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

14. Implementation and measurement

This chapter presents the analysis of Q35 to Q39 about implementation and measurement. It covers respondents’ views on the support needed to implement the National Specification, questions to include in self-assessment and ways of supporting services to reduce inequalities in the outcomes and experiences of service users.

Q35. Overall, what support do you think services will need to implement the National Specification for the Care and Treatment of Eating Disorders in Scotland?

Two thirds left a comment in Q35. In addition, in most consultation questions, respondents noted support needed to implement specific Outcomes or the Specification generally. These comments have been analysed and written up under Q35 to avoid repetition. Suggestions for particular Outcomes have been included in the relevant question.

Resources

Adequate resourcing was most commonly identified as vital to effectively implementing the Specification. Respondents emphasised that without resources, implementation would be challenging to achieve. Resources called for encompassed: investment and sustainable, ringfenced, year-on-year funding; sufficient multidisciplinary workforce and service capacity; consistent and equitable service provision and treatment options across Scotland; dedicated clinician time; administrative support; management and leadership personnel; accommodation, infrastructure development and clinical space-including food preparation facilities; medical monitoring equipment; and technology. Respondents advocated funding across tiers and services including: GPs and primary care, secondary care, community services, specialist eating disorder services, intensive-day care services, crisis teams, outreach teams, inpatient wards, in-reach services, teams supporting those with co-occurring considerations, social care, and third-sector organisations.

The need for local and national workforce planning and supporting staff recruitment and retention, including of specialist staff, was highlighted by some. A few advocated a longer-term staff expansion plan and a national strategy to address the shortage of medical staff.

Money for ED services to be ringfenced… Some services are currently moving away from ED specialists being co-located into one team and spread across services. This runs counter to these recommendations…NHS England has ensured that teams provide specialist teams. Dedicated money and training has ensured that this is the case, without this, ED services in Scotland are set to become increasingly diluted and unsafe.” – Healthcare respondent

Training

Many raised the issue of training, education, continuous professional development (CPD), and clinical supervision as being integral to successful implementation. Points raised echoed those already noted at Outcome 8, including the need for funding, protected time, and operational cover for training, and for training to have a broad reach. A few healthcare respondents also called for higher education institutions to contribute to a national action plan on multidisciplinary succession planning for eating disorder services, and to encourage people into the specialism by developing mental health and core eating disorder teaching and training places for nursing, medicine, clinical psychology, dietetics and AHPs.

Leadership and Governance

A recurring theme was the need for leadership and governance support for implementation. Respondents called for:

• Service-level leadership in the form of management buy-in, clinical leads governance groups to take ownership of, and accountability for, driving change and enhancing partnership working.
• Local and national strategic groups, short-life working groups, or Managed Clinical Networks.
• Scottish Government leadership in the form of funding, constructive dialogue with staff, national staff succession planning, a robust action plan, supporting collaboration between the NHS and third sector, alignment with other related national strategies and workforce planning. One healthcare respondent called for the Scottish Government to engage directly with eating disorder services to understand their unique challenges in meeting the Specification.
• A focus on staff wellbeing as part of creating a more supportive and effective system to meet the needs of people who use services and staff.

“Working across interfaces is essential for pathway development, and hence the assistance of senior leaders and managers in the local organisations will be required to facilitate… it will be for service managers to work together with the teams to help develop the local service design in a way that works for that area. There are models for this across the country (UK) that can be used as benchmarks in a valuable way” – RCPsych. Scottish Faculty of Eating Disorders

Wide reaching support

Several participants urged that supports such as training and funding are not only directed at specialist eating disorder services, but also reach everyone who has a role in supporting those with eating disorders. This includes families and carers, peer support workers, third sector organisations, staff/teams supporting those with co-occurring considerations such as diabetes and neurodiversity, GPs and psychiatrists, and disciplines with current gaps such as physiotherapy. An advocacy organisation also called for including eating disorders in public mental health campaigns to promote public awareness.

Further implementation information and guidance

More detail within the Specification or accompanying guidance and implementation plans were called for by several. Respondents requested:

• Available intelligence on, and baseline measurements of, current eating disorder care and treatment provision, staffing levels, accommodation, and facilities.
• Clearer Specification of key deliverables.
• Guidance on prioritising Outcomes over what timeframe, within current budgets.
• Information about financial, leadership, and practical support being provided to enable Specification implementation, including anticipated funding and increased capacity to meet the Specification.
• Clear information about how recommendations will be operationalised and examples of new focuses for treatment, such as exercise management.
• Clarity on which services and professionals the Specification applies to and around thresholds for specialists for eating disorder services.
• Planned evaluation mechanisms.
• Accompanying statutory guidance so that Health Boards and Health and Social Care Partnerships are aware of expectations around service delivery.

Other themes

The overarching themes of partnership working and monitoring, evaluation, research, and regulation were also evident at Q35. See Chapter 3 for more details.

