T, Islam Z, et al. Transition Experiences of Mental Health Service Users, Parents,

and Professionals in the United Kingdom: A Qualitative Study. Psychiatr Rehabil J

2012;35(3):251-57.

6. Fegran L, Hall EO, Uhrenfeldt L, et al. Adolescents' and young adults' transition experiences when

transferring from paediatric to adult care: a qualitative metasynthesis. Int J Nurs Stud

2014;51(1):123-35.

7. Kennedy I. Getting it right for children and young people: Overcoming cultural barriers in the NHS

so as to meet their needs. London: Department of Health, 2010.

8. NHS England. 2017 [NHS Commissioning]. Available from:

https://www.england.nhs.uk/commissioning/.

9. Flanagan J. The critical incidence technique. Psychol Bull 1954;5:327-83s.

10. Richie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R,

eds. Analysing qualitative data. 1 ed. Oxford: Blackwell Publications, 1994.

11. Lincoln Y, Guba A. Naturalistic Inquiry. Beverley Hills: Sage Publications, 1985.

12. Kvale S. Doing Interviews. London: Sage Publishers, 2007.

13. Patton M. Qualitative research and evaluation methods. London: SAGE Publications, 2002.

14. Rubin HJ, Rubin IS. Qualitative interviewing: The art of hearing data. 2 ed. California: Sage

Publications Inc. , 2005.

15. Turner D. Qualitative interview design: a practical guide for novice investigators. Qual Rep

2010;15(3):754-60.

16. Aldiss S, Rose L, Cass H, et al. Moving from child to adult health care: development of

benchmarks for transition. Archives of Disease in Childhood 2015;S3(100):A67.

17. Peckham S, Wilson P, Williams L, et al. Commissioning for long-term conditions: hearing the voice

of and engaging users – a qualitative multiple case study. Health Serv Res 2014;2(44).

18. NICE. Transition from children's to adult's services for young people using health or social care

services. NG43. London: National Institute for Health and Clinical Excellence, 2016.

19. Fair C, Cuttance J, Sharma N, et al. International and Interdisciplinary Identification of Health

Care Transition Outcomes. JAMA Pediatr 2016;170(3):205-2011.

20. Suris JC, Akré C. Key elements for, and indicators of, a successful transition: an international

Delphi study. J Adolesc Health 2015;56(6):612-18.

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16

ADDITIONAL NOTES

This paper summarises independent research funded by the National Institute for Health

Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0610-

10112). The views expressed are those of the authors and not necessarily those of the NHS,

the NIHR or the Department of Health.

*The Transition Collaborative Group consists of: the authors of this paper; other co-

applicants: Caroline Bennett, Gail Dovey-Pearce, Janet McDonagh, Tim Rapley, Debbie

Reape; advisors: Nichola Chater, Helena Gleeson; local investigators: Anastasia Bem,

Stuart Bennett, Amanda Billson, Stephen Bruce, Tim Cheetham, Diana Howlett, Mark

Linden, Maria Lohan, Melanie Meek, Jenny Milne, Julie Owens, Fiona Regan, Nandu

Thalange.

A competing interests statement. No competing interests.

Authors’ contributions:

AC contributed to the study design, data analysis, and the writing of the initial report and the

subsequent manuscript (especially the introduction, discussion, and the reviews of the

literature); and approved the final version of the manuscript.

ALC contributed to the study design, data analysis and to the writing of the initial report and

the manuscript (especially discussion); and approved the final version of the manuscript.

GM contributed to the data analysis and writing of the initial report (especially the results);

and approved the final version of the manuscript.

LV Contributed to the overall design; the writing of the initial report and the subsequent

manuscript (especially methods); and approved the final version of the manuscript.

NK contributed to the study design, data collection plan, and data analysis; led the writing of

the initial report and the subsequent manuscript; and approved the final version of the

manuscript.

SMC led review of all the literature and the development of the data collection plan and

materials, collected the data, and contributed to the data analysis; co-led the writing of the

manuscript; and approved the final version of the manuscript.

Data sharing: The data are not shared through a public repository as this was not part of

the initial consent and, after careful consideration, anonymising it for public sharing is not

considered feasible. Researchers interested in accessing the data should contact the

authors directly to discuss access arrangements.

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17

Acknowledgements: We thank Dr Angela Bate for her assistance in planning the study and

for her oversight of it in its early stages, and Ms Debbie Reape for her critique of and

contribution to the data analysis. We are also grateful to the members of the steering group

which met twice during this specific study and advised the research team.

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nlySupplemental file S1: A review of literature about commissioning transition

A systematic review of peer-reviewed literature relevant to commissioning for transition was

conducted to inform this study. The core bibliographic databases used were: Medline (1996-

), Web of Knowledge (WOK) (1996- ) and Scopus (1996- ). A structured search strategy

was formulated using controlled search terms, including free text terms and MESH headings

where available. Given the complexity and ambiguity of the terms ‘commissioning’ and

‘transition’, all alternative terms were used in order to be as thorough as possible. Search

terms (Box S1) were applied across databases. To ensure that the literature review

remained up to date, searches were conducted regularly over the duration of the review from

September 2013 to March 2017. The identified papers were reviewed using explicit

exclusion criteria (Box S2).

The PRISMA diagram (Figure S1) shows how the searches of Medline and WOK databases

were structured. Separate searches for papers on commissioning and transition identified

302 papers relevant to both topics, which were then screened and assessed for eligibility

according to the exclusion criteria. The most common reason for exclusion was that the

paper focused only on transition, with no content about commissioning. No academic

publications on commissioning for transition were identified.

Box S1. Academic literature search

Commissioning search terms

“Delivery of Health Care” OR [(Contract Services OR Contract* OR Commission* OR fund*

OR purchase* OR budget* OR plan* OR provide* OR manage* OR procurement* OR

assess*NEAR/1needs) AND healthcare]

Transition search terms

Transition to Adult Care OR Health Transition OR transition* OR continuity* OR pathway

OR "service mapping" OR transfer*

AND healthcare AND (‘to adult OR ‘from paediatric’) AND (young person* OR young

adult* OR adolescent* OR youth OR child*)

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nlyBox S2. Academic literature exclusion criteria

Title and abstract criteria

1. Non-English Language

2. Transitions other than from children’s services to adult services

3. Populations other than young people with ‘complex health needs’ as defined for the

research programme

4. Only identify current problems to transition, no mention of approaches to improve

transition or barriers to successful transition

Full text criteria

1. It was a book

2. Not an academic or peer reviewed research study

3. Transition papers with no focus on commissioning (or related) processes

4. Focus of the paper not on commissioning or transition processes in the NHS

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nlyFigure S1. Academic literature PRISMA diagram

Medline & Web of Knowledge (1996 - )

