National Review of Eating Disorder Services: report and recommendations

Recommendations

The following 15 recommendations will ensure that Scotland meets the Vision, using the principles articulated above, within 10 years.

Short term recommendations are numbers: 1, Covid-19 response; 2, implementation planning; 4, lived experience panel; 6, self-help resources; and 13, families and carers.

Medium term recommendations are numbers: 3, co-ordination of national activity; 8, primary care; 9, medical care; and 12, education and training.

Longer term recommendations are numbers: 5, public health; 7, early intervention; 10, specialist care; 11, workforce planning; 14, in-patient care; and 15, research.

Recommendation 1: Covid-19 response

Emergency funding should be provided to rapidly meet the urgent needs of eating disorder patients and services as a direct result of an increase in the number and severity of eating disorder presentations related to the Covid-19 pandemic. Funding should prioritise physical health stability, risk reduction, support inpatient discharge and prevent admission to hospital.

Ownership: Scottish Government providing funding, individual health boards responsible to Scottish Government.

1.1 This urgent funding is to enable expansion of medical, nursing, dietetic and therapist time and additional support workers (including peer and carer support workers) within a rapid time frame for the next 12 months. Specific requirements are likely to vary in each area.

1.2 Additional funding for adaptation of facilities may be included if facilities need to be made Covid-safe or adapted to provide the same level of care during the pandemic as would normally be expected.

1.3 The third sector could be contracted to provide support services to work alongside NHS eating disorder services. (For example, Beat are able to provide training for carers, support for adult patients while waiting for therapy and support for families.)

1.4 Training on a national basis (for example, through virtual training days) is recommended for all newly recruited staff; this could be done together with third sector organisations.

1.5 Fair allocation of funding should take into consideration population density.

Recommendation 2: Implementation planning

An Implementation Group should be set up by Scottish Government. This short-term group will be responsible for the implementation of these service review recommendations, planning for and setting the strategic direction, vision and ethos for improvement and service delivery over the next 10 years. This group should report directly to Scottish Government.

Ownership: Scottish Government, Scottish Government's appointed chair of Implementation Group

We suggest that core tasks of the Implementation Group could be to:

2.1 Take note of the data generated by the Mental Welfare Commission and this Service Review in Phase 2 (provided in Appendices).

2.2 Finalise the costing of the recommendations of this Service Review including the specific manpower needs are once the recommendations of this review are accepted.

2.3 Operationalise the recommendations of this Service Review across Scotland taking into account the context, needs and constraints of different health boards.

2.4 Conduct project planning for the implementation of all aspects of the recommendations as led by the implementation group.

2.5 Develop further and plan for implementation of quality standards of care across Scotland for all levels of treatment for eating disorders, in line with SIGN, MARSIPAN, and Scottish Government's Mental Health Transition and Recovery Plan Scottish Mental Health Strategy and policy, GIRFEC and other relevant policy documents.

2.6 Develop a skills and competency framework, and training strategy in partnership with NHS Education Scotland (NES) and Eating Disorders Education and Training Scotland (EEATS), for all staff, including third sector, who may see or work with people who have eating disorder symptoms or diagnosis, see recommendation 12.1-12.3 for more detail.

2.7 Build a public health strategy for Scotland with Public Health Scotland and other agencies that makes eating disorder prevention everyone's business.

2.8 Design as a priority a comprehensive plan for systematic data collection and ongoing analysis across Scotland, to address current lack of data. This needs to include planning and funding for appropriate staffing and IT infrastructure to be able to collect, analyse and report the data systematically across Scotland. Datasets should include annual audit of the prevalence of all eating disorder diagnoses, nationally agreed measures to evaluate service delivery and outcomes, and collation of Significant Incident Reviews together with local medical leads to report annually to the National Eating Disorder Group.

Recommendation 3: Coordination of national activity and data collection

A National Eating Disorder Network should be established and funded by Scottish Government. This permanent Network will take over from the work of the Implementation Group to support the implementation of the recommendations on an ongoing basis. It will also be responsible for the coordination of national functions including training, national level service development, setting quality standards, and coordinating research and innovation networks for eating disorders.

