North of Scotland Managed Clinical Network for Eating Disorders

Meeting: NoSPG Date: 30 th June 2010 Item: 40/10 (i) North of Scotland Managed Clinical Network for Eating Disorders Annual Report April 2009 March 2010 1

Contents Foreword 3 Summary of Network Achievements over the past year 4 Network Activities The Eden Unit 5 NHS Grampian Eating Disorder Conference 13 Annual MCN Workshop 14 Information Leaflets Patient and Public Involvement 15 General Hospital Liaison 17 Eating Disorders Education & Training 19 Electronic Clinical Record 20 Grampian Eating Disorders Service 22 Tayside Eating Disorders Service 23 Highland Eating Disorders Service 25 Financial Report 26 Membership 27 MCN Workplan 20010/2011 28 APPENDICES Eden Unit Poster 31 EEATS Poster 32 Eden Unit Operational Policy 33 Eden Unit Clinical Protocol 47 2

Foreword The Eating Disorders Managed Clinical Network has had a very challenging year. We have made progress in several areas but have been hampered by staff shortages across the North of Scotland in specialist Eating Disorder Services which has meant a number of our planned initiatives have had to be delayed. The Eden Unit (Regional Inpatient Eating Disorders Unit) opened in February 2009 and has been going from strength to strength. More information about the unit can be found on pages 5 to 10. Our MCN Secretary, Rona Walker, left us this year to join the staff of the Eden Unit and we would like to thank Rona for her hard work over the past 3 years. Rona has been replaced by Alison Sherriffs who joined the MCN as our new secretary in May 2009. We would like to take this opportunity to thank all staff across the Managed Clinical Network for all their hard work in the past year which has contributed greatly to the progress we have made. Linda Keenan Network Manager Dr Harry Millar Lead Clinician Contact: Linda Keenan, Network Manager, Managed Clinical Network for Eating Disorders, Bennachie Building, Royal Cornhill Hospital, Cornhill Road, ABERDEEN AB25 2ZH, Tel: 01224 557858, linda.keenan@nhs.net Web: www.eatingdisorder.nhsgrampian.org 3

Summary of Achievements in the past Year The Eden Unit opened on 1 st February 2009 and has been going from strength to strength. Another successful Eating Disorders Conference was held in Aberdeen in November 2009. The Eating Disorder Education and Training Scotland accreditation scheme was launched in November 2009. Continue to be involved in discussion with NSD and private sector providers. Generic Clinical System Electronic patient record. The system is now being used in the Eden Unit on a daily basis and work continues to progress the ability for NHS Tayside and NHS Highland to view their patients records whilst in the inpatient unit. Information Officer Post funding secured for a further year and good progress is being made in extracting data from the electronic patient record system. Information leaflets for patients are being redrafted so that they will be suitable for use across the North of Scotland. 4

Eden Unit The Eden Unit Team Update from Dr Phil Crockett Consultant Psychiatrist to Feb 2010 The new North of Scotland Regional Eating Disorders Inpatient Unit Eden Unit has been open since February 2009. This opening of the unit was preceeded by a thorough staff induction over 4 weeks. The process of the induction and initial Operational and Clinical Protocols (See Page 33) were informed by meetings of the Clinical Project Group and Steering Group that met up in the preceeding months. The Clinical Protocol and Operational Policy were also developed through consultation and benchmarking with other units. They represent a substantial contribution to the ongoing clinical governance of the unit. Since its opening the inpatient numbers have gradually increased, which is unsurprising given that the duration of admission is usually a number of months and in some cases a substantial number of months. Currently the unit is full (March 2010). The day patient service, which has been staffed since the beginning of November with a nurse and a Cognitive Behaviour Therapy (CBT) Therapist, is increasingly active and has 4 day places available. These places can be filled in a variety of ways e.g. patients being discharged from the unit to a day place x 3 days per week or someone coming in once a week, never having been in the unit but still requiring support with their illness. The places are used in a flexible way and have been well utilised by both Grampian and Tayside patients. 5

The Unit has had to deal with some extremely low weight patients, a number of whom have being succesfully discharged in the last few months. Re admissions have usually related to a patient reconsidering, having chosen to leave the unit prematurely. Future re admissions however are likely to involve relapses in the primary eating disorder in some cases, but the day patient unit should reduce the frequency of this by easing transitions back into the community. Physical markers such as Body Mass Index, prior to admission and at discharge have shown significant improvements as would be expected. However, full physical recovery prior to discharge is not necessarily the aim of admission for a given individual. Some patients may benefit more from a focussed admission designed to reduce risk, or to stimulate positive change in the condition that can be further propagated post discharge in day patient treatment or outpatient services. Except for the Western Isles, all the other 5 regional consortium areas have had admissions to the unit with Grampian and Tayside having the highest uptake to date, in keeping with population size. The unit tailors clinical interventions around the individual needs of patients. Therapeutic interventions can include eating skills, skills of daily living, occupational therapy, art therapy, physiotherapy interventions such as body awareness therapy, CBT, systemic therapy (family therapy), dietetic assessment and treatment, gastroenterology input, psychiatric intervention, nursing supervision and support. The unit is seeking to develop areas of its practice to offer a greater range of CBT and other therapy based interventions in group settings and to further develop the use of family therapy. Both these targets will be assisted by the appointment of Dr Jane Morris as the Psychiatrist for the unit who commenced this post on 1st March 2010. Dr Philip Crockett, who had been covering the unit, has returned to his former job concentrating on the Grampian Outpatient Eating Disorder Service. As indicated already, another area that is in rapid development is the day patient service. This required the appointment of staff to give a coherent identity to the interventions that function as an effective step down care element and should decrease the relapse rate and ease transition back into the community. This is essential for eating disorder patients, especially after particularly long admissions. It can also be used, at times, to help prevent full admission, thus saving money and manpower resource. The day patient service has taken patients from outlying areas including some from Tayside. A limited degree of day patient service was offered by inpatient staff prior to the substantive appointments of the day patient staff to allow the facilitation of transition arrangements. Now that dedicated staff have been appointed a vital gap has been filled and will allow the vital task of developing the current service to proceed and ensure its effectiveness. It is worth pointing out the considerable involvement still of the North of Scotland Managed Clinical Network for eating disorders in the form of Mrs Linda Keenan and Dr Harry Millar. They have provided enormous amounts of logistic and technical support in the setting up of the unit and its ongoing running. Furthermore, there is a very valuable contribution from Dr Alastair McKinlay, Consultant Gastroenterologist and Staff Grade, Dr Becky McKay who have taken up the opportunity of the clinical sessions the unit was offering. They have given the unit a thread of extremely valuable consultation and treatment advice, and, in some instances, urgent and very important physical treatments and investigations. Both these contributions to the unit 6