Transition

n = 1351 Commissioning

n = 121,211

Titles and abstracts screened

n = 291

Records excluded for: not NHS,

not transition of adolescents,

not complex health needs,

and/or no focus on improving

transition, implementing

successful transition or barriers

to successful transition

n = 224

Full text articles assessed for

eligibility (after duplicates removed)

n = 67

Academic, peer reviewed literature about

commissioning for transition

n = 0

Records excluded for: only book

availability, US papers with

insurance focus, not academic or

peer-reviewed research study, not

specific, no focus on improving

transition, implementing successful

transition or barriers to successful

transition, and/or no focus on

commissioning

n = 67

Publications not specific to

commissioning but potentially

informative for programme

n = 18

Commissioning AND transition

n = 303

Excluded non-English

language records n = 12

Scr

ee

nin

g

Incl

ud

ed

Eli

gib

ilit

y

Ide

nti

fica

tio

n

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nlyThe lack of peer-reviewed papers about commissioning for transition led us to undertake a

further grey literature search. By grey literature we understood “information which is

produced on all levels of government, academics, business and industry..., but which is not

controlled by commercial publishers".1 It is more broadly described as material not published

commercially or indexed by major databases,2 e.g. policy papers, discussion papers,

briefings not covered in the bibliographic search. The same search terms used for the peer-

reviewed literature were applied wherever possible (Box S3). We hand-searched the

following sources: Social Care Institute for Excellence (SCIE), Health Management

Information Consortium (HMIC) (Department of Health, Kings Fund), Nuffield Trust, Public

Health England (PHE), NHS Evidence (NICE), NHS Institute for Innovation and

Improvement, NHS Improving Quality, Health Services Management Centre (HSMC),

National Research Register Archive, UK Clinical Research Network, and Google Scholar.

These searches were further supplemented using backward and forward searching

techniques 3 on any key literature, looking at its references, citations and other papers

written by same authors. ‘Snowball’ referencing was used to retrieve references cited in key

primary research texts. Papers were also retrieved from email subscription, discussion

listings, and supplemented by literature obtained within the wider programme of research.

The identified literature was screened for inclusion using exclusion criteria (Box S4). The

search of grey literature was completed in June 2014; we decided to keep the search open

and update it throughout the study up to July 2016.

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nlyBox S3. Grey literature search strategy

SCIE search terms

‘Commissioning for Transition’ – simple search box didn’t permit combining terms with ‘AND’

/ ‘OR’ in same manner as Academic database search.

HMIC search terms

‘Commissioning’ control vocabulary selected:

Locality Commissioning OR General Practice Commissioning Groups OR Practice Based

Commissioning OR Commissioning Agencies OR Hospital Commissioning OR Lead

Commissioning OR Commissioning

AND

‘Transition’ control vocabulary selected:

Palliative care OR "Quality of patient care" OR Patient transfer OR transition to adult

services OR Mental health services OR Learning disabilities

AND

Management practice OR Primary Care Trusts OR Healthcare OR Primary care OR

Organisational culture

AND

‘Adults’ or ‘Young People’

Nuffield Trust and PHE search terms

Hand searched publications on website under Commissioning topic where possible

Box S4. Grey literature exclusion criteria


2. Non-comparative health care system – developing countries

3. Older populations

4. Lower grade cases, or non-disability cases e.g. dentistry

5. Lack of commissioning or lack of transition content

6. Only book availability


8. Lack of focus on health care (purely social or educational services)

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nlyFigure S2. Grey literature PRISMA Diagram

The review of grey literature identified two main areas literature: commissioning, and

organisation and delivery of care.

1 Commissioning

Within the grey literature, no specific policies relating to commissioning for transition were

identified. However we identified some key themes from policies with a focus on improving

outcomes for children and young people, key delivery plans with a focus on personalisation

of care, and some commissioning guidelines. Together these themes may provide useful

insight into some of the issues which may be relevant for commissioning for transition. The

Social Care Institute for Excellence

SCIE (1996 - )

Titles and abstracts screened

n = 171

Records excluded for: transition of

commissioning practice/structure,

not healthcare (social or

educational focus), developing

country, not transitioning

adolescents with disability, lack of

content in either transition or

commission (or equivalent)

n = 144

Full text articles assessed for eligibility

SCIE: n = 13 (and 7 unavailable)

HMIC: n= 14 (5 unavailable)

Literature included narrative synthesis

SCIE: n = 7

HMIC: n = 7

Records excluded due to lack of

content or focus on specifically

commissioning for transition in

health care

SCIE: n = 6, HMIC: n = 7

‘Useful’ publications identified

SCIE: n = 4, HMIC: n = 3

Partial relevance / not

commissioning

Commissioning and transition

SCIE: n = 125

HMIC: n = 46

Scr

ee

nin

g

Incl

ud

ed

E

lig

ibil

ity

Id

en

tifi

cati

on

Health Management Information

Consortium HMIC (1996 - )

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nlyfour sub-themes related to commissioning were: transition protocols, clinic structure, funding,

and co-ordination.

1.1 Transition protocols

A number of recommendations were made for robust or a ‘successful and consistent’

transition protocol 4-6. There is currently a lack of joint planning and commissioning and the

need to improve this, specifically between children and adult services, was recognised. In

order to facilitate this the key responsibilities of commissioners were described as (i)

developing service specifications based on local needs assessments; (ii) stimulating the

market place to fill identified gaps in service provision and (iii) stimulating providers to

provide best practice services based on research evidence 5. CQUIN (Commissioning for

Quality and Innovation) was suggested as a mechanism to aid effective commissioning

practice 4. Further, the need for a transition protocol to embed the principles of personalised

planning as part of the personalisation agenda was highlighted 6. Finally, there was a

practical suggestion that the management of transition in hospitals, primary care and

community care should be factored into the overall rating which is calculated as part of CQC

inspection models, in order to incentivise improved performance.

1.2 Clinic structure

The ‘age conundrum’ was identified as a barrier to successful transition 4. This means that at

age 18 a young person should be treated in adult services but for children and young people

with complex health needs, including learning difficulties and mental health difficulties, this is

not necessarily the most developmentally appropriate age to transfer to adult health care

providers. Further, age boundaries were perceived to be set arbitrarily and as such

considerable variety and inconsistencies existed between different services. There was

variation in suggestions for how this ‘age boundary’ challenge should be addressed. Some

suggested a distinct young person’s service, e.g. spanning age 14-25; whilst others

suggested a flexible approach to managing transition within the existing structures 7.

Development of young person focussed services in the community were also suggested to

provide additional support for children from 11-25 8.

1.3 Funding

Funding for transition was noted to be complex, fragmented and often not clear. In order to

improve this it was suggested that funding responsibilities for equipment and short-term

breaks should be agreed earlier between commissioners and providers in order to avoid

delays during transition 7. Current funding for adolescent health and social care was deemed

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nlyinsufficient, particularly with respect to developmental disorders and mental health, where

workloads were perceived to be rising amidst inadequate staffing and resources 4.

Upstream investment, in terms of the commissioning of evidence based preventative

measures, and early stage intervention in children and young people services were

advocated. This shift in investment was cited as having the potential to enable the child or

young person to receive appropriate services more swiftly and for a shorter time and as a

means to achieve future savings 4.

