Diabetes: Mind Over Matter conference

 

So unless you’ve been living under a rock last week you will have noticed that the DSN forum UK in collaboration with NHS England presented the Mind Over Matter conference at BMA house London on Tuesday.  The conference came out of a little idea to improve mental health services in Kent. Rebecca Watt DISN from Medway NHS Foundation Trust had the idea and with thanks to Dr Partha Kar, Lorraine Beverly, Becky Reeve and the rest of the team from Sanofi we were able to make it a reality.  

Dr Partha Kar kindly agreed to chair the meeting and with his vast connections in diabetes he was able to secure some fantastic speakers for the opening talks. The DSN forum had a chat about what we needed in the agenda and after over 100 comments on a post we were able to secure some great speakers from across the country for the workshops.  Partha and I went through the shortlist of examples and got it down to the final 6.  I will talk about them all individually later in this blog. 

On the day the Medway team arrived in our masses, it was so lovely to have the support of my colleagues when doing something like this for the first time, thank you team MedwayAKA the #MedwayMassive

Partha gave an introduction to the day and a thank you to Becky Watt and I for the idea and we were off.  First up was Chris Askew from diabetes UK whom after this event will now be known as the Mr Darcy of diabetes curtesy of Jen for that one.  Chris gave us the patient organisation view point of emotional, psychological and mental health support.  Chris discussed the James Lind alliance priority setting partnership and how diabetes and mental health featured in 3 of the priorities.  

1. Priority 5- What are the cognitive and psychological effects of living with type 1 diabetes
2. Priority 4- How do stress and anxiety influence the management of type 2 diabetes and does a positive mental wellbeing have an effect? 
3. Priority 9- How can psychological or social support be best used to help people with, or at risk of, type 2 diabetes and how should this be delivered to account for individual needs. 

Chris recognised the need for greater investment in research and acknowledged the views of people with diabetes about what we should do to improve mental health support.  He highlighted the APPG spring report findings (see full document here) and enlightened us on responses from people with diabetes from the current survey so far.

Chris then went through the next steps which included publishing policy report of Diabetes UK insight and evidence early next year, working with NHS England and other nations across the UK to develop solutions, and bringing together the research community and people with diabetes to identify areas of research where greater investment could have the most impact.  

Next up was the fantastic Miss Jen Grieves for the patient viewpoint.  Jen wowed the audience with her talk on the impact of living with diabetes day to day.  She kept the whole room of over 120 Healthcare professionals engaged as she told her story.  A few quotes included ‘attached to every pump, pen and glucose meter is a human being’ ‘Diabetes has a constant chipping away at my brain power’ ‘I was never asked about my state of mind, when I did talk about it I was told to get on a plane to Bali’ ‘HCPs need to acknowledge the impact of diabetes care 24 hours per day 365 days per year.  Acknowledge the human side of diabetes and the numbers will follow.’  Jen has tweeted about recording her talk so other HCPs can have a listen. I can’t wait to be able to share this across the DSN forum so you all can have the pleasure of listening to her thought provoking viewpoint.  The world of twitter seemed to agree with Jen on this tweet which was liked 78 times and retweeted 14! 

From patient viewpoint to the GP view.  Dr Abbie Brookes gave a very in-depth take on what support is available in general practice.  Dr Brookes is a GP in York and covers an area of 57,832 people.  Dr Brookes took us through a typical day in General Practice explaining how time is not on our side with 10 minute appointments.  She told us that patients sometimes come in for a totally unrelated reasons and then it may become apparent that mood is low during the consultation.  Dr Brookes told us about what was available locally such as IAPT, access to a wellbeing triage service, CMHT, inpatient care, charity and voluntary sector initiatives and social prescribing.   She talked us through the challenges in diabetes such as the vast amount of appointments people with diabetes already receive and how they do not always want to have more in relation to mental health.  She talked about the GPs limited opportunity to see people with type 1 diabetes and screen for mental health related issues as they are quite often seen by secondary care.  Co-morbidities makesprescribing in general practice difficult and there is concern over giving people access to medication such as insulin which can potentially lead to overdose and death if the person is having difficulties with their mental health.  Dr Brookesdiscussed some of the case studies she had seen in her practice and it was a real eye opener for the audience to hear that GPs are dealing with some very complex cases in their 10 minute appointments,  so next time you are in a GP surgery and they are running late be mindful of that. 

From GP to specialist viewpoint, Dr Richard Holt form Southampton gave us a viewpoint from secondary care.  Dr Holt talked about statistics in mental health in diabetes and how the prevalence of depression was twice as high in those with diabetes compared to those without.  

Dr Holt talked about diabetes distress, depression and the effect on quality of life, depression and it’s effect on self-care, depression and the association with diabetes complications, and the mortality and co-morbid depression and diabetes.  He also talked about the need for holistic care and how people with diabetes and mental health problems are less likely to receive the basic care such as eye or foot examination, screening for HbA1c or cholesterol, structured education and prescription for a statin.  He summarised his talk by stating that access to mental health is an important component of specialist care because; psychological and psychiatric co-morbidity occurs commonly and worsens the quality of life in people with diabetes and that specialist teams can make a difference. One message from Dr Holt quoted from the day on twitter was ‘We are happy to look at feet, urine and blood pressure, so why do we not address the psychological side? It’s not rocket science we can and should be doing this’ This tweet reached over 4000 impressions with 43 engagements.  

