EATING DISORDERS SECTION. Royal College of Psychiatrists Spring 2013

Transcription

1 Issue 11 EATING DISORDERS SECTION Royal College of Psychiatrists Spring 2013 INSIDE THIS ISSUE: 1) Foreword from the editors 2) Foreword from the Chair 3) The EDSECT Spring Conference: Treatment resistant Anorexia 4) Feedback on new Eating Disorder Commissioning guidance 5) MARSIPAN. Review of its implementation 6) Perspective on the ICED conference in Montreal 7) List of Executive Members of EDSECT

2 1. Foreword from the Editors Finally, finally spring has arrived and with it the EDSECT Spring Newsletter though both have made their appearance noticeably later than usual. It s the time to review the work of the Section over the last year and start to think of new projects and goals for the next which will be finalised at the EDSECT Strategy Day in June. By this time we may be joined by new committee members as some of the longer serving members move on. The spring meeting was, as so often, oversubscribed which is testament to the quality of these days and their value to EDSECT members professional development. Feedback from the day on treatment resistant Anorexia has been excellent with comments on the clarity of the presentation and thoughtfulness of subsequent discussions. Hopefully one of the outcomes for the day will be the development of some clinical guidelines on the management of patients with treatment resistant anorexia, a piece of work led by Frances Connan. As Chair of the multidisciplinary expert reference group reporting to The Joint Commissioning Panel for Mental Health (JCP-MH), Lorna Richards gives an update on the work the group has undertaken and summarises the recently drafted guidance for Eating Disorder Service Commissioners which will be published later this year. EDSECT members will have received news from Paul Robinson via EDSIG on plans to update the MARSIPAN document this year and Jessica Morgan gives feedback on the implementation of MARSIPAN nationally. Finally Irene Yi reflects on her experience of the ICED conference in Montreal earlier this month. With best wishes Rebecca Cashmore Irene Yi Editor Rebecca.cashmore@leicspart.nhs.uk Irene.Yi@sabp.nhs.uk Co-Editor

3 2- Foreword from the Chair Dear Colleagues, The brave new world of NHS change continues, with ever-expanding challenges for our specialty. Recent developments will continue to impact on our services over the coming year. But our Section has made multiple advances in establishing our speciality and raising clinical standards. The changes are a curate s egg with the potential to encourage evenhandedness and remove regional discrepancies. The Eating Disorder Section will review its priorities at our annual Strategy Day in June. Our members always express multiple interests and enthusiasms, but I would encourage us to focus our energies on a few, key goals. By this means, we have made tangible achievements in complex areas, including setting of quality standards, organisation of internationally acclaimed conferences and engagement with commissioning processes. Next year s priorities will soon be defined and I welcome suggestions from out with the Executive Committee, in advance of the Strategy Day. Professor John F Morgan Chair, EDSECT 3. The EDSECT Spring Conference: Treatment resistant Anorexia Work continues on the development of guidance for best interest decision making in very complex and difficult to treat cases. Guidance will aim to provide a body of opinion to support decision making in difficult to treat cases and presentation of evidence to the courts. The Section Spring meeting critically examined the recent court of protection rulings, and the utility of the Mental Capacity Act in Anorexia 3

4 Nervosa. There was broad agreement about application of the MCA, what factors should contribute to best interest assessment, and the importance of prognosis in decision making. There was less consensus about when it might be appropriate to stop coercive treatment. The ruling in the case of E is unhelpful in this respect, presenting a polarised dilemma between extremely coercive treatment or death. All options should be considered, particularly those that occupy the middle ground. MCA definition of best interest requires a change of culture, expanding a narrow medical concept to include psychosocial and subjective perspectives on best interest. The concept of futility can also usefully be broadened beyond the medical model to include ethical futility. This remains contentious. The work of the Spring meeting will usefully inform the drafting of Guidance, which will then be shared widely for consultation within the section, but also with multidisciplinary colleagues and those with expertise in law and ethics. best wishes Frances Dr Frances Connan Consultant Psychiatrist & Clinical Director Vincent Square Eating Disorders Service frances.connan@nhs.net 4