The implication of a lack funding was that there may be limited available services suitable for

young adults including: a lack of age appropriate short break facilities; few chances of

meaningful employment; few residential places that can take young people with very

complex health needs; and few health specialists with a holistic approach to a young

person’s care 5.

1.4 Co-ordination

Appleton 4,p19 argues that effective commissioning practice depends on important

relationships between key groups. “Engagement between commissioners and local

clinicians, as well as with young people and their families will be increasingly important in the

new commissioning environment.” Building relationships has been highlighted in a number of

reports as a critical factor in successful transition planning. The role of commissioners in

helping services to join up could include facilitating a local Transitions Forum, including

representatives from children’s and adult’s services, the voluntary sector and service user

groups to review and monitor transition protocols, and providing an arena for review and

service development.

“Current commissioning models often place CAMHS commissioning and AMHS within

different frameworks, structures and organisations. Not facilitated joint working across the

two sectors and has not enabled a sharing of ideas and solutions. As a result, separate

service development has taken place that has not properly addressed the issues relating to

transition” 4,p10 Commissioners should ensure that joint agency planning and commissioning

enable the development of person centred, co-ordinated and integrated packages of care

and support for children and young people, and the smooth transition to adult services and

avoid crises 9.

2 Organisation and delivery of care

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nlyAlthough this literature review was focussed on commissioning for transition, a number of

the papers we reviewed contained information or recommendations related to the

organisation and delivery of care. An understanding of what good organisation and delivery

of care may be helpful for commissioners to inform commissioning strategies. As such, a

brief summary of the key topics which emerged are noted here. The four sub-themes

related to organisation and delivery were: transition plan, health professionals, holistic care,

and coordination.

2.1 Transition plan (TP)

Transition planning, which should be stated and updated in a document shared with the

young person, should: start early and continue if necessary into adult care. It should be

tailored to the needs of young person and family and be age and developmentally

appropriate. The TP should also include education, social services and voluntary agencies

as active partners 5,p40 7 9. Transition planning is not happening everywhere and opportunities

are being missed to focus on employment and housing options at an early stage, for

example by embedding career planning in person-centred transition pathways 10. There is

debate about whether a health passport is implied in a TP or whether it should be a separate

document 7 11.

2.2 Health professionals

The literature reviewed here referred to three different health professionals involved in

transition: the GP, key worker, and coordinator. It was noted that “the adult sector and adult

physicians may have little experience in ‘paediatric’ diseases in adult life” and as such the

involvement of GPs at an earlier stage was recommended for future service planning. 7

A key worker was described as a person who assists an individual to negotiate transition

which all transition patients should have 7 9 11. Co-ordination of transition care is critical and, if

this does not already exist, a key worker should be identified for each young person to

oversee their transition, ensuring links with a counterpart within the receiving adult service 5.

A coordinator is a person working in a service that involves Transition, who works at a

managerial level to ensure effective processes which might include: reminding young people

by text of forthcoming clinics, ensuring transition plans are drawn up, the appointment of a

named key worker. Best practice for managing transition should be followed 7 9.

2.5 Holistic care

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nlyTo support holistic care transition should include arrangements for: Independent living,

employment, health and social inclusion 9,p41 11. Key characteristics of an effective holistic

transition process include: young person centred, wide age range, informal, flexible,

voluntary, confidential, free, independent, early intervention, continuity, etc. During transition

there should be support of multiple needs: emotional; mental; personal; physical; social

welfare; practical; and safeguarding with complementary interventions delivered under one

roof 12.

2.4 Effective co-ordination

To support the delivery of a regional multi-agency transition strategy, there should be a

transition lead in every region, supported by an implementation group involving all key

stakeholders, in particular young people and their families10. In order to be truly effective

CCGs and Local Authorities should actively listen and learn from young people and their

families’ experiences 7. One of the five ambitions, promoted by Youth Access, is that

“services will be integrated and care will be coordinated around the individual, with an

optimal experience of transition to adult services for those young people who require

ongoing health and care in adult life.” 8,p3

3 Conclusion

The purpose of this grey literature review was to supplement a systematic review of

academic literature, as described in Figure S1, which failed to identify any papers meeting

the criteria which required a focus on commissioning for healthcare transition. This has been

identified as a gap in the academic literature. The grey literature reviewed did not provide

sufficient detail, nor consensus to allow rigorous review or theming of content, however it

has provided some useful information and opinions on key topics such as transition

protocols, clinic structures, funding and coordination. We hope this review is of use and

interest to academics and other professionals working in this area.

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nlyReferences

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Washington, 2014.

3. Levy Y, Ellis T. A Systems Approach to Conduct an Effective Literature Review in Support

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4. Appleton S, Pugh K. Planning Mental Health Services for Young Adults –Improving

Transition: A Resource for Health and Social Care Commissioners. In: Unit. NMHD,

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5. Department of Health. Better Care: Better Lives: Improving outcomes and experiences for

children, young people and their familiaries living with life-limiting and life-

threatening conditions. London: Department of Health, 2008.

6. Department of Health. Equity and excellence: Liberating the NHS. London: Department of

Health, 2010.

7. CQC. From the pond into the sea: children's transition to adult health services. . In:

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8. Youth Access. Making integration a reality. Part 1 - joining up the commissioning across

young people's services across health, social care, housing and youth services.

Commissioning Briefing: Young People's Health Partnership, 2014.

9. RCGP., RC PSYCH. Improving the Health and Wellbeing of People with Learning

Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning

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Observatory, ed. London:

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%20Commissioning%20Guide%202012%2010%2009%20FINAL.pdf, 2012.

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learning disabilities. Making it happen for everyone. London: Department of Health,

2009.

11. National Autistic Society. Discussion paper: Improving commissioning standards in

services for ASD Patients. London: National Autistic Society, 2006.

12. Youth Access. Making integration a reality. Part 2 - developing effective holistic services

for young people in transition. . London: Young People's Health Partnership, 2014.

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nlySupplemental file S2

Figure S3 provides a summary output of the results in terms of stakeholders’ perceptions of

the organisational structures, processes and relationships that drive commissioning for

transition. It illustrates the interrelated nature of the themes that emerged, and reflects the

complexity of the commissioning process as described by the participants.

Figure S3. A visual summary conceptualising the process of commissioning for transition as

it emerged from the data analysis

Orange = Financial and legislative. Green = the structures, processes, pathways and

relationships in commissioning for transition. Blue = Service-level co-ordination, sign-

posting, and relational support. Purple = Outcomes. Red = Contract evaluation and

feedback.

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study


Manuscript ID bmjpo-2017-000085.R1


Date Submitted by the Author: 03-Aug-2017






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1

Title:



Authors: Kolehmainen Niina, McCafferty Sara, Maniatopoulos Greg, Vale Luke, Le Couteur

Ann, Colver Allan; on behalf of the Transition Collaborative Group*

Authors’ Institutions: Institute of Health and Society, Newcastle University, Newcastle, UK

Corresponding author: Niina Kolehmainen, Institute of Health and Society, Newcastle

University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK

Tel: +44(0)796 4329630 Email: [email protected]





outcomes.





transition.