give a firm base that goes a long way to support its day to day functioning in an effective and coherant manner. Another developing area of the service is liaison with local services in partner Health Boards. There are regular telephone meetings with Tayside Eating Disorder Service to discuss their patients and there is the intention of development of closer links with Highland when they have patients in the unit. We are continually developing our system of patient reports which update the referring areas on the patients progress. The service itself also uses Excelicare (Electronic Patient Record or EPR) which gives a very efficient form of communication between different shifts of staff and the Grampian Outpatient Service as regards their patients. There is a proposal to make the EPR available to Tayside and Highland ED services as well so that they can access their patients records whilst in the unit. Current Staffing Medical Staff Wte Notes Consultant Psychiatrist 0.6 Commenced 01.03.10 Specialty Doctor 0.5 Consultant Physician 0.2 AHP s and Psychologist Clinical Psychologist 0.5 Currently Vacant Dietitian 1.0 Occupational Therapist 1.0 Physiotherapist 0.5 Art Therapist 0.3 Social Worker 0.5 Currently Vacant Pharmacist 0.20 Nursing Staff Band 7 Unit Manager 1.0 Band 6 Deputy Unit Manager 1.0 Currently Vacant Band 5 Staff Nurse 8.76 Band 3 Nursing Assistants 9.2 Other Medical Secretary 1.2 Cook 1.0 Phlebotomy 0.10 Domestic Cleaner 1.0 Day Patient Programme CBT Therapist 1.0 Band 6 Staff Nurse 0.5 Occupational Therapist 0.5 Currently Vacant 7

Update from Pauline Milne Unit Manager At the end of the first year the Unit is running well. We are at full capacity as far as inpatients go and day patient numbers are increasing as far as we can with minimal staffing. It is imperative that we fill the remaining post as soon as possible. The only member of staff we have lost so far is the Deputy Unit Manager who has returned to Grampian Outpatient EDS to a promoted post. Nursing Staff continue to work rotationally, meaning that they all take turns of working days and nights and that seems to be working well. In general staff feel more confident in dealing with eating disordered behaviours and the day to day running of the ward is working extremely well. Individual members of staff are taking on various aspects of further training, including Mindfullness, Brief Solution Focussed Therapy, CBT, Counselling Skills and Body Image work at a variety of different levels. The AHP s have made significant contributions to the overall work of the Unit and I feel we genuinely have a well functioning Multi Disciplinary Team. They have proved themselves, without exception, to be flexible in their approach and are always willing to share information and skills with others. The challenge for the forthcoming year, with the welcome substantive appointment of our new Consultant Psychiatrist will be to continue to develop the unit. In particular, I would like to see the psychological input to the unit increased to improve the range of therapies we are able to offer people. The Day Programme is also in its developmental stage and already we can see a need for an increase in, for example, dietetic and physiotherapy time as well as occupational therapy. The Unit was officially opened by the Minister for Public Health and Sport on 25th May 2009. The event was very well attended with representation from all over the North of Scotland. Below are some photographs that were taken at the event. 8

Mr David Cameron, NHSG, Dr Harry Millar, MCN for Eating Disorders, Mrs Shona Robison, Minister for Health and Sport Some of the guests at the official opening. Mrs M McKimmie, Dietitian,Grampian EDS, Mrs Pauline Milne, Eden Unit Manager, Mrs Heather Cassie, NEEDS, Scotland, Mrs Jane Fletcher, Lead Dietitian, NHSG Mental Health Services, Mrs Beryl McKinnon MrJack Stuart,General Manager, Aberdeenshire, CHP, Mrs Pauline Milne, Eden Unit Manager, Mr Richard Carey, Chief Executive NHS Grampian, Mrs Shona Robison, Dr Annie Ingram, NoSPG 9

Eden Unit Activity February 2009 February 2010 Update from Linda Keenan, MCN Manager The information given below gives some statistical information on the unit which, since opening has been running with a percentage occupancy rate of between 61.3% and 99% with an overall average of 76.9% occupancy. (These figures include information regarding patient pass days ). The average length of stay over the past year is 122 days. Admissions to the Eden Unit February 2009 to March 2010 5 4 No. of Admissions 3 2 1 0 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Grampian 2 2 1 2 1 1 4 2 1 1 Highland 1 1 1 1 1 Tayside 1 1 1 2 1 1 1 Orkney 1 Shetland 1 There have been a total of 32 admissions to the Eden Unit since opening in February 2009. The total broken down by area is as follows: NHS Grampian 17 NHS Tayside 8 NHS Highland 5 NHS Orkney 1 NHS Shetland 1 NHS Western Isles 0 Admissions to the unit are for patients aged 18 and over. In extreme circumstances it may be possible to admit patients aged 16 18 but this would be a decision made between clinicians and only in exceptional circumstances. 10

