ABSTRACT

MENTAL ILLNESS AS PORTRAYED IN THE MOVIE A BEAUTIFUL MIND

Associated Signs and Symptoms of Schizophrenia

The movie A Beautiful Mind is an adaptation of the book by the same name and is a biopic based on the life of Nobel Prize winning economist, John Forbes Nash, Jr. The movie portrays the symptoms and treatment for paranoid schizophrenia from which John Nash suffers. He has episodes of auditory and visual hallucinations and has frequent interactions with imaginary people. This paper attempts to present a reflective case study of the patient as presented in the movie. The patient when treated for hallucinations has certain negative reactions to the medicine, to overcome which, he avoids them, relapsing into his earlier condition. The patient mentions taking ‘newer’ medications later on which also help him decide between the reality and delusion. At the end of the movie, the patient is seen to have overcome this disorder by learning to ignore his hallucinations. This paper discusses alternate treatment as well as recommendations for future mental health nursing practices.

In the movie, A Beautiful Mind, the protagonist, demonstrates the classical symptoms of paranoid schizophrenia. The protagonist, John Nash, suffered from schizophrenia which was only discovered at a later stage. During his college years at Princeton, John’s room-mate and best-friend was a man named Charles, who is later found out to be one of John’s hallucinations (A Beautiful Mind 2001). As time goes by, his hallucinations become more frequent and violent as he soon believes himself to be working for the US government on a top secret project to which no one, not even his wife had access to. When he started missing classes a psychiatrist was called in to look into his condition and he found the stay at the asylum unpleasant and believed it to be a Soviet plan to stop him from working on his secret governmental mission. His wife had trouble believing the psychiatrist at first as she believed her husband’s story to be true and very real. But she realized the problem when she went to his college to find out what he used to do during work and found magazine clippings pasted all over the room. She also discovered the unopened confidential envelopes that were supposed to be sent out to Mr. Parcher, the person who put John up to the secret mission. The story revolves around how John has to face reality when his make-belief world is so real to him. He can finally confront his reality when he realizes that Charles’ niece, Marcee, never grew any older than when he had first met her. With continual medication, he learns to ignore the fictional characters in his life and starts to teach again, at Princeton. He goes on to win the Nobel Prize in Economics and lives a happier life.

Paranoid schizophrenia is only one of numerous categories of schizophrenia which is a chronic mental disease. People suffering from this kind of mental illness are not able to interpret reality in a normal way and are said to suffer from psychosis. Around 40 percent of schizophrenic cases are of paranoid schizophrenia. The symptoms usually start being displayed at later ages from around the ages of 25 or 30. The typical symptoms of paranoid schizophrenia include hallucinations and delusions that have no connection with reality. The ability to think and function normally is affected and though paranoid schizophrenia is a milder form of the disorder it can have lifelong ramifications and can even result in suicidal behavior and other complications. Usually the onset of the illness is marked by a sense of grandiosity and this preponderance is seen in case of delusion and/or a sense of persecution. The onset of the disease can be quite sudden and the deterioration in the condition of the patient can be quite rapid. The recognition and identification of these symptoms can be quite difficult for people with no prior experience or exposure to this situation. More perceptive relatives and friends may be able to recognize a heightened state of nervous tension, irritability, anger, jealousy and argumentative behavior (Kennard 2008). However, the good news is that with proper diagnosis and treatment patients overcome the symptoms and lead a happy life.

Treatment Modalities Specific to Schizophrenia

The symptoms displayed by John Nash in the film are very distinct and classic. The hallucinations of his room-mate, Charles and later that of Mr. Parcher, the US government official, and finally of Marcee show that his illness was detected at a very advanced stage where the diagnosis of paranoid schizophrenia needed to be treated symptomatically and with continued medication and therapy. The medications that Nash is put under are the antipsychotic drugs and insulin shock therapy. He was confined and had to be kept under constant supervision at the mental hospital. During particularly severe conditions he had to be bound and kept in solitary internment.

The major part of Nash’s treatment included Dr. Rosen’s recommendation of insulin shock therapy, which is a conventional method of treating mental illness and is now considered to be outdated and antipsychotic drugs. The insulin coma therapy and convulsive therapy have now been replaced by antipsychotic drugs that have greater efficacy and lesser adverse effects. Antipsychotic drugs are tranquilizing medicines that are used to treat schizophrenia and bipolar disorders. The first generation of anti-psychotic drugs included clozapine (Monson 2008) which acted on the receptor sites of neurotransmitter, dopamine.

