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

6. Outcome 2: Service Structure

This chapter presents the analysis of Q11 to Q13 related to Outcome 2: Service structure.

The vast majority (95%) of those answering Q11 agreed to some extent that Outcome 2 would improve the experiences of people accessing eating disorder treatment; 39% strongly agreed and 56% agreed. All individuals who answered agreed, with 55% strongly agreeing; this is the joint highest level of strong agreement recorded by individuals across the consultation.

Among those answering Q12, 93% agreed to some extent that Outcome 2 would improve the outcomes of people accessing eating disorder treatment; 32% strongly agreed and 61% agreed. Over nine in ten in each sub-group agreed to some extent, including 45% of individuals who strongly agreed.

Q13. Reading the “Outcome in Action”, which is intended to describe how the “Outcome 2 - Service structure” will be delivered, do you have any other comments?

Specialist all age services

Over 75% of respondents commented on Q13. However, across the consultation, many gave their views about the proposal for all age or specialist eating disorder services. To avoid repetition, these comments have been included under Outcome 2.

Respondents expressed mixed views about all age or specialist services. Several disagreed or identified concerns or caveats to their support, including that it:

• Is unrealistic and impractical.
• Is being introduced as a cost-saving measure.
• May increase waiting times, especially for adults and older adults if children and young people are prioritised in line with early intervention recommendations.
• May increase thresholds for acceptance of referrals and reduce accessibility.
• Would de-skill staff in other mental health services or limit their access to training and funding.
• May lead to a loss of age-specific skills among staff.
• Could risk eating disorders becoming a diagnosis of exclusion for other services.
• Would not be appropriate in inpatient settings.
• Would require patients to attend specialist provision when their needs would be better met in the community.
• Does not align with current professional training programmes, workforce pools, or National Specifications and strategies.
• Could suffer from lack of effective clinic leadership given the broad age remit.
• Is not evidence-based.
• Could result in challenges delivering, or inappropriate and unsafe treatment for young people, older adults, and people with co-occurring considerations.
• May neglect certain groups such as young children or those with an eating disorder diagnosis other than anorexia.
• A whole age range and weight range service may present challenges in managing waiting rooms.
• Would be a significant change in service organisation given that services for young people and adults are currently very separately and differently funded.
• Could lead to destabilisation and staff burnout due to inadequate resourcing and pressures of whole system change.
• Would be difficult to ensure successful delivery across Scotland due to variations in current service designs.

A small number proposed alternatives to introducing all age services such as focusing on improving transitions and partnership working between child and adult services and adequately resourcing and shoring up existing services before attempting major service re-design. Suggestions encompassed improving recruitment, retention and succession planning and ensuring current services have safe and sustainable staffing complements.

Some described benefits to all age or specialist services or expressed support for this. Reasons given included that: it would better meet the needs of older adults; would be more efficient; would provide consistency of care; and would reduce the unhelpful effects of age-related transitions. A small number agreed with treatment being based on need and developmental stage rather than age cuts off. They felt that young people focused treatment may continue to be appropriate beyond 18 years of age, or they suggested extending the age range of children and young people’s services to 25 years, for instance.

“An all age specialist approach will help to ensure people don’t get missed in either the pre-conceived notion that people have to be young to suffer with EDs, and that people don’t fall in the gap between child and adult mental health/ED services.” – Individual

Some were unsure if they supported a move to all age services. They felt the changes require further consultation, discussion and guidance, or identified conditions needed for success. These included: significant financial investment; accommodation; protected management and staff time to facilitate; service managers working with teams to develop service design appropriate to local settings; consideration how this will be integrated smoothly and sustainably within existing services; governance structures; sufficient training and supervision on evidence-based psychological therapies across the age-range; and adequate attention to how other teams and services including CMHTs, Liaison Psychiatry, and Primary Care teams can contributed to the provision of eating disorder assessment and treatments, where people do not meet criteria for specialist services or present in acute care settings.

A small number felt the proposals for an all age service are confusing or require greater clarity or detail, in terms of: anticipated thresholds for access; clearer definitions of specialist services; if these would encompass in-patient and out-patient treatment; whether everyone with an eating disorder would be seen within specialist eating disorder services, changing the current tiered structure; and whether there is an evidence-base to support this proposal, from pre-existing all age services in England, for instance.