Discharges from Eden Unit February 2009 March 2010 3 No. of Discharges 2 1 Grampian Tayside Grampian Tayside Grampian Highland Tayside Highland Orkney Shetland Grampian Grampian Grampian Tayside Grampian Grampian Tayside 0 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Grampian 2 1 1 1 1 2 2 1 Highland 2 2 Tayside 1 2 1 1 1 Orkney 1 Shetland 1 The chart below shows a breakdown of age on admission to the unit Breakdown by Age on Admission to Eden Unit Feb 2009 Feb 2010 2 1 1 1 Under 18 18 20 8 21 25 26 30 4 31 35 36 40 41 45 46 50 7 4 11

Day Patient Activity The table below indicates the activity levels for the Day Patient part of the service. There are 4 day places available and patients may attend on a variety of days e.g. one day per week or every day. They may also attend for a just a few hours per day or all day dependent on their individual needs. The substantive staff for the day patient element of the service were only appointed in November 09. Prior to this the inpatient unit staff were utilised to provided this element of the overall service available in the Eden Unit. The day patient element, so far, has been mainly utilised by NHS Grampian and NHS Tayside patients. Type of activity Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Totals Place Days Avail N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Total Attendances 29 65 65 63 34 29 26 55 59 49 476 DNA/CNA 0 4 8 3 0 0 1 0 0 1 17 Eden Unit Occupied Bed Days Feb 09 Mar 2010 250 240 230 220 No. of Days 210 200 190 180 170 160 150 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 12

NHS Grampian Eating Disorders Conference November 2009 Another very successful Eating Disorders Conference was hosted by NHS Grampian in November 2009. The Conference was entitled Eating Disorders: Research into Practice. It was extremely well attended and well received with renowned speakers such at Professor Christopher Fairburn, Department of Psychiatry, Oxford University and Ulrike Schmidt, Professor of Eating Disorders, Institute of Psychiatry, London. A Poster Presentation session was also well received with several extremely interesting posters submitted. The Eden Unit submitted a poster at this session and a copy is attached at Page 31. This is the second year that a poster presentation session has been held and is growing in popularity. We also had several stands at this years conference including NEEDS Scotland (ED Support Group), Working Together Care, Blackwells Bookshop and EEATS (Eating Disorders Education and Training Scotland). In conjunction with the Conference the Eating Disorder Education and Training Scotland scheme was launched. This is an exciting new venture which was funded by NES. More information is available on Page 19 of this report. Planning is already well underway for the 2010 conference entitled Discovering New Skills: The Journey to Recovery which will take place on 11 th and 12 th November 2010 at Aberdeen Exhibition and Conference Centre. The conference is now a well established annual event and is attracts audiences from far and wide. If you wish to book a place on the conference for this year please contact Carol Deans (cdeans@nhs.net) who will be happy to assist you. Below is some of the feedback received from the November 2009 Conference: Was excellent to see a very inclusive conference with many different disciplines represented. It meant you could learn much from others experiences and views. Seeing the patients journey from both clinician (therapist) and patient s perspective was exceptional. Thank you very much for the continued inspiration. New treatments presentations were superb. For a non psychiatric participant a very stimulating conference. An excellent conference in all aspects. Excellent opportunity to re connect with ED Clinicians across the country as well as down South. Increased my optimism in discovery of effective treatment for eating disorders, especially AN. 13

Annual MCN Clinical Workshop The annual MCN clinical workshop was held on 12 th May 2009 and focussed on 2 separate areas. Those being Information Leaflets and The Management of Very Seriously Ill patients. All areas, including the Eden Unit gave information on the leaflets they were currently using within their service and Linda Keenan gave the feedback, from the patients, on these. (Details of the patient feedback is given on Page 16) There was a general consensus that a regional leaflet would be a good idea, giving general information with more area specific leaflets being made available in each regional area. Dr Millar produced 2 draft leaflets later in the year (Information for Patients and Relatives Eating Disorder Services and Information from Patients and Relatives What are Eating Disorders/Help with Eating Disorders) and these are out for final consultation at the time of writing this Annual Report. Once feedback has been received it is envisaged that these leaflets will be made available across the North of Scotland. Session 2 of the workshop concentrated on the Management of Seriously Ill Patients and there were presentations from both Highland and Grampian. These presentations provoked further discussion around the problems with appropriate general physician liaison being available in NHS Highland and NHS Tayside. It was agreed that this was something that the MCN could take forward and more information on how this is being achieved is given on Pages 18 and 19. 14