Clozapine is a prescription drug for advanced conditions of schizophrenia and is also sold in the market under the trademark of Clozaril and FazaClo. It is sold specifically under prescription as tablets. It reduces the heightened sensitivity by blocking dopamine and serotonin from being transmitted in the brain. Some adverse side effects of clozapine can be drowsiness, constipation, and weight gain. Sodium valproate is an anticonvulsant that is now commonly used in treating psychiatric disorders particularly in the treatment of psychosis and depression (Omranifard, Amel & Amanat 2010).

Some common side effects of prolonged use of these medicines are weight gain, diabetes, drowsiness, spasms and tremors (NIH 2010). Some other symptoms like tardive dyskinesia (NIH 2010) which causes twitching around the mouth region are also seen in some patients. If these symptoms are noticed in patients being treated with these medicines, the doctor’s intervention should be sought. Patients suffering from schizophrenia have to be on life-long treatment for this condition.

In the movie, A Beautiful Mind, we also see the use of shock therapy in the form of insulin shock therapy. Nash had to undergo this kind of therapy five times a week for duration of ten weeks. In the conventional mode of treatment, it was thought that convulsions were a way to prevent occurrence of schizophrenia. Hence, this method of treatment was used on patients to induce convulsion and electroconvulsive was often used to protect the patient from personality disorders. In modern times, doctors use anesthesia and varieties of muscle-relaxants to this therapy more bearable.

Intervention, Support Program and Therapy for Schizophrenia

Apart from medical intervention, the patient needs to undergo behavioral therapies such as training in social skills in order to function normally in their daily lives. Support and awareness programs should be conducted for the patient as well as the family members. Support at a community level should also be given to the care-givers to cope with the situation and prevent relapses (Dawson 2010). Family members and support groups must encourage patients to follow through with their treatment and get check-ups done regularly.

Basic skills that need to be reinforced with a person suffering from schizophrenia should include:

• Training for rehabilitation like being able to perform basic hygiene routine and being able to eat on one’s own
• Being able to use public transport
• Train for a job: basic skills and communication
• Learn how to manage money
• When to take correct doses of medicines
• How to recognize signs of relapse and communicate with the therapist.

Diagnostic Tests for Schizophrenia

Current Prevalence

The first step in the detection and prognosis of the clinical conditions experienced in schizophrenic and bipolar patients is through reliable diagnostic techniques such as CT scan of the brain, magnetic resonance and other imaging techniques which may help eliminate possible confusion in the diagnosis of this disease. As there are few or no medical tests available that will warn a person of an onset or prevention of this disorder, the psychiatrist must carry out a thorough evaluation of the patient’s family background and genetic history by interviewing the patient and the care givers. The doctor must also take into account the course the illness has taken and how long the symptoms have been prevalent, patient’s reaction to medication and therapy.

The current prevalence of this condition at a global level stands between 0.5 and 1 percent (Bhugra 2010). However, prevalence of this disorder can be calculated only through registered cases of Schizophrenia and other psychiatric disorders. The risk of occurrence of this disease is higher than the actual prevalence recorder statistically. Prevalence in developed countries is higher than in developing countries, partially because more cases are registered and more commonly because of the nomadic and unstable lifestyles (Saha et al 2009). There is no appreciable difference in the male and female cases of occurrence, though the migrant populations have a higher propensity for this disorder.

Impact of Psychosocial Issues like Discrimination

John Nash had strange mannerisms and his odd behavior put some of his students and friends off (A Beautiful Mind 2001). His constant writing of formulae on window panes and wearing his knitted hat at all times seemed out of place and caused his friends to ridicule him. The incident of his being dared to speak to an unknown girl and her slapping him for his effort caused him to become the brunt of his friends’ jokes. There was an incident with his teacher who was worried about Nash’s performance in Princeton but that was later transformed to appreciation because of the brilliance of his project.