After a quick break for coffee break we heard from Dr Claire Reidy who gave us the Psychologist viewpoint.  Dr Reidy was able to enlighten the audience on the potential impact that a psychological service working within a diabetes service can have on improving outcomes, she gave advice on how we could incorporate psychology services into our local diabetes services and how the role of the psychologist can influence improved outcomes and help remove the barriers to patient empowerment and motivation to self-management.  Dr Reidy discussed the current situation giving stats as to the prevalence of diabetes and people with diabetes achieving the recommended NICE targets.  She talked about the minding the gap report from diabetes UK (see full document here) the report showed that expert psychological support is unavailable in the majority of UK diabetes centres and that there were significant geographical variations.  Dr Reidy showed us that poor emotional and psychological wellbeing in people with diabetes is associated with suboptimal glycaemic control, increasing the risk of diabetes related complications, increased costs to healthcare and lost productivity.  Dr Reidy went through points that can have an impact on psychological well being such as diagnosis, transition, pregnancy, new or a change in treatment, onset of complications, change or circumstances, bereavement, and the burden of managing diabetes day to day.  The impact of these challenges can be depression, anxiety, distress, burnout, feeling isolated, sleep disturbances, and eating disorders.  Dr Reidy discussed the DAWN2 study where although 73% of participants received regular HbA1c testing, only 32% reported being asked about being anxious or depressed by a HCP and even less at 23.7% reported that their healthcare team had asked them how diabetes impacted on their life.  She explained to the audience tactics on how to ask the question and referenced the language matters document that was recently released (see Here).  She gave us a good insight in to ways of supporting autonomy see the slide below, very useful thank you for sharing.  

DR Reidy then went on to discuss example in practice and person centred interventions.  She talked about digital heath interventions which were found to improve self-management.  She also discussed the barriers and facilitators in diabetes self-management and the necessity of genuine choice in terms of decision making regarding healthcare.  See below for her summary slide 

Next up Professor Khalida Ishmail gave the psychiatrist viewpoint. Professor Ishmail showed us the prevalence of mental and behavioural disorders and the association when you have diabetes, many of the conditions were 2 or 3 times more likely if diabetes is present.  Dementia was shown to be more prevalent in those who had diabetes and depression. Professor Ishmail showed us the relationship between alcohol intake and progression to type 2 diabetes, with a nonlinear u shape graph. Professor Ishmail went through the association of antipsychotics with weight gain, type 2 diabetes and 20 years mortality gap. Professor Ishmail stated that eating disorders that are associated with insulin restriction such as anorexia and bulimia are associated with a 3 times increased risk of mortality. Professor Ishmail added that the future practice should see diabetes and mental health working together to get the best outcomes for people living with diabetes.  

All through the speakers there was an opportunity to send questions in anonymously via a sli.do website.  I taught myself how to use it over the weekend just before the event and now I’m totally addicted! Expect to see it at every event that the DSN Forum UK does from now on.  It was really easy for participants to use and it meant that people who would normally not ask questions in such a large group of people (like me) would have the chance to send their message to the panel without actually having to stand up and ask it, much easier.   There were questions on the use of language, what should be the goal of interventions for people with diabetes, why do HCPs no routinely refer people to Diabetes UK etc information and forums at diagnosis, do diabetes community teams have CPD/ training budgets and could this be used to access mental health training, what are the plans to tackle compulsive overeating, how do you support the somebody who does not want to address their psychological problems, how can practice nurses mental health skills be enhanced, how does this affect the one appointment one problem rule in general practice, plus many used the sli.do to congratulate the speakers on their talks.   The panel answered as many of the questions as they could but soon it was time to break for lunch.  I got my starring role introducing the workshops and the new timings as we had run over slightly, I was very nervous I hope it didn’t show.  

After a lovely lunch it was time for the workshops.  The workshops were split into 2 groups of 3.  Each workshop ran twice so participants were able to choose 2 out of 3 in group 1 and then 2 out of 3 in group 2. 

Zoe Sherwood from Birmingham and Solihull Mental Health Foundation Trust

Unfortunately Birmingham and Solihull team were unable to attend so I stepped in and did their slides, it was really nice for me to learn about their services and I hope I did them justice when presenting their work.  They have an inpatient diabetes nurse service within their mental health trust, this is quite novel and they are one of the only trusts in the country to have a designated diabetes team inhouse.  Part of their role is to do medication reviews, this was particularly interesting to see the effect some antipsychotic medication has on blood glucose, there was a case study where a patient with a pre-diabetes HbA1c of 44 ended up with blood glucose levels of 55mmols after starting medication for his mental health.  The diabetes team picked this up and were able to refer on to the acute hospital to start insulin urgently.  When discussing the slides with Zoe she told me that often symptoms of diabetes can be masked by those of mental health conditions, once someone has that diagnosis it can be difficult for HCPs to see beyondthis and pick up on symptoms of diabetes as the mental health condition is almost certainly blamed for behavioural issues.  This is why her role is so important, hyperglycaemia can lead to issues with mood, add that to an existing mental health condition and the problem can become much worse.  Zoe also told me about their novel approach to improving retinal screening rates, they are able to share information with the screening team and cross reference those people who are known to their mental health service and have diabetes.  They can check if they have had screening in the last 12 months and if not they can arrange an appointment as an inpatient on day leave or refer onto the community team.  They also are able to ensure those people who may have missed invites due to being homeless or having multiple moves are not missed from the referral invitations.  This has significantly increased the uptake and I look forward to seeing their full report when it is ready later this year.  

