Summary
Diabetes Care for You (DCFY) is a community diabetes service provided by Sussex Community Foundation Trust (SCFT), commissioned in 2016 to provide care to two Clinical Commissioning Groups (CCGs). It integrates diabetes psychotherapy and emotional support with the patient pathway and the multidisciplinary team (MDT). This includes clinical work with women with sexual dysfunction, contributing to group education for Type 1 (T1) patients and providing psychological information for a new Type 2 (T2) education curriculum. A specific eating disorder pathway was created for T1 (Diabulimia) and T2 patients with Binge Eating Disorder (BED). Psychological assessment is in place for patients requiring insulin pump therapy and the team works with the young adult clinic (YAC) MDT. Two psychological approaches are used: Cognitive Analytic Therapy (CAT), where patients are treated holistically, but focus is on aspects of diabetes management causing distress or harm, and Low Intensity Cognitive Behaviour Therapy (LiCBT), for patients who want to self-care but need support with needle phobia or exercising, for example. Psychotherapy supervision is available to all in the MDT and psychological training is provided.
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Innovation
Diabetes services traditionally focus on education, and government initiatives for mental health have focused on behavioural approaches for single, homogeneous emotional difficulties, such as anxiety or depression. But if emotional heterogeneous (complex multi-comorbidity) problems are not considered within the diabetes team, mind and body remain separate. Diabetes staff may be unclear about the support patients are offered out of house and patients benefit from seeing psychological staff with diabetes knowledge. People with diabetes require multiple appointments, so offering mental and physical health in one venue is efficient, supports the patient and reduces local healthcare costs. Diabetes psychotherapy provided by DCFY is a novel, in-house and integral form of multidisciplinary working, featuring psychological considerations in all aspects of the diabetes care plan. CAT, unlike CBT, is ‘relational’ and deals with the patient’s relationship with self-care. Sustainable improvement can be achieved by examining ‘why do I do this’, rather than treating observable symptoms. Early life experiences are a key component of diabetes psychotherapy. In-depth psychological work helps patients develop enduring skills to manage their lives. LiCBT analyses behaviours, emotions, physical symptoms and thoughts that are maintaining issues. People with long-standing problems, like sexual abuse, receive deeper treatment. Uniquely, DCFY offers patients flexibility to ‘step-up’ or ‘step-down’ within the psychotherapy team, tailoring their treatment and working within their psychological, cognitive and educational capabilities. The psychotherapists train staff in ways to discuss sensitive subjects, such as sexual dysfunction, insulin omission and (binge) eating disorders. The team participates in the T1 education programme and describes the psychological aspects of diabetes and treatment available. It also designed the psychological input for a new T2 group education curriculum. Women with diabetes are twice as likely to experience sexual dysfunction as those without, so a specific intervention was developed.
Method
A psychotherapy team was recruited with knowledge of, and interest in, diabetes. Members attend all MDTs, specialist meetings and young adult clinics (YAC). Letter templates, posters and handouts ensure a psychological input across all clinics. Patients are psychologically screened by the MDT using four questions and, if necessary, referred to the team for an in-depth telephone conversation to elicit the patient’s perception of their difficulties and goals. These patients are discussed weekly and allocated to the appropriate therapist. Full assessment utilises the Diabetes Distress Scale (DDS17), the Patient Health Questionnaire (PHQ9) and Generalised Anxiety Disorder (GAD7). The psychological service is explained in group education programmes, describing the referral process and the relationship between emotional wellbeing and diabetes management. Patients are given handouts on ‘obstacles to goals’ and ‘relapse prevention’. MDT education is provided on female sexual dysfunction and information sheets are available in waiting rooms. There is a tick box on the nursing and consultant template to ensure this conversation takes place.
Results
The MDT feels supported and better placed to manage diabetes education. Appointments are more effective and cover both the physical and psychological dimensions. Nationally, male mental health is poor, with male patients reluctant to ask for help. Improved Access to Psychological Therapies (IAPT) has a male access rate of 36% but DCFY averages 41%, reflecting the normalisation of psychotherapy provision in the diabetes care pathway. The effectiveness of psychotherapy is shown by drops in anxiety, depression and diabetes distress among the cohort. The 85 recipients had an average drop in HbA1c of 9mmols between pre- and post-therapy. Patients report the effectiveness of the psychotherapy via Friends and Family (qualitative) documents. Pre- and post-test questionnaires and blood results are used to monitor wellbeing and HbA1c levels. The female sexual dysfunction work won the NHS Trust’s Quality Improvement award in 2018. Both patients and staff feel that this conversation is comfortable, acceptable and an important component of diabetes care. Psychotherapy input to the YAC improves transition from paediatric to community care and rates of diabetic ketoacidosis (DKA) and hospital admissions within this cohort are being monitored.
Sustainability and Spread
As the psychotherapy team works within the MDT, sharing of knowledge, skills and ideas is regular and ongoing. Challenging/non-engaging patients are often supported by the team. Role-modelling, in joint appointments trains staff while ensuring that vulnerable patients receive comprehensive and holistic care. Members of the MDT now have the tools and skills to discuss emotions. Weekly virtual supervision slots allow staff to discuss psychological solutions to difficult consultations. Team members are involved in policy development and planning across the UK and speak on sexual dysfunction in women, eating disorders and mental health and diabetes at conferences and in the media. Psychology is a fundamental part of the new T2 education curriculum, to be rolled out across Sussex. The service has been recommissioned until June 2021.
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