People suffering from schizophrenia are often labeled, stereotyped (Marder 2010) and discriminated against. The common perception is that the patient is responsible for having the behavioral changed that are a part of the symptoms of the disorder. Often negative stereotypes are created and the people suffering from schizophrenia are believed to have undesirable or uncontrollable characteristics. In the film, it has been demonstrated by the absent-minded behavior of John Nash when he allows his son to nearly drown in the bath-tub while he goes off to complete his secret work. His constant delusion of being engaged in highly classified and confidential state matters caused his wife and friends distress and at certain periods to mistrust his words, when in reality he was making up stories due to his hallucinations and delusions.

These stereotypes often lead to discrimination against the sufferers of schizophrenia and they are considered as social outcasts. Discrimination often takes the form of patients being rejected in society and their job applications being rejected on the basis of their mental health reports. The same has been observed in the case of letting out apartments to people with a history of schizophrenia. They are not considered socially competent and find themselves subjected to derision and not being taken seriously. The quality of their work is often scrutinized more than the average worker and that causes them additional mental trauma.

Certain ethical issues that may come up during the prognosis and treatment of this disorder may come in conflict with human rights issues. For example, patients who were treated with electroconvulsive therapy were never consulted and had to endure extreme pain and terror often without reaping the benefits of being completely cured.

Another significant point to be remembered in this regard is that the person suffering from schizophrenia is often driven to desperate acts like self-mutilation because the people they trust do not believe them and sometimes reject them outright. This, to my mind, adds insult to injury because the need to be heard and understood is very high in people who are confused and trying to grapple with their own demons.

Role of Nurse in Treatment of Schizophrenia

The role of a nurse in the treatment of schizophrenia is important as they can be effective in intervening with people suffering from schizophrenia and their families. They are trained to use interventions that have been proven to be effective. They can be administer IV injections and monitor the condition of patients so that the chances of a relapse are minimized. They can help in educating the family members, improve the family’s ability to cope with the stress of having to care for a mentally ill patient and improve their communication skills. The nurse is particularly trained to observe drug compliance and manage the situation professionally in times of crisis.

Nurses can also monitor the physiological condition of the patient and make educated reports to the doctor in charge of the patient’s treatment. For the family, the diagnosis of schizophrenia in a loved one is experienced as a disruptive event that changes the family life and affects a family member permanently and scars him/her for life. This unhappy experience mars the patient’s relationships with his family members and friends who begin to perceive him as a stranger who is needy and requires constant attention. The presence of a trained nurse can mitigate this situation as it is easier to confide in, trust and unburden one’s grief to a third party whose perception of the situation will be more objective. Also the nurse’s training in this specific field can be used as a better supervisor to monitor the day-to-day progress in a patient’s condition.

Recommendations A family member or care-giver may be emotional about it and not be able to assess the situation objectively or even adhere to drug-compliance and post recovery counseling. Nurses can also help the client to recognize hallucinations and talk about the hallucinations dispassionately. Nurses are also in the unique position of being trusted by the patients whom they can reassure by telling them that there are other patients who have similar symptoms (Nursing Care Plan 2010). A patient is more likely to receive a nurse’s recommendations for treatment more seriously than family members and help the patients to recover more quickly.

The movie is much acclaimed and very well made as it has not used a clichéd approach to schizophrenia as a mental disorder and ways in which people deal with this debilitating disease (Hausman 2010). In the movie, the ending is touching but it shows how people once afflicted with this disorder will have to live with it for their lives. However, I would think that with the newer techniques of treatment and advancement in pharmacology, these kinds of disorders will be able to reduce the trauma of the patient and their families.

Realistic films such as A Beautiful Mind should advertise the newer modes of treatment that will reduce the suffering of the people and allow them to lead happy lives. I would recommend that this powerful medium be used to create awareness amongst common people so that the patients of schizophrenia are not discriminated against and their disorders can be stemmed at the initial stages.

This assignment will address the public health issue of the increasing prevalence of diabetes mellitus (diabetes) and explore links with health inequalities both nationally and locally. It will discuss the frameworks available which give guidance for standards of care for diabetes patients and their influence on diabetes care. It will then critically discuss the issue of diabetes management in relation to patient education and the ability of patients to self-manage their chronic long-term condition, evaluating both the role of both healthcare professionals and individuals in achieving the best possible healthy outcomes. It will then discuss whether all people get the same level of diabetes care, in particular focusing on people who are not able to attend GP surgeries.