Ownership: Scottish Government, Implementation Group with stakeholders, all Health Boards

Responsibilities of the National Eating Disorders Network may include:

3.1 Implementation across Scotland of the all the plans for change designed by the Implementation Group with ongoing further development as appropriate.

3.2 Working with Public Health Scotland and other agencies to continue to build, implement and evaluate a public health strategy for Scotland that makes eating disorder prevention everyone's business.

3.3 Collating national data and providing on an ongoing basis annual audits of the prevalence of all eating disorder diagnoses, analysis of nationally agreed datasets to measure service delivery and outcomes, collation of Significant Incident Reviews to report annually to Scottish Government.

3.4 Support and lead on training for healthcare and other stakeholder professionals, see recommendation 12 for more details.

3.5 Hosting a Scottish Eating Disorder Network website with signposting, educational material, and providing access to online self-help/management programmes, as well as providing a platform to host any Scottish information gathering, research and sharing activity.

We suggest that the National Eating Disorder Network could be staffed by:

• A National Eating Disorder lead who leads and manages the Network.
• A core staff team comprising both child and adolescent and adult multi-disciplinary professionals at Consultant grade who are national level leaders – this could include nursing, allied health professionals, psychology, psychiatry, physical medicine and 3^rd Sector membership. Each core staff team member will have responsibility in leadership and development for their profession/sector/geographic location, as well as allocated responsibilities for the Networks work plan.
• A lived experience panel comprising people with a range of lived experiences which advises and works alongside the Network.
• In addition, there should be adequate administrative and data analyst support for the remit of the Network to be carried out.

Recommendation 4: Lived Experienced Panel

There should be a lived experience panel set up who will advise the Implementation Group and work alongside the National Eating Disorders Network. The lived experience panel should include patients, families and loved ones, and third sector representatives and there should be diversity in the panel, for example, including all eating disorder diagnoses, men with eating disorders, LGBT representatives and people from ethnic minorities. The panel will advise on all eating disorder national changes.

Ownership: Implementation Group then National Eating Disorders Network, Scottish Government

4.1 The Lived Experience panel will help ensure equality and diversity and parity of esteem is central to the implementation.

4.2 Panel members should be reimbursed for their time and travel.

4.3 Panel membership should be on a fixed term basis to ensure diversity.

Recommendation 5: Public health

The Scottish Government should fund and support development of a comprehensive public health strategy for Scotland that makes eating disorders prevention everyone's business.

Ownership: Scottish Government, National Eating Disorders Network and Public Health Scotland

We suggest that this may include:

5.1 Support from eating disorder national lead for engagement of government and other agencies with industry (fashion, advertising, sports and fitness, food industry, social media) in how they can work to promote a positive body image culture in Scotland.

5.2 Provision of evidence-based parenting advice on promoting positive body image for all, sensible healthy eating and exercise, emotional literacy, risk factors for and signs of eating disorders. This could be done via the National Eating Disorder Network website or in conjunction with existing evidence-based parenting programmes delivered by schools and parent organisations, 3^rd sector, or primary care (for example, via health visitors).

5.3 Support from eating disorder national lead for engagement of Scottish Government and relevant health agencies with the fitness sector (gyms, sports teams and clubs, personal trainers, dance schools and elite as well as grassroots sports organisations) in developing standards in the industry that promote health at all shapes/weights, prevent eating disorders and increase awareness to enable early identification of emerging eating disorders and Relative Energy Deficiency in Sport (http://health4performance.co.uk/healthcare-professionals/) with signposting to treatment.

5.4 Developing with NES, Public Health Scotland and the education sector, evidence-based, school-based (state and independent sector) prevention packages which include mental wellbeing, emotional resilience, social media literacy, moderating anti-obesity public health messages, and dealing with precursors of eating disorder such as body image issues, and compliant with the SHANARRI indicators (https://www.gov.scot/policies/girfec).

5.5 Engaging with Public Health Scotland on the delivery of "Healthier future: Scotland's diet and healthy weight delivery plan" (2018) to ensure joined up thinking in relation to obesity and eating disorders. (https://www.gov.scot/publications/healthier-future-scotlands-diet-healthy-weight-delivery-plan/)

5.6 The National Eating Disorder Network providing eating disorders expertise to existing programmes tackling mental health stigma, such as https://www.seemescotland.org/about-see-me/ and in mental health wellbeing resources such as https://young.scot/campaigns/national/aye-feel.

