The Committee has asked for a further update and presentation on the Eating Disorder Service. This follows consideration of a report at the December 2018 meeting. Eating disorders are serious, often persistent, mental health disorders associated with high levels of impairment to everyday functioning and development, and a high burden on families and carers. They can be associated with life-long physical, psychological, educational and social impairment and in some cases can be fatal.
The Committee had previously considered a report on the All Age Eating Disorder Service at the December 2018 meeting with a further update having been requested at this meeting. In 2014, NHS West Kent Clinical Commissioning Group (CCG) had sponsored a project across Kent and Medway to improve eating disorder services. At this time, waiting times had been longer than national standards, patients were experiencing excessive travel times and there were concerns about the effectiveness of the service in treating eating disorders. A procurement process had been undertaken with NELFT having become the provider of the £2.7 million contract in 2017. A key feature of the new service was that it now covered both children and adults, helping to overcome the previously problematic transition from child to adult services. The service was now considered to be good although it was acknowledged that there were associated issues that needed to be addressed. This included a lack of inpatient beds and GPs often not referring patients to the Eating Disorder Service soon enough. There was also a need to increase outreach work with schools to raise awareness of eating disorders and the services available.
NELFT was involved in national level work to bid for funding with the aim of being able to deliver more services closer to the patient home. In the year April 2018 to March 2019 there had been 98 referrals to the Eating Disorder Service, with an increase in referrals having been seen in the autumn. 61 of the referrals had been made by GPs. There had been 12 re-referrals. The current caseload was 66 with 5 male patients and 61 female. Patients covered the age range 8 to 65 with the majority being children and young adults. It was noted that a small Medway specific service would not be able to have the range of specialists that a service, covering both children and adults, across Kent and Medway could.
There were currently no children waiting for non-urgent treatment. Assessment for non-urgent child cases was completed within four weeks and for urgent cases, within seven days. Where there was an urgent physical health need liaison was undertaken with acute health trusts to enable more urgent treatment to take place. The target for assessing non-urgent adult cases was 8 weeks with there currently being 10 adults waiting. Urgent cases were due to be assessed within 7 days but could be admitted to hospital immediately where there was an urgent physical need. An out of hours team was available to provide support 24/7. Following treatment, patients were discharged to the care of their GP. Each patient was provided a relapse plan. A range of support was available following discharge.
The firstline treatment for under 18’s was family therapy with this also being available for over 18’s where required. There were also under 18’s and over 18’s carer groups available to provide support to the families of patients. Child inpatients could be admitted to a unit in Staplehurst but there were no specialist beds available in Kent and Medway for either children or adults with the most complex needs. The Maudesley Hospital in London had specialist day and inpatient services available.
There had been an increase in eating disorders nationally with bed admissions more than doubling from 7,000 in 2011 to 16,000 in 2018. Of the current 10 adult inpatients from Kent and Medway, none was from Medway, while 1 of 13 children was a Medway child.
Future plans for development of the Eating Disorder Service included considering how digital services could be developed and strengthening links with schools. A good working relationship with the ambulance service had already been established, one example being that ambulances could be on standby when a patient attended a clinic who was considered likely to need hospital admission.
A Member asked a number of questions as follows:
· Why the number of people being treated was relatively low
· How patients and their families were supported to travel to appointments and treatment and whether help was available with travel costs
· How the number of patients self-referring and the number of male patients could be increased
· The reasons for re-referral
· How accessible a specialist clinician would be to a person visiting Medway hospital when in crisis
· What was defined as a complex case
· Whether statistics were available showing the number of patients who showed sustained improvement and what the mortality rates were amongst service users
· What training was available for GPs
In response, the NELFT representatives advised that the caseload figure was the number of people being treated at a point in time. This would be lower than the total number of people that had been treated. When NELFT had taken on the contract for the Kent and Medway Service there had been no specialist children’s service. It was only possible to offer early intervention when a patient was identified at an early stage, which was problematic. Education of GPs could help to address this but would not help to identify those who did not visit their GP. Through increasing training and education it was hoped that people would be encouraged to seek help sooner. NELFT was not currently the provider for patients requiring tier 4 inpatient beds. Patients would not be discharged from the service until it had been assessed that they were ready to be. They would be provided a relapse plan at discharge but patients sometimes deviated from this plan, which was a cause of re-referral. Some patients initially referred to the service did not feel ready for treatment and could then be re-referred once they were.
