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					Response to the Scottish Government consultation: Better Diabetes Care

The Scottish Branch of the British Psychological Society thanks the Scottish
Government for the opportunity to respond to this consultation.

The British Psychological Society (“the Society”) is the learned and professional
body, incorporated by Royal Charter, for psychologists in the United Kingdom. The
Society is a registered charity with a total membership approaching 50,000, almost
3500 of whom are based in Scotland.

Under its Royal Charter, the objective of the Society is "to promote the advancement
and diffusion of the knowledge of psychology pure and applied and especially to
promote the efficiency and usefulness of members by setting up a high standard of
professional education and knowledge".

The Society is committed to providing and disseminating evidence-based expertise
and advice, engaging with policy and decision makers, and promoting the highest
standards in learning and teaching, professional practice and research. The Society
is an examining body granting certificates and diplomas in specialist areas of
professional applied psychology.

We are content for our response, as well as our name and address, to be made
public. We are also content for the Scottish Government to contact us in the future in
relation to this consultation response. Please direct all queries to:-

Policy Support Unit, The British Psychological Society,
48 Princess Road East, Leicester, LE1 7DR.

Email: Tel: (0116) 252 9926/9577 Fax: 0116 227 1314

This response was prepared on behalf of the Scottish Branch by Dr Andrina
McCormack, CPsychol, AFBPsS, member of the Division of Health Psychology-
Scotland, with contributions from Michelle Cook, member of the Scottish Branch and
Dr Vivien Swanson, CPsychol, Chair of the Division of Health Psychology-Scotland.
We hope you find our comments useful.

Dr C A Allan, CPsychol, CSci, AFBPsS         Dr V Swanson, CPsychol
Chair, Professional Practice Board           Chair, Division of Health Psychology-

The Society welcomes the consultation document “Better Diabetes Care” and the
Scottish Government‟s initiative in improving services for current and future patients
with diabetes (Types 1 & 2).

We offer comments, below, on several sections of Chapter 3 and on Chapters 4 and
5. These are followed by brief concluding comments.

Comments on Chapter 3: Developing High Quality Diabetes Care

Diabetes is a classic example of a long-term condition which carries a heavy
psychological burden. Good self-management of diabetes requires a high level of
attention to monitoring blood glucose levels, managing diet, activity levels and other
health behaviours such as smoking and alcohol use. Coping with diabetes in addition
to the demands of day-to-day living is very demanding. Many people, struggling to
maintain optimal diabetes self management consistently over the life-cycle, manifest
significant psychological distress. People who have fewer coping resources or
particularly high levels of demands in their day-to-day living can find diabetes
management especially challenging.

3.3 Supporting Improvement

The value of Scottish Care Information - Diabetes Collaboration (SCI-DC) is
acknowledged and its widespread use throughout Scotland is welcomed. However, it
is stated in Section 3.3.3, that SCI-DC was accessed on 1,646,000 occasions by
2621 users, showing that users accessed SCI-DC an average of 628 times each. As
the „users‟ cited here represent “a very wide variety of different professional groups”
(p.8), these figures suggest there may be potential to increase usage within many
professional groups, including psychologists. SCI-DC could be more widely
publicised in order to encourage its use by a greater number of professionals in
future, For example, a short article in “The Psychologist” (the official monthly
publication of the British Psychological Society) could access practising applied
psychologists across the country (over 15000 UK-wide, around 1500 of whom are
based in Scotland).

3.4 Focussing Improvement

Regarding Section 3.4.4: it is our experience that some parents may fail to accept or
acknowledge the diagnosis of diabetes or find it hard to acknowledge the long term
implications of future health problems for their children. Offering psychological
support to parents during difficult transitional periods may help to develop their own
confidence and coping abilities in relation to diabetes care. Similarly, providing
psychological support to children with diabetes and their teachers in school contexts
may be helpful.