Feedback from Patients on the draft Information Leaflets Information Leaflets At our MCN Clinical workshop held in May 2009 we had decided to look at the information leaflets that the various Eating Disorder Services were using across the North of Scotland. We wanted to hear from patients what they wanted to know from a leaflet, what they would find helpful etc and to that end we invited (through our patients/carers database) people to come along and give their views on the leaflets that were currently being used and how these could be improved. The feedback from the patient/carers included the following Grampian Leaflets Outpatient Service Don t like the different leaflets for the different diagnoses. Feels as though if you handed one on a specific topic you are being labelled. It would be preferable to have one booklet with all the information in the leaflets combined. Leaflets are very factual and clinical? Perhaps simpler language could be used. Would like to see a welcoming booklet about the EDS Service along the lines of NHS Tayside/NHS Highland s one. The leaflet on Bulimia does not list treatment options. Tayside Leaflet Outpatient Service Nice Language simply explained No link to MCN website Highland Leaflet Outpatient Service Nice language used simply explained Links to other websites apart from b eat Like suggested reading list but feel this would be more beneficial as a list of books for carers? Suggestion Would it be possible to combine all into one booklet to be used across the North of Scotland, using all the factual leaflets from Grampian but including the leaflets about each OP service across the north at the front of the booklet? Patients were also asked to comment on the booklet that was being developed in the Eden Unit for patients Eden Unit Leaflet Did not like the section on OT. Felt it was too much did not like imagery. Felt it should be shorter and more concise. Felt patients, on admission would not be cognitively able to comprehend it. They felt that the last 2 paragraphs in the OT section were the most relevant and gave the information that was required. Physiotherapy Section not keen on flowchart but like the wording and found it easy to understand. 15

They thought that the list of mealtimes/snack times may be off putting as the leaflet does not mention any of the other day to day activities/therapies that take place in the unit and therefore prospective patients/inpatients may focus onto this and feel that this is all that takes place in the unit EATING! They also felt the list of mealtimes/snack times seemed to indicate that all patients would be on 3 full meals plus snacks immediately and I was unsure if this was actually the case and they felt this would also be offputting. The leaflet, as a whole, requires more information on what happens on a day to day basis i.e. the clinical programme, types of therapies offered. No mention of community meetings in the leaflet. No mention of what facilities are/are not available in the leaflet e.g. hairdryers, DVD Players, Freeview, PS3, no internet access etc. Would like to see some testimonials from recovered patients at the front of the leaflet. Would like to see a page dedicated to what you can bring/what you cannot bring into the unit. No directions to the unit once you actually reach Cornhill Hospital. The layout of the leaflet needs to be looked at: Suggestions: The roles of the staff should go nearer the back of the booklet. More information on day to day programme in the unit needs to be included. Other suggestions: Some parts of the leaflet require more simplistic language to be used. Don t use so much clipart. A glossier/more professional look for the leaflet should be looked at. The ideas and suggestions given by the patients were taken forward to the MCN Annual Clinical Workshop event for further discussion. 16

General Hospital Liaison For a number of years those working with severe eating disorders have been aware of problems in organising the necessary joint medical and psychiatric care required for these patients. The most severely ill patients require admission to general hospitals. However, the behavioural difficulties associated with severe eating disorders can result in major problems implementing safe re feeding and some uncertainty regarding where responsibilities lie between general hospital and psychiatric services. The Case of Miss A The Scottish Public Service Ombudsman produced a report on the death of Miss A at the age of 19 in September 2004. This patient had an extremely severe and difficult anorexia nervosa and in the terminal course of her illness she was transferred repeatedly between a psychiatric unit and a general hospital. The Ombudsman found that there was a failure in the service provided by the Health Board. The conclusions included recognition of an unmet need for adult inpatient psychiatric provision for these patients but also a wider need for acute inpatient medical services with appropriate specialist knowledge and expertise for patients with eating disorders whose physical condition requires medical input. The Ombudsman felt that these needs applied to a greater or lesser extent to Scotland as a whole and he also identified a shortfall in the levels of knowledge about and awareness of, the legal position with respect to some treatments for eating disorders amongst health practitioners in both primary and secondary care settings. Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) Following the 2008 Annual Meeting of the British Association for Parenteral and Enteral Nutrition (BAPEN), at which there was discussion of a case of a young woman with anorexia nervosa who died in a medical unit, a group of professional colleagues was brought together to draw up guidelines. Contributors to this group included intensive care physicians, a paediatrician, adult and child adolescent psychiatrists, dieticians and a pharmacist. Others consulted in the development of the guideline included a Professor of general practice, a nurse, the authors of the NICE guideline on nutritional support for adults, the CEO of the main user and carer organisation in the UK and 2 carers. In December 2009 this group produced a draft guideline document which they hope is close to its final form and they are seeking endorsement from the Royal College of Physicians, The Royal College of Psychiatrics, The Royal College of Pathologists, The British Association for Parenteral and Enteral Nutrition (BAPEN), b eat (the eating disorders self help charity) and the Intercollegiate Group on Nutrition. The North of Scotland In the context of these concerns and developments the MCN has been looking at how best practice can be developed within the North of Scotland. In February 2009 the Eden Unit providing inpatient and intensive day patient treatment for severe eating disorders was opened in Royal Cornhill Hospital and a key element of this development was formal recognition of the importance of the closest possible liaison between the Eden Unit and the general hospital specialist 17

expertise. Funding was secured to consolidate the contribution of Dr Alastair McKinlay, Consultant Gastroenterologist with a special interest in nutrition and Dr Becky McKay, Specialty Doctor in Gastroenterology. This means that they are able to make a regular commitment to assess and advise on the management of the patients in the Eden Unit and also to make arrangements for transfer of care to Ward 13, Aberdeen Royal Infirmary (ARI), where staff have developed experience and expertise in the management of severe eating disorders. The clinical staff involved in this development have drawn up a detailed clinical protocol. This guides staff on the physical monitoring of inpatients while in the Eden Unit, physical risk assessment and management, and arrangements for seeking advice on possible transfer to Ward 13, ARI. Dr McKinlay and Dr McKay are also able to offer advice to the rest of the north region out with Grampian. Very early, following the opening of the Eden Unit, indeed in dealing with the very first admission from Highland, it became clear that there remained a need to ensure that there were satisfactory procedures in place throughout the region to ensure medical stabilisation of patients prior to transfer. In keeping with the MARSIPAN guidance we were able to identify Consultants in Raigmore hospital, Inverness and Ninewells Hospital, Dundee who would take on a particular interest in ensuring best possible care for these patients when admitted to their hospitals. The Consultants involved are Dr Hazel Younger in Raigmore Hospital and Dr Nigel Reynolds in Ninewells Hospital. Further clarification of local procedures has been hampered by the lack of a substantive Consultant appointment in Eating Disorders in Tayside (although that has been recently resolved) and the long term sick leave absence of the Consultant Psychiatrist in eating disorders in Highland. However, preliminary contact with the MCN has been established and it is expected that in the coming year local arrangements in Raigmore and Ninewells Hospital will be further clarified. Regarding patients admitted to the Eden Unit, Dr Alastair McKinlay from NHS Grampian has been able to offer temporary transfer to Ward 13 in ARI for all patients who need this regardless of their Health Board of origin. 18

