National Specification for the Care and Treatment of Eating Disorders in Scotland - Consultation Analysis Report

9. Outcome 5: Assessment and Medical Monitoring

This chapter present the analysis of Q20 to Q22, related to Outcome 5: Assessment and medical monitoring.

Nine in ten (90%) of those answering Q20 agreed to some extent that Outcome 5 will improve the experiences of people accessing eating disorder treatment; 21% strongly agreed and 69% agreed. However, this was the lowest level of strong agreement recorded across the nine outcomes. All other organisations who answered agreed, as did 92% of healthcare respondents and 82% of individuals who answered.

Four fifths (82%) of those answering Q21 agreed to some extent that Outcome 5 will improve the outcomes of people accessing eating disorder treatment; one quarter (24%) strongly agreed and 58% agreed. All other organisations who answered agreed, as did 87% of healthcare respondents. Two thirds (64%) of individuals agreed, which is the second lowest level of agreement recorded by this group; one quarter (25%) were neutral and 17% disagreed.

Q22. Reading the “Outcome in Action”, which is intended to describe how “Outcome 5 - Assessment and medical monitoring" will be delivered, do you have any other comments about the Outcome?

Medical monitoring

Almost 70% of respondents commented at Q22. Views on proposals about medical monitoring was the most common theme. A small number emphasised the importance of clarity around responsibility for medical monitoring or were encouraged by the Specification’s recommendation to ensure this. An advocacy organisation urged that this Outcome also include the importance of medical monitoring for those not seeking treatment.

“I have experienced big issues over who has responsibility when an inpatient and when changing geographical area. Physical health monitoring is poorly communicated as is who is responsible for it and its recording, with it getting overlooked, ignored, or replicated/duplicated. This wastes time and resources and can be dangerous and distressing.” – Individual

However, barriers to mental health services providing medical monitoring included: inadequate accommodation and medical equipment; a lack of psychiatrists, specialist, and non-specialist medical staff; local variability in service user’s ability to access physical monitoring; poor communication around who is responsible for medical monitoring; and insufficient specialist inpatient provision in parts of Scotland. One individual felt the Specification needed more detail about how these barriers would be addressed, including the inclusion of reference to a named clinician. One healthcare respondent called for services’ MDT compliment to include psychiatrists, GPs, or paediatricians specialist in eating disorders to allow for consistent care. Others advocated national guidance and funding to ensure equity of access to physical monitoring, a national action plan for medical staff recruitment, and safe and sustainable senior medical staffing for eating disorder services. One suggested that those with low or medium risk be monitored in primary care and emphasised the importance of primary care staff not becoming de-skilled in monitoring those with an eating disorder.

“This can be a problem-who is in overall 'charge' of this person with an eating disorder? Some clinicians will manage their 'section of the care' but not assume overall care. The GP is in a good position to coordinate holistic care, but this is a big ask. ‘Agreement and documentation of which service holds clinical responsibility' is too vague. Organisations need to name an individual clinician who hold clinical responsibility for each patient with an eating disorder." – Individual

Primary care and shared care arrangements

Several commented on shared care arrangements with primary care, or the specific role of GPs within medical monitoring. SupportED and a professional/academic organisation felt the Specification should explicitly mention the role of GPs and their involvement in referral pathways at this Outcome since they usually have the most contact with patients.

Barriers to reaching shared care arrangements for medical monitoring were highlighted, including: lack of integrated IT systems; resource and capacity constraints in primary care; lack of funding for GPs to take on physical risk monitoring; inconsistency of physical monitoring provision for mental health patients across Scotland; and differences in practice across the primary care sector making it difficult to establish shared care arrangement and clinical baselines as part of physical health monitoring. Two also highlighted challenges for those living in rural areas where the use of locums may be higher or where there has been a failure to reach shared care agreement between primary and specialist care providers. They questioned what liaison could be introduced for better collaboration between mental health teams and GP practices.

There were calls for closer links with GP colleagues and the provision of consultation from eating disorder services, funding, time, training, and education for GPs to ensure recommendations for shared care agreements can be implemented. A healthcare respondent, however, suggested specialist services should be resourced to hold all medical monitoring responsibilities. A professional/academic organisation highlighted the need for clear role boundaries to ensure safe care; they advocated the Specification be clear that GPs are not expected to monitor patients between referral and being seen by specialist services. Edinburgh Carers council requested that the Specification extend shared care arrangements to include private services, given that the reality of long waiting lists means some opt to access these.