Recommendation 6: Self-help resources available to all

Scottish Government should provide funding to the Third Sector to build platforms and a range of community services to enable the Scottish public to have free access to evidence-based self-help/management programmes and supports, including peer support networks.

Ownership: Scottish Government, the National Eating Disorder Group, Public Health Scotland and the Third Sector

We suggest that this could include:

6.1 The Third Sector working with the National Eating Disorder Network to create and host evidence based self-help and early intervention programs as recommended by SIGN, for example for Binge Eating disorders.

6.2 Developing peer support networks with the Third Sector to provide peer support to people with eating disorders and their families irrespective of the stage of the illness or whether they are in treatment.

6.3 The Scottish Government increasing the Scope of www.caredscotland.co.uk to include eating disorders across all ages and link it to the National Eating Disorder Network so that CaredScotland can serve as an information point for all family and carers with loved ones across the age range and all eating disorder diagnoses.

6.4 Developing online support for family and carers, which could be coordinated between the National Eating Disorder Network and the Third Sector, to provide additional practical and emotional support for people with eating disorders and their families to augment services provided by the NHS.

6.5 Peer support networks which can be developed with the Third Sector to provide support for all carers and adapted to meet the needs of all, including fathers/partners and siblings.

Recommendation 7: Early Intervention

Key Stakeholders and Healthcare professionals should be able to identify the signs and symptoms of all eating disorders including at early stages and know how to support and sign post people into treatment.

Ownership: Implementation Group, National Eating Disorders Network, Key stakeholder organisations, healthcare professional organisations

We Recommend:

7.1 Key stakeholders in the early identification of eating disorders should include, school staff, youth services, sports, and fitness sector.

7.2 Key healthcare professionals who may see people with eating disorders should be trained and supported to be able to identify the signs and symptoms of all eating disorders including at early stages and know how to signpost people to treatment. See recommendation 12.4 – 12.8 for training details.

7.3 Key Primary healthcare practitioners should be enabled to become skilled in the early identification of people with eating disorders, and supported to signpost these people quickly into assessments and treatment.

7.4 Key Secondary healthcare practitioners, including in weight management and dentists should be enabled to become skilled in the early identification of people with eating disorders, and supported to signpost these people quickly into assessments and treatment.

7.5 The National Eating Disorder Network website outlined in Recommendation 3.5 should share information on early identification and early access to treatment and map service provision in Scotland and signpost the public to support and advice services offered across Scotland.

7.6 The National Eating Disorder Network website Recommendation 3.5 should also share information regarding relevant Third Sector organisations for people with eating disorders and their loved ones and the services these organisations offer, such as helplines, support groups and participation in advocacy programmes.

Recommendation 8: Primary care

Awareness, detection and early, effective treatment of eating disorders at primary care is important. There should be an ongoing training programme for all primary care clinicians to ensure consistent high standards are maintained in identification and management of patients who may have eating disorders, and their families. There should be increased support from specialist services when primary care is asked to assist with physical monitoring or support, for instance when patients live far away from specialist teams.

Ownership: Implementation Group, healthcare professional organisations, Eating Disorder Education and Training Scotland (EEATS) and NHS Education Scotland (NES)

Please refer to Recommendations 2 and 3 about the role of the proposed Implementation Group and National Eating Disorder Network. We recommend that:

8.1 The Implementation Group and National Eating Disorder Network should work with stakeholder organisations representing staff working in primary care settings (General Practices, primary mental health and other community level healthcare) such as health visitors, midwives, community nurses and counsellors to agree training and care standards regarding eating disorders.

8.2 Primary care should be supported and resourced, where appropriate, to provide some aspects of care in conjunction with specialist teams depending on population and geography.

8.3 Primary care practitioners should NOT be required to hold medical responsibility for significant or severe eating disorders, except where this is appropriate for specific cases in partnership or agreement with specialist medical practitioners.

8.4 Scottish Government has committed to increasing the mental health workforce in 2021-22 by providing dedicated mental health professionals to work in all A&Es, all GP practices, police custody suites and prisons. These staff should all have training on identification and essential management of eating disorders.

