North Yorkshire and York North Yorkshire and York Specialist Eating Disorder Specialist Eating Disorder

Service Service

Joanie Barber Bee, Nicola Birkin and Liz Joanie Barber Bee, Nicola Birkin and Liz Hill Hill

Specialist Practitioners; Eating disorders Specialist Practitioners; Eating disorders

Not everyone is for us: what Not everyone is for us: what to do:to do:• BMI higher than 17.5 BMI higher than 17.5 • Normal bloodsNormal bloods• Bulimia with no physical problemsBulimia with no physical problems• Binge Eaters with no physical problemsBinge Eaters with no physical problems

• Refer to Primary Mental Health Worker Refer to Primary Mental Health Worker attached to the GP surgeryattached to the GP surgery

• Counsellor attached to the GP surgeryCounsellor attached to the GP surgery

Aim of serviceAim of service• Service commissioned by NYYPCT Dec 2007 Service commissioned by NYYPCT Dec 2007

to:to:– Improve the quality and effectiveness of services Improve the quality and effectiveness of services

in North Yorkshire & the City of York for people in North Yorkshire & the City of York for people with eating disorders with eating disorders

– Decrease the length of time between the onset of Decrease the length of time between the onset of eating disorders and access to appropriate helpeating disorders and access to appropriate help

– Limit the physical and psychiatric morbidity, Limit the physical and psychiatric morbidity, social disability and mortality caused by eating social disability and mortality caused by eating disorders disorders

Who Are We?Who Are We?Lesley Hudson: Team SecretaryLesley Hudson: Team Secretary

Bootham Park Hospital tel 01904 721173 Bootham Park Hospital tel 01904 721173

Dr Mark Willis: Consultant Psychiatrist Dr Mark Willis: Consultant Psychiatrist X 3 sessions per week X 3 sessions per week Bootham Park Hospital Bootham Park Hospital

Nicola Birkin: Specialist PractitionerNicola Birkin: Specialist PractitionerYork & Selby York & Selby

Bootham Park Hospital Bootham Park Hospital

Who Are We?Who Are We?Joanie Barber-Bee: Specialist Practitioner :Joanie Barber-Bee: Specialist Practitioner :

Scarborough, Whitby & RyedaleScarborough, Whitby & Ryedale

Tony Brownbridge: Specialist PractitionerTony Brownbridge: Specialist PractitionerHarrogate, Ripon & Craven Harrogate, Ripon & Craven

Liz Hill: Specialist PractitionerLiz Hill: Specialist Practitioner Ripon, Hambleton & RichmondshireRipon, Hambleton & Richmondshire

Who Are We?Who Are We?Bernadine McDonald: Advanced Dietitian Bernadine McDonald: Advanced Dietitian

Harrogate, Ripon & Craven Harrogate, Ripon & Craven Hambleton & RichmondshireHambleton & Richmondshire

Elaine Sargeson: Advanced Dietitian Elaine Sargeson: Advanced Dietitian York & Selby York & Selby

Scarborough, Whitby & RyedaleScarborough, Whitby & Ryedale

Service Remit Service Remit • Our service is directed at working with Our service is directed at working with

clinical cases which represent a moderate clinical cases which represent a moderate to severe eating disorder presentation: to severe eating disorder presentation: – severe purging (severe bulimic episodes severe purging (severe bulimic episodes

resulting in physical signs and symptoms) and/ resulting in physical signs and symptoms) and/ or or

– rapid rate of weight loss (25% body weight in 6 rapid rate of weight loss (25% body weight in 6 months) and/or low BMI (<17).months) and/or low BMI (<17).

– Essentially these are cases where there is a Essentially these are cases where there is a high probability of interface with specialist in-high probability of interface with specialist in-patient services and community services.patient services and community services.

Service remit cont’d Service remit cont’d • Less severe physical presentations would Less severe physical presentations would

typically be seen within primary care services, typically be seen within primary care services, although it is acknowledged that such cases although it is acknowledged that such cases often represent similar levels of complexity. often represent similar levels of complexity.