Eating Disorders Education and Training Scotland A number of developments in recent years highlighted the need to promote improved training for those providing care and treatment for eating disorders. The Framework for Mental Health document on eating disorders (Scottish Executive health Department, 2001) and the Quality Improvement Scotland (QIS) recommendations for Management and Treatment for Eating Disorders in Scotland (2006) both highlighted the need to develop improved training. NHS Education Scotland (NES) supported the development of a curriculum/accreditation scheme for multidisciplinary training across the age range in eating disorders. This led to a steering group being set up which is chaired by Dr Jane Morris, Consultant Psychiatrist (Eden Unit), with administrative support from Linda Keenan, Manager, MCN for Eating Disorders North Scotland. The training is appropriate for a range of different professional groups and is open to anyone from a clinical background who wishes to develop an accredited level of knowledge and expertise in the assessment and management of eating disorders. It is anticipated that, over time, it will become a basic requirement that those working in specialist services for eating disorders should hold or be working towards this accreditation. The Accreditation Scheme was officially launched at the Aberdeen Eating Disorder Conference in November 2009 and has its own website where candidates register online, can undertake the online knowledge test and access helpful documentation. ( www.eeats.co.uk). Dr Morris and Linda Keenan were invited to present a poster at the Psychological Interventions Conference held at Heriott Watt University on 17 March 2010. (Poster can be viewed on page 32. For further information on the scheme and eligibility to undertake the accreditation process please contact Linda Keenan on 01224 557624 (email: linda.keenan@nhs.net) 19

Electronic Clinical Record Over the past year a number of things have happened with the Electronic Clinical Record. The main one being that we have now moved to a web based version of the system. We had thought that this would make it easier for NHS Highland EDS and NHS Tayside EDS to have access to the system but this has not been the case. We have had several discussions with IT representatives in all 3 mainland health boards but progress was extremely slow. There are several other IT initiatives, both within, individual health boards and across Scotland which have had an impact on being able to progress rolling the system out including the new Patient Management System (PMS) which is due to be implemented in several boards in the next couple of years and individual boards progressing other systems within their own health board area. Despite these obstacles it is likely that we will be able to allow both NHS Tayside and NHS Highland EDS staff to have access to their own patients records whilst they are inpatients in the Eden Unit. The system is now being used within The Eden Unit on a daily basis and work is currently underway at AxSys to develop new forms for specific use within the unit. We have also managed to secure the services of our Information Officer until December 2010. This is allowing us to ensure that the quality of data already input is good and this is allowing us to produce good quality reports with accurate data. This is quite a time consuming process and Some examples of the type of information we can glean from the system is shown below: New Referrals to Eating Disorder Specialist Services in North Scotland April 2009 to March 2010 30 25 20 No. of Referrals 15 10 5 0 APRIL MAY JUN JULY AUG SEP OCT NOV DEC JAN FEB MAR Grampian 7 13 14 11 15 23 12 18 16 10 11 26 Tayside 9 7 6 5 5 5 1 6 8 10 9 6 Highland 3 10 5 5 10 5 5 4 7 4 3 6 Totals 176 77 67 20

Re Referrals to Specialist Eating Disorder Services in North Scotland April 2009 March 2010 10 9 8 7 No of Re referrals 6 5 4 3 2 1 0 APRIL MAY JUN JULY AUG SEP OCT NOV DEC JAN FEB MAR Grampian 9 6 5 2 4 8 5 3 6 4 6 6 Tayside 0 0 0 1 0 0 0 0 1 1 2 0 Highland 3 2 1 4 0 1 4 2 1 0 0 4 TOTALS 64 5 22 NB The Tayside service has few re referrals. It only started up in November 2007 21

Grampian Eating Disorder Service The service has come through a time of relatively low staffing levels in the last year. Further changes are forthcoming and at this time the department is not far off its complement of staff. A new full time nurse therapist has been appointed, a new 0.5 wte pscyhology post has been filled in the form of an experienced counselling psychologist. The service continues to evolve in respect of the interventions offered in that the contemplation group tries to establish a motivational stance for the department as a whole so that it continues to run to good effect. New additions or re established parts of the service include the beginning of a mentalisation based therapy group for sufferers of Anorexia Nervosa or Atypical Anorexia Nervosa which will start in the spring of 2010. A self help resource to the department has been remodelled with help from a recent psychiatric trainee so that now the web based Overcoming Bulimia Online is to be introduced to patient management replacing the previous CD Rom version which was outdated. The department continues to benefit from the electronic patient record which runs within the service and although there are still glitches being ironed out, it certainly adds to the efficient communication of information about patient management between professionals and allows for very valuable resource data in terms of audit and research. In that respect the department is in a good position to work on quality assurance issues in the coming months. With better staffing levels staff supervision has entered a more steady period with ongoing CBT supervision and departmental supervision on a monthly basis as well as provisions for the different modalities of working that people are using. The department continues to have a mix of groups and individually delivered therapies but, obviously, with a relatively small number of staff the challenge remains to keep the groups running regularly enough so that waiting times for treatment are not inappropriately long. Group based treatments currently running include, as previously mentioned the Contemplation Group, the Nutrition Education Group, Shema Focussed therapy Group, the Mentalisation Based Therapy Group, the Bulimia Nervosa Therapy Group and the Binge Eating Disorder Group. The latter was recently able to be re started after a temporary closure due to lack of staff during the middle part of 2009. Other challenges that remain will be to maintain standards in the current funding climate. Perhaps even look to possibilities of future developments where the department is lacking such as occupational therapy resource. Dr P Crockett Consultant Psychiatrist/Psychotherapy in Eating Disorders Service Team Leader 22

