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

11. Outcome 7: Discharge

This chapter present the analysis of questions Q26 to Q28 about Outcome 7: Discharge.

High levels of agreement (92%) that Outcome 7 will improve the experiences accessing eating disorder treatment were recorded by those answering Q26. One quarter (23%) strongly agreed and 69% agreed. All individuals and other organisations who answered agreed, as did 88% of healthcare respondents, though strong agreement was notably lower among healthcare respondents than other groups (13%).

Nine in ten (89%) of those answering Q27 agreed that Outcome 7 will improve the outcomes of people accessing eating disorder treatment; 24% strongly agreed and 66% agreed. All other organisations who answered agreed, as did 88% of healthcare respondents and 90% of individuals. However, strong agreement was notably lower among healthcare respondents than other groups (17%).

Q28. Reading the “Outcome in Action”, which is intended to describe how “Outcome 7 - Discharge" will be delivered, do you have any other comments about the Outcome?

Discharge planning and decision-making

Just over half of respondents commented at Q28. Most commonly, respondents noted views about discharge planning and decision-making. Some emphasised the importance of collaborating with, and considering the views of, individuals, families, and carers within this. Others agreed that discharge decisions should be based on a holistic assessment of clinical need rather than service need or clinical measures such as BMI.

There were also calls to consider the persons’ readiness to commit to treatment and their right not to engage with services, therapists’ views about the benefits of treatment, and to recognise that there are times when discharge may be appropriate. One healthcare respondent requested the Specification to include guidance on supporting those not benefiting from specialist service input.

“This is a decision which should be based on a number of factors, including the degree to which the patient is ready and able to engage in treatment. In some cases, the therapist may suggest a therapeutic break or discharge based on the patient's readiness to work in treatment. Open and honest conversations should be encouraged where both the therapist and patient have an opportunity to express their views and professional opinions.” – Healthcare respondent

Some expressed support for developing collaborative discharge and relapse-prevention plans and improving communication around discharge. A few advocacy organisations felt that services should provide information about reasons for discharge and discharge protocols from the outset of treatment, share copies of discharge plans, and provide people with a post-discharge guide and follow-up letter to GPs. A healthcare respondent and the RCPsych. Scottish Faculty of Eating Disorders stressed that communication was especially important when there was disagreement about discharge decisions or unplanned discharge.

“Not all discharges will be planned - sometimes patients leave services and do not want to complete their contact with them for a wide variety of reasons... We have to be clear there will occasionally be situations where either the patient does not want to be discharged or the service does not want the patient to take their discharge, but it still has to go ahead. In those cases, then encouraging as much communication and sharing information about the reasons for this, and what the next steps can be, is important.” – RCPsych. Scottish Faculty of Eating Disorders

The overarching theme of partnership working was evident at Outcome 7. Some highlighted the importance of coordination with partners in discharge planning and to deliver discharge related recommendations. There were calls, for instance, to foster positive working relationships between the NHS, social services and education and to collaborate and communicate with GPs, dentists, AHPs, and employers. It was felt this would provide assurance about follow-up care, support people to self-manage their condition, identify concerns post-discharge, and support people to transition back to work.

Some advocated the inclusion of charity and third-sector organisations within discharge planning and ongoing support pathways. A healthcare respondent suggested there should be collaborative decision-making about discharges between inpatient and outpatient teams. One individual called for consistent care between hospital and the community and the option for some to be fed by NG tube in the community.

“AHPs are experts in supporting self-management, and long-term management plans, and physiotherapists working with people in ED services to embed dysfunctional exercise management, can be key to ensuring that there is not a focus shift post discharge if concerns have already been addressed. Physios in ED can also address other physical symptoms of ED including postural change, poor body image, pain, tension, hypermobility and continence through physiotherapy specific physical interventions.” – Mental Health Physiotherapy, NHS Ayrshire and Arran

Alternatives to full discharge

Several commented on proposals for a phased approach to discharge, the option to re-engage with services post discharge, and the provision of longer term support for those experiencing a long-term eating disorder. Several, including individuals, healthcare respondents and advocacy organisations, supported these proposals. Reasons given included that this:

• Recognises the potential for an eating disorder diagnosis to have an enduring and chronic impact on a person’s life.
• Reduces the fear of discharge and reassures those who find this daunting.
• Offers secondary protection -supporting people to seek help earlier should they need it or identify further goals to work on.
• Provides flexibility and supports successful transition of care.

“I think the idea of a 'light touch' pathway for those patients who haven’t responded optimally to treatment or who lack the motivation to engage is a super idea. Boundaries are also valuable in terms of offering a time limited evidence based therapy or services quickly get saturated holding cases who are not engaged in treatment but also not safe enough to discharge. The value of encouraging independence rather than dependence on services particularly for those with some Dependent PD traits is essential. More flexibility around this would be good including improved coordination with other services including third-sector ones.” – Greater Glasgow and Clyde Adult Eating Disorder Service

An advocacy organisation requested that the light-touch approach be extended beyond those with enduring illness. However, a few healthcare respondents felt that more detail was required within the Specification about these proposals or raised concerns about these. These included the need to address capacity within post-discharge services to implement the suggestions and the importance of endings and boundaries to encourage autonomy and self-efficacy. South Glasgow CMHTs and the RCPsych. Scottish Faculty of Eating Disorders felt that the option for re-referral should still require clinical triage or be based on clinical judgement and negotiation, rather than a catch all.

“The specification does not touch on in any real depth on working with those with enduring eating disorders. In those case’s what might contact the service actually involve e.g. physical risk monitoring? What does re-engaging directly with the service actually mean- the specification needs to be more specific about the details of what that would involve. It may again mean better pathway development with partner organisations to assist in that process, as well as welcoming the input when possible from families and carers. We would suggest that if this is a self-referral in type then that will still a need proper clinical triage of the situation led by an experienced member of staff.” – RCPsych. Scottish Faculty of Eating Disorders

Other themes

A small number identified barriers to achieving discharge related recommendations including inpatient ward bed-pressures, capacity issues, challenges engaging community services, including social workers, and lack of avenue for onward referral.

Each board area has different services - some have specialist in-service facilities, some don't, some have day services, some don't, within primary care you generally don't consistently see the same GP for consistency with managing patients in the community. Inpatient service have challenges around discharging patients safely into the community or delayed discharges when transferring patients to other services, this means that there can have a waiting list for an inpatient service, and in some urgent cases have had to go to private facilities out of area. Delayed discharges and delayed transfer of care is hugely challenging at the moment for the NHS.” – Scottish Physiotherapists in Mental Health and UK Physiotherapy Network Group