Some requested support to develop and agree on service structures and pathways within and between NHS services, other agencies, and the third sector. One individual felt that without a framework for service structure and delivery for local services to realign provisions, meaningful change would not occur.

A few respondents also highlighted the importance of staff buy-in to Specification implementation. One healthcare respondent called for a reduction in stigma towards eating disorders. One individual highlighted the importance of ensuring staff have time to reflect on their practice and consider how to develop.

Over four fifths (86%) of those answering Q36 agreed to some extent that the Specification should be measured using a validated self-assessment tool. One third (35%) strongly agreed this should be the case, while half (51%) agreed; 11% were neutral and 3% disagreed. While each sub-group recorded high levels of total agreement, strength of agreement varied, ranging from 27% of individuals to 50% of other organisations.

High levels of total agreement (86%) that the Specification should be measured using a range of indicators were also recorded by those answering Q37. Half (51%) strongly agreed this should be the case, while one third (35%) agreed. Three out of four other organisations and 64% of individuals strongly agreed with this proposal; this was the highest level of strong agreement recorded by these groups across the consultation questions.

Q38. Do you have any other comments on the possible questions to include in the self-assessment, including any further suggestions?

Just over one quarter of respondents commented on Q38. SupportED and a healthcare respondent agreed that a mixed-methods approach including the collection of qualitative data as well as diagnostic only data sets is essential. Suggested questions to cover in the self-assessment included:

• Did you feel as though access to the care and support suitable for you was easy to access?
• Do you feel you were listened to during your first assessment, and that early intervention was implemented?
• Did you feel informed and included in your treatment plan?
• Did you have access to a range of treatment options that met your identified needs (please give examples)?

Individualised qualitative goal-based outcomes and case studies to demonstrate activity were also proposed for inclusion within self-assessment. An advocacy organisation called for a core data set of outcome measures, including goal-based outcomes, to be implemented and publicised across Scotland.

Further design considerations

One healthcare respondent felt that the questions used in the self-assessment should align with the final Specification, so there is a logical flow in assessing how service delivery relates to agreed Outcomes. They also argued that the self-assessment tool be applicable across statutory, voluntary, and private sectors, primary care and general mental health services, and include all professions involved in the delivery of the Specification including AHPs, creative therapists and the broader health professional community. Two noted the design of measures should be benchmarked and designed by drawing from other mental health clinical treatment measures or the international literature.

Self-assessment challenges

A small number raised concerns about, or challenges linked to, self-assessment including biases in reporting and difficulties ensuring information is collated in a trustworthy manner. One individual shared their negative experience of raising concerns and complaints and expressed doubts that self-assessment would be transparent. A healthcare respondent called for a degree of external assessment in addition to self-assessment, such as from the Mental Welfare Commission.

“There is always bias, intentional or otherwise, and there is always an instinct to get paperwork done without bringing on extra work by implementing changes. Often services are not aware of their shortcomings or problems are unreported or underreported. There has to be work on an ethos of openness and transparency, accountability, opportunity for anonymous raising of concerns even if they show on a report/self-assessment.” – Individual

Other themes

One healthcare respondent stated that disseminating the self-assessment tool will need careful consideration given the different service delivery models across Scotland.

Themes outlined at Q38 echoing overarching themes from Chapter 3 included:

• The need to consider compliance with the Specification and how to any continued differences of service user experience between services and health boards will be addressed, especially where those differences constitute an inequity, inconsistency, or postcode lottery of care;
• Including those with lived experience and their families and carers within self-assessment tool design and evaluation more broadly is important. One healthcare respondent recommended using Care Opinion to obtain feedback from individuals and carers.

“Services should facilitate service user panels and representatives and these groups to meet and regularly assess the service in general against indicators and to report specific incidents or areas for improvement. They should regularly be met by someone out with their treatment/care team.” – Individual

Q39. How would you suggest that we support services to reduce inequalities in the outcomes and experiences of people who use services, including in the measurement of the Specification?

Attend to specific inequalities

Two fifths of respondents commented at Q39. Some raised specific inequalities, identified those more likely to experience discrimination or inequitable care, and urged clearer reference within the Specification to consider the needs of, and reaching, underserved groups. These included: people with severe and enduring mental health conditions; those with personality disorder diagnoses; people with BED; LGBTQ+ people; men and boys; black, asian, and minority ethnic groups; women from ethnic minority backgrounds; people from more deprived areas; care experience people; refugees; and neurodiverse people.

See Me suggested the Specification draws from learning from the National Suicide Prevention Leadership Group research flagging the experiences of adversely racialised people and adhering to the recommendations within the Coalition for Racial Equality and Rights Anti Racist Policy report. They also cited research co-created by See Me and Feniks with Polish men living in Scotland which emphasises that there are different experiences of mental health stigma within these communities.

