We spoke with Dr Sandeep Ranote, Consultant Child and Adolescent Psychiatrist and Greater Manchester CAMHS Clinical Lead, about the Greater Manchester Eating Disorder Pathway.
The Eating Disorder Service in Greater Manchester is a developing example of implementing a whole-system pathway across all of the THRIVE needs based groupings. This provides an example of how devolution, can make a real difference when implementing THRIVE in Greater Manchester as a devolved health and social care partnership.
Greater Manchester has a 2.8million population across 10 localities, each with a core Child and Adolescent Mental Health Service (CAMHS). For eating disorder services, there is a minimum catchment area of 500,000 people, so rather than having multiple disjointed Community Eating Disorder Services for Children and Young People (CEDS-CYP), devolution provided the opportunity to take an approach across the whole of the Greater Manchester (GM) region. A networked approach using a cluster model, resulted in the development of three services rather than 6 services based on the national guidance population minimum of 500,000: West, Central and East.
In response to the national Access and Waiting Time (AWT) standards for eating disorders, a commissioning priority was to roll-out community eating disorder services for young people across the whole of GM. This was achieved through the creation of a single service specification with GM standards, aligned with the THRIVE needs based groupings. A core GM value is: ‘We will be i-THRIVE in all our services’. These standards have been operationalised since 1st April 2017. In addition, a formal partnership was agreed between BEAT (the UK’s leading charity supporting those affected by eating disorders) and the community eating disorder pathway, with BEAT establishing an office in the northwest. Rather than being a subcontracted voluntary and community sector organisation, BEAT is now firmly embedded within the pathway.
Getting Advice and Signposting
A pilot is underway in the West and East clusters whereby BEAT is delivering awareness training and direct support to clusters of secondary schools. This training includes prevention, identifying early warning signs, and accessing ‘Getting Help’, and is delivered to senior school staff, school mental health leads and pastoral care staff. Some classroom work is also provided. In addition, a dedicated school telephone support line is provided to those schools who sign up to the training as part of the joint pathway.
The BEAT team is staffed by people and carers who have lived experience of eating disorders and have gone through the bespoke BEAT training programme. They do not deliver interventions with young people, rather training and the support line to school staff. However, they can signpost young people to CEDS-CYP. The BEAT team have clinical advisors and receive regular clinical supervision. As they are part of the eating disorder pathway they also have access to the national whole-team eating disorder training curriculum with the CEDS-CYP, and they are invited to all in-house learning and development events.
BEAT are invited to attend team meetings, e.g., if they are particularly worried about a cluster of schools, or they have picked up trends from the data. This partnership working supports relationship building across the provision.
A joint audit is currently underway to evaluate the impact of this Getting Advice and Signposting pilot.
Feedback from the first quarter of delivering the schools support line has been very positive. Highlights include schools reporting that receiving follow-up support was invaluable, e.g., where cases were fast tracked to Getting More Help within the Eating Disorder Service, or where they were signposted to their local community eating disorder service. The teams are working to encourage wider school engagement to ensure equitable access to support.
The partnership between CEDS-CYP and BEAT has increased capacity, enabling the previously identified Getting Advice and Signposting gap in service provision to be filled. Referrals are received from all agencies that work with young people, from schools, social care, GPs and paediatrics. The next phase is to move towards promoting self-referral, and the new partnership is really helping to provide professionals and families with the confidence to ask whether they need to get more help.
Getting Help and Getting More Help
In Greater Manchester, the three cluster specialist community eating disorder services (West, Central and East) provide Getting Help and Getting More Help. They are locality based therefore service users get access, locally, to a dedicated community eating disorder service embedded within generic CAMHS. This way of working prevents working in provider silos, as organisational and system boundaries can be crossed easily.
The three teams meet for quarterly Network Meetings focused on data sharing, engage in case discussion forums and reflective practice, and continued professional development. Once these services form mature networks they plan to have quarterly case-study opportunities where young people and families can talk about their experiences, and for the families to participate in the co-development of the pathway. Meetings are attended by the specialist community eating disorder teams, BEAT the voluntary community sector, representatives from cluster schools who have engaged with BEAT, commissioners, Greater Manchester Digital, and young people and families. There is a system-wide approach to service delivery, continuous improvement, relationship development and capacity building, and improving the service users’ experience by ensuring equitable access and improved outcomes.
The most recent data shows all 3 clusters are meeting the access and wait time standard of 100% of young people and families being seen for assessment and treatment within 1 week for urgent referrals. The East and Central clusters are also meeting the access and wait time standard of 100% of young people and families being seen for assessment and treatment within 4 weeks for routine referrals. This is above the 95% national target. The West cluster is meeting the national average access and wait time standard with 83% of young people and families being seen within 4 weeks for routine referrals. As there is a networked approach between the clusters there are opportunities for shared learning and capacity building across the workforce, the adoption and spread of good practice, and data sharing and data masterclasses to support referral management and improved flow.