5 4. Joint Commissioning Panel for Mental Health guidance for ED commissioners The Joint Commissioning Panel for Mental Health (JCP-MH) ( is co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists. It is a collaboration between seventeen leading organisations, inspiring commissioners to improve mental health and wellbeing, using a values based commissioning model. Over the past 18 months, the JCPMH has developed practical guidance on what good services for mental health should look like. A multidisciplinary expert reference group chaired by Dr Lorna Richards (Consultant Psychiatrist in Eating Disorders, Barnet, Enfield and Haringey MHT) has developed a guide for commissioners of eating disorders services which will be published in June The key points are summarised below:- 1. Eating disorders (ED) are severe mental illnesses with serious psychological, physical and social sequelae. Anorexia nervosa (AN) has the highest mortality amongst psychiatric disorders 1. People with ED commonly experience additional mental health problems, particularly depression 2, physical compromise, difficulties in intimate relationships and interruption of educational/occupational goals. The impact on quality of life is profound with ED being placed 15 th among the top 20 causes of disability in Australian women Over 1.6 million people in the UK are estimated to be directly affected by eating disorders 4. This is likely to be an underestimate as we know there is a huge level of unmet need in the community 5. These illnesses usually begin in adolescence and young adulthood with a worrying trend towards younger children developing ED. Onset at this critical time in a young person s life can have a devastating effect on normal development with restriction of opportunities that can extend into adult life. The attainment of personal autonomy can be arrested which also has an impact on meaningful engagement with treatment and outcome. 3. Transitions between different services, as they are currently organised, is sadly the norm for patients with ED: primary, secondary and tertiary care; medical and mental health services; child and adolescent services

6 and adult services; family home and student abode. Robust transitional policies must be developed and training needs met to avoid the associated risks to patients. 4. The burden of ED on carers is very high. People with ED are often ambivalent about treatment even in the face of severe illness. This places carers in a position of battling against their loved one whilst worrying that they are to blame. Caring for someone with an ED carries a high emotional and economic cost. Carers of anorexic patients have reported similar experiences in terms of the difficulties encountered to those of carers of adults with psychosis and higher levels of psychological distress There is a critical window for intervention for people suffering with ED. AN does not usually improve spontaneously and the prognosis for ED tends to worsen with time. Recovery is less likely if AN has remained untreated for more than 3-5 years 1;7;8. Early identification and intervention with access to effective stepped care pathways is of paramount importance to improve clinical outcome and increase cost effectiveness. 6. Good quality comprehensive services for people with eating disorders are not yet available in many parts of England 9. The majority of people suffering with ED are therefore managed in non-specialist settings where treatment is very variable 10. Access to specialist treatment for all people suffering with an ED in England should be a priority in the new commissioning landscape. 7. New commissioning arrangements have the potential to disrupt a patient s treatment because community services and more intensive services (daycare and in-patient) are commissioned separately. Ensuring clinical and cost effectiveness requires flexible and responsive access to both community and intensive/residential components with well managed seamless transitions. This must not be hampered by divided funding streams. A priority for commissioners of comprehensive eating disorders services must be to commission integrated care pathways that support flexible and seamless patient care. NHS England and Clinical Commissioning Groups should have a commitment to work together to ensure this. 8. Health care costs for eating disorders in England have been estimated as m with overall economic cost likely to be more than 1.26bn per year 11. This highlights the importance of optimising service 6

7 provision for this group of patients. Effective well managed care pathways will be critical to this. 9. Stigma related to eating disorders has serious, unacceptable and farreaching effects. Misunderstanding of these illnesses influences 1) sufferers who are deterred from asking for help and support through fear of being judged, 2) carers who often feel blamed, 3) health professionals in their treatment decision-making 4) the health service and commissioners through lack of structural investment in eating disorders services. 10. Further research is necessary to develop optimal interventions and care pathways for people with eating disorders. Severe and enduring or treatment resistant cases present the highest cost (per patient). Evidence for the most effective management of these cases is sparse. In order to improve overall outcome and cost-effectiveness, ongoing investment in clinical services for research, development and innovation is a must. Lorna Richards Consultant Psychiatrist in Eating Disorders, Barnet, Enfield and Haringey MHT 7