Help with patient travel costs was available and NHS England was now paying some travel costs of relatives. Increasing the levels of self-referral was challenging as people often did not recognise or want to admit that they were unwell. Awareness raising of eating disorders, particularly targeted at men, had been undertaken as part of Eating Disorder Week and via social media, but it was acknowledged that more needed to be done. The communications team at NELFT was working with the Communications team at NHS Medway Clinical Commissioning Group to look at how awareness could be further increased.
Patients admitted to hospital were provided with a comprehensive care plan, with NELFT staff visiting patients on the ward. NELFT was already the provider of eating disorder services in north east London and Essex and had applied learning from these areas to the development of the Kent and Medway service. It was not yet possible to provide detailed outcomes as the service had only been operating for one full year but these could be included in future updates. NELFT had worked with a GP in the West Kent area to review the service and identify what could be done to raise the profile of eating disorders and the service with GPs.
Other questions asked by Committee Members were responded to as follows:
Increased referrals in autumn– the Committee was advised that referrals tended to increase in the autumn due to parents and family members realising that their child was facing difficulties while they were home during the school summer holidays. Engagement work was taking place with schools and via children’s events to raise awareness.
Need for local services – A Member said that there was a need for more Medway specific provision and was concerned about increasing demand and the pressure this would put on services if action was not taken imminently. Other Members said that there was a need for the development of specific provision in Medway.
The Associate Director of Mental Health and Children’s commissioning at NHS West Kent CCG said that demand was increasing across mental health services, that the acuity of patients was increasing and that serious problems were affecting younger children. CCGs would continue to review demand to ensure that the services commissioned could meet demand. The NELFT representatives said that specialist beds could not be provided in each locality due to the complexity of the service. While provision would be as close to the patient as possible it could not be guaranteed that this would be in Medway.
The Director of Public Health emphasised the need to better identify and signpost people to services. The next Annual Public Health report was due to focus on mental health wellbeing.
Presentation at hospital, patient travel, voluntary sector capacity and support for adults – A Member highlighted that some people with eating disorders had had a poor experience when presenting at accident and emergency and was concerned about the impact of having to travel a distance for treatment on patients and their families. The Member also questioned the ability of the voluntary sector to assist in tackling eating disorders and asked how the families of adult patients could be supported. Another Member emphasised the importance of providing support for patients and their families where patients had to travel significant distance to appointments.
The NELFT representatives said that there were regular discussions with legal advisors about the issue of patient capacity as there was a very limited amount of action that could be taken where an adult did not want help or did not want family members to be involved. Relatives of adults with an eating disorder could attend the carers’ support group without a referral. Through this, relatives could be supported to encourage the person with an eating disorder to get help. Voluntary sector organisations were encouraged to signpost people to the eating disorder service rather than to try to provide direct support.
An online learning tool was available for bulimia and it was hoped that online learning could be provided for other eating disorders in the future.
Patients recovering from severe eating disorders had the opportunity to regularly attend a clinic for between six months and a year in order for them to be supported to maintain their improvement. Such clinics were available across Kent and Medway, including in Medway and outreach visits could also be undertaken to patient homes. Discussions had taken place with Medway Foundation Trust to strengthen partnership working, helping to ensure that patients attending the hospital had a positive experience.
The Associate Director agreed that the ability of patients and their families to travel for treatment was important from a commissioning point of view and undertook that this would be given further consideration.
The Committee noted and commented on the report and requested:
i) That consideration be given to establishing the provision of specialist eating disorder inpatient provision within Medway.
ii) That an update be presented to a future meeting of the Committee.