3.5 Psychological and Emotional Support

The need for psychological support for people with diabetes is of high importance
and has been highlighted in several documents including:

Scottish Intercollegiate Guidelines Network (SIGN) Guidelines for Diabetes
National Institute for Health and Clinical Excellence (NICE) Guideline for
Diabetes (2008);
Diabetes UK (2008). Minding the Gap: Provision of psychological support and
care for people with diabetes in the UK

Although the above policy documents recommend increasing psychological provision
for people with diabetes, there is no evidence that such provision has increased
since the first of these documents was published or since the publication of the
Scottish Diabetes Group (SDG) Psychology Working Group report (2006) which
described psychological provision for diabetes in Scotland as „woeful‟.

It is very gratifying to see that this consultation highlights the psychological demands
of diabetes and the need for psychological support throughout. However, as noted in
the consultation document, there is still a lack of appropriate psychological and
emotional support and achieving progress has been a challenge.

Although increasing funding for psychology time is an important first step, this is not
only an issue of funding. There is also a need for dialogue between psychologists
and those providing care for people with diabetes to discuss the best way to deliver
psychological support for people experiencing short- or long-term psychological
distress. Since the number of people with diabetes is already large, and increasing,
the most effective routes for delivering psychological support are likely to be by
working with patients in a stepped care model and by training diabetes staff in
psychosocial skills rather than by simply increasing the delivery of one-to-one
therapy. Chartered Psychologists have the requisite skills and competencies to
deliver this support and contribute to professional training.

The SDG has made significant efforts to address psychosocial issues by funding two
major pilot projects. The first offered psychology-based training in communication
and behaviour change skills to health professionals working in diabetes care across
Scotland. There was substantial interest, enthusiasm and positive feedback on skills
development from health professionals who participated in this course, suggesting
that this type of training was perceived as very useful. However, there was also a
sense that this type of training only tackles the „tip of the iceberg‟ and that the training
would be much more effective if supported in the longer-term by continued input from
psychologists at Managed Clinical Network (MCN)/Community Health Partnership
(CHP) level.

The aims of the second project address this by embedding psychology time into
MCNs at local level, employing part-time Chartered Psychologists to work with
Diabetes teams in a 3-year programme from 2009/10. This is an exciting national
project, which should add substantial value to psychology provision.

It is important that this project should be rigorously evaluated to provide evidence for
the benefits or otherwise of this model of working. It is also crucial, that if successful,
funding for continuation of these posts should be prioritised by MCNs.

The Living Better initiative to improve the mental health and wellbeing of people with
diabetes and coronary heart disease is discussed in Section 3.5.6. This initiative
aims to improve the detection, assessment and management of depression, anxiety
and stress. Some health professionals working in diabetes care may require
additional training in the recognition of depression and anxiety. Teams should
consider routinely administering a measure of psychological wellbeing within the
annual Diabetes Review process. The Diabetes Psychology Working Group
recommended utilising the Hospital Anxiety and Depression Scale (HADS; Zigmond
& Snaith, 1983). Outcomes could be recorded on the SCI-DC clinical database and
relate to clear policies for acting upon information yielded by this measure. For mild
depression and anxiety it may be appropriate for health professionals within the team
to co-work with, or seek support from, applied psychologists. It is also very important
that teams have clear referral pathways for those found to be experiencing clinically
significant levels of depression or anxiety.

Comments on Chapter 4: Putting Patients at the Centre

Developing patient-centred care and encouraging better self-management in people
with diabetes are underpinned by the need for behaviour change skills in people with
diabetes and in those supporting them, including health professionals working in
diabetes care.

There is good evidence that psychological interventions can have a significant impact
on aspects of diabetes self-management (including dietary and activity behaviours),
and glycaemic control (Ismail et al., 2004; Winkley et al., 2006). These skills, which
can include self-monitoring, goal-setting, action planning and coping planning, are
relevant for people with both Type 1 and Type 2 Diabetes, and across the lifespan.
They can easily be taught to people with diabetes, their carers and health
professionals involved in diabetes care.