Getting Risk Support
Each of the three community eating disorder services are embedded within a generic CAMHS and have separate providers. In regular work hours the CEDS-CYP services respond to crises from within their specialist teams through a duty “first responder” system. For example, in the West cluster team they have a first responder on duty each day, with a clear diary and the capacity to respond to any crisis calls and crisis presentations in A&E. Each of the services are integrated across BEAT, CAMHS and paediatrics. In practice this means all 3 clusters have integrated CEDS CYP consultant paediatric sessions and a paediatric nurse link. Integrated multi-disciplinary team (MDT) specialist assessments include the paediatrician and MDT reviews include the paediatrician and paediatric link nurse with a follow up provided with the same paediatrician. This integration allows for the “Junior MARSIPAN” intervention for brief refeeding on the paediatric ward to be delivered by the CEDS team.
As CEDS-CYP are embedded in the CAMHS service there is wrap-around 24/7 crisis care in the evening and at weekends. While this is not dedicated to eating disorders, it provides rapid response and crisis care to meet the mental health needs of all young people who present in difficulty. All service users have clear care plans with specific recommendations, and if a child or young person known to CEDS-CYP accesses crisis support there is a handover the next working day to the CEDS-CYP team. The crisis support teams are staffed by experienced mental health clinicians.
There were a number of areas of improvement identified and one such area is the management of cases where little or no improvement is being made in the agreed outcomes, but an element of risk is present. There is a recognition that this could be done through better review arrangements and being able to challenge the team through asking the following questions:
- Are we getting this person better?
- If we are not getting the person better what should we do?
- Would therapeutic breaks be effective?
- Do we need a second opinion?
- Are we consulting with our Tier 4 units?
As a network, the services are now able to ask for second opinions and speak with other services to think through complexities and care plans. The whole-team training curriculum has helped move this agenda forward and has highlighted that decisions should not be uni-professional. This is further supported by whole-team supervision, whole-team initial assessments, case discussion clinics, and regularly reviewing outcomes data.
In some cases there may be a need for a paediatric admission due to the child or young person (CYP) being very unwell physically, and there is now an integrated pathway. This is helpful for brief admissions where physical instability occurs and there is an acute need, or when a CYP is severely unwell with anorexia and brief re-feeding on a paediatric ward may mean they can come back into the CEDS-CYP service without having to go into specialised day or inpatient units. The integrated pathway allows the community team to follow the CYP to the ward and out, and to provide in-reach during admission. The emphasis is on continuity of care and keeping the young person and family at the centre of care.
Approximately 10-15% of cases may still need “Tier 4” specialised CAMHS input. The proposal in Greater Manchester is to have two named specialised Eating Disorder inpatient sites within the seven general inpatient CAMHS sites. This should help manage patient flow better but also allow for CYP from GM to stay in GM for continued inpatient care and these two sites would work more collaboratively with each of the 3 CEDS CYP cluster services developing and strengthening working relationships to achieve a truly whole pathway approach for all.
There has been pleasing quarter 1, 2, and 3 data from a Greater Manchester perspective. There has been a reduction in Tier 4 referrals, reduced waiting times and in terms of the clusters, all are above the national average for access and wait times for urgent referrals, with the Central and East clusters also above the national average for access and wait times for routine referrals and the West cluster is meeting the national average access and wait times for routine referrals. The aim is to standardise the clusters by working together as a Greater Manchester network and to consider patient flow and data management as each service is interpreting referrals and the AWT standards differently, with data also being recorded differently.
A single service report is produced on a quarterly basis with data from the three clusters. Unlike the AWT standards report, the single service report provides a narrative and includes additional information such as workforce development and capacity building. It was recognised, through this service report, that the quarter where performance dipped married completely with when there were workforce vacancies, which would not be reflected in the AWT standards report. Also included in the single service report is a case story that brings alive patient experiences, information on service user involvement and any achievements or celebrations.
It is anticipated that devolution will provide Greater Manchester the opportunity to become stronger as a whole-system, with shared accountability, risk, and responsibility and help identify clear boundaries through system-wide commissioning and whole-system i-THRIVE training. Once the cluster system has matured the aim is to have shared workforce opportunities and shared digital solutions.
For Getting Advice and Signposting they would also like to provide prevention and awareness training in primary care, and in the second year of the BEAT partnership carry out joint triage assessments. Greater Manchester is also interested to see what impact the partnership with BEAT will have on referrals, anticipating an increase.
For Risk Support, crisis care is undergoing a redesign, phased over the next two years. This will provide a GM-wide approach to crisis care across organisational boundaries. There will be four multi-disciplinary and multi-agency cluster rapid response teams, including social care, mental health, youth support and voluntary community sectors, operating from safe zones and with direct links to A&E. When this is operational they will have a clear remit from CEDS-CYP to the rapid response teams in terms of training and capacity building, information sharing, developing collaborative care plans and liaison with CEDS-CYP. GM Health and Social Care Partnership, the devolution footprint, has also allowed a collaborative bid by all 3 providers of CEDS CYP services, supported by BEAT, across GM to deliver a GM wide day provision from 2 sites to enhance the Getting More Help and Getting Risk Support needs based groups of the THRIVE framework, further supporting the whole pathway, whole-system approach to care.
For more information about the Eating Disorder pathway in Greater Manchester please contact Sandeep Ranote at: Sandeep.Ranote@nwbh.nhs.uk.
Written March 2018.