Experiencia del Convitto Ecclesiastico

Primary care is an important component of diabetes care and it is much more oriented and resourced to deal with it. Which makes the findings of poor liaison and poor knowledge of local diabetes services seem strange. However, there is evidence of problems in the interface between primary care and mental health where care gaps can lead to patients getting poorly co-ordinated care or falling through the net altogether (Druss 2007).

This study has found problems with the interface between mental health and primary care services relating to poor knowledge and confidence of MHNs

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regarding local diabetes services was low. The lack of integrated care in conditions such as diabetes runs contrary to best practice but a lack of involvement seems common in such cases e.g. Oud et al (2009) found a lack of GP involvement in MHSUs treatment plans; only 12% (n= 23) out of 186 GPs agreed they were involved.

Oud et al (2009:6) stated that their study found that the

“...collaboration between GPs and mental health specialists in chronic cases leaves much to be desired. There is no cohesion in the care given.”

This study concurs with this. While some diabetes care was given, it was not delivered in an integrated way, which increases the risk of a lack of continuity of care. This can have a great impact on the quality of care given and the outcomes for patients for complex long-term conditions such as diabetes. For example, Cabana and Jee (2004), in a systematic review found sustained continuity of care improved quality of care and receipt of preventive services for patients with chronic conditions such as asthma and diabetes.

Levinson-Miller et al (2003:1159) used interviews to explore MHSUs perceived barriers to primary care. They found that around 40% (n=21) of respondents indicated that coordination between their medical and mental health caregivers was poor, 45% (n=23) said that their mental health provider did not ask them about medical issues, and 39% (n=20) said that their medical provider did not ask about mental health issues. Furthermore, overall experience of medical care quality was poor. This is similar to the experiences of service users in this study. However, while Levinson-Miller et al (2003) findings where suggestive of poor integration of care, this study suggests that there is a purposive splitting of mental and physical health.

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This study has found what appears to be a splitting of both complex long-term conditions, which has resulted in two distinct illness identities, or labels; (i) the diabetic and (ii) the mental health service user. The outcome of this separation is that the MHSU is largely ignored in primary care and the ‘diabetic’ is largely ignored in mental healthcare. This prompted participant’s concern at the lack of integrated diabetes and mental healthcare.

Poor liaison and the mind/body split may be explained by the low levels of confidence of MHNs in liaison with local diabetes care services and their self- reported lack of knowledge of diabetes services. Such liaison also featured highly on the self-assessed education and skills needs requested by MHNs. Bridging the divide between mental and physical health was a clear participant desire and also a clear learning need for MHNs because the separation of mental and physical health contributed to a feeling of a lack of whole person care. This has the potential to impede continuity of care or the development of care partnerships, which MHSUs desired.

In exploring MHSUs experiences of healthcare, Kai and Crosland (2001:732) found two areas that contribute to positive service user evaluations

“The development of good therapeutic relationships with professionals and good continuity of care was regarded as central to quality of care.”

These views are similar to those expressed by MHSU participants in this study where they needed to have therapeutic relationships with MHNs so that they could work in partnership, rather than surrendering their diabetes care to MHNs. However, MHSU participants felt that at times of mental health crisis MHNs would need to be more proactive and manage diabetes care, but this would revert to partnership working once the mental health crisis had passed. Kai and Crosland (2001) found MHSUs became frustrated with the lack of continuity in care and that this could have an adverse effect on health. There was certainly some evidence of a lack of integrated diabetes and mental health care noted by MHSUs and lack of

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knowledge and confidence in liaising with diabetes services was recognised by MHNs.

Therefore, while the biological and clinical science knowledge is important MHNs would need to know about the organisation of local diabetes care services to include aspects such as referral procedures, types of services MHSUs can access and how to set up joint care plans. This would also entail MHNs acting as advocates in order to prevent vulnerable MHSUs falling through the care net, or improving the quality of care that MHSUs with diabetes receive.