NHS Tayside Eating Disorder Service NHS Tayside Eating Disorders Service is based in Dundee, and provides outpatient clinics in Dundee, Angus, Perth and Kinross. The service offers specialist assessment and treatment to adults suffering from severe and/or enduring eating disorders, having access to psychological, nursing, psychiatric and dietetic interventions. The service also seeks to support the work of colleagues managing eating disorders at the Primary Care and Community Mental Health Team levels within NHS Tayside, through training events, consultation and advice. Clinical Staff 0.6 wte Consultant Clinical Psychologist/Lead Clinician Dr Paula Collin 1.3 wte Clinical Psychologists Dr Suzanne Deas (Perth and Kinross), Dr Diane Forrest (Dundee) and Ms Louise Hobbs (Angus) 1.0 wte Specialist Nurse Mr Brian Grieve 0.5 wte Consultant Psychiatrist Dr Lesley Dolan 0.5 wte Assistant Psychologist Ms Moira Cook 1.0 wte Administrator Ms Diane Atkinson 0.8 wte Dietitian currently vacant Service Developments 2009/10 There have been a number of staff changes within the service over the past year, with Dr Ankur Gupta (Psychiatry), Dr Gillian Paterson (Psychology) and Ms Elizabeth Stewart (Dietetics) leaving the service, and Dr Lesley Dolan, Dr Diane Forrest and Ms Moira Cook joining. Despite periods of reduced staffing, the service has managed to run without a waiting list to date. The service is in the process of transferring its management structure, from under Angus, to Dundee, Community Health Partnership, and, in line with this, the service base is shifting into more ample and clinically appropriate accommodation. Service staff have undertaken training in Interpersonal Psychotherapy this year, and have introduced this as a therapeutic option. Mr Brian Grieve of the service continues to work towards accreditation with the British Association of Behavioural and Cognitive Psychotherapists. Service Challenges 2010/11 To maximise the efficiency and effectiveness of the service by utilising a variety of intervention formats (e.g., group treatments, monitoring clinics and active non interventions ). To ensure optimal liaison between the eating disorders service and all other interfacing services within NHS Tayside To support the development and delivery of local support groups for eating disorder sufferers and their carers. To continue to support the work of the NHS Education Scotland Eating Disorders Education and Training initiative, and the North of Scotland Managed Clinical Network for Eating Disorders. To continue to identify and adopt appropriate IT systems (including videoconferencing systems) that will meet the service s requirements. Teaching Commitments Teaching on eating disorders is provided by the service on an ongoing basis, to both professional and non professional groups, locally and nationally, e.g. Angus 23

Community Health Partnership Protected Learning Event (November 2009) and Scottish Association of Teachers of Psychology Conference (February 2010). Training Placements There is currently 1.0 wte (five year, flexible) Trainee Clinical Psychologist, Ms Vivien Smith, attached to the service. Another Trainee Clinical Psychologist, Ms Melissa Hanna, was attached to the service between April and September 2009. In addition, short term placements have been provided for a medical student and a nurse over the past year. Research Activities Psychology staff attached to the service continue to undertake eating disorder research in partnership with the Priory Hospital in Glasgow and, more recently, with the inpatient and outpatient eating disorders services based in Aberdeen. A Trainee Clinical Psychologist from the NHS Highland Eating Disorders Service, Ms Kirsty MacDonald, has been gathering data for her final year thesis in collaboration with the service. An up date of the service s research activities was presented at the NHS Grampian Eating Disorders Conference in November 2009. Research papers accepted for publication/published 2009/10: The Relationship Between Parental Bonding, Social Problem Solving and Eating Pathology in an Anorexic Inpatient Sample (Swanson, Power, Collin, Deas, Paterson, Grierson, Yellowlees, Park and Taylor) Published, European Eating Disorders Review. The Effectiveness of, and Predictors of Response to, Inpatient Treatment of Anorexia Nervosa (Collin, Power, Karatzias, Grierson and Yellowlees) Accepted for publication, European Eating Disorders Review. A Mediational Model of Self esteem and Social Problem Solving in Anorexia Nervosa (Paterson, Power, Collin, Grierson, Yellowlees and Park) Accepted for publication, European Eating Disorders Review. General Psychopathology in Anorexia Nervosa: The Role of Psychosocial Factors (Karatzias, Chouliara, Power, Collin, Yellowlees and Grierson) Accepted for publication, Clinical Psychology and Psychotherapy. Committees/Professional Groups Scottish Eating Disorders Interest Group Dr Paula Collin, Dr Suzanne Deas (committee member), Ms Louise Hobbs, Mr Brian Grieve and Dr Lesley Dolan. Scotland Eating Disorders Education and Training Committee Dr Paula Collin North of Scotland Managed Clinical Network for Eating Disorders Steering Group Dr Paula Collin, Mr Brian Grieve and Dr Lesley Dolan. Dr Paula Collin Consultant Clinical Psychologist 24