Word Count: 3575

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interview study

ABSTRACT


are the challenges of commissioning for transition. We aimed: 1) to identify explicit and


around transition; 2) to identify challenges faced by commissioners; and 3) to develop a











building pathways and universal services. A multitude of challenges were described in

commissioning for transition, ranging from inconsistent national guidance, fragmented

resources, incompatible local processes, lack of clear outcomes, and professional roles and

relationships. No single, specific process of commissioning for transition emerged;—instead








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interview study

INTRODUCTION






outcomes.2-6






monitored. It is widely, internationally recognised that to understand and improve any service

provision, including transition process, the functions of planning, contracting and monitoring

need to be understood.9

There is currently a paucity of peer-reviewed evidence about commissioning for transition;

our systematic review found no published papers (Supplement S1). The present study is the

first to contribute evidence about commissioning for transition, and through that to inform

practice and guidance on commissioning for transition. The study explored what constitutes

successful commissioning for transition, and what are the challenges of commissioning for

transition. The objectives were: 1) to identify the explicit and implicit organisational

structures, processes and relationships which drive commissioning around transition; 2) to

identify the challenges faced by commissioners; and 3) to develop a conceptual model of

commissioning for transition.

While there are differences in health systems in terms of commissioning, it is also likely that

there are also shared points of learning. UK health system provides one diverse set up from

which such learning can be obtained. In the UK over the last 20 years there has been a

fundamental separation of the bodies that commission services from the bodies that provide

them. Some specialised services are commissioned centrally and more general services are

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commissioned by local groups with strong representation from primary care and local

authority. The process of commissioning involves assessing needs, deciding priorities and

strategies, and then buying services on behalf of the population from providers such as

hospitals, clinics, and community health bodies. It is an ongoing process, where the

commissioners constantly respond and adapt to changing needs and circumstances.

METHODS

This was an interview study, using conversational techniques to gather data, within a 5-year

Transition Research Programme funded by the National Institute for Health Research (RP-

PG-0610-10112) to generate evidence for commissioning and provision of better transition

for young people with long-term conditions. This interview study received ethics approval

from the Newcastle University Faculty of Medical Sciences Ethics Committee (ref:

00767/2014).















Data collection





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the interviewer. The interviews lasted a median of 45 minutes, with a range of 27-68

minutes, and were conducted 04/2014-08/2014, audio-recorded verbatim, and later

transcribed. Three interviews were conducted by phone, the remainder face to face.

The interview schedule was piloted with A L C who had both clinical and academic

experience of transition and commissioning. The interview guide was designed to use open

questions, which were used dynamically (as described in Table 2). Questions were not

adapted for different roles, rather the use of probes was tailored to fully elicit different

experiences between roles


Background/ Context

1 Can you tell me what you understand by the term ‘transfer’ or transition’ in health

care? How would you define a “successful transition”?

2 Can you tell me about your role and:

a. How you are or have been involved in transition?

b. How you are or have been involved in commissioning?


3 Can you describe an example of when transition or commissioning for it has been

undertaken successfully? (Outcomes)


4 With respect to the example shared can you describe the activities, actions or

processes that were undertaken to achieve this outcome?



undertaken unsuccessfully? (Outcomes)



processes that were undertaken which resulted in this outcome?

Any other points

7 Are there any other issues which you consider to be relevant that you would like to

discuss?

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Data analysis

The transcripts were analysed using framework analysis.11 Framework analysis allows both

emergent data themes and the explicit recognition and use of a priori issues in the analytical

framework. Framework analysis is increasingly being used within health services research,

and it fitted the aims of our study as we had pre-defined areas we wished to investigate

while remaining open to the emergence of further topics and themes. A series of

interconnected steps within the framework approach describe the processes that guide the

systematic analysis, these steps allows an iterative refinement of themes and are described

below.12

An initial conceptual framework based on literature and researchers’ experiential knowledge

was expanded and modified in iterative cycles using themes emerging from the data. This

produced a cumulative, refined framework that integrated the initial conceptual framework

and the study results. The specific steps were as follows. Familiarisation: two researchers

(GM, NK) developed an initial sense of the data by reading through a sample of transcripts.

Identifying the initial coding framework: three researchers (GM, NK, SMC) independently

recorded their impressions and deductive themes. GM and NK discussed these impressions,

related them to their previous knowledge and expertise, and agreed the initial conceptual

framework. This process was repeated for six rounds, with the two researchers reading

further transcripts between each discussion round. The discussions consisted of the

researchers talking through the emerging issues, themes and relationships, and agreeing

themes, codes and relationships which were added to the framework. Indexing: Once the

framework became stable (i.e. few modifications were required on each round), GM used it

to ‘index’ the remaining transcripts one by one. This involved ‘sifting and sorting’ the

remaining data and allocating these into the coding framework. The researcher took notes of

any changes to the framework and issues, and these were discussed with NK. This process

was repeated until all data were indexed and the final framework agreed. Charting: Data

from the transcripts were summarised according to the themes and codes (‘categories’) to

reduce the data while carefully retaining the original meanings. References to illustrative

quotations were tagged and managed using Microsoft Word and NVivo10.

Quality assurance

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� The sequencing and posing of questions was carefully

considered, and was dynamic so that the questions promoted

positive interaction between the participant and the interviewer

and stimulated the participant to share their experiences and

points of view 14

� All interviews included an opportunity for participants to comment

on any topic covered in the interview, or any new topic which

they felt was relevant14-17


contrasted



� Frequent de-briefing: study progress, methods, emerging themes

and any issues were reported to and scrutinised by the research



population characteristics (see Results) were clearly recorded

and reported

Dependability

and

confirmability

� To allow a nuanced, multifaceted analysis and reconciliation of

any tensions in the coding and concepts, researchers from

different disciplinary backgrounds with different expertise

contributed to the data analysis, including: GM sociology; NK

behaviour change, NHS practice in long-term conditions; SMC

commissioning, health economics; AC paediatrics; ALC child and

adolescent psychiatry; LV health economics; and DR (in

acknowledgements) NHS management


expertise also helped to ensure that the framework was adapted

to reflect the data rather than making the data ‘fit’ the framework

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� Audit trail: researchers kept field notes (SMC) and a logbook of

data analysis (GM, NK), and established an electronic data

analysis and synthesis trail of the development of the themes

RESULTS


range of roles across the target population (Table 3). Reasons for non-participation were: no

response to email or email follow up; change in role, and lack of time to participate.










NHS director/ manager (n=2)



NHS



Local authority









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Personalised, planned, co-ordinated, collaborative with focused on broad developmental and

life outcomes:








Regional)
















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Challenges

Four meta-themes related to challenges in commissioning for transition emerged: 1) The

broad context: legislation, policy and wider life transitions; 2) structures, processes,

pathways and relationships; 3) Service-level co-ordination, sign-posting, and relational

support; and 4) Outcomes and contract evaluation.