Public health is defined as “The science and art of promoting and protecting health and wellbeing, preventing ill health and prolonging life through the organised efforts of society” (Faculty of Public Health 2008). Health equality is a key element of social justice and as such justifies the government and other health agencies to work in collaboration to develop health policies which improve the public’s health regardless of social class, income, gender or ethnicity through promoting healthier lifestyles and protecting them from infectious diseases and environmental hazards (Griffiths & Hunter 2007). Yet many health inequalities still exist in the UK, some of which will be discussed in this paper.

There are predominantly two types of diabetes mellitus (diabetes); type 1 diabetes occurs when the body does not produce any insulin and type 2 diabetes occurs when the body does not produce enough insulin to function properly or when the body cells do not react to insulin. Type 2 diabetes is the most common and accounts for around ninety five per cent of people with diabetes. If left untreated both types of diabetes can lead to further complications which include heart disease, stroke, blindness, and kidney failure (Who 2011). Life expectancy is reduced by up to 10 years in those with this type of disease (Whittaker, 2004). In the majority of cases, type 2 diabetes is treated with lifestyle changes such as eating healthier, weight loss, and increasing physical exercise (Diabetes UK, 2007b).

There are currently 2.6 million people in the UK with diabetes, and it is thought up to a further 1.1 million are undiagnosed. (Diabetes UK, 2010). Other evidence suggests that approx 50% of people are not aware they have the condition, living a normal life with only mild symptoms (reference). Men are twice more likely to have undiagnosed diabetes, than women, possible because on average they tend to visit their GP less (Nursingtimes.net 2009). Diabetes is one of the most widespread chronic diseases, which is potentially life threatening. It is currently thought to be the leading 4th disease causing death in most developed countries worldwide with estimated prevalence of 285 million people.

Most experts agree that more than 4 million people in the UK will have Type 2 diabetes by 2025 with potentially 5.5 million living with this chronic condition by 2030 (Diabetes UK 2010, and International Diabetes Federation (IDF)2010). These statistics are startling; type 2 diabetes is one of the biggest challenges facing the UK today with people often treated entirely by the National Health Service (NHS) who provide care for all levels of diabetes. Diabetes control is considered poor in Europe with the UK being identified as having the worst control. The reasons for this are not clearly identified. However what is clear is the potential impact on people in terms of complications and shorter lives (Liebl et al 2002). People with diabetes who have complications cost the NHS 3.5 times more than people who have no evidence of complications (IDF 2006).

The NHS currently spends about 10% of its total resources on diabetes, which equates to £286 per second. This places a significant drain on resources which will potentially rise in line with the growing prevalence of diabetes and associated complications unless alternative ways to reduce the burden of the disease can be found Diabetes.co.uk).

There are many reasons for the growing prevalence of type 2 diabetes in the UK, two of the main ones being the modernisation of industrialisation and urbanisation, which has changed people’s lifestyles and eating habits and caused and escalation in obesity (Helms et al 2003). Diabetes and obesity are closely linked; eighty percent of patients diagnosed with diabetes are obese at the time of diagnosis (Diabetes UK, 2006). Kazmi and Taylor (2009) agree and say type 2 diabetes can be linked to genetics, although increased levels are more likely to be attributable to obesity resulting from a decrease in physical exercise and westernised diets. A 2008 survey highlighted the UK as having the highest obesity levels in Europe, currently 24% of adults are considered obese which tends to increase with age. (Organisation for Economic Co-operation and Development 2010). However this figure should be treated with caution as England is one of the few countries who uses actual measurements of weight and height, other countries preferring to use self reported measures. The UK has an increasing elderly population which combined with rising levels of obesity is likely to further increase type 2 diabetes prevalence(DH2010).

The links between socioeconomic deprivation and ill health are well established (Yamey 1999, Acheson 1998, Chaturvedi 2004). This can be observed within the UK, as type 2 diabetes does not affect all social groups equally, it is more prevalent in people over 40, minority ethnic groups, and poor people (The National Service Framework (NSF) for Diabetes). Several studies have established people with type 2 diabetes living in deprive areas suffer higher morbidity and mortality rates than those in more affluent areas. (Roper et al 2001, Wilde et al 2008, Bachhmann 2003).

