Care and treatment of eating disorders: national specification

Principles and Values

The Specification is underpinned by principles and values aligned with quality healthcare provision.

• Person-centred. Providing care that is responsive to individual personal preferences, needs, and values and assuring that patient involvement/engagement guides and informs all clinical decisions (Healthcare Quality Strategy, NHS Scotland, 2010). The Specification supports patients to uphold their rights, for example through active engagement of individuals with lived/living experience in the design and evaluation of eating disorder services. The Specification has been informed by living/lived experience feedback from the National Review of Eating Disorder Service (2021).
• Safe. Patient safety is fundamental to the delivery of eating disorder treatment and care. Safe treatment for eating disorders addresses all aspects of the illness including physical, psychological, nutritional, and functional. The service structure and underlying protocols and pathways play an essential role in the delivery of safe care.
• Several patients' deaths and other near-miss incidents have occurred following transfer between services at all levels. This includes child to adult mental health services, between two inpatient units, between medical units and specialist inpatient services, and between primary and secondary care (MEED, 2022). Similarly, transitions have been highlighted by stakeholders in the National Review of Eating Disorder Services (2021) as being particularly problematic. This led to the SIGN Guidelines for Eating Disorders (2022) to develop specific recommendations on managing transitions to supplement the existing Royal College of Psychiatrists (2017) Transition Guidelines for Patients with Eating Disorders.
• An aim of the Specification has therefore been to reduce and prevent gaps in care via the provision of clear protocols and service agreements where essential transitions take place (e.g., differing levels of intensity of service provision within eating disorder services) and to change service structure to minimise unnecessary transitions where possible.
• Effective. The recommendations within the Specification are underpinned by scientific knowledge and include the provision of evidence-based interventions as recommended by SIGN (2022) and MEED (2022). The use of person-reported outcomes should be implemented in parallel with the national specification, following guidance by the National Eating Disorder Network.
• Equitable. Equitable healthcare involves providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socio-economic status. Stakeholders in the National Review of Eating Disorder Services (2021) and the Mental Welfare Commission (2020) report described variability in the availability of services, referring to a "postcode lottery". The Specification aims to reduce this variability while acknowledging the diverse population needs of Scotland and the need for responsive implementation aligned with local models of delivery and partnership working.
• Timely. The need for early identification and intervention has been reinforced by the SIGN Guidelines for Eating Disorders (2022) which highlighted the potential accumulation of harm that can take place during an untreated eating disorder. This is partly a consequence of many eating disorders being more likely to develop during adolescence and early adulthood, a sensitive period for brain development (Schmidt, et al., 2016) and a time when an eating disorder can have a significant impact on physical health, social functioning, and educational attainment (Allen, et al., 2020). Treatment outcomes appear to be best during the first three years of illness (Treasure et al., 2015), yet most individuals do not access treatment for their eating disorder until many years after they first develop symptoms, if they access treatment at all (Allen, et al, 2020). SIGN (2022), highlights that our current NHS systems and pathways can compound delays in accessing treatment. Therefore, this Specification will support timely access to specialist eating disorders services, reduce barriers to care, and promote a culture of proactive engagement.
• Efficient. An efficient approach to eating disorder care and treatment is aligned with early intervention due to the significant impact this can have on health care use, psychological wellbeing, and quality of life. Initial evidence from First Episode Rapid Intervention for Eating Disorders (FREED) a service model designed to give young people rapid access to evidence-based treatment for eating disorders, suggests that the proportion of FREED patients that went on to require day or inpatient admissions was lower than typical service delivery models, giving cost savings (Allen et al., 2020, Austin et al., 2022; Fukutomi et al., 2020). This is replicated by international modelling analyses that have highlighted the long-term savings from early intervention for eating disorders (Butterfly Foundation, 2014; Bode et al., 2017).
• Efficiency is also aligned with minimising duplication and reducing repetition. The ethos underpinning the Specification has been to change service structure to minimise unnecessary transitions and where possible to reduce obstacles in accessing specialist care e.g., unnecessary gatekeeping and/or multiple assessment processes leading to repetition of a patient's story.
• Supportive relationships. The Specification recognises the impact that eating disorders can have on the support networks around an individual including friends, family, and carers and the essential supportive function that extended interpersonal networks play in supporting recovery. The Specification mirrors the SIGN Guideline (2022) recommendations for the appropriate inclusion of family and/or carers in the support of individuals with eating disorders.