“(O) mental health conditions that children suffer from do not actually make the grade for

adult mental health services. (O)” (Clinical leader, National)




“(O) [the Government] send guidance on what they think a health need is and what an





responsibility to feed you? (O)” (Commissioner/related manager 4, Regional).

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“(O) Government, is saying, “Well we need to go through to 25” that’s fine, but as long as

there’s an 18-year-old cut-off and there isn’t the fundingO the world isn’t going to change.”




“(O) my role (O) it’s half funded by the local authority (O) I think the principle of a joint post

is good, (O) children in education, there’s links to social care; it’s all a very interlinked (O) [I


health need or a social need, and who should pay (O)” (Commissioner/related manager 4,

Regional)



“(O) whilst we’re aware that [transition] is an issue, we’re also acutely aware that there are

bigger issues at stake (O) you tend to find that the big issues, like the fact that we’re about,


transition (O)” (Commissioner/related manager 5, Regional)




“(O) with CCGs [Clinical Commissioning Groups] and commissioning support, with NHS


council, the education bit and the care bit. (O) Responsibility, process, who to talk to, who,

who is doing what. (O)” (Commissioner/related manager 4, Regional)

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clinician roles.

“(O) [in transition] the paediatrician is referring to an adult respiratory doctor, an adult

gastroenterologist and an adult neurologist to replace [the paediatrician] (O). [who] may

have dipped in and out of the paediatric specialities in those areas (O).” (NHS clinician 2,

Regional)






“(O) the way that commissioning works currently is that (O) usually the providers identify



commissioning a full pathway from start to finish.(O)” (NHS Director 1, Regional)



“(O) we had a very good commissioning team at the time (O) [the commissioners] worked in

the same building. So they had a very good understanding of transition and the gaps (O) the

children’s commissioner worked alongside the adult commissioner (O) once we’d









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“(O) parents build up great relationships with these paediatricians and so, if they’ve got, any





transition there’s no equivalent (O)” (Commissioner/related manager 9, Regional)

“(O) I think we need to involve the GPs from very much earlier on. (O) maybe if you

involved the GP, gives the confidence to the families as well. (O)” (NHS clinician 3,

Regional)



“(O) identifying the children and young people at around [age] 14, 15 then the transition

workers will introduce themselves and begin to get that process in place (O)” (General








“(O) outcomes based commissioning (O) with health, I mean outcomes are so often, you

know, they’re not, (O) it depends on how you determine or define the outcomes (O) it is

very difficult to (O) I think everyone, yeah, sort of talks around outcomes based


(O) it still feels a bit too hard to do and there isn’t this kind of universal understanding of



“(O) it is so complicated and it’s so multiagency (O) we don’t have a shared value base of

what we’re trying to achieve with young people and their families. (O) commissioning circles,

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(Laughter) (O)” (Member of transition planning workforce 3, Regional)


to be difficult.

“(O) you look at it within the contractual management (O) [Historically] commissioning has

been very much [about] (O) number of contacts, number of review appointments, maybe

even staffing numbers (O) all the kind of rhetoric and theory around commissioning for

outcomes (O) everybody talks about it all the time, but to actually make it meaningful (O) it’s

relatively easy to measure activity; it’s very hard to measure outcomes. (O)”




this data.


While the participants provided rich reflections on key characteristics and challenges related

to commissioning for transition, there was limited discussion about any unique steps related

to commissioning for transition (as opposed to commissioning in general). There was little

evidence of a specific ‘transition process for commissioning transition’. Instead, the accounts

reflected complex and nuanced processes entangled with other local and organisational

structures, processes, and relationships as described above. Figure 1 provides a summary

output of the results in terms of stakeholders’ perceptions of the organisational structures,

processes and relationships that drive commissioning for transition. It illustrates the

interrelated nature of the themes that emerged, and reflects the complexity of the

commissioning process as described by the participants.

Figure 1

A visual summary conceptualising the process of commissioning for transition as it emerged

from the data analysis

[Figure 1 to be inserted here]

DISCUSSION

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relation to commissioning for such transitions ranging from inconsistent national guidance,

fragmented resources, incompatible local processes, lack of clear outcomes, and

professional roles and relationships. No single, specific process of commissioning for

transition emerged—instead complex, multi-layered, interactive processes were described.

Commissioners identified clearly the inevitable tension between the need to commission for

personalisation of healthcare, whilst at the same time securing pathways of care. There is no

easy solution to this. One option is for the responsibility for personalisation to lie mainly with

the service providers whilst commissioners set the required pathways of care by purchasing

the necessary staff and facilities.


which provide confidence in the findings. Interviews continued until data saturation was

reached, between subgroups of participants and in general. The data on commissioning

processes specific to transition were thin. It is possible that this is a true finding, i.e. that

there are no steps unique to commissioning for transition, or that a different elicitation

method would have yielded richer data with a different finding. We did not approach young

people to ask their views about commissioning because in the UK, commissioning is very

separate from service provision and patients for the most part only experience services.

Young people in transition have the major task of gradually taking responsibility for their own

healthcare in the context of the services available; we thought it unlikely they would have

knowledge of commissioning. Efforts have been made to engage the public in the work of

commissioners but this has been very difficult and especially difficult to engage adolescents

in discussions about commissioning.18

This is the first peer-reviewed paper on commissioning for transition. The findings concur

with other stakeholders’ views on the criteria for successful transition and further elaborate

these by identifying some of the barriers to commissioning for such transitions.19 For

example, the findings on fragmentation in funding and the tendency to commission

individual, single solutions as opposed to pathways provide possible explanations for the

“gap” between children’s and adults’ services reported in studies with service users. Notably,

these types of learnings are likely relevant across commissioning systems and thus has the

potential to inform commissioning beyond the study setting of the UK.

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exercises 21 22.

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of young people with complex health needs from childhood to adulthood? In: report to NIHR:

Programme Development Grant. Newcastle: Newcastle University, 2010.






failed to make the transition from child to adult services: the TRACK study. BJPsych 2016;40(3):142-

48.


and Professionals in the United Kingdom: A Qualitative Study. Psychiatr Rehabil J 2012;35(3):251-57.



2014;51(1):123-35.





9. WHO. The WHO Health Systems Framework [Available from:

http://www.wpro.who.int/health_services/health_systems_framework/en/.




12. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Researcher

2011;18(2):52-62.







2010;15(3):754-60.