“The all age service concept was broadly welcomed by the carers although it is unclear if the service is supposed to be complementary to, or to replace existing services for both CYP services as well as adult services... It was not clear if this all age service was for both in and outpatient services. If it is intended for inpatient, it is not clear how this fits within the overall Mental Health Strategy to ensure young people are admitted to age-appropriate wards and have age-appropriate clinical staff… Overall, much more clarity on the nature of the all age service and how it would be deployed would be an improvement to the specification.” - Edinburgh Carers Council

Multi-disciplinary professionals

Comments on the proposed MDT for eating disorder services were the second most common theme. While a small number agreed with the range of professionals suggested, others identified challenges including: lack of funding to enable this staff complement; the reality of small teams with a limited range of professionals especially in rural areas; insufficient dietetic, medical, or psychiatric provision to meet this proposal; challenges for service users having to repeat themselves to a large MDT; and the scale of the change proposed given current silos between inpatient and outpatient services and child and adult mental health services. Mental Health Physiotherapy, NHS Ayrshire and Arran also highlighted the need to fund and provide training for in-reach services (such as physiotherapy) to ensure equality of access to certain professions and cross-service care can be delivered.

“The Specification… does not take into account that some smaller health boards have very limited resources, with limited access to MDT workforce…. It touches on how some boards may operate a regional service; however there needs to be more narrative around this and how this works on an operational level when core posts remain unfilled.” – NHS Dumfries & Galloway- Adult MH service

Other suggested improvements included:

• Outlining the evidence base for the core disciplines proposed to add credibility.
• Including advocacy workers, Speech and Language Therapists (SALTs) and third-sector representatives within the ideal team list.
• Providing clear role guidance and consideration of the range of staffing profiles of different services.
• Elaborating on the role of Allied Health Professionals (AHPs), specifically Occupational Therapists, Physiotherapists, SALTs, and dietitians.
• Including a clear and consistent statement on the NHS response when carers choose to access private services whilst waiting for NHS services.
• Offering more detail around lived experience and the role of peer support, including that peer support workers should be required to have specific lived experience of eating disorders and that they are adequately supported in their role.
• Including guidance on indicative minimum staffing levels relative to population size.

Delivery of care options and treatment approaches

Some offered comments on the range of care delivery options. As well as supportive comments, barriers to, or supports required, to deliver these were again highlighted. Examples included the need for: significant and sustainable funding, staffing, and training; increased staffing levels, especially nursing, to offer assertive outreach; accommodation for day services; consideration of the age mix; improved access and efficacy of inpatient care; increased treatment options at outpatient level; and improved digital and online technology for self-help offers.

Two respondents called for clarity on the key elements, remit, and function of day and assertive outreach services - including the ‘intensity’ of support these should be able to provide. While one felt that barriers to engaging with services should be explored where someone does not attend appointments, the other queried how assertive outreach would: balance with the principles of the least restrictive option principle of the Mental Health Act; fit with the SIGN guidance on management of severe and enduring eating disorders; and align with evidence-based models of motivation. They argued for being mindful that some people may not wish a referral to a specialist Eating Disorder Service and may prefer support from primary care or the third sector. They also expressed concern about assertive outreach, introducing a postcode lottery for those closest to the service. They suggested offering outreach remotely to those comfortable to engage electronically. However, the Scottish Women’s convention cautioned against over-reliance on self-help and digital technologies due to these being difficult to use, variances in digital literacy, poor connectivity in rural locations, lack of access for those on low incomes and individual preference for face-to-face appointments.

“This [range of options] is also great but must be sustainable. Options such as day services and intensive outreach have great outcomes. However, they have been removed in the past from areas such as Lothian. If we are adding options we must ensure that these are sustainable and will not be taken away again.” – SupportED

Other suggested treatment approaches at Outcome 2, included: therapeutic communities; cognitive behaviour therapy; family-based therapy; group work such as BodyWise; formulation; support to manage activity levels and referral to other services to support physical conditions secondary to eating disorders e.g. osteoporosis; trauma-informed models; and family/carer peer support models (drawing on example of good practice). A professional/academic organisation also advocated drawing on NES’ Psychological Matrix guidance to inform recommended psychological interventions.

“Section 2.9 appears to default back to medical model. Is there consideration of how we ensure social, personal, and trauma-informed models, as well as medical models of care, are used? (CSP 2023).” – Mental Health Physiotherapy, NHS Ayrshire and Arran

Pathways and protocols

Some expressed support for pathways and protocols, requested more detail and guidance on follow-up protocols or unattended appointments, requested GPs be involved in and funded for pathway or protocol development, or highlighted barriers to protocol implementation, including resource implications. A professional/academic organisation suggested a clear communication pathway with 24/7 contact so that teams can be updated, for example when a paediatric emergency department is discharging someone with an eating disorder.

“The document notes the need for assertive and proactive follow up protocols. In GGC this would be care shared between CMHT and the specialist ED team. There should be greater clarity about the expectation of who should be responsible for offering this type of outreach/ follow up and specialist services should be adequately funded to employ a skills mix which allow them to undertake this role.” – South Glasgow CMHTs