Summary
Sherwood Forest Hospital has piloted a specialist service for young adults (YA) of 18-25 years old, with Type 1 diabetes (T1D). A fully integrated approach has been developed, placing the clinical psychologist and dietitian as core members of the YA diabetes team in clinic with the consultant and the diabetes specialist nurse and contributing to all diabetes multidisciplinary clinic appointments. The aim is to provide a proactive and holistic care approach to a vulnerable cohort, by destigmatising discussion about psychological issues and reinforcing the view that the team weighs mental and physical health equally.
Innovation
This innovative service puts holistic care at its heart, providing an integrated MDT, with clinical psychology and dietetics in the team. This not only destigmatises conversations around mental health and eating-related distress but encourages a more psychologically minded approach to care delivery. A ‘Hello to Adult Services’ welcome letter and a YA pre-clinic questionnaire help tailor the MDT clinics to patients’ needs. Person-centred care is delivered in a flexible and amenable style designed for YA. Communication by text and email is encouraged and educational materials and workshops for TikTok, YouTube and Instagram are being developed, as social media is the norm for YA and its use improves engagement. Dedicated specialist nurse time provides rapid-access clinics and YA-focused pump clinics in a seven-day service. Another aspect is routine psychological screening. Having a clinical psychologist in the specialist YA service has enabled more open conversations about psychological well-being.
Equality, Diversity and Variation
The team understood the importance of developing an equitable service and discussed approaches to mitigate against barriers to equality. Finding ways to address neurodiversity and social deprivation was important as neurodiversity is more prevalent in childhood onset T1D than in the general population and associated with poorer glycaemic control. Approaches included keeping healthcare professionals consistent, a quieter waiting room, tailoring communication style, and offering one-to-one appointments to support familiarisation with diabetes technology/carbohydrate counting, etc. YA are also involved in planning. Raising awareness, promoting patient education, implementing screening campaigns and activating patients to take charge of their own healthcare are approaches that have brought a more equitable and appropriate patient-centred specialist YA diabetes service. The service reduces the burden on services and paves the way for a healthier, happier population. People are not ‘hard to reach’ but they are easy to miss so the service was designed to work for local people, in an area with high levels of deprivation. Multi-site clinics were instituted to support and encourage attendance. In the pilot phase patients in focus groups reported that accessibility and reduction in travel costs for attending appointments were key issues. To support YA with low incomes, hypo packs were given out at the regular (four-monthly) MDT appointments.
Results
The service seeks to ‘see the whole person’ and has achieved high attendance rates, significant reductions in HbA1c levels, marked reductions in emergency DKA hospital admissions and meaningful improvements to mood and quality of life. For example, the service helped a T1D patient with a history of adverse childhood experiences who had had frequent hospitalisations for DKA and overdoses. The integrated MDT worked with her complex presentation from a medical and psychological perspective. Consistency in staff was paramount in building trust. With flexible reviews by the diabetes specialist nurse and regular text contact, she engaged with the MDT. She now has a continuous glucose monitor, has engaged with mental health services and has greater control over diabetes management. Diabetes practitioners should assess their patients to better understand potential contributors to the disease, and to uncover more about the individual’s social environment. In addition to more common screening assessments of depression or anxiety, they should also assess for trauma. National NHS funding was won to implement this model of enhanced care for YA diabetes services, over a two-year period. The pilot phase completes in March 2025 and final reports will be disseminated in summer 2025. Preliminary results include improved health outcomes and patient engagement, with a 93% attendance rate, a 30% reduction in DKA admission numbers and 40% reduction in Length of Stay. Over the past six months 65 patients have completed self-reported Patient Reported Outcome Measures. These show 35% of YA patients are experiencing significant emotional distress due to diabetes, 52% are in the clinical range for depression, with 20% severely depressed. Also 50% of patients screened have identified eating-related distress. Focused support of mental health and emotional issues and promotion of psychological resilience are priorities in the service. Following psychologically informed care by the MDT and individual therapy for more complex patients, reductions in disordered eating and overall diabetes distress, and improvements in mood and well-being are being observed.
User Feedback
Feedback questionnaires from YA are positive, demonstrating an appreciation of access to specialist support from the full team in the same place, with consistency of staff, including diabetes specialist nurse, consultant, clinical psychologist and dietitian. YA report greater confidence and empowerment relating to diabetes self-care and management. Praise and recognition for the model have come from Sherwood Forest Hospital Trust, Regional Integrated Care Board, NHS England, Diabetes UK, pharmaceutical companies and other NHS Trusts.
Dissemination and Sustainability
The model has been presented at Sherwood Forest Hospital Trust Board, NHS England meetings and Regional Steering Group meetings. The team has also liaised with Diabetes UK and pharmaceutical companies about the service. NHS England has been collecting data since January 2024, with publication of findings due in September 2025. The data will be linked to the National Diabetes Audit and the Secondary Uses Services datasets in order to assess the impact. A YouTube video has been made promoting and disseminating this work. This pilot supports a clear role for an integrated physical health and clinical psychology service as part of routine care for young adult patients with diabetes. With funding beyond the pilot, this can be a model of care to be mirrored across Nottinghamshire and beyond. Protocols are being developed to support rollouts at other sites.