However globally the links between deprivation and type 2 diabetes are less clear as there is less information available on diabetes and deprivation related outcomes. In conflict with the UK, studies in Finland, Italy and Ireland found no significant variations in different socioeconomic groups (Gnavi et al 2004, O’Conner 2006). Reasons which may have negated the impact on socioeconomic deprivation may have been due to differences such in the population studied, health care delivery or available treatments.

Links between deprivation and type 2 diabetes appear evident in the locality of Derbyshire. All but three local areas in Derbyshire have a diabetes and obesity levels which are significantly worse than the England average (Derbyshire County Primary Care Trust (PCT) 2008). In Derbyshire there are clear significant variations in levels of deprivation, High Peak has very little deprivation, and yet Bolsover is in the 20 per cent most deprived areas in England, with thirty two per cent of people living in poverty and mortality and morbidity levels significantly worse than the England average (Bolsover District Financial Inclusion Strategy 2009). These worrying levels have triggered the Department of Health to declare Bolsover a Spearhead area for improvement (DH 2009, Derbyshire PCT 2008). Some steps have been taken in Bolsover to reduce morbidity and mortality rates by introducing healthy initiatives aimed at improving people’s life styles (Bolsover 2010). However, although morbidity and mortality rates have reduced over the last ten years they remain significantly higher than the England average (Bolsover District Financial Inclusion Strategy 2009). Derbyshire has a growing elderly population (Derbyshire PCT 2008). This together with proven links of levels of obesity rising with age would suggest a future increase in levels of diabetes.

Diabetes is a national priority and Derbyshire has a higher than England average prevalence, but the local NHS strategy (2008) does not specify diabetes as a key priority. This may be a factor why Derbyshire is failing to meet its targets to reducing morbidity and mortality by ten per cent by 2010 in the poorest areas of Derbyshire (DH 2009).

Frameworks and policies exist to give guidance on standards of care, improve the quality of life and life expectancy of people with diabetes and lessen the financial burden on health services. (Reference x2). In response to European influence the NHS plan (2000) set out guidance for modernising services, raising standards and moving towards patient centred care. Subsequently the NSF for Diabetes (2001) was published which outlines twelve standards of care aimed at delivering improved services and reducing inequalities over a ten year period with the ultimate vision of people suffering with diabetes receiving a world class service in the UK by 2013. This framework was followed by the NSF for Diabetes: Delivery Strategy (2003) which gives guidance on how the NSF for diabetes could be achieved.

Frameworks are a useful outline for action and set out clear goals and targets, but do not address the social, economical and environmental causes of ill health or take account of available financial and staffing resources (Reference from book). The NSF for Diabetes (2001) appears to support this statement; other than retinal screening, no funding was initially made available to implement the twelve standards (Cavan 2005). The availability of this funding will have been significant in the achievement of one hundred per cent of people with diabetes now being offered this service (English National Screening Programme for Diabetic Retinopathy, 2009). It wasn’t until 2004 the Quality Outcome Framework offered financial rewards to meet other targets within the NSF, for instance maintaining practiced based registers of people with diabetes, to enable primary care providers to provide proactive care (NHS 2004).

Ten years on this framework is still credible and sets the ‘gold standard’ of care for patients with diabetes in the UK (NICE 2000) which would seem to be an outstanding achievement. There have been significant improvements in caring for people with diabetes since it was published. However, it could be criticised that some standards are not enforceable until 2013 (NSF 2001).

Numerous publications have followed the NSF for Diabetes (2001) in an attempt to give guidance for health professionals to follow (NICE 2004, NICE 2008, NICE 2009, RCN, NMC). These frameworks are not intended to work in isolation but collaborate with each other at different levels, whilst attempting to produce a quality health service (Reference). .