• Primary care cases would usually have a BMI of Primary care cases would usually have a BMI of 17 or over and the compensatory weight control 17 or over and the compensatory weight control behaviours would not put them at immediate behaviours would not put them at immediate risk. We are happy to offer consultation to risk. We are happy to offer consultation to primary care services. primary care services.

Who do we work with ?Who do we work with ?• Work collaboratively with: Work collaboratively with:

– Service Users/CarersService Users/Carers– CMHTCMHT– Local Mental Health inpatient unitsLocal Mental Health inpatient units– CAMHS CAMHS – Primary Care Primary Care – Medical units Medical units – Tertiary services Tertiary services – Specialised Commissioning Group Specialised Commissioning Group – Other agencies Other agencies

Information needed at Information needed at referralreferral• Weight, height & Body Mass indexWeight, height & Body Mass index• Information about eating patterns and Information about eating patterns and

frequency of binge/ purge behavioursfrequency of binge/ purge behaviours• Information about associated mental Information about associated mental

health problemshealth problems• Information about additional risk factors Information about additional risk factors

such as diabetes, pregnancy or such as diabetes, pregnancy or substance misuse.substance misuse.

Information needed at Information needed at referralreferral• Results of blood tests/physical Results of blood tests/physical

monitoring and medical risk monitoring and medical risk • Information about any previous Information about any previous

interventions/admissionsinterventions/admissions• Information re aim of referral and Information re aim of referral and

level of motivation level of motivation

Service user journeyService user journey

• Referral to be sent to CMHT initiallyReferral to be sent to CMHT initially• Joint assessment undertaken by CMHT/SedsJoint assessment undertaken by CMHT/Seds• CMHT take on role of Care CoordinatorCMHT take on role of Care Coordinator• Outcome of assessment sent to GP and often Outcome of assessment sent to GP and often

service user; with summary of risks, management service user; with summary of risks, management plan and recommended physical monitoring. plan and recommended physical monitoring.

• The GP remains responsible for physical The GP remains responsible for physical monitoring; we recommend monitoring in line monitoring; we recommend monitoring in line with Kings College Guide to Medical Risk with Kings College Guide to Medical Risk Assessment for Eating DisordersAssessment for Eating Disorders

Service user journeyService user journey• If presenting with very low BMI/high If presenting with very low BMI/high

medical risk medical admission may medical risk medical admission may be indicated be indicated

• May need admission to specialist May need admission to specialist eating disorder uniteating disorder unit

• May need to consider use of MHA if May need to consider use of MHA if resistant to treatment and presenting resistant to treatment and presenting as high medical risk as high medical risk

Service user journeyService user journey

• In less severe case; management In less severe case; management plan may include:plan may include:– Joint working with CMHTJoint working with CMHT– Alternate sessions with Seds Practitioner/Alternate sessions with Seds Practitioner/

Dietician /CMHT Dietician /CMHT – Individual work with Seds PractitionerIndividual work with Seds Practitioner– Individual work with CMHT supervised by Individual work with CMHT supervised by

Seds PractitionerSeds Practitioner

Service user journeyService user journey

• Many service users on caseloads for Many service users on caseloads for several yearsseveral years

• Some require several inpatient admissionsSome require several inpatient admissions• Some not ready to change; discharge from Some not ready to change; discharge from

service if no response to motivational service if no response to motivational enhancement enhancement

• Some drop out of treatment; often re-Some drop out of treatment; often re-present at a later stage present at a later stage

Service user journeyService user journey

• Tragically, but very rarely some die; in Tragically, but very rarely some die; in our experience this has been with other our experience this has been with other complex co-morbiditycomplex co-morbidity

