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Bringing together physical and mental health 1 2 3 4 5 6 7 •• psychological: –– improving psychological functioning •• social: –– providing practical assistance to address social problems. Psychological treatment typically involves CBT to treat a range of problems. These can be motivational issues, depression, anxiety, family conflict or unhelpful health beliefs. Diabetes-specific issues include difficulty in accepting the diagnosis, needle phobia, fear of insulin, and eating disorders (among other things). Examples of social issues that can prevent successful self-management of diabetes include problems with housing or debt. The support workers can provide direct support for these issues or signpost to other services. Patient-led case meetings are held regularly with members of the multidisciplinary team. The purpose of these meetings is to plan and co-ordinate care. By encouraging the patient to lead the meeting, the team can obtain in-depth knowledge of the problems faced by each individual and tailor the support and treatment accordingly. Meetings allow patients to maintain relationships with routine care teams, which helps them to re-engage with them during recovery. Upon discharge, individuals return to routine diabetes care in the hospital, community or in primary care. Outcomes An evaluation of phase 1 (August 2010 to March 2012) and phase 2 (September 2012 to March 2014) found very promising results in relation to improved outcomes (Doherty et al 2016). For example, the average reduction in HbA1c from referral to six months later was greater than the improvements seen with the introduction of new medication and greater than improvements achieved by local community diabetes clinics. Reduction in HbA1c levels can reduce the likelihood of developing complications such as retinopathy and cardiovascular disease. A 1 per cent reduction can decrease rates of diabetes-related complications by up to 40 per cent (UKPDS Group 1998). In addition, statistically significant improvements were achieved in psychological scores relating to depression (PHQ-9 scale), anxiety (GAD7 scale) and diabetes-specific distress (Diabetes Distress Scale). Improvements in social functioning were measured on the ‘Outcomes Star’ scale across multiple domains, including accommodation, personal responsibility and social networks. Appendices: case study site profiles 75
Bringing together physical and mental health 1 2 3 4 5 6 7 The 3DfD team has received positive feedback from professionals and is credited with having increased the skillset of the various diabetes teams – for example, in relation to the types of mental health issues that people with diabetes can experience, and the psychological interventions that can help. The 3DfD model has been adapted for implementation elsewhere at the Hillingdon Hospitals NHS Foundation Trust and Central and North West London NHS Foundation Trust. Key enablers •• Strong leadership and advocacy from the clinical lead for diabetes and the consultant liaison psychiatrists was key to embedding the service and overcoming initial doubts that a bespoke service for diabetes and mental health was needed. •• The 3DfD service has followed an explicit improvement methodology, namely the Plan-Do-Study-Act (PDSA) cycle. •• Close working relationships between 3DfD team members and the hospital and community diabetes teams were helped by consistent multidisciplinary team meeting attendance, an easy referral process and swift responses to referrals. •• Team members have offered and delivered various forms of training to health care professionals in Lambeth and Southwark. •• Advance planning for continuation funding was crucial. The team has engaged with six different commissioning bodies during piloting, which was very challenging; advance communication and negotiation with commissioners was vital. Further information • • Dr Anne Doherty, Consultant Liaison Psychiatrist, King’s College Hospital NHS Foundation Trust. Email: anne.doherty@kcl.ac.uk Appendices: case study site profiles 76
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