Mental health at the centre of diabetes care
Mental health should be at the centre of every patient’s care. Anyone working in diabetes care recognises the importance of this. However, with the increasing workload in primary and secondary care, and multiple demands on time, there are concerns about our capacity to deliver ‘parity of esteem’ in diabetes.
Since the publication of the coalition government’s ‘No Health Without Mental Health’ in 2011, access to psychological services has increased. However ‘The Five Year Forward View for Mental Health’, published in 2016, points to underdeveloped models of mental health care, lack of comprehensive standards, and a lack of evidence for effective interventions. At the same time, the document identified training gaps among healthcare professionals and recommended:
· training programmes focused on caring for people with mental health problems
· coordinated care for patients with multiple comorbidities and long-term conditions
· multidisciplinary teams engaging in the development of local services
· collaborative working with specialists.
These gaps in the system and training have to be addressed but the issues of how to link diabetes care with mental health services, and what training in diabetes and mental health is needed, are still vague.
More questions than answers
In Oxfordshire, we still have more questions than answers about both service organisation and training of non-mental health specialists. We also have concerns about whether the local healthcare system supports healthcare practitioners well-enough to effectively address the mental health needs of patients with diabetes.
· Do GPs, practice nurses, consultants and diabetes specialist nurses know where to refer or signpost their patients if they cannot effectively support them anymore?
· Are staff coping with the volume of patients and is it straightforward for them to make a decision as to which service is most appropriate?
· Is it clear to staff at what point patients should be referred or signposted to a specialist mental health service?
· Are staff informed about the timeframe of the external support and what is expected of them after the patient is discharged from the specialist service?
Diabetes-specific training in mental health
The need for a diabetes-specific approach to mental health training has been already expressed in a joint report by NHS Diabetes and Diabetes UK (2010), Emotional and Psychological Care and Treatment in Diabetes. The question remains as to what knowledge, skills and attitudes newly trained and well-established healthcare professionals currently have to deliver mental health care to people with diabetes. We need to think about which competencies related to mental health awareness and psychological skills should be included within the curriculum for diabetes care and other long-term conditions.
Virtual clinics
To address the above concerns, as part of the Oxfordshire Integrated Diabetes Care Programme, we have been organising virtual clinics with primary care practitioners and mental health specialists (a consultant psychiatrist) to discuss patients with diabetes who do not achieve their clinical outcomes. Liaising with mental health specialists is a well-established practice, but the approach we took was to bring this expertise into the team and make it available to all patients struggling with their diabetes management, not only those we thought may have mental health problems.
The initial feedback on this type of collaboration is very positive; team members appreciate finding out about available interventions, identifying gaps in the service, and having reassurance about the quality of care provided. This approach supports more formal training in mental health, and also ensures development of psychological awareness (for example recognising the reasons for non-adherence to treatment) and psychological skills (for example patient communication needs) in diabetes.
As a result, non-psychological specialists build their confidence in working on physical and psychological aspects of health concurrently. Importantly, team members are also able to reflect on their reactions and frustrations with particularly challenging patients, and feel empowered to continue working with them – particularly relevant in the current climate of financial constraints and workforce burnout.
References:
1.HM Government and Department of Health (2011) No Health Without Mental Health: a cross-government mental health outcomes strategy for people of all ages. Link
2.The Mental Health Taskforce (2016) The five year forward view for mental health. Link
3.NHS Diabetes and Diabetes UK (2010). Emotional and Psychological Care and Treatment in Diabetes. Report from the emotional and psychological support working group of NHS Diabetes and Diabetes UK. London: Diabetes UK. Link