Highland Eating Disorder Service 2009 2010 has been a challenging year for us, with our consultant psychiatrist being off sick since the summer and our secretary since the New Year. However, thanks to all remaining team members dedication, we have continued to provide an outpatient service for eating disorder patients from Highland and to meet our targets of seeing urgent referrals within one week and routine referrals within two to three months. Referral numbers have remained around the same level as last year. We have been extremely fortunate to have locum consultant cover by Dr Chris Freeman from Lothian and the continued support of our colleagues in the North of Scotland MCN. Our consultant psychiatrist hopes to have returned to work by this May and, as our secretary will be retired, we hope to have a replacement for that post around the same time. This will bring our staffing complement back to: 0.3 wte Consultant Psychiatrist 1.2 wte Nurse Therapists x 2 0.3 wte Dietetic input 0.6 wete Staff Grade Psychiatrist 1 wte Secretary We have had a nurse therapist working on secondment for one day a week over the year who has successfully moved on to a full time generic cognitive therapy post for Inverness outpatients. We intend to continue to offer this nurse training secondment and will be recruiting soon. As one of our nurse therapists is about to go on maternity leave, we are hoping to recruit some maternity leave cover too! This year we have had the benefit of a full time psychology trainee working with us this year, carrying out research on cognitive function in Bulimia Nervosa. One of our nurse therapists has completed Dialectical Behavioural Therapy and the other has had training in Mindfulness. Our staff grade psychiatrist completed the South of Scotland Post Graduate Certificate in Cognitive Behavioural Therapy and continues to follow an interest in Eye Movement Desensitisation and Reprocessing. He is currently working on a research proposal to look at using this in the treatment of patients with eating disorders. As a multi disciplinary team we are able to offer Cognitive Behavioural Therapy, Interpersonal Therapy, Dialectical Behavioural Therapy, Mindfulness and Eye Movement Desensitisation & Reprocessing to our patients. Our dietician, with support from the Highland Users Group, has successfully resurrected Highland s Self Help/Support Group for Eating Disorders which is now meeting regularly again. Liaison with Grampian staff at the Eden Unit has facilitated specialist inpatient care being provided for our patients, when necessary, in an NHS setting with which we have a close working relationship allowing for enhanced continuity of care. We have continued to make use of our teleconferencing facilities to maintain links with Grampian and, on occasion, to provide therapy for patients living at some distance from Inverness for whom travelling to and from therapy would otherwise be onerous. As a team, we continue to participate fully in all of the MCN working groups and contribute to EEATS and SEDIG developments. Further details of our service are available on both the MCN website and Highland Internet Site. Dr Yvonne Edmonstone Consultant Psychiatrist 25

CREDITORS < 1 YEAR MCN for Eating Disorders Account Code Account Level 9 Name Annual Budget YTD Budget YTD Actuals YTD Variance POP ACCRUALS NON NHS 0.00 0.00 0.00 0.00 Sum: 0.00 0.00 0.00 0.00 MSCELLANEOUS INCOME Account Code Account Level 9 Name Annual Budget OTHER MISCELLANEOUS INCOME 63,717.76 Sum: 63,717.76 YTD Budget 63,717.76 63,717.76 YTD Actuals YTD Variance 45,380.28 18,337.48 45,380.28 18,337.48 Account Code Account Code Cost Cent Code NON PAY Account Level 9 Name Annual Budget YTD Budget YTD Actuals YTD Variance OTHER INST & SUNDRIES ISSD 0.00 0.00 3.42 3.42 HOSPITALITY CHGS 200.00 200.00 813.84 613.84 DISPOS SACKS 0.00 0.00 4.27 4.27 PUR:COMP & SOFTWARE 1,000.00 1,000.00 24.64 975.36 S/C: COMP & SOFTWARE 700.00 700.00 729.17 29.17 SPECIALIST SUBS 0.00 0.00 31.42 31.42 TRAVEL 1,000.00 1,000.00 737.32 262.68 SUBSISTENCE 0.00 0.00 9.08 9.08 REG US LUMP SUM ALL OTHER STAF 0.00 0.00 759.96 759.96 TRAVEL BOOKING FE 0.00 0.00 14.00 14.00 COURSE TRAVEL SUBS 3,500.00 3,500.00 284.67 3,215.33 PRINTING 0.00 0.00 565.36 565.36 STATIONERY 500.00 500.00 0.00 500.00 CARRIAGE 0.00 0.00 15.00 15.00 HIRE CHARGE 0.00 0.00 341.72 341.72 OTHER MISCELLANEOUS 0.00 0.00 271.55 271.55 Sum: 6,900.00 6,900.00 4,577.42 2,322.58 PAY Account Level 9 Name Annual Budget YTD Budget YTD Actuals YTD Variance A & C GRADE 6 659.54 659.54 0.00 659.54 A & C GRADE E 539.99 539.99 0.00 539.99 ADMIN OFFICER OFFICE SVCES 23,723.76 23,723.76 6,680.52 17,043.24 ADMIN OFFICER H L GEN/MAN SVS 32,425.44 32,425.44 13,514.46 18,910.98 ADMIN MANAGER GEN/MANAGE SYS 3,224.00 3,224.00 22,203.58 18,979.58 CONS PSYCH MI 34,614.12 34,614.12 32,725.97 1,888.15 Sum: 95,186.85 95,186.85 75,124.53 20,062.32 Annual YTD YTD YTD Cost Centre Level 9 Name Budget Budget Actuals Variance MCN FOR EATING DISORDERS 38,369.09 38,369.09 34,321.67 4,047.42 Produced by NHS Grampian Finance Department 26