8.5 Mental health workers and identified General Practitioners with special interests in mental health in all GP practices should be offered special training and support in eating disorder identification and the essential management of eating disorders.

8.6 Staff employed in the NHS 24 Mental Health Hub and in Mental Health Assessment Units developed in line with the Mental Health – Transition and Recovery Plan should have training on the identification and essential management of eating disorders.

Recommendation 9: Safe medical care

Medical aspects of care should be prioritized, with clear lines of responsibility and leadership from suitably trained medical experts. We recommend named eating disorder medical leads for every health board/region with oversight over the medical care of every patient with an eating disorder, who report data to the National Eating Disorder Network. This can be done in collaboration with General Practitioners, Acute Medicine and Paediatrics according to the local context of who has appropriate training in managing the medical aspects of eating disorders.

Ownership: National Eating Disorder Network, All health boards

We recommend:

9.1 Designing a sustainable training programme to develop and maintain medical expertise in eating disorders within and across Scotland is a priority, see recommendation 12.9 – 12.11.

9.2 There should be expert medical oversight ensuring safe medical management of all patients with moderate to severe eating disorders across Scotland. Every health board/region should have named pairs of medical leads, for adult eating disorders and child and adolescent eating disorders respectively. They should be: a named lead physician and adult eating disorder psychiatrist; and a named lead paediatrician and eating disorder child and adolescent psychiatrist. These named medical leads should be responsible for oversight of the medical care of patients with eating disorders. These named health board/regional leads should have a day a week funded for this task on an ongoing basis and be specially trained to be expert in nutritional and medical aspects of eating disorders.

9.3 We recommend the named eating disorder medical leads for every health board/region should have oversight over the medical care of every patient with an eating disorder. The named leads should be able to provide input to local clinicians looking after patients, as well as be involved in training staff as required. This can be done in collaboration with Psychiatry, General Practitioners, Acute Medicine, Paediatrics according to context who have appropriate training in managing the medical aspects of eating disorders.

9.4 These leads should be tasked with collating data about every patient with eating disorders within their catchment, to report to the National Eating Disorder Network. They should receive all data from the area about any critical incidents and complaints, and also analyse and report all deaths amongst patients with eating disorders.

9.5 That the named psychiatric leads should be able to consult and share responsibility as appropriate with colleagues from other mental health services for patients who have complex mental disorders and neurodevelopmental disorders; similarly the named medical leads should similarly be able to consult and share responsibility with physician/paediatrician colleagues from other medical services for patients who have complex medical problems including diabetes, or medical consequences of eating disorders such as osteoporosis, and neurological, gastrointestinal, renal or endocrinological problems.

Recommendation 10: Investment in specialist eating disorder services.

The Scottish Government should commission and fund equitable provision of high-quality accessible specialist community-based services for eating disorders across Scotland for all ages, which see all types of eating disorders across the range of severity.

Ownership: Scottish Government, Implementation Group, National Eating Disorder Network, All health boards

We suggest that:

10.1 The Scottish Government should appoint an Implementation Group (see Recommendation 2) and provide funding for a programme of work to build a workforce with the skills and competencies to be able to provide specialist eating disorder treatment within specialist teams in Scotland as quickly as is possible to do so.

10.2 All specialist eating disorder services across the age range should accept self-referrals and referrals from any relevant professional, including counsellors, school nurses, third sector workers, as well as General Practitioners to enable rapid and equitable access regardless of age, severity and diagnosis.

Outcome: All eating disorder services should be reporting referral rates and sources to the National Eating Disorders Network lead for data collection by the end of 12 months, and thereafter on an ongoing basis. Furthermore, they should have appropriate resourcing of IT and administrative staff to enable this.

10.3 All eating disorder services should see patients fairly regardless of age, location and personal characteristics such as gender, sexuality, race, ethnicity, culture, language and religious beliefs. Duration of illness, age, type of eating disorder, body weight and presence of co-morbid medical or psychiatric disorders or neurodevelopmental disorders should not be used as barriers to treatment, and medically or psychiatrically unwell patients should be seen more quickly.

Outcome: All eating disorder services should be reporting demographics and characteristics (such as age, gender, diagnosis and severity) of all referrals, outcomes of referrals and all patients accepted into their services to the National Eating Disorder Network lead for data collection by the end of 12 months and thereafter on an ongoing basis.