8 5. National Review of MARSIPAN Implementation MARSIPAN, MARSIPAN, MARSIPAN, what does it mean to you? Well, to your average medic, it is the rather yucky, yellowy bit in between the overly sweet white bit and the overly alcoholic brown bit of a Christmas cake. However, to those of us working in the field of Eating Disorders, MARSIPAN is the acronym for MAnagement of Really SIck Patients with Anorexia Nervosa. As most of you will know, the MARSIPAN Working Group was set up and chaired by Dr Paul Robinson in order to develop a set of recommendations to advise on the acute management of patients with severe eating disorders and potential physical problems. The College report (CR162) was published in October 2010, and in November 2012 the Eating Disorders Executive Committee of the Royal College of Psychiatrists decided to conduct a survey across England, Scotland, Wales and Northern Ireland to monitor overall compliance with the recommendations made in the report. To this end, on behalf of the College Executive, I surveyed the regional representatives across these areas, enquiring into progress with implementation of MARSIPAN recommendations. The information gathered from this survey has been forwarded to Paul Robinson, who is currently updating the report CR162, and the following article is a summary of the findings as well as suggestions as to how to overcome the hurdles of MARSIPAN implementation. Results We wrote to a total of 14 regional representatives covering London, South East, South West, East, Trent, West Midlands, North East, Yorkshire, North West, Wales, Scotland and Northern Ireland as well as the Clinical Lead from North Wales. We received 10 responses (none from Central London), illustrating a wide range of progress in the implementation of the guidelines. Therefore, at the risk of sounding like a discriminatory school ma am, I have grouped the responses into three categories of very good, satisfactory and room for improvement!

9 Very Good There were 6 responses, showing very good implementation of MARSIPAN recommendations. To my delight, they were disproportionately northern in their distribution. Within these areas, MARSIPAN had been identified as a key area for development over the previous two years and in some identified as a CQUIN (or similar) target by specialist commissioning. In all of them, the Specialist Eating Disorder Unit had initiated development of a multidisciplinary MARSIPAN group aimed at addressing the needs of MARSIPAN patients. These groups usually consisted of a Consultant Psychiatrist in Eating Disorders, a Gastroenterologist for a Nutritional Support Team, an Eating Disorders Dietitian, a Nutritional Support Team Dietitian, Commissioners (in some) and other interested clinicians. These MARSIPAN groups had developed a shared clinical care pathway for the early identification and management of MARSIPAN patients as well as specific guidelines to be used in non-specialist centres, for example, nutritional management, over a weekend in a DGH without specialist ED input. The pathways also recognised the essential need for joint working between physician and psychiatrist. Further, these groups met approximately every six months to review the pathway, and compliance with it, with respect to individual cases and, in some groups, a system for auditing compliance with the pathway was in place or being developed. Some of these sites recognised the need and usefulness of involving liaison psychiatry and most were involved in dissemination of knowledge of MARSIPAN beyond the specialist units where cases often present, for example, The Accident and Emergency department of a district general hospital. Some were providing training to professional groups who were more likely to require knowledge of MARSIPAN such as Gastroenterology trainees, as well as providing training for medical students, trainee physicians, and trainee psychiatrists. Satisfactory Two responses were received. Within this group, clinical pathways had been developed for the implementation of MARSIPAN recommendations. There had been a positive push from the commissioning angle as an incentive to provide this with subsequent development by the local ED 9