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125x94mm (300 x 300 DPI)

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where available. Given the complexity and ambiguity of the terms „commissioning‟ and

„transition‟, all alternative terms were used in order to be as thorough as possible. Search












Commissioning search terms “Delivery of Health Care” OR [(Contract Services OR Contract* OR Commission* OR fund*



Transition search terms Transition to Adult Care OR Health Transition OR transition* OR continuity* OR pathway




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1. Non-English Language 2. Transitions other than from children’s services to adult services 3. Populations other than young people with ‘complex health needs’ as defined for the

research programme 4. Only identify current problems to transition, no mention of approaches to improve

transition or barriers to successful transition Full text criteria 1. It was a book 2. Not an academic or peer reviewed research study 3. Transition papers with no focus on commissioning (or related) processes 4. Focus of the paper not on commissioning or transition processes in the NHS

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Transition n = 1351

Commissioning n = 121,211

Titles and abstracts screened n = 291

Records excluded for: not NHS, not transition of adolescents,

not complex health needs, and/or no focus on improving

transition, implementing successful transition or barriers

to successful transition n = 224

Full text articles assessed for eligibility (after duplicates removed)

n = 67

Academic, peer reviewed literature about commissioning for transition

n = 0

Records excluded for: only book availability, US papers with

insurance focus, not academic or peer-reviewed research study, not

specific, no focus on improving transition, implementing successful transition or barriers to successful

transition, and/or no focus on commissioning

n = 67

Publications not specific to commissioning but potentially

informative for programme n = 18

Commissioning AND transition n = 303

Excluded non-English language records n = 12

Scre

en

ing

Incl

ud

ed

Elig

ibili

ty

Ide

nti

fica

tio

n

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written by same authors. „Snowball‟ referencing was used to retrieve references cited in key






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SCIE search terms

„Commissioning for Transition‟ – simple search box didn‟t permit combining terms with „AND‟

/ „OR‟ in same manner as Academic database search.

HMIC search terms





AND




AND



AND

„Adults‟ or „Young People‟












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1 Commissioning






Social Care Institute for Excellence SCIE (1996 - )


Records excluded for: transition of commissioning practice/structure,

not healthcare (social or educational focus), developing

country, not transitioning adolescents with disability, lack of

content in either transition or commission (or equivalent)

n = 144

Full text articles assessed for eligibility SCIE: n = 13 (and 7 unavailable)


Literature included narrative synthesis SCIE: n = 7

HMIC: n = 7

Records excluded due to lack of content or focus on specifically commissioning for transition in

health care SCIE: n = 6, HMIC: n = 7

‘Useful’ publications identified SCIE: n = 4, HMIC: n = 3 Partial relevance / not

commissioning

Commissioning and transition SCIE: n = 125 HMIC: n = 46

Scre

enin

g In

clu

ded

El

igib

ility

Id

enti

fica

tio

n

Health Management Information Consortium HMIC (1996 - )

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and co-ordination.


A number of recommendations were made for robust or a „successful and consistent‟














The „age conundrum‟ was identified as a barrier to successful transition 4. This means that at






variation in suggestions for how this „age boundary‟ challenge should be addressed. Some

suggested a distinct young person‟s service, e.g. spanning age 14-25; whilst others




1.3 Funding





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person‟s care 5.

1.4 Co-ordination







representatives from children‟s and adult‟s services, the voluntary sector and service user










avoid crises 9.


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and coordination.










document 7 11.




physicians may have little experience in „paediatric‟ diseases in adult life” and as such the










2.5 Holistic care

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roof 12.






families‟ experiences 7. One of the five ambitions, promoted by Youth Access, is that




3 Conclusion









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nlyReferences

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study


Manuscript ID bmjpo-2017-000085.R2


Date Submitted by the Author: 14-Aug-2017






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Title:



Authors: Kolehmainen Niina, McCafferty Sara, Maniatopoulos Greg, Vale Luke, Le Couteur

Ann, Colver Allan; on behalf of the Transition Collaborative Group*

Authors’ Institutions: Institute of Health and Society, Newcastle University, Newcastle, UK

Corresponding author: Niina Kolehmainen, Institute of Health and Society, Newcastle

University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK

Tel: +44(0)796 4329630 Email: [email protected]





outcomes.





transition.











Word Count: 3575

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interview study

ABSTRACT


challenges are associated with this. We aimed: 1) to identify explicit and implicit

organisational structures, processes and relationships which drive commissioning around

transition; 2) to identify challenges faced by commissioners; and 3) to develop a conceptual

model.










building pathways and universal services. A multitude of challenges were described; ranging

from inconsistent national guidance, fragmented resources, incompatible local processes,

lack of clear outcomes, and professional roles and relationships. No single, specific process

of commissioning for transition emerged;—instead complex, multi-layered, interactive

processes were described.







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interview study

INTRODUCTION






outcomes.2-6






monitored. It is widely, internationally recognised that to understand and improve any service

provision, including transition process, the functions of planning, contracting and monitoring

need to be understood.9

There is currently a paucity of peer-reviewed evidence about commissioning for transition;

our systematic review found no published papers (Supplement S1). The present study is the

first to contribute evidence on this topic, and through that to inform practice and guidance on

commissioning for transition. The study explored what constitutes successful commissioning

for transition, and the challenges associated with this. The objectives were: 1) to identify the

explicit and implicit organisational structures, processes and relationships which drive

commissioning around transition; 2) to identify the challenges faced by commissioners; and

3) to develop a conceptual model.

While there are differences in health systems in terms of commissioning, it is also likely that

there are also shared points of learning. UK health system provides one diverse set up from

which such learning can be obtained. In the UK over the last 20 years there has been a

fundamental separation of the bodies that commission services from the bodies that provide

them. Some specialised services are commissioned centrally and more general services are

commissioned by local groups with strong representation from primary care and local

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authority. The process of commissioning involves assessing needs, deciding priorities and

strategies, and then buying services on behalf of the population from providers such as

hospitals, clinics, and community health bodies. It is an ongoing process, where the

commissioners constantly respond and adapt to changing needs and circumstances.

METHODS

This was an interview study, using conversational techniques to gather data, within a 5-year

Transition Research Programme funded by the National Institute for Health Research (RP-

PG-0610-10112) to generate evidence for commissioning and provision of better transition

for young people with long-term conditions. This interview study received ethics approval

from the Newcastle University Faculty of Medical Sciences Ethics Committee (ref:

00767/2014).















Data collection






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the interviewer. The interviews lasted a median of 45 minutes, with a range of 27-68

minutes, and were conducted 04/2014-08/2014, audio-recorded verbatim, and later

transcribed. Three interviews were conducted by phone, the remainder face to face.

The interview schedule was piloted with A L C who had both clinical and academic

experience of transition and commissioning. The interview guide was designed to use open

questions, which were used dynamically (as described in Table 2). Questions were not

adapted for different roles, rather the use of probes was tailored to fully elicit different

experiences between roles


Background/ Context

1 Can you tell me what you understand by the term ‘transfer’ or transition’ in health

care? How would you define a “successful transition”?

2 Can you tell me about your role and:

a. How you are or have been involved in transition?

b. How you are or have been involved in commissioning?



undertaken successfully? (Outcomes)



processes that were undertaken to achieve this outcome?



undertaken unsuccessfully? (Outcomes)



processes that were undertaken which resulted in this outcome?

Any other points

7 Are there any other issues which you consider to be relevant that you would like to

discuss?

