In 2006, NHS Quality Improvement Scotland published a report, 'Eating disorder services in Scotland: recommendations for management and treatment' (1). The recommendations in this report were developed by a group led by Drs Chris Freeman and Harry Millar and incorporated NICE Guideline 9 (2004) on Eating Disorders where applicable to the Scottish context, as well as published evidence and current best practice within NHS Scotland.
Since then, a number of substantial developments have taken place in eating disorder services. This includes the first NHS adult specialist eating disorder in-patient unit opening in Aberdeen in 2009 to serve the population of the north of Scotland together with a Managed Clinical Network serving the same population. A further regional unit for adults opened in 2012 in south east Scotland to serve the populations of NHS Lothian, Borders, Fife and Forth Valley. There have been developments in specialist community eating disorder teams across the country in adult services, often with very different models of care and different referral criteria. Some areas have provided intensive home treatment to reduce the need for in-patient treatment, and some areas have 'all-age' eating disorder services. Within services for children and young people under 18, those with eating disorders tend to be seen within generic child and adolescent mental health services (CAMHS) rather than specialist children and young people's eating disorder services which have been commissioned across all areas in NHS England (2).
Even with the developments noted, there is a lack of adequate service provision to ensure that anyone in Scotland can access timely, safe, person centred, effective, efficient and equitable care for an eating disorder when they need it which is the ambition of the Scottish Government's mental health strategy 2017 – 2027.
The National Institute for Health and Care Excellence (NICE) updated its guidance in 2017, 'Eating Disorders: recognition and treatment' (3). Clinicians in Scotland raised some concerns about the applicability of the guideline to the specific context of eating disorder services across Scotland, and it was agreed that a SIGN guideline (Scottish Intercollegiate Guideline Network) would be appropriate. It had originally been hoped that the guideline, chaired by Dr Jane Morris, would be published around April 2021, but this has been delayed due to the Covid-19 pandemic. It is hoped that the guideline will be published later in 2021. Two of the leads of this review (SA & CO) are also on the SIGN Guideline Group.
In light of concerns raised by people with lived experience of having an eating disorder, or caring for someone with an eating disorder, as well as reports from clinicians and other work, the Mental Welfare Commission for Scotland undertook a national themed visit of eating disorder services in 2018 and 2019 (4,5). The Commission made a number of recommendations for integration authorities, as well as recommendations for Scottish Government and Healthcare Improvement Scotland. This report, titled 'Hope for the Future,' together with a mapping of services across Scotland were published in September 2020. The Commission's recommendations were as follows:
Recommendations for integration authorities
An integration authority can be a local authority, a health board or an integration joint board, according to the model of integration adopted locally.
We recommend that integration authorities:
- have clear and detailed operational guidance and policies relating to services that look after people with eating disorders and ensure care transitions are coordinated;
- have a comprehensive range of services available across all ages and gaps in provision are identified and addressed; have clearly defined access to inpatient mental health beds for people with eating disorders, across the age range;
- ensure support is maintained following discharge from hospital and specialist community services including support for families/carers;
- develop protocols about physical health monitoring, including the assessments and investigations that should be undertaken by primary and secondary care providers and clear guidance on how different services are expected to work together;
- put in place protocols outlining how the provision of medical care for 16-17 year olds, who require medical inpatient treatment, will be supported by mental health and eating disorder services;
- ensure that there is access to the appropriate level of training in ED for their staff;
- have in place a range of supports, in relation to all aspects of health, for people with an eating disorder;
- family/carers should be involved, where appropriate, in the planning of treatment, and have access to a range of information and support that can provide help when caring for a person with an eating disorder, or when in a crisis situation.
Recommendations for Scottish Government
While undertaking this themed visit, we were told that eating disorder services will be subject to a national review by the Scottish Government, designed to assess and improve support for people with eating disorders.
We recommend that Scottish Government:
- use this report to help inform the work of their national review;
- look to establish a managed network in relation to eating disorders; this would help to address issues of inequality in access to services, public education, staff education and the sharing of best practice.
Recommendations for Healthcare Improvement Scotland (HIS)
We recommend that HIS prioritise a review of the Scottish Intercollegiate Guidelines Network (SIGN), which requires review, revision and update of the efficacy of treatments and therapies to support people with eating disorders in Scotland.
In March 2020, Clare Haughey, Minister for Mental Health announced that a national review of eating disorder services would be undertaken. The review was launched on 16th October 2020 with the aim of reporting to Scottish Government by the end of March 2021.