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Keywords:

  • consultation–liaison psychiatry;
  • diabetes;
  • health services;
  • psychology;
  • survey

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

Aims  To assess the availability and types of psychological services for people with diabetes in the UK, compliance with national guidelines and skills of the diabetes team in, and attitudes towards, psychological aspects of diabetes management.

Methods  Postal questionnaires to team leads (doctor and nurse) of all UK diabetes centres (n = 464) followed by semi-structured telephone interviews of expert providers of psychological services identified by team leads.

Results  Two hundred and sixty-seven centres (58%) returned postal questionnaires; 66 (25%) identified a named expert provider of psychological services, of whom 53 (80%) were interviewed by telephone. Less than one-third (n = 84) of responding centres had access to specialist psychological services and availability varied across the four UK nations (= 0.02). Over two-thirds (n = 182) of centres had not implemented the majority of national guidelines and only 2.6% met all guidelines. Psychological input into teams was associated with improved training in psychological issues for team members (P < 0.001), perception of better skills in managing more complex psychological issues (P ≤ 0.01) and increased likelihood of having psychological care pathways (P ≤ 0.05). Most (81%) expert providers interviewed by telephone were under-resourced to meet the psychological needs of their population.

Conclusions  Expert psychological support is not available to the majority of diabetes centres and significant geographical variation indicates inequity of service provision. Only a minority of centres meet national guidelines. Skills and services within diabetes teams vary widely and are positively influenced by the presence of expert providers of psychological care. Lack of resources are a barrier to service provision.


Abbreviations
NICE

National Institute for Health and Clinical Excellence

NSF

National Service Framework

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

Psychiatric disorders and psychological problems are common in diabetes [1]. There is a twofold increase in depression [2–4] and eating problems [5] and these are associated with suboptimal glycaemic control [6,7]and increased mortality [8]. There are cost-effective treatments for depression in diabetes [9] and psychotherapeutic approaches to improve glycaemic control [10–13] but, despite this, the majority of psychological and psychiatric problems go undetected and untreated [2,14].

There are no formal clinical pathways for delivering expert psychological care in diabetes. The National Service Framework (NSF) has set standards to provide counselling (standard 3) and management of depression (standard 12) [15] and the National Institute for Health and Clinical Excellence (NICE) has also made explicit recommendations [16] (Table 1).

Table 1.   Proportion of diabetes centres complying with each national guideline (n = 267 centres)
Guidance or standardAgree that guidelines necessary (%)Currently meet the guidelines (%)Actively addressing any deficit Perceived requirements needed to be able to meet guidance/ standards
  1. MDT, multidisciplinary tear; NICE, National Institute for Clinical Excellence; NSF, National Service Framework.

NSF standard 3: counselling/behaviour change support skills97.064.039.2%Not asked
NSF standard 12: depression surveillance and management89.572.024.4%Not asked
NICE 1: alert to depression/anxiety98.524.0Not asked68.0% more MDT training 87.0% more psychological staff
NICE 2: detect and manage non-severe psychological problems across cultures94.037.0Not asked53.0% more MDT training
NICE 3: familiar with counselling and psychiatric medication92.038.0Not asked52.0% more MDT training
NICE 4: alert to eating disorders99.035.0Not asked60.0% more MDT training 83.0% more psychological staff

The aim of this national survey was to describe and quantify the provision of psychological services for adults with diabetes and the extent to which national guidance was being met.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

Design and setting

A cross-sectional postal survey was sent to all diabetes centres (n = 464) in the UK. Paediatric and retinal screening units were excluded.

The survey was carried out from August 2006 to October 2007 in two stages. Part 1 was a questionnaire sent to both the senior physician and nurse of each centre. Non-responders were sent a second questionnaire 1 month later. Part 2 involved a telephone interview with the relevant provider of psychological care (defined as psychologist, psychiatrist or other mental health professional, such as psychiatric nurse) identified in completed Part 1 questionnaires.

Measures

In Part 1, the questionnaire measured the quantity, as defined by number of sessions per week, and types of psychological services, adherence to national guidelines and intrinsic team skills in and attitudes towards the psychological care of people with diabetes.

We defined ‘psychological services’ as those provided by mental health professionals (psychiatrists, psychologists, psychotherapists and counsellors). They were labelled ‘expert providers’ if they had sessions specifically for diabetes patients.

Psychological problems were categorized as: mild (such as adjustment problems or difficulties with optimizing diabetes self-care regimen); moderate (such as anxiety or depression, diabetes-specific anxieties including fear of hypoglycaemia and fear of needles); and severe (usually requiring secondary mental health services, e.g. psychosis and high risk of suicide). We derived six standards of psychological care for people with diabetes from the NSF and from NICE (Table 1).