Comments on Chapter 5: Better Prevention

Given the rise in obesity in Scotland, and the Government‟s targets in relation to
increasing physical activity, the prevention of diabetes is becoming increasingly
important. There is a need to carry out innovative translational research into
improving diabetes prevention. Thismight be guided by work such as the Finnish
Diabetes Prevention Study (Tuomilehto et al., 2001), which targeted high-risk groups
such as first-degree relatives of people with Type 2 diabetes. This study, which
targeted moderate weight loss, reduced fat intake, increased dietary fibre and
moderate exercise, achieved a 58% reduction in the risk of diabetes in the
intervention group over a four-year follow-up period. This suggests prevention of
Type 2 diabetes can be achieved through a behavioural intervention implemented in
a primary care setting. We recommend that targeting behavioural change
interventions at high-risk groups should become a priority for the Government, to
reduce the need for subsequent chronic disease management.

Concluding Comments

Applied psychologists have important roles to play in the management of diabetes.
These include clinical psychologists, counselling psychologists, educational
psychologists, health psychologists, and sports and exercise psychologists. Many
applied psychologists are experts in the science of behaviour change, can deliver
interventions to change behaviour for people with diabetes, and can teach and train
others (particularly health professionals) in these skills.

For example, the Division of Health Psychology in Scotland (DHP-S) has a large
membership and there are currently over 30 health psychologists in training who will
achieve professional Chartership in Scotland, via different training routes over the
next two or three years. This number includes seven trainee health psychologists
currently jointly funded by NHS Education for Scotland and NHS Health Boards in
Scotland working to provide „added value‟ in relation to the Government‟s health
improvement agenda and HEAT targets, including delivering behaviour change
There is substantial expertise and capacity in applied psychologists in Scotland to
teach and train others (including people with diabetes, carers and health
professionals) in behaviour change skills; however, there are currently very few NHS
posts employing psychologists in diabetes. One reason for this may be a lack of
knowledge/awareness among NHS managers regarding the skills and competencies
that psychologists can offer in relation to behaviour change. Promoting dialogue
between psychologists and those responsible for diabetes care would be a useful
first step towards matching supply and demand.


Ismail, K., Winkley, K. & Rabe-Hesketh, S. (2004). Systematic Review and Meta-
analysis of Randomised Controlled Trials of Psychological Interventions to Improve
Glycaemic Control in Patients with Type 2 Diabetes. The Lancet, 363 (9421), 1589-

NICE (2008). (Multiple) Technology Appraisal Guidance No. 151 – Continuous
Subcutaneous Insulin infusion for the Treatment of Diabetes Mellitus. London;
National Institute for Health and Clinical Excellence.

SDG Psychology Working Group (2006). Survey of Psychology Provision to Adults
and Children with Diabetes in Scotland. Edinburgh; Scottish Diabetes Group.

SIGN (2001). Guideline 55. Management of Diabetes: A national clinical guideline.
Edinburgh; Scottish Intercollegiate Guidelines Network.

Tuomilehto, J., Lindstrom, J., Eriksson, J.G., Valle, T.T., Hamalainen, H., Ilanne-
Parikka, P., Keinanen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M.,
Salminen, V., Uusitupa, M., Aunola, S., Cepaitis, Z., Moltchanov, V., Hakumaki, M.,
Mannelin, M., Martikkala, V. & Sundvall, J. (2001). Prevention of Type 2 Diabetes
Mellitus by Changes in Lifestyle Among Subjects With Impaired Glucose Tolerance.
New England Journal of Medicine, 344(18),

Winkley, K., Landau, S., Eisler, I. & Ismail, K.(2006). Psychological Interventions to
Improve Glycaemic Control in Patients with Type 1 Diabetes: Systematic review and
meta-analysis of randomised controlled trials. British Medical Journal, June 2006,
accessed from the Internet10/10/08:

Zigmond, A.S. & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale.
Acta Psychiatrica Scandinavica, 67(6), 361-70

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