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Data analysis

The transcripts were analysed using framework analysis.11 Framework analysis allows both

emergent data themes and the explicit recognition and use of a priori issues in the analytical

framework. Framework analysis is increasingly being used within health services research,

and it fitted the aims of our study as we had pre-defined areas we wished to investigate

while remaining open to the emergence of further topics and themes. A series of

interconnected steps within the framework approach describe the processes that guide the

systematic analysis, these steps allows an iterative refinement of themes and are described

below.12

An initial conceptual framework based on literature and researchers’ experiential knowledge

was expanded and modified in iterative cycles using themes emerging from the data. This

produced a cumulative, refined framework that integrated the initial conceptual framework

and the study results. The specific steps were as follows. Familiarisation: two researchers

(GM, NK) developed an initial sense of the data by reading through a sample of transcripts.

Identifying the initial coding framework: three researchers (GM, NK, SMC) independently

recorded their impressions and deductive themes. GM and NK discussed these impressions,

related them to their previous knowledge and expertise, and agreed the initial conceptual

framework. This process was repeated for six rounds, with the two researchers reading

further transcripts between each discussion round. The discussions consisted of the

researchers talking through the emerging issues, themes and relationships, and agreeing

themes, codes and relationships which were added to the framework. Indexing: Once the

framework became stable (i.e. few modifications were required on each round), GM used it

to ‘index’ the remaining transcripts one by one. This involved ‘sifting and sorting’ the

remaining data and allocating these into the coding framework. The researcher took notes of

any changes to the framework and issues, and these were discussed with NK. This process

was repeated until all data were indexed and the final framework agreed. Charting: Data

from the transcripts were summarised according to the themes and codes (‘categories’) to

reduce the data while carefully retaining the original meanings. References to illustrative

quotations were tagged and managed using Microsoft Word and NVivo10.

Quality assurance



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� The sequencing and posing of questions was carefully

considered, and was dynamic so that the questions promoted

positive interaction between the participant and the interviewer

and stimulated the participant to share their experiences and

points of view 14

� All interviews included an opportunity for participants to comment

on any topic covered in the interview, or any new topic which

they felt was relevant14-17


contrasted



� Frequent de-briefing: study progress, methods, emerging themes

and any issues were reported to and scrutinised by the research



population characteristics (see Results) were clearly recorded

and reported

Dependability

and

confirmability

� To allow a nuanced, multifaceted analysis and reconciliation of

any tensions in the coding and concepts, researchers from

different disciplinary backgrounds with different expertise

contributed to the data analysis, including: GM sociology; NK

behaviour change, NHS practice in long-term conditions; SMC

commissioning, health economics; AC paediatrics; ALC child and

adolescent psychiatry; LV health economics; and DR (in

acknowledgements) NHS management


expertise also helped to ensure that the framework was adapted

to reflect the data rather than making the data ‘fit’ the framework



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� Audit trail: researchers kept field notes (SMC) and a logbook of

data analysis (GM, NK), and established an electronic data

analysis and synthesis trail of the development of the themes

RESULTS


range of roles across the target population (Table 3). Reasons for non-participation were: no

response to email or email follow up; change in role, and lack of time to participate.










NHS director/ manager (n=2)



NHS



Local authority










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Personalised, planned, co-ordinated, collaborative with focused on broad developmental and

life outcomes:








Regional)
















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Challenges

Four meta-themes related to challenges emerged: 1) The broad context: legislation, policy

and wider life transitions; 2) structures, processes, pathways and relationships; 3) Service-

level co-ordination, sign-posting, and relational support; and 4) Outcomes and contract

evaluation.











“(O) mental health conditions that children suffer from do not actually make the grade for

adult mental health services. (O)” (Clinical leader, National)




“(O) [the Government] send guidance on what they think a health need is and what an





responsibility to feed you? (O)” (Commissioner/related manager 4, Regional).

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“(O) Government, is saying, “Well we need to go through to 25” that’s fine, but as long as

there’s an 18-year-old cut-off and there isn’t the fundingO the world isn’t going to change.”




“(O) my role (O) it’s half funded by the local authority (O) I think the principle of a joint post

is good, (O) children in education, there’s links to social care; it’s all a very interlinked (O) [I


health need or a social need, and who should pay (O)” (Commissioner/related manager 4,

Regional)



“(O) whilst we’re aware that [transition] is an issue, we’re also acutely aware that there are

bigger issues at stake (O) you tend to find that the big issues, like the fact that we’re about,


transition (O)” (Commissioner/related manager 5, Regional)




“(O) with CCGs [Clinical Commissioning Groups] and commissioning support, with NHS


council, the education bit and the care bit. (O) Responsibility, process, who to talk to, who,

who is doing what. (O)” (Commissioner/related manager 4, Regional)

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clinician roles.

“(O) [in transition] the paediatrician is referring to an adult respiratory doctor, an adult

gastroenterologist and an adult neurologist to replace [the paediatrician] (O). [who] may

have dipped in and out of the paediatric specialities in those areas (O).” (NHS clinician 2,

Regional)






“(O) the way that commissioning works currently is that (O) usually the providers identify



commissioning a full pathway from start to finish.(O)” (NHS Director 1, Regional)



“(O) we had a very good commissioning team at the time (O) [the commissioners] worked in

the same building. So they had a very good understanding of transition and the gaps (O) the

children’s commissioner worked alongside the adult commissioner (O) once we’d









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“(O) parents build up great relationships with these paediatricians and so, if they’ve got, any





transition there’s no equivalent (O)” (Commissioner/related manager 9, Regional)

“(O) I think we need to involve the GPs from very much earlier on. (O) maybe if you

involved the GP, gives the confidence to the families as well. (O)” (NHS clinician 3,

Regional)



“(O) identifying the children and young people at around [age] 14, 15 then the transition

workers will introduce themselves and begin to get that process in place (O)” (General








“(O) outcomes based commissioning (O) with health, I mean outcomes are so often, you

know, they’re not, (O) it depends on how you determine or define the outcomes (O) it is

very difficult to (O) I think everyone, yeah, sort of talks around outcomes based


(O) it still feels a bit too hard to do and there isn’t this kind of universal understanding of



“(O) it is so complicated and it’s so multiagency (O) we don’t have a shared value base of

what we’re trying to achieve with young people and their families. (O) commissioning circles,

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(Laughter) (O)” (Member of transition planning workforce 3, Regional)


to be difficult.

“(O) you look at it within the contractual management (O) [Historically] commissioning has

been very much [about] (O) number of contacts, number of review appointments, maybe

even staffing numbers (O) all the kind of rhetoric and theory around commissioning for

outcomes (O) everybody talks about it all the time, but to actually make it meaningful (O) it’s

relatively easy to measure activity; it’s very hard to measure outcomes. (O)”




this data.


While the participants provided rich reflections on key characteristics and challenges, there

was limited discussion about any unique steps related to commissioning for transition (as

opposed to commissioning in general). There was little evidence of a specific ‘transition

process for commissioning transition’. Instead, the accounts reflected complex and nuanced

processes entangled with other local and organisational structures, processes, and

relationships as described above. Figure 1 provides a summary output of the results in terms

of stakeholders’ perceptions of the organisational structures, processes and relationships

that drive commissioning for transition. It illustrates the interrelated nature of the themes that

emerged, and reflects the complexity of the commissioning process as described by the

participants.