10 Service. However, due to a combination of geography, lack of specialist eating disorder unit, and lack of engagement of consultant physicians, the pathways had not been integrated into clinical care and consequently, a lack of enthusiasm to plan for use of the pathway. Room for Improvement Two responses were received within this category. Generally, this was probably due to a combination of lack of specialist eating disorders unit and wide geography. However, in one of these areas, the neighbouring specialist eating disorders unit provided a wide range of liaison with acute medical wards when a MARSIPAN patient was admitted, prior to transfer to their unit. They had also used liaison teams widely, in attempt to improve the care of MARSIPAN patients on medical wards, and the local ED Service would offer advice to the wards when possible. Helpful Tips From this basic review of MARSIPAN implementation, it seems that the main limitations affecting the implementation are: The presence of a specialist eating disorder unit. A wide geographical area thus less likelihood of specialist services in general. The willingness of a gastroenterology team to engage in the process. In areas such as these, there is a need to develop more innovative ways for implementing MARSIPAN. Useful Suggestions are: 1. Utilise liaison psychiatry teams in facilitating the implementation of MARSIPAN. 2. In order to improve MARSIPAN for the future, it is essential that it is included at all levels of medical training. 3. It is helpful if there is commissioner involvement in areas where MARSIPAN implementation has been difficult to develop. 4. Attempts to raise the profile of MARSIPAN. Jessica Morgan 10

11 6. Perspective on the ICED Conference In Montreal May 13 What an amazing 3 days in this beautiful city!! I believe there were nearly 900 attendees and the whole venue at the grand Hilton hotel was buzzing with clinicians, researchers and interested parties from all over the world. Many congratulations to the conference committee and the co-chairs Nadia Micali (UK) and Bryn Austin (USA) for a truly inspiring program. The theme of the conference was Crossing Disciplinary Boundaries in Eating Disorders and this was aptly started off with the keynote speech from David Barlow describing about how novel treatment approaches to emotional disorders might apply in Eating Disorders and reminding us of the transdiagnostic approach of Chris Fairburn. The plenary sessions kicked off with applying neurobiological research to emotional processing and as usual Kate Tchanturia s presentation on the Experimental Study of Emotion in Eating Disorders was excellent. I found the second plenary session on Eating disorders among males particularly thought provoking. The societal and cultural pressures imposed upon boys and men are huge and makes me wonder about all the boys and young men who are out there, not able to or simply missed to access services. No wonder the prevalence of eating disorders in males is still unclear. Day 3 plenary was equally inspiring exploring innovative treatments as well as the potentials and limitations of specific versus non-specific treatment approaches. I did miss the last plenary session on Mindfulness unfortunately. As a child psychiatrist, I tried to be dutiful and attend the workshops and scientific paper sessions on children and adolescents. The Maudsley Intensive Therapeutic Programme raised many interests from our American colleagues and is a great model provided adequate resources are in place. It would be a great presentation to the specialist commission groups throughout the country over here. I was also intrigued by another workshop session on a family protocol to support the successful transition of adolescents from inpatient to outpatient care at the Mayo clinic using a very behavioural approach. So in conclusion an inspiring and thought provoking 3 days, slightly overwhelming at times as one does need to be very organised to get the best out of so many choices. It was also good to see some familiar faces amongst so many attendees and to catch up with a friend as well. 11

12 Many thanks also to the beautiful city of Montreal and the locals who are all very friendly and welcoming. Irene Yi 7. EXECUTIVE MEMBERS OF EDSECT Member Year of joining Position Dr John Morgan 2011 (E) Chair Dr Jane Shapleske 2007 (E) Financial Officer Dr Carol Wilson 2012 (A) Dr Rebecca Cashmore 2011 (E) Psychiatric Training Committee Rep Elected Member Dr Frances Connan 2007 (E) Academic Secretary Dr Philip Crockett 2011 (E) Elected Member Dr Christopher Freeman 2011 (E) Elected Member Dr Philippa Hugo 2011 (E) Vice Chair Ms Veronica Kamerling 2011 (C) Co-opted Member Dr Nikola Kern 2011 (E) Elected Member Dr Adrienne Key 2007 (E) Elected Member Dr Jessica Morgan 2011 (E) Elected Member Dr Elizabeth Morris 2011 (E) Elected Member Dr Sandeep Ranote 2011 (C) Co-opted Member Dr Lorna Richards 2007 (E) Elected Member Ms Susan Ringwood 2008 (C) Co-opted Member 12

13 Dr Christine Vize 2011 (E) Elected Member Dr Irene Yi 2011 (C) Co-opted Member 13