In Part 2, the structured telephone interview with the expert provider covered the nature, type and organization of psychological treatments available, ease of access and setting. Perceived gaps in service provision for psychological problems were explored.

spss (v15; SAS Institute, Cary, NC, USA) was used for statistical analyses. Continuous data were non-normally distributed and were analysed using non-parametric tests. Chi-squared tests were used for categorical data.

The full methods and questionnaires used can be viewed on the Diabetes UK website [17].

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

Expert psychological input into teams

Two hundred and sixty-seven centres (58%) returned Part 1 questionnaires; 85 (32%) reported expert psychological provision and 66 (25%) identified an expert provider of psychological services, 53 (80%) of whom were interviewed for Part 2 (Fig. 1).

image

Figure 1.  Flowchart of responders.

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There were national differences in the proportion of teams that had expert psychological input (Northern Ireland 44%, Wales 6%, England 33% and Scotland 31%). The differences in provision between Wales and England (P = 0.02, Fisher’s exact test) and between Wales and Northern Ireland (P = 0.02, Fisher’s exact test) were both statistically significant.

Expert providers were predominantly clinical psychologists (58%), with the remainder comprising liaison psychiatrists (18%), psychotherapists (4%), counsellors (4%) or other therapists (18%). Just over half (59%) of centres provided a defined service for people with diabetes. The median number of sessions (half days) for psychological care was 2.5 (range 0.25–11) per week per team. The most common treatment offered was cognitive behaviour therapy (CBT) and over 90% offered care for psychological problems of moderate severity.

Where it existed, expert psychological provision was associated with a perception by respondents of better skills by the team in managing moderate and severe psychological problems (P ≤ 0.01), improved training for the team in psychological issues (P < 0.001), and increased likelihood of having psychological care pathways (P ≤ 0.001), but no increase in the availability of screening or assessment tools for psychological well-being (P = 0.10).

Psychological components intrinsic to teams

Under half (41%) of questionnaire respondents (Part 1) stated they had one or more ‘non-psychological’ team member trained in psychological therapies. A minority (12%) of centres had screening and assessment tools for psychological problems and a majority (80%) had no protocols or guidelines for referral of patients with psychological problems of moderate severity. Approximately half (49%) had referral pathways to specialist care for patients with more severe mental illness.

Compliance with national standards and guidelines

With regard to national guidance (Table 1) over two-thirds (69%) of centres did not comply with the majority (≥ 4/6) of guidelines or standards; only 2.6% complied with all six and 26% did not comply with any. This was despite high levels of agreement by respondents with the appropriateness of the guidance.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

This is the first national study of the state of provision of psychological care for adults with diabetes in the UK. Only one-quarter of diabetes centres had direct access to psychological care for their patients. The majority of diabetes services do not meet national guidance for delivering psychological care in diabetes. Expert psychological care is highly variable in type, quantity and quality when compared among diabetes centres and also among regions of the UK, indicating a clear inequity of service provision. Service availability seems to depend on the presence of an interested psychologist or psychiatrist in the local area rather than a coherent national plan. Lack of resources also appears to be a barrier to service provision.

Our survey relied on subjective reporting of quality and quantity of service provision and our findings may be an overestimate of services because of centres with psychological input possibly being more likely to respond to the postal questionnaires. Similarly, those interviewed by phone may have been biased in terms of optimism about services. Previous surveys estimated availability of psychological care at 50% [18,19]; however, this would be an overestimation when compared with our findings.

The Darzi Report on the future of the National Health Service (NHS) [20] states ‘there is no physical health without mental health’ and that there has to be equity in the availability of services. One solution to the current inequity suggested by our survey is to encourage commissioners to require services to offer evidence-based identification, assessment and treatment of psychological and psychiatric problems. Another solution would be for the development of local and national guidelines for the resources required to provide expert and intrinsic psychological care within diabetes teams at primary, intermediate and secondary level. It is interesting to note that such guidelines, including recommendations for training of psychological professionals, already exist in Germany [21] and these could serve as models for similar initiatives in the UK.

Future studies should monitor the response to this highlighted shortfall in services to ensure national standards are achieved throughout the UK, with consequent benefits for people with diabetes. Cost-benefit analyses of providing such services are also needed.

Competing interests

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References

Nothing to declare.

Acknowledgement

The authors thank Mustansir Alibhai for help with data collection and entry.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Competing interests
  8. References