10.4 All eating disorder services should ensure that they actively engage with service users to co-design and evaluate services. This would ensure that services are, and continue to be, environments that are accessible and welcoming to everyone and promote the formation of strong therapeutic relationships and recovery irrespective of gender, race, ethnicity, culture, sexuality, age or class.

10.5 We recommend an 'all age' approach to treating eating disorders. Initial changes could take the form of staff of current child and adolescent and adult eating disorder services forming virtual or face to face multidisciplinary teams to work together to provide seamless treatment which is developmentally appropriate to each patient.

10.6 Specialist eating disorder teams should hold responsibility for medical aspects of safe care for their patients. This can be done in collaboration with specific General Practitioners, Acute Medicine and Paediatrics as appropriate, however training in the medical aspects of eating disorders would be needed. We suggest that the Implementation Group should convene a working group to work with relevant stakeholders and all the named medical leads to discuss how this can be done.

10.7 Where health boards have smaller populations, creation of regional specialist eating disorder multidisciplinary teams may be appropriate. This could include having staff based in various health board locations and returning to a central base for multidisciplinary work, as well as utilising remote telehealth. This would ensure that people with eating disorders and their families are able to access the same range and quality of therapies and medical care wherever they live. We recommend that all health boards/regional teams should demonstrate that they can offer the entire range of SIGN-approved treatments and supports to their patients regardless of location of residence.

10.8 We suggest that telehealth should continue to be extensively used to enable treatment to be delivered anywhere in Scotland. This will enable co-working across geographic areas to occur across Scotland so that all patients can access the treatment they need. Scottish Government have already committed that 'we will move to a position of "Near Me" as the default option where that is right for the person and they are happy to use the service.' To promote digital inclusion, Scottish Government advocates creating innovation Hubs (included in the Mental Health Transition and Recovery Plan). Eating disorder services should ensure all health and care consultations are by Near Me or phone whenever clinically appropriate, using the Hubs as needed to support access and provide local community support. Scottish Government have committed to expanding a specific online Cognitive Behavioural Therapy (CBT) platform and enhanced internet based supported CBT; eating disorder specific enhanced CBT (CBT-E) is one of the few evidence-based treatments for eating disorders and we suggest this should be included in the Scottish online CBT resource.

10.9 Health Boards and Integrated Joint Boards should be held to nationally agreed levels of service provision, types of therapies offered and quality care standards (recommendations 2.5 above) and as recommended in the upcoming SIGN Guidelines. The National Eating Disorder Network should have oversight of compliance and conformity to SIGN Guidance and agreed Quality Standards, evaluated via collection of the national datasets.

10.10 For patients of all ages, it is crucial that eating disorder clinicians develop and maintain strong links and working relationships with other local specialist and generic services, so as to collaborate and work together to meet the complex needs that arise from comorbid mental health issues, such as personality disorders, addictions, post-traumatic stress disorder (PTSD). In turn, eating disorder services should work with these services to manage disordered eating and mild eating disorders amongst their patient group, which also prevents development of severe eating disorders. Eating Disorder Services need to develop improved links with services working with people on the autism spectrum, as well as training for ED and autism services on the appropriate management of eating disorders in people who have autism. The Implementation Group should convene a forum with Scottish leads for the different other specialties with eating disorder lead clinicians to enable consensus about how to work more closely together; this network of eating disorder lead clinicians should have ongoing meetings hosted by the National Eating Disorder Network to continue developing consensus and working relationships.

10.11 Eating disorder teams should develop and maintain strong working relationships with both national and local statutory and Third Sector agencies who are crucial in supporting all patients with eating disorders and their families. The presence of comorbidities increases the complexity and need for support in order to address all needs and achieve recovery.

10.12 The National Eating Network should host regular national Morbidity and Mortality meetings with lead clinicians across Scotland to review all critical events, near misses and deaths amongst patients with eating disorders. This data will be collated together with records of patient and family complaints and reported regularly to Scottish Government, together with the agreed learning points for improvement of patient care and safety.

