Improving Diabetes Care in Inpatient Mental Health Settings

Diabetes is two to three times more common among those with serious mental illness than in the general population, which is why improving diabetes care across Mental Health Trusts is a priority. 

Until recently Acute Trusts have been auditing diabetes inpatient care using the National Diabetes Inpatient Audit (NaDIA), in order to assess local practice, identify best practice and recognise improvements. However, despite the prevalence of diabetes among those living with serious mental illness, diabetes inpatient care is not currently audited within mental health inpatient settings. 

Following a test pilot in Southern Healthcare NHS Foundation Trust (2017) and South London and Maudsley NHS Foundation Trust (SLaM) (2014), the London Physical Health Leads Network created an audit to assess diabetes inpatient care across all London NHS Mental Health Trusts. 

The London Physical Health Leads Network is a partnership between the HIN, UCLPartners (UCLP) and King’s Health Partners (KHP) Mind and Body Programme.

Findings have already been shared with the nine London NHS Mental Health Trusts, and many are already taking action to improve diabetes care including: 

• Launching a weekly physical health forum to discuss improvements eg management of hypoglycaemia. 
• Secured funding to introduce diabetes training for staff and patients. 
• Recruitment of staff to undertake Quality Improvement projects based on various outcomes from the audit. 

“Good healthcare can significantly improve outcomes for people with diabetes, yet those with serious mental illness are more likely to miss out on this care. Despite great local initiatives there is no accepted standard for care of mental health inpatients who have diabetes. The London Physical Health Leads Network believes that this needs to change and we are delighted to present this audit as the first step.”

Dr Ed Beveridge, Dr Kate Corlett – Co-chairs, Pan-London Physical Health Leads’ Network

Report Summary

Improving the diabetes care of people with serious mental illness (SMI) is a priority for the London Physical Health Leads Network, a network hosted by UCLP, the HIN, KHP Mind and Body Programme and the Physical Health Leads from across the nine London NHS Mental Health Trusts. 

In comparison to acute inpatient settings that have had the benefit of the national diabetes inpatient audit (NaDIA) tool, there is currently no standard national audit for diabetes care in mental health settings. Following a test pilot in Southern Healthcare NHS Foundation Trust and SLaM, the HIN collaborated with SLaM, KCH and the London Diabetes Clinical Network to create an audit, based on the NaDIA, to assess diabetes care in inpatient mental health settings. 

The newly created audit was piloted on seven inpatient wards at SLaM. The audit findings were then analysed and retested to inform adjustments to the template before it was rolled out the remaining eight London NHS Mental Health Trusts completing the audit. 

A wide range of inpatient clinical wards were represented in the audit, including:  

• Acute Adult Ward (Mixed)
• Forensic 
• Acute Adult (Male)
• Older Adult  
• Mixed Psychiatric Intensive Care Unit (PICU) 
• Acute Adult (Female)  
• Rehabilitation  
• Female PICU 
• Children and Young Person 
• Male PICU  
• Forensic (Female)  
• Triage  
• Learning Disability  
• Perinatal

The report makes 23 recommendations

• Integrated Care Systems (ICSs) / Trusts to consider:
  • The provision of diabetes specialist roles for mental health inpatient settings; 
  • How to ensure diabetes specialist pharmacists form part of the Mental Health Trust pharmacy teams, educating ward staff to support safe insulin usage.
  • Mental Health Trusts to communicate with their wards: 
  • Who their Physical Health Champion is, their role and how to contact them;
  • How to access diabetes specialist clinicians;
  • What out of hours services are available and how to access them;
  • How to contact diabetic emergency services. 

• Mental Health Trusts to consider: 
  • Types of education they currently offer to staff, patients and carers;  
  • Provision of training in various languages and inclusion of cultural variances to ensure every population is included; 
  • Ensuring patient education is holistic; 
  • Introducing the Diabetes Know Your Risk Tool to wards that do not currently screen for diabetes on admission or consider alternative systems to flag if a patient has a diabetes diagnosis on admission; 
  • Offering patients the option to be involved in their diabetes care during their inpatient stay; 
  • Ensuring appropriate information to support self-management is available for inpatients; 
  • Having a diabetes self-management policy which is communicated with all wards; 
  • Seeking dietician support for wards that are not currently working with a specialist or non-specialist dietician;
  • Providing patients with the opportunity to give weekly feedback on their meals; 
  • Where Trusts do not have access to care plans for patients with diabetes, consider liaising with the wider system to understand if this is available for them or creating a shared care platform; 
  • Ensuring multidisciplinary team members understand if a patient with diabetes has a care plan and how to access it;
  • Having an effective electronic patient prescribing system for detecting, recording, and avoiding errors in insulin and oral hypoglycaemic agent (OHA) prescribing errors;
  • Ensuring Web-linked blood glucose and ketone meters are actively used to alert diabetes specialists across the Mental Health Trusts and at ward level;
  • Accelerating the roll out of digital systems and associated apps to support patients living with diabetes; 
  • Introducing a risk scoring system for all hospital admissions; 
  • How each ward accesses diabetes specialists, Multidisciplinary Diabetes Foot Teams (MDFTs) and Tissue Viability Nurses;
  • Using the Malnutrition Universal Screening Tool (MUST) and reviewing MUST scores weekly as advised.