“Services including GPs need further education around the parameters for specialist ED service referrals. Often clinicians are ill informed and perpetuate inaccurate myths regarding the need for BMI to be low to meet criterion for services. Specialist services should have resources to hold all the medical monitoring needs of their patients due to the resistance frequently shown by GPs to provide this care.” – Greater Glasgow and Clyde Adult Eating Disorder Service

Other professionals involved in assessment and monitoring

One healthcare/professional organisation felt that the Specification is weighted towards psychiatric assessment and queried whether assessment by a psychiatrist is essential for all those with an eating disorder. Some respondents mentioned other professionals who do, or could, carry out assessment and medical monitoring, or requested greater consideration of their roles within the Specification. These included Emergency Department staff such as paediatricians and liaison psychiatrists, Nursing and Allied Health Professional advanced practitioners, and Physician Associates (who may be more cost effective than other medical staff but who do require supervision). A professional/academic organisation noted that patients are often sent to Emergency Departments for medical assessment due to lack of capacity in the community and called for fully staffed community services to prevent this. They also requested agreed joint working processes and clear escalation plans for individuals admitted to medical wards, to support patient flow and continuity.

Two healthcare respondents raised the lack of access to NHS dentists across Scotland as a barrier to dental monitoring for those with purging behaviour. They suggested this section of the Outcome be reworded to note the importance of dental prevention and timely access to treatment.

National guidance in medical monitoring

A few healthcare respondents valued the reference to SIGN and MEED (Medical Emergencies in Eating Disorders) guidance, with one calling for this to be strengthened at Outcome 5 to better acknowledge their role in clinical decision-making, treatment planning, and monitoring. NES agreed with the suggestion of a description of expected assessment processes from primary care to specialist level and suggested a rolling training programme to ensure SIGN and MEED are adhered to across all professional groups involved in assessment and monitoring duties.

Wider assessment and formulation

Two healthcare respondents requested the Specification to differentiate between ‘physical’, ‘psychiatric’ and ‘psychological’ assessment and monitoring, rather than combining these under the ‘medical monitoring’ umbrella. They argued these types of assessment and monitoring have different remits, require different skill sets, or can be undertaken by different clinicians to improve cost efficiency. A view expressed in two comments was that the Outcome title be changed to Physical Assessment and Physical risk monitoring to better reflect the role of services described.

Two healthcare respondents felt that psychological formulation should be mentioned as part of the assessment process to guide treatment in an evidence-based way. Another called for the Specification to refer more to treatment generally and expressed disappointment about the lack of guidance and direction provided about this.

Other points made about assessment included:

• The need for more guidance on mental health assessment
• A call to consult non-medical organisations, such as guidance teachers, as part of the wider assessment process
• See Me felt the appropriateness of the assessment and the tone in which it is written should also be considered. They emphasised that language, tone of assessment tools, and unconscious bias can play a role in how assessments are carried out, affecting outcomes for individuals. They advocated that those in assessment roles undergo training with input from people with lived experience.

Excessive training, exercise, and steroid use

Some suggested enhancing Outcome 5’s recommendations about excessive training, exercise, and steroid use. One healthcare respondent, for instance, felt there is a need for greater awareness among clinicians and the general public regarding the impact of these behaviours and clarity around referral pathways for refers. NHS Dumfries & Galloway Adult MH service also felt this recommendation highlighted a requirement for a training needs analysis for all staff groups and access to up-to-date training.

“It should not just be excessive training and exercise but should include over activity too. Support to manage dysfunctional activity and exercise is the more favoured term currently as it encompasses all aspects of exercise and activity which can be challenging for someone with an eating disorder. To highlight that support to manage this should be with a clinician with the right experience and training who understands all the potential medical and mental health risk factors, e.g., a physiotherapist. Misuse of steroids is mentioned within the exercise statement but perhaps there needs to be an additional statement on support for individuals that are misusing medication/substances (illicit, over the counter or prescribed) e.g. steroids, laxatives, diuretics, diet pills, alcohol.” – Scottish Physiotherapists in Mental Health and UK Physiotherapy Network Group

Other themes

A few expressed views on engagement and the proactive outreach approach. The Edinburgh Carers council called for inclusion of a recommendation to support staff to take a proactive outreach approach to facilitate carer engagement. However, there were calls to consider models of motivation and change and an individuals’ readiness to engage in treatment. One healthcare respondent supported the position that patients have a right to decline treatment unless they lack capacity, and that over-assertive attempts to engage patients can result in disengagement. Greater Glasgow and Clyde Adult Eating Disorder Service questioned whether alternative pathways need to exist where individuals have low motivation for recovery, for example, a monitoring pathway working towards improved quality of life and assessing readiness for engagement.

“There is focus on an "outreach approach" which of course will be appropriate in some cases, however there is no consideration to the stages of change model in considering readiness for treatment. This may lead to responsibility for recovering failing to consider the person presenting with eating disorder as an active agent in their own treatment.” – South Glasgow CMHTs

A small number identified omissions or suggested improvements about Specification content linked to assessment and medical monitoring. These included that:

• The Specification focuses on the immediate health concerns of those with anorexia and lacks consideration for those with eating disorders other than anorexia whose long term health may also be compromised. For instance, the lack of detail about medical monitoring of those with BED was highlighted.
• ‘Appropriately trained clinician’ needs to be defined.
• Mechanisms for transition from traditional assessment models to more person centred care should feature more prominently, for example the Specification could outline guidance on how to involve young people and families meaningfully in assessment.