The main reasons for the onset of diabetes and risk of further complications is due to suboptimal health relative behaviours which include little physical activity, high calorie intake and inadequacy to maintain good glucose control and it is said individuals with diabetes play a central role in determining their own health status (Clarke 2008 Reference 1). Whittaker (2004) concurs and says that much of the burden relating to care lies with individuals themselves. Patient education is seen as fundamental in the treatment of diabetes to ensure the best possible healthy outcomes for individuals (Alexander et al, 2006, Brooker & Nicol 2003, Walsh, 2002). Standard 3 of the NSF for Diabetes (2001) clearly demonstrates a move away from medical care to encourage individuals to take responsibility for their own health but also places the onus on health care professionals to educate, support and empower people to enable them to effectively care for themselves. The recent Public Health Whitepaper (2010) endorses future healthcare services should focus on wellness rather than treating disease and supports empowering people to put some effort into staying well. It acknowledges healthcare services only contribute to one third of improvement made to life expectancy stating that a change in lifestyle and removing health inequalities contribute to the remaining two thirds. Giving people the skills, knowledge and tools to take control of their own health logical as people with diabetes spend an average of 3 hours per year with their healthcare professional and around 8700 hours managing themselves (Ref N3. For example there is much evidence concluding that maintaining blood glucose levels as close to normal as possible slows down the progression of long term complications and if patients can be empowered to take control of their diabetes, not only will it increase the individuals quality of life but also reduce the financial burden on the NHS. (Whittaker, 2004). (Ref: 4.1, 4.2).

The Diabetes Year of Care programme (2008) has been developed to help healthcare professionals move away from a paternal approach to care planning to a more personalised approach for people with chronic long term conditions. This approach involves both healthcare professionals and patients working together to prioritise individual needs. Helmore (2009) agrees that a personalised approach to care planning which should be holistic and include the person’s social circumstances, will empower patients to take a central role in their own healthcare and suggests that nurses and patients should work together to set goals the patient can work towards which would include self care and the services they will use. For example a depressed patient will not want to venture outside to exercise and comfort eating may cause them to gain weight. The priority in this case would be to deal with the patient’s depression. The nurse could then liaise with other community services and social care to resolve non medical issues which would enable the patient to manage their weight and increase activities (Helmore 2009). Rollings (2010) believes nurses should take a lead role on behalf of the GP consortia as they are the ones best placed to identify the care requirements of patients with diabetes, they have experience in patient pathways and are able to co-ordinate local and professional services.

The Department of Health (2010) has highlighted care planning as an area for improvement to ensure one hundred per cent of diabetic patients have individual care plans (DH 2010). Currently it is thought only sixty per of people with long-term conditions in England have an individual care plan (www.gp-patient.co.uk).

Diabetes self-management education programmes (DSME) have been developed to educate and empower patients to take control of their own conditions by improving their knowledge and skills to enable them to make informed choices, self-manage and reduce any risk of complications. DSME also aims to help people to cope with physical and mental of living with diabetes (Ref 21 p 114. These programmes which should be age appropriate can be delivered to individuals or groups. (6 and 40 p 119 and 120). . (reference 7 p119). Programmes available include the Expert Patent Programme (EPP), its derivative X-PERT and Diabetes Education and Self-Management for ongoing and newly diagnosed (DESMOND) which are available in all PCT’s in the country. These programmes offer the necessary information and skills to people to enable them to manage their own diabetes care and they offer the opportunity for people with diabetes to share problems and solutions on concerns they may have with on everyday living (N9). They encourage people to find their own solutions to issues such as diet, weight management and blood glucose control, enlisting the help of diabetes professionals if needed (N9). The literature suggests this will result in well educated, motivated and empowered patients and consistently supports patient education as crucial to effective diabetes care (use many refs).

Much research has taken place on the effectiveness of DSME. Some of which suggests that patients who have not participated in DSME are four times more likely to encounter major diabetes complications compared to patients who have been involved in DSME (Reference).Other evidence suggests that it is not possible to establish whether patient education is effective at promoting self-management in the long term to reduce the effects of diabetes or the onset of complications and improve the patient’s quality of life (reference). From studies that have taken place, it is evident that although knowledge and skills are necessary they are not sufficient on their own to ensure good diabetes control. People require ongoing support to sustain the enable them to sustain self-management and therefore the longer period of time the course run the more likelihood people will remain empowered (Ref)

The majority of people in the UK are offered some form diabetes education, the bulk of which is offered at the time of diagnosis. Also the style, length, content and structure of DSME vary. Very few education programmes have been evaluated; therefore it is not conclusive which intervention strategy is the most effective for improving the control of diabetes. The America Diabetes Association suggest that as people are individuals and different methods of education suit different people, there is no one best programme, but generally programmes which incorporate both psychosocial and behaviour strategies appear to have the best outcomes.