Figure 1

A visual summary conceptualising the process of commissioning for transition as it emerged

from the data analysis

[Figure 1 to be inserted here]

DISCUSSION

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relation to commissioning for such transitions ranging from inconsistent national guidance,

fragmented resources, incompatible local processes, lack of clear outcomes, and

professional roles and relationships. No single, specific process of commissioning for

transition emerged—instead complex, multi-layered, interactive processes were described.

Commissioners identified clearly the inevitable tension between the need to commission for

personalisation of healthcare, whilst at the same time securing pathways of care. There is no

easy solution to this. One option is for the responsibility for personalisation to lie mainly with

the service providers whilst commissioners set the required pathways of care by purchasing

the necessary staff and facilities.


which provide confidence in the findings. Interviews continued until data saturation was

reached, between subgroups of participants and in general. The data on commissioning

processes specific to transition were thin. It is possible that this is a true finding, i.e. that

there are no steps unique to commissioning for transition, or that a different elicitation

method would have yielded richer data with a different finding. We did not approach young

people to ask their views about commissioning because in the UK, commissioning is very

separate from service provision and patients for the most part only experience services.

Young people in transition have the major task of gradually taking responsibility for their own

healthcare in the context of the services available; we thought it unlikely they would have

knowledge of commissioning. Efforts have been made to engage the public in the work of

commissioners but this has been very difficult and especially difficult to engage adolescents

in discussions about commissioning.18

Our findings concur with other stakeholders’ views on the criteria for successful transition

and further elaborate these by identifying some of the barriers to commissioning for such

transitions.19 For example, the findings on fragmentation in funding and the tendency to

commission individual, single solutions as opposed to pathways provide possible

explanations for the “gap” between children’s and adults’ services reported in studies with

service users. Notably, these types of learnings are likely relevant across commissioning

systems and thus has the potential to inform commissioning beyond the study setting of the

UK.

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exercises 21 22.

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of young people with complex health needs from childhood to adulthood? In: report to NIHR:

Programme Development Grant. Newcastle: Newcastle University, 2010.






failed to make the transition from child to adult services: the TRACK study. BJPsych 2016;40(3):142-

48.


and Professionals in the United Kingdom: A Qualitative Study. Psychiatr Rehabil J 2012;35(3):251-57.



2014;51(1):123-35.





9. WHO. The WHO Health Systems Framework [Available from:

http://www.wpro.who.int/health_services/health_systems_framework/en/.




12. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse Researcher

2011;18(2):52-62.







2010;15(3):754-60.











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125x94mm (300 x 300 DPI)

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where available. Given the complexity and ambiguity of the terms „commissioning‟ and

„transition‟, all alternative terms were used in order to be as thorough as possible. Search












Commissioning search terms “Delivery of Health Care” OR [(Contract Services OR Contract* OR Commission* OR fund*



Transition search terms Transition to Adult Care OR Health Transition OR transition* OR continuity* OR pathway




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1. Non-English Language 2. Transitions other than from children’s services to adult services 3. Populations other than young people with ‘complex health needs’ as defined for the

research programme 4. Only identify current problems to transition, no mention of approaches to improve

transition or barriers to successful transition Full text criteria 1. It was a book 2. Not an academic or peer reviewed research study 3. Transition papers with no focus on commissioning (or related) processes 4. Focus of the paper not on commissioning or transition processes in the NHS

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Transition n = 1351

Commissioning n = 121,211


Records excluded for: not NHS, not transition of adolescents,

not complex health needs, and/or no focus on improving

transition, implementing successful transition or barriers

to successful transition n = 224

Full text articles assessed for eligibility (after duplicates removed)

n = 67

Academic, peer reviewed literature about commissioning for transition

n = 0

Records excluded for: only book availability, US papers with

insurance focus, not academic or peer-reviewed research study, not

specific, no focus on improving transition, implementing successful transition or barriers to successful

transition, and/or no focus on commissioning

n = 67

Publications not specific to commissioning but potentially

informative for programme n = 18

Commissioning AND transition n = 303

Excluded non-English language records n = 12

Scre

en

ing

Incl

ud

ed

Elig

ibili

ty

Ide

nti

fica

tio

n

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written by same authors. „Snowball‟ referencing was used to retrieve references cited in key






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SCIE search terms

„Commissioning for Transition‟ – simple search box didn‟t permit combining terms with „AND‟

/ „OR‟ in same manner as Academic database search.

HMIC search terms





AND




AND



AND

„Adults‟ or „Young People‟












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1 Commissioning






Social Care Institute for Excellence SCIE (1996 - )


Records excluded for: transition of commissioning practice/structure,

not healthcare (social or educational focus), developing

country, not transitioning adolescents with disability, lack of

content in either transition or commission (or equivalent)

n = 144

Full text articles assessed for eligibility SCIE: n = 13 (and 7 unavailable)


Literature included narrative synthesis SCIE: n = 7

HMIC: n = 7

Records excluded due to lack of content or focus on specifically commissioning for transition in

health care SCIE: n = 6, HMIC: n = 7

‘Useful’ publications identified SCIE: n = 4, HMIC: n = 3 Partial relevance / not

commissioning

Commissioning and transition SCIE: n = 125 HMIC: n = 46

Scre

enin

g In

clu

ded

El

igib

ility

Id

enti

fica

tio

n

Health Management Information Consortium HMIC (1996 - )

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and co-ordination.


A number of recommendations were made for robust or a „successful and consistent‟














The „age conundrum‟ was identified as a barrier to successful transition 4. This means that at






variation in suggestions for how this „age boundary‟ challenge should be addressed. Some

suggested a distinct young person‟s service, e.g. spanning age 14-25; whilst others




1.3 Funding





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person‟s care 5.

1.4 Co-ordination







representatives from children‟s and adult‟s services, the voluntary sector and service user










avoid crises 9.


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and coordination.










document 7 11.




physicians may have little experience in „paediatric‟ diseases in adult life” and as such the










2.5 Holistic care

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roof 12.






families‟ experiences 7. One of the five ambitions, promoted by Youth Access, is that




3 Conclusion









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nlyReferences

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9. RCGP., RC PSYCH. Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups (CCGs). In: Royal College of General Practitioners RCoP, Learning Disabilities Observatory, ed. London: http://www.improvinghealthandlives.org.uk/securefiles/170405_1846//RCGP%20LD%20Commissioning%20Guide%202012%2010%2009%20FINAL.pdf, 2012.

10. Department of Health. Valuing people now: a new three-year strategy for people with learning disabilities. Making it happen for everyone. London: Department of Health, 2009.

11. National Autistic Society. Discussion paper: Improving commissioning standards in services for ASD Patients. London: National Autistic Society, 2006.

12. Youth Access. Making integration a reality. Part 2 - developing effective holistic services for young people in transition. . London: Young People's Health Partnership, 2014.

13. Together for Short Lives. Commissioning children's palliative care: a guide for Clinical Commissioning Groups (CCGs). London: Together for Short Lives, 2013.

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