• Some move on to other areasSome move on to other areas• Some reach “safer BMI” then either Some reach “safer BMI” then either

drop out or mutual decision to discharge drop out or mutual decision to discharge • Some engage very well and complete Some engage very well and complete

treatment treatment

What Is My Role as Specialist What Is My Role as Specialist Practitioner?Practitioner?• Devise care pathways for people with EDDevise care pathways for people with ED

• Offer specialist skills & interventions as part Offer specialist skills & interventions as part of care package working with CPA care co-of care package working with CPA care co-ordinatorordinator

• Offer specialist supervision to CPA care co-Offer specialist supervision to CPA care co-ordinators, CMHT’s, GPs. Additional advise ordinators, CMHT’s, GPs. Additional advise can be offered to PCMHW’s and counsellors. can be offered to PCMHW’s and counsellors.

What Is My Role as Specialist What Is My Role as Specialist Practitioner cont?Practitioner cont?

• Individual work with a small amount of Individual work with a small amount of clients considered as within the more clients considered as within the more severe range of EDsevere range of ED

• Offer training/educative role and provide Offer training/educative role and provide evidence based research across all stakeholdersevidence based research across all stakeholders

• Maintain regular contact with tertiary service Maintain regular contact with tertiary service support transition in and out of care – access support transition in and out of care – access tertiary care after conducting assessmenttertiary care after conducting assessment

• Promote and maintain multi disciplinary Promote and maintain multi disciplinary involvement in all aspects of patient careinvolvement in all aspects of patient care

Role of the Dietitian?Role of the Dietitian?• To work as an integral part of the ED team To work as an integral part of the ED team

to offer advice and support in all aspects of to offer advice and support in all aspects of nutrition to both staff and clients.nutrition to both staff and clients.

• To provide psycho-education sessions To provide psycho-education sessions around nutrition to clients.around nutrition to clients.

• To ensure optimal nutrition is achieved To ensure optimal nutrition is achieved throughout all parts of treatment.throughout all parts of treatment.

• To work with the client to plan the step by To work with the client to plan the step by step recovery process and challenging step recovery process and challenging beliefs around food issues.beliefs around food issues.

Limitations of serviceLimitations of service• Office space not available in all localities Office space not available in all localities • Difficulty accessing clinical space in some Difficulty accessing clinical space in some

localitieslocalities• No IT system available for clinical No IT system available for clinical

notes/data other than York & Selby localitynotes/data other than York & Selby locality• Specialist Consultant Psychiatrist only Specialist Consultant Psychiatrist only

available in York & Selby localityavailable in York & Selby locality• Limited dietetic availability to cover large Limited dietetic availability to cover large

geographical area. geographical area.

Limitations of serviceLimitations of service• Early interventions not available Early interventions not available

within service remit. within service remit. • Limited Support Worker availability Limited Support Worker availability

within localities to work more within localities to work more intensively with service usersintensively with service users

• Reluctance of some GP’s to complete Reluctance of some GP’s to complete physical monitoring physical monitoring

A few stats: A few stats:

020406080100120140

Mar-11

Mar-12

Sep-12

Not everyone is for us: what Not everyone is for us: what to do:to do:• BMI higher than 17.5 BMI higher than 17.5 • Normal bloodsNormal bloods• Bulimia with no physical problemsBulimia with no physical problems• Binge Eaters with no physical problemsBinge Eaters with no physical problems

• Refer to Primary Mental Health Worker Refer to Primary Mental Health Worker attached to the GP surgeryattached to the GP surgery

• Refer to a Counsellor attached to the GP Refer to a Counsellor attached to the GP surgerysurgery

Not everyone is for us: what Not everyone is for us: what to do cont:to do cont:• If under 18 years of age then you can If under 18 years of age then you can

refer to the Castlegate Counselling refer to the Castlegate Counselling Service.Service.

• If the client is a York University If the client is a York University student then they can be referred to student then they can be referred to the ‘Open door’ facility at the the ‘Open door’ facility at the UniversityUniversity

• Offer the self help material outlinedOffer the self help material outlined