 

Debbie Hicks 

Debbie gave an insightful talk about the work in Barnet, Enfield and Haringey Mental Health Trust.  Debbie talked about staff education and the implementation of diabetes mentors.  She talked about safety their action plan for development of a hypoglycaemia policy, adding hypo boxes to wards which may seem like a given to us In acute care but in mental health units these are not common practice.   She also discussed action plans to aid the recognition of hyperglycaemia and ketosis with the addition of ketostix and fully quality assured blood glucose meters so the units can seek appropriate medical intervention in a timely way to avoid diabetic ketoacidosis.   Debbie also told us about the pilot study to take a HbA1c on every admission to the forensic unit (if consent given) and depending on the results can take action in line with WHO criteria.  Debbie also went through some useful case studies to help the audience understand the types of issues faced in this setting.  

 

Ruth Miller and Shantell Naidu

This workshop was split into 2 I will start with Ruth Miller, Nurse Consultant North West London Transformation Program.  Many of you will have heard about Ruth and her 10 point training, this time it was focused on the mental health setting. Ruth’s simple yet effective method has helped to upskill mental health workers in diabetes care across Northwest London CCG.  See below for her 10 points. 

Next up was Shantell Naidu, nurse consultant from Camden Diabetes Integrated Practice Unit. Shantell went through the formation of the integrated practice unit in 2015, their strategy was based on 4 basic principles 

1. A whole system approach, ensuring that the improvement of physical health of people with diabetes and severe mental health illness was everyone’s responsibility, not just the diabetes team. 
2. Pro-active patient centred approach, tackling head on the issue of disengagement, taking care to the patient, rather than waiting for the patient to come to us
3. Building capacity within the system, with a strong program of educational support for diabetes care within mental health services 
4. Monitoring and evaluation, monitoring whether the strategy has had an impact. 

They use; education and support, MDT team case meetings, improved coding, increased consultation times, proactive work by the diabetes team in relation to DNA rates, and a simplification of care plans to improve outcomes of people with diabetes and severe mental illness across Camden.  

Katy Davenport & Jeannie Grisoni Cambridge University Hospital NHS Foundation Trust 

Integrated Psychological wellbeing practitioner service, this is one I was unable to attend as I was delivering the Birmingham talk however I have the information from my colleague Becky Watt who absolutely loved the session.  Becky stated that this talk involved lots of interaction and group work.  They outlined how they managed to form an integrated practice and they made it sound very doable.  Yes it took 7 years and a lot of hard work finding the right people to help but it gave Becky inspiration that it can be done.  They highlighted that its not always about money as the services are there and paid for its just a case of accessing them and integrated them bringing it all together.  

Jackie Fosbury Sussex Community NHS Foundation Trust 

Jackie was able to talk the audience through her psychologically orientated community diabetes service.  She discussed how Brighton and Hove and High weald Lewes Havens CCGs had scope to improve clinical outcomes for people with diabetes in terms of reducing complications, admissions to hospital and length of inpatient stay.  She talked about how they have 2.7 WTE psychotherapists as part of their diabetes MDT.  They see people with diabetes who also have depression, anxiety, disordered eating, diabetes burn out, low level personality disorder, fear of hypoglycaemia, and sexual disfunction.  They provide MDT feedback to the rest of the team, psychological skills training for staff, they can sit in on clinics, and they participate in virtual clinics.  Becky went to this one as again I was doing the second Birmingham talk and I cannot repeat her words as she tends to get very passionate about mental health and it did contain swear words in a good way. Basically she was very jealous of the service that Jackie and her team provide to their patients, thank you for so much for sharing with us Jackie watch this space this may be one Medway will try to replicate.  

 

Last but not least was West Hertfordshire Integrated Diabetes and Mental Health service by Dr Thomas Galliford and Dr Sara McNally.  The team talked about developing a diabetes and mental health team within and integrated service.  See aims and outcomes slide below.  

Another quick coffee break and we went back into the great hall for the finally.  I was able to start of another round of discussions from the tables, each table took turns to say what they had learnt from today.  It was lovely to hear that the day had led to HCPs thinking about the services they provide and how they now feel inspired to integrate mental health more into their practice.  A quick look back to the sli.do questions by Partha and then a thank you to all involved to close the day.  

I hope you have enjoyed reading my take on the day, for the tweets see the #MMdiab18 we started with MOM2018 but this was already taken….another learning taken from the day check hashtags before you announce them haha live and learn. 

 

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