King's College London

Diabetes is a serious and growing problem. Diabetes UK estimates it costs the NHS £1million per hour, a figure that's steadily increasing. A partnership between King's Health Partners, London Boroughs and community organisations has developed a model that will improve the quality of care for patients and enable them to manage their conditions effectively.

People with diabetes can face a complex web of different health and social challenges, which are most effectively addressed with an integrated approach. For example, worries about housing or employment or psychological stress can prevent people managing their condition effectively, and the best treatment deals with all these issues together.

3DFD is a patient-centred multidisciplinary service integrating psychological and social care with diabetes care which has demonstrated improved psychological, social and medical outcomes for patients with multi-morbidity, at risk of diabetes complications, in two of the most ethnically and socioeconomically diverse boroughs in the UK: Lambeth and Southwark. 3DFD comprises clinical psychologists, third-sector support workers and a consultant liaison psychiatrist, integrated into the diabetes teams across primary, community and secondary care. Interventions are tailored to needs and include social support, brief psychological interventions, psychiatric assessment, psychotropic medications and the systemic management of complex patients, integrating mind and body care and addressing health inequalities. The service receives an average of 300 referrals per year: over 1100 patients have been referred into the programme.

On referral, patients had a mean HbA1c of 96mmol/mol (SD 20.3) (10.9% (SD 1.9) DCCT) and reported a reduction in HbA1c of 17mmol/mol, highly significant in reducing the risk of diabetes complications: UKPDS has shown the reducing HbA1c by 10mmol/mol reduces risks of complications by up to 40%. Sixty percent of patients received a new diagnosis of a psychiatric disorder (with 60% depression, a very treatable condition), indicating significant unmet health need. In the year following the intervention, compared with the previous year, 3DFD patients had reductions in A&E attendances of 45%, hospital admissions of 43%, and bed-days of 22%. The service cost £190K for two boroughs but saved £225K in one year (£850 per patient per year): this is a cumulative saving mainly based on the reduction in hospital admissions.

3DFD provides evidence that a multidisciplinary approach is effective and adds value in the management of complex comorbidity in diabetes, with improvements in the domains of psychological functioning, social functioning, biomedical well-being and the appropriate utilisation of health services.

Awards

3DFD was awarded the BMJ Diabetes Team of the Year award, 2014. In addition, the team was awarded an NHS Innovation Challenge Prize in the Diabetes category in 2015: Diabetes, was awarded the Named Mary McKinnon Lecture at the Diabetes UK professional conference in 2015, and in 2011 was awarded three Quality in Care Awards: Community Initiative of the Year (first), Health Inequalities (first) and Best Integrated Care Initiative (second).

Policy

3DFD has been referenced in a number of key local and national policy documents:

• King’s Fund Transforming mental health in London. (in press)
• Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012
• Moulin L, Parsonage M. Why wait to make psychiatric interventions? HSJ, February 2014.
• NHS London Strategic Clinical Networks. London’s care pathway for diabetes. London, 2014.
• NHS London Strategic Clinical Networks. A commissioner’s guide to primary care mental health. London, 2014.
• Mental Health Network; NHS Confederation. Investing in emotional and psychological wellbeing for patients with long-term conditions. London, 2012
• Diabetes UK Case Study: Three dimensions for diabetes (3DFD): Integrating psychological, social and diabetes care for patients with poor glycaemic control. London, 2014.
• WISH Report: Patel V, Saxena S, De Silva M, Samele C. Transforming lives, enhancing communities: Innovations in mental health. Report of the Mental Health Working Group 2013. Presented at the World Mental Health Summit at Qatar.

Publications

Doherty AM, Gayle C, Morgan-Jones R, Archer N, Pryce L, Ismail K, Werner-Hermann A. Improving quality of diabetes care by integrating psychological and social care for poorly controlled diabetes: 3 Dimensions of care For Diabetes (3DFD). International Journal of Psychiatry in Medicine. 2016; 51 (in press).

Doherty AM, Gayle C, Ismail K. 3 Dimensions of Care for Diabetes: integrating diabetes care into an individual's world. Practical Diabetes. 2015; 32: 345–349.

Archer N, Ismail K, Bridgen O, Morgan-Jones K, Pryce L, Gayle C. Three Dimensions of Care for Diabetes: A pilot service. Journal of Diabetes Nursing. 2012 16; 3: 123.

ThinkPublic. Findings from interviews with patients of the 3DFD service: A research report based on interviews with patients of the 3DFD programme. London 2011.