Recommendation 11: Workforce

A comprehensive workforce plan will be developed that aims to build the workforce to be able it to meet the service standards over the next 10 years. This plan should emphasise staff retention and training within eating disorders services as well as recruitment.

Ownership: Scottish Government, Implementation Group, National Eating Disorders Network, All health boards.

We suggest that:

11.1 The comprehensive training plan described in recommendation 12 is prioritized in order to build a trained workforce for Scotland in the prevention, early identification and treatment of eating disorders.

11.2 Specialist teams should be created which have minimum numbers of essential disciplines, and advancement for all professionals. Teams should include therapists, medical and psychiatric staff, nurse practitioners, psychologists, dietitians and other allied health professionals; all of which could have a leadership role in these teams.

11.3 In addition to the creation of new posts, attention should be paid to the issue of retention of skilled staff once they are fully trained. This may include, equal training opportunities for all, roles determined by skills and competency and not limited by profession, role rotations, and the progression of staff through grades including in nursing and allied health professionals.

11.4 The National Eating Disorder Network should provide a forum where specialist teams actively work together to support staff, prevent burn out and provide research and other personal development opportunities.

Recommendation 12: Education and Training

A comprehensive training plan will be developed which will aim to equip the entire healthcare workforce which might see people with eating disorders and their families, to deliver high quality care for people with eating disorders in all settings ranging from early intervention to highly specialist care, and from community to inpatient. In addition, there should be appropriate education and awareness training for other relevant professionals, such as youth workers, counsellors, and sports coaches. Training should be appropriate to the role that each professional has with respect to prevention, identification, signposting, treatment and support of people with eating disorders.

Ownership: Scottish Government, National Eating Disorder Network, Eating Disorder Education and Training Scotland (EEATS) and NHS Education Scotland (NES)

We suggest the Implementation Group, prioritise:

12.1 The development of a skills and competency framework, in partnership with NHS Education Scotland (NES) and Eating Disorders Education and Training Scotland (EEATS), for all staff, including third sector, who may see or work with people who have eating disorder symptoms or diagnosis. The initial focus should be developing medical expertise in eating disorders within Scotland to ensure safe medical treatment of all patients with eating disorders, regardless of where they are seen.

12.2 Work in partnership with NES and EEATS and the third sector, to develop a training strategy that translates the NHS skills and competency framework into a framework suitable for non-healthcare/NHS professionals and supports appropriate training and awareness in schools, further education, third sector mental health workers and the fitness sector. This could include the use of digital technologies for training and supervision. Where possible and appropriate, resources already developed could be adopted and used. (For instance, training has already been created by Beat and the Royal College of Psychiatrists and can be rapidly implemented if desired.)

12.3 Enabling the National Eating Disorders Network to develop and host national remote training for all types of healthcare and other professionals.

In relation to early intervention, we suggest that:

12.4 The Mental Health Transition and Recovery Plan could make commitments to increase training for all school healthcare staff such as school nurses and school counsellors in conjunction with the Mental Health in Schools Working Group and the National Eating Disorder Network. This should include education on eating disorders. There is an existing commitment to increase college and university counsellors and we suggest these staff should have training on the identification and signposting of eating disorders.

12.5 There should be training in the identification and signposting of eating disorders for all staff in Mental Health and Wellbeing services, as part of the Scottish Government's Transition and Recovery Plan being rolled out in all local authority areas during 2021.

12.6 The National Eating Disorder Network, in partnership with EEATS and the third sector, as part of Recommendation 3.4, could train youth services workers to work with them to support early identification and signposting of young people with eating disorder symptoms to appropriate levels of support or treatment.

12.7 The National Eating Disorder Network, in partnership with EEATS and the third sector, should provide training to the sports and fitness industry concerning good practice in sports and fitness to prevent eating disorders, enable early identification and signposting of people with eating disorder symptoms to appropriate levels of support or treatment.

12.8 Primary care training should be an important part of the national training strategy and its implementation should be prioritised.

In relation to Medical aspects of care, we suggest that:

12.9 Designing a sustainable training programme to develop and maintain medical expertise in eating disorders within and across Scotland is a priority.