The Scottish Women’s Convention cited evidence to suggest that 75% of people affected by an eating disorder are women. One individual, however, did not feel specific minorities or certain groups should be targeted for support.

“Without fully incorporating information (about the gendered element of eating disorders) into national planning, it is unlikely to be an effective tool for healthcare professionals to use in the prevention and treatment of eating disorders. Therefore, we recommend a fully intersectional approach is taken throughout the national planning process, which considers the unique experience of women across Scottish society. Through this commitment, attempts can be made to understand why women and girls are more likely to develop eating disorders, and how the structural processes in place may contribute to further harm or discrimination.” – The Scottish Women's Convention

A small number highlighted the inequity of service delivery across Scotland or inequitable care in rural areas. They linked this to limited staff and service provision, large geographical spread, long travel distances to access services, unreliable public transport, and digital poverty. One healthcare respondent felt that the Specification proposal of regional services might allow better standardisation and higher levels of care in these areas but highlighted the importance of a mechanism to engage local care teams.

Inequalities within measurement

Suggestions to use measurement, research, and regulation to address inequalities and inequities in care included:

• Draw on, listen to, and act on diverse feedback.
• Provide a variety of methods for those with lived experience to provide feedback.
• Seek feedback not just from staff and people who use services but also from those who decline, disengage, or express discontent with services.
• Analyse outcome data and referral rates against demographics to gauge progress towards addressing inequalities.
• Fund and research the needs of diverse intersectional communities to ensure that lived experience is central.
• Establish short-life working groups to collate qualitative data about experiences.
• Routinely audit training and education packages.
• Keep equity of service user experience and outcome as central to service delivery and communicate findings generated through the self-assessment tool.
• Improving inspection and scrutiny regimes.
• Anonymous self-assessments of the service completed by staff.
• Encourage honest discussions and self-reflection without fear of blame or consequences.
• Foster a culture where people can tell staff that they don't feel their needs have been met and be thanked for bringing it to their attention.

“Our clinical impression is that different socio-cultural and ethnic groups, including that of more deprived areas of the country, may be at risk of having their needs not fully understood or included. It will be important to draw on diverse feedback, and also benchmarking from other areas of the UK with respect to their developments, to avoid these pitfalls.” – RCPsych. Scottish Faculty of Eating Disorders

“Inspections undertaken by the Mental Welfare Commission and Care Inspectorate services produce assessments on what is currently there but not identifying things that are not there that should be (Scot Law, 2022). This may mean that, in some organisations, capacity and resources to support mental health is not universal, with some people getting better care than others resulting in structural discrimination. Providing a consistent scrutiny body would help eliminate the “postcode lottery” effect to mental health care. We would suggest expanding the remit of scrutiny bodies to address gaps or unifying the current bodies and making this clear within the accountability standards.” – See Me

Supports and actions to reduce inequalities

Some identified supports needed to reduce inequalities in the outcomes and experiences of people who use services, such as adequate specialist service provision, funding, sufficient staffing, and training. Suggested training topics included: accessible inclusive care, cultural competency, understanding or marginalisation and systems of power, and anti-mental health stigma and discrimination training. A healthcare respondent also requested services have the opportunity to learn how other services are meeting the diversity of needs of users. They called for collective leadership and government support to ensure learning opportunities are meaningful and future-focused.

Other suggestions to help address inequities of care included that an intersectional approach be more apparent in the Specification, and that the Specification be promoted widely, in an accessible format, so that all are aware of the ideals services should be held to. A few felt involving a diverse range of people with lived experience in service evaluation, Specification planning and implementation groups, tool development, and training, would be helpful. One healthcare respondent advocated prioritising the recruitment of an appropriately governed peer support workforce and volunteer community with specific attention to the views and best interests of people from minority and hard to reach groups and those at increased risk of developing an eating disorder.

A few called for inclusive and accessible approaches to care and treatment, such as individualised, person-centred, and recovery-focused care. See Me made several proposals for ensuring an accessible approach to care, including:

• Workers should check what forms of communication and language people require on first contact before any initial assessment. Staff recorded this information for future contacts with that person, notify necessary colleagues, and check regularly whether people’s communication requirements have changed.
• Support people in accessing information in the format and language they require, e.g., Easy Read, Moon, Braille, BSL, and community languages.
• Ensuring accessible information is available to advocates and carers for people who may need support in accessing and understanding advice.
• Consider the appropriateness of the assessment, the language used, unconscious bias from practitioners and the tone in which it is written.
• Provide people with the opportunity to select their format of care.
• Follow recommendations in the Mental Welfare Commission’s Racial Inequality 2021 report that there should be an explicit commitment to ensuring a diverse mental health workforce.
• Tackling stigma and discrimination in the workplace, including education and support for staff and creating a culture where staff can have open and supportive conversations about mental health without fear of being stigmatised or dismissed.