However the Healthcare commission (2006) found people in England are not being offered adequate information about their condition to facilitate effective self-management. They reported just eleven per cent of respondents had attended an educational course on how to live with diabetes and disturbingly seventeen per cent of respondents did not even know whether they had type 1 or type 2 diabetes (Reference 2 p 119).

The success of DSME is dependent many variants which include the patient’s individual characteristics, the context of their social environment, the extent of the disease, and the patient’s interface with the care and education provided.

Overall there is a great deal of evidence to suggest DSME is the ‘cornerstone’ in effective diabetes care (NSF 2001). It is recommended that DSME is delivered by a multi-disciplinary team together with a comprehensive care plan (reference 1). Experts agree that effective management of diabetes mellitus increases life expectancy and reduces the risk of complications (NICE Guidenance for the use of patient education models of diabetes Referece 1 p 119

Changing the health related behaviours of people with diabetes has been proved to be successful in reducing or even eradicating the risk of complications (reference). Many different health promotion models of exist which can help a patient to digest health promotion advise and want to change their health related behaviours (Kawachi 2002). Health promotion models are useful tools to assist with this process. The Stages of Change health promotion is a frequently used model for weight management as it identifies 6 stages of readiness to change which helps health professionals identify the intervention actions to recommend and support.

Standard 3 has also ensured people with diabetes receive regular care (Hicks 2010), although Hillson (2009) would argue the quality of which is still open to debate. Every person with diabetes should receive the highest standards of individualised care, no matter who delivers it or where or when it is delivered. Access to specialist services should be available when required (Hillson 2009).

Diabetes patients receive different standards of care depending on whether or not they can attend their doctor’s surgery (Knights and Platt 2005). Diabetes patients who are unable to attend the surgery are being overlooked and missed out on screening and reviews of their diabetes, consequently receiving a lower standard of care despite the NSF for Diabetes stating inequalities in provision of services should be addressed to ensure a high standard of care which meets individual patient needs.(Gadsky 1994 ,Hall 2005, Harris 2005,).

Until recently the district nursing team were some of the few professionals who provided care in the home for diabetes patients and only usually had input with diabetes patients when treatment was required for a complication (Wrobel 2001). District nurses have historically been seen as generalists and able to provide care and treatment for patients with a wide range of conditions and therefore do not necessarily have specialist disease knowledge (Hale 2004). Sargant (2002) agree with this and suggests the quality and advise district nurses give to diabetic patients is questionable as they don’t have the in-depth level of knowledge in relation to diabetes. In recognition of the inconsistency of care being provided to patients with chronic illnesses in their own homes, the role of Community Matron was introduced in 2004 to ensure patients with diabetes receive the first class service advocated by the Department of Health (1999) and the NHS PLAN (2000) by managing their all encompassing care requirements and help patients effectively manage their long term conditions which in theory should result in reduce hospital admissions. (NHS Improvement Plan 2004). However a study conducted by Gravelle et al (2006) would suggest the Community Matron role has not been effective in reducing hospital admissions. Forbes et al (2004) concurs that district nurses, given the time and with the right training could extend their roles and satisfactory undertake appropriate care for housebound people with diabetes. However Brookes (2002) suggests training and resources are big issues and Harris (2005) says that district nurses may not be fulfilling their Professional Code of Conduct by failing to care sufficiently for this group of patients (Nursing and Midwifery Council 2008).

The growing prevalence of diabetes and the drain on NHS resources continues to be a concern for the UK, in terms of life quality and life expectancy of patients. Many health inequalities exist for people with diabetes; there are proven links with obesity and deprivation; and diabetes care provided is not equal for all patients. Patients who are able to attend their GP surgery receive better care than those who are housebound, although this inequality is being addressed and care is improving. The NSF for Diabetes is a useful framework for healthcare professionals to follow when providing care for people with diabetes. The quality of diabetes care has improved since this framework has been introduced. However, the implementation of some recommendations has been slow and will not be complete until 2013. Patient education is paramount to successful diabetes control and there appears no doubt that the key to successfully slowing the onset of diabetes and the recognised associated complications is to engage patients in DSME.