12.10 We suggest that this should include Scottish Government-funded fellowships in advanced nutrition for paediatric and acute medicine/gastroenterology higher trainees. These fellowships will enable medical higher trainees to have placements within both specialist eating disorder units and acute medical care settings, to develop advanced knowledge and skills in nutrition and eating disorders. These trainees will be expected to become named consultant physicians and paediatricians who hold oversight of the medical aspects of treatment for eating disorders as part of their consultant roles, in addition to working as nutritional experts within their medical departments.

12.11 That a training programme is needed for staff of Weight Management Services in Scotland so that they are able to identify and manage patients in their services who have disordered eating, early eating disorders or established eating disorders, especially Binge Eating Disorder. These staff should co-work with eating disorder service colleagues to treat these patients.

In Relation to undergraduate training, we recommend:

12.12 Working with UK-wide organisations to increase the eating disorders content of curricula within medical school, dental school, general nursing, dietetics and clinical psychology training. This will require the National Eating Disorder Network and other eating disorder leaders to work at the UK level with the General Medical Council and General Dental Council, as well as organisations such as the Royal College of General Practitioners, Royal College of Psychiatrists, Royal College of Paediatrics and Child Health, Royal College of Physicians, Royal College of Nursing, and British Dietetic Association and British Psychological Society.

In Relation to Specialist care, we recommend that:

12.13 The National Eating Disorder Network should set up national specialist training and other programs which enable clinicians to have equal access to high quality skills and competency-based training, supervision, and opportunities for personal development irrespective of profession and location, in order to meet the nationally agreed quality standards.

12.14 The National Eating Disorders Network develops and provides remotely a training and education programme with accreditation for all specialist eating disorder clinicians to ensure consistent standards of training across Scotland and to enable all eating disorder services to provide the same level of evidence-based treatment and therapies to all patients as defined by the national quality standards. This should be done in partnership with the Eating Disorder Education and Training Scotland (EEATS) and NHS Education for Scotland (NES).

Recommendation 13: Families and carers

Families and carers should be given a high level of support from the start of their loved ones eating disorder, and for as long as they need it. Experts by experience (both patients and families) should be involved in service design and implementation as well as quality improvement.

Ownership: Specialist eating disorder teams, the National Eating Disorder Network and the Third Sector

We suggest that:

13.1 The Government should increase the Scope of www.caredscotland.co.uk as an information point for all family and carers with loved ones across age range and diagnosis (See Recommendation 6.3).

13.2 Online support for family and carers should be coordinated by the Third Sector, these should include practical and emotional support.

13.3 Peer support networks should be developed with the Third Sector to provide support for all carers and adapted to meet the needs of all, including fathers/partners and siblings and other family members or loved ones who may be supporting patients.

13.4 Specialist eating disorder teams should ensure that all family and carers are given the opportunity for support and information about eating disorders.

13.5 Specialist teams should provide family and carers who are actively involved in providing care and support to their loved ones, with a high level of support and advise, irrespective of their loved ones age.

13.6 Advice and support for families and carers should be provided on employment rights and benefits.

Recommendation 14: Inpatient eating disorder services

Inpatient eating disorder provision is currently variable and inequitable across Scotland particularly for adult men. Inequitable access to inpatient care has significant impact on community services. Where there are inequalities, Health Boards should work together to ensure there are equitable access to services. We recommend a further, smaller review specifically of national inpatient provision across all ages in 5 years' time, after community service improvements have been implemented.

Ownership: The Scottish Government, Implementation Group and National Eating Disorder Network, all Health Boards

Recommendation 15: Eating disorders Research in Scotland.

Scottish Government should consider funding eating disorders research through NHS Research Scotland. Specific calls for eating disorder research should be made to support research which would fill gaps in knowledge and understanding of eating disorders in the Scottish population, and their treatment in Scotland. Particular note should be taken of gaps in the research base that SIGN identifies.

Ownership: Scottish Government, NHS Research Scotland, National Eating disorders Network, Health boards and eating disorder clinicians.

15.1 Developing a strong research culture should both make Scotland more attractive and able to recruit, train and retain high calibre research-oriented clinicians, and establish a culture of enquiry, innovation and accountability which will help drive up standards across all services.

15.2 Both the research agenda and the funded research should be co-produced by researchers with those with lived experience and clinicians working within the field.

15.3 This funded research should always aim to improve the treatment and welfare of people with eating disorders and their families.