The introduction of a new primary care mental health service for people with diabetes in Sheffield, the Improving Access to Psychological Therapies Health & Wellbeing Service (IAPT-HWS), was driven by the Five Year Forward View for Mental Health (FYFVMH), for parity of esteem between mental and physical health. Also, there was a large unmet need for people with diabetes and additional mental health issues locally. Collaboration between two NHS trusts resulted in a new integrated care pathway offering psychological support as a routine part of physical health care.
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The relationship between physical and mental health for people with diabetes is complex. Depression is twice as prevalent among people with diabetes as in the general population. Levels of emotional distress not requiring mental health services can also be high. Healthcare professionals working with people with Type 1 diabetes need to be alert to the presence of depression or anxiety, particularly if the person reports problems with self-management. Specialist psychological support is a finite resource and existing mental health services lack training in diabetes and the relationship between this and mental health/psychological distress. In 2009 IAPT services started to make psychological therapies accessible for people with depression, anxiety disorders and simple trauma. The FYFVMH (2017) set out plans to expand IAPT services to people with long-term conditions and medically unexplained symptoms. Prior to the development of the Sheffield IAPT-HWS, clinical psychology had been provided into the Sheffield Teaching Hospitals (STH) diabetes team for around 15 years. Anecdotally, this limited resource was used carefully, with only the most acute or complex presentations referred for psychological assessment and intervention. Clinicians perceived an unmet need for the remaining people with diabetes and psychological or mental health needs. Sheffield’s new IAPT-HWS commenced in October 2017. Commissioned by Sheffield Clinical Commissioning Group (CCG), the HWS works in partnership with the CCG, STH NHS Foundation Trust, primary care and community partners to deliver an ambitious integrated IAPT programme within ten medical pathways, including diabetes (Types 1 and 2). It provides new options for people with diabetes who are also struggling with anxiety, depression or trauma. The more acute and complex presentations, including those where MDT working is necessary, can still be seen by the diabetes psychologists, but there are alternatives available with IAPT-HWS for the rest.
A steering group was established in 2017, with IAPT staff training in a range of long-term conditions, including diabetes, started in September 2017. This equipped the team to deliver psychological interventions, taking the person’s diabetes into account. The HWS developed rapidly, with courses and individual support available from October 2017. Initially patients self-referred to IAPT-HWS, so it was essential that diabetes clinicians had the knowledge and skills to point patients to the service. Promotional material was developed, with leaflets and posters displayed at both hospital sites and included in hospital appointment letters. Information was disseminated to the whole service at the STH diabetes annual away day (April 2018). Service and referral information was also shared at meetings of diabetes dietitians, specialist nurses and consultants, an animation was played in diabetes clinic waiting areas, and DAFNE and DESMOND courses offered IAPT-HWS leaflets. STH clinicians noticed that self-referral was a barrier to patient access to IAPT-HWS, so a ‘direct booking’ system was agreed. The diabetes clinician (with patient consent) uses the patient electronic record to make a referral to IAPT-HWS for a telephone assessment. This has integrated IAPT-HWS into STH clinical record functions and has increased the number of people with diabetes accessing the service.
Prior to IAPT-HWS, interventions for mood/diabetes were only available from the limited diabetes psychologist service. GPs seeing those accessing generic mental health services were unlikely to know about diabetes. In one year of IAPT-HWS (2018/19), 157 people with diabetes entered the service and 114 completed treatment. Uptake of IAPT-HWS by diabetes patients was boosted through a direct referral system, started in February 2019. There were 32 referrals from STH to IAPT-HWS from February to April 2019, each booked for a telephone assessment. Of these, seven did not attend the assessment (21.9%) and one was not assessed as she was awaiting assessment at a more suitable mental health service. Assessment was completed for 24, 20 of whom (83.3% were suitable for IAPT-HWS and four unsuitable [16.6%]). Overall there has been a significant uptake of IAPT-HWS by people with diabetes and most have been suitable for IAPT-HWS options. IAPT-HWS uses the IAPT Minimum Data Set to evaluate the impact of interventions: mental health – PHQ-9 and GAD-7 (or alternative measure for specific anxiety disorder); perceptions of physical health – Diabetes Distress Screening Scale; health care utilisation – Client Service Receipt Inventory; and patient experience is collected via feedback forms at end of treatment. In the financial year 2018/19, 157 people with diabetes entered the service and 114 completed treatment. Most people with diabetes saw a significant improvement in their anxiety and depression following treatment by IAPT-HWS.
Sustainability and Spread
With effective collaboration it was possible to implement change across NHS trust boundaries, and make a new service accessible to patients, without any extra resource from the hospital diabetes team. There is a commitment from both services for this collaboration to continue. In April 2019 it was agreed that diabetes patients with an identified mental health need would be asked to consent to referral to both clinical psychologists in diabetes and IAPT-HWS. In this way, patients consent to move between services to the most suitable level and type of intervention. There is an ongoing commitment from the STH diabetes team to include IAPT-HWS in team events. Mutual respect between the teams offers multiple opportunities for joint working and collaboration in the future. Continued audit suggests that the majority of those referred attend a telephone appointment and IAPT-HWS services suit their needs. The next steps are to ensure that referrals to both clinical psychology and IAPT-HWS are embedded across the whole STH diabetes team.
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