Membership of the Managed Clinical Network for Eating Disorders Steering Group Name Title NHS Board Area/ Organisation Ms Jackie Agnew Service Manager NHS Highland Mr Peter Cartwright Lead Nurse (MH) NHS Argyll & Bute Dr Paula Collin Consultant Clinical NHS Tayside Psychologist Dr Jon Cresswell Public Health Medicine NHS Grampian Dr Yvonne Edmonstone Consultant Psychiatrist NHS Highland Mrs Pauline Milne Unit Manager, The Eden NHS North Unit Scotland Mr Neil Fraser Strategy & Performance NHS Tayside Manager Mr Bill Harrison General Manager NHS Grampian Ms Roseanne Urquhart Head of Healthcare NHS Highland Strategy Mrs Linda Keenan MCN Manager NHS North Scotland Dr Harry Millar Consultant Psychiatrist & NHS North Lead Clinician Scotland Mr Alan Murdoch Community MHT Manager NHS Shetland Dr Elaine Anderson Consultant Psychiatrist NHS Western Isles Vacancy General Practitioner Mrs Lorna Carrol Dietitian NHS Highland Dr Cleo Hart Consultant Psychiatrist NHS Grampian (CAMHS) Mr Brian Grieve Nurse Therapist NHS Tayside 27

MANAGED CLINICAL NETWORK FOR EATING DISORDERS NORTH SCOTLAND ANNUAL WORKPLAN APRIL 2010 MARCH 2011 Document Control Information Control Status Final Date Last Printed Version Number 1.0 Author Linda Keenan 28

Subject/Aim Rationale Objective for 2008/2009 The Steering HDL (2002) 69 and To continue to Group should (2007) 21 state that provide direction, provide the overall each MCN should assist in decision direction and have clarity about its making and focus of the management contribute to any Managed Clinical arrangements service redesign Network Patient & Carer Involvement HDL (2002) 69 and (2007) 21 state that patient involvement is integral to the development of the MCN To continue to involve users of the EDS services in developments of the MCN Proposed Action Eden Unit Consultant to be invited to join Steering Group Help to clarify governance protocols and structures for Eden Unit Continue to develop patient involvement in MCN Activities Further explore contacts with user groups Aid development of patient satisfaction information Development of Care Pathways Develop a Quality Assurance Programme HDL (2002) 69 and (2007) 21 Each network should have a defined structure, which sets out the points at which service is to be delivered and the connections between them, clearly indicating the ways in which the network relates to the planning function of the body or bodies to which it is accountable HDL (2002) 69 and (2007) 21 Each network must have a Quality Assurance programme Care pathways are currently in place but will be kept under review in the light of experience of the new regional inpatient unit To Develop a Quality Assurance Programme and submit to NoSPG and then Quality Improvement Scotland for accreditation Once senior clinical staff are in post review care pathways with them, clinical teams, patients, carers and other stakeholders Audit Sub Group set up to look at audit and take forward QAP ongoing due to staff shortages over the past year 29

To continue to develop the website to meet the requirements of stakeholders Education & Training Tier 4 Services IT Systems Information should be available to patients/carers and health professionals HDL (2002) 69 and (2007) 21 states that educational and training potential should be used to the full HDL (2002)69 and (2007) 21 states that there must be evidence that the potential for networks to generate better value for money has been explored To develop the website further to include information on Eden Unit To help promote the EEATS accreditation scheme in its inaugural year Continue to raise awareness with GP s/counselling services across the region Review Eden Unit s 1 st operational year and ensure monitoring systems are in place and being adhered to Development of Electronic Patient Record reports Seek to give NHS Tayside/NHS Highland read only access to the EPR Improve data quality of information being input Develop specific pages for Eden Unit Continue to offer awareness sessions to GP s/counselling services across the MCN region Establish Intelligence Officer as a substantive post Intelligence Officer to develop and promote EPR and offer assistance to other HB s with collation of Eating Disorder Data for audit purposes 30

Eden Unit Poster presented at Aberdeen Eating Disorder Conference November 2009 31

EEATS EEATS www.eeats.co.uk eating disorders education & training scotland Chair: Dr Jane Morris, Adminstrator Ms Linda Keenan EATING DISORDERS SERVICES IN SCOTLAND Scotland is investing in enhanced Eating Disorders services, from specialist outpatient clinics and intensive outreach services through to the first two NHS Eating Disorders inpatient units in Aberdeen and (shortly) in the South East. In the North and SouthEast, Managed Clinical Networks (MCNs) have been set up, whilst the West has its own governance arrangements In 2006 Aberdeen launched a series of annual two day Eating Disorders Conferences. In 2009 the new Scottish Mental Health Research Network (SMHRN) adopted an Eating Disorders Research Group for protocol development. In primary care, some GPs are opting to become GiPsis GPs with special interests, which in some cases means a special interest in Eating Disorders. This welcome expansion creats a demand for high quality training and indeed, supervision which may not be readily met by the small nucleus of overstretched eating disorders experts in Scotland. As some of the pioneers in their field reach retirement age there is even more urgency to pass down and refresh their wisdom. It is an expensive solution to rely on individuals travelling to England to attend training events of variable quality and imperfect relevance for the context to which they return. TRAINING At the end of 2006, a group of clinicians from across Scotland met to bid for a small grant intended to set up Eating Disorders training. It was agreed with funders that training should foster and approve practice in line with the recent Ø QIS Recommendations (2006) which incorporated many of the recommendations already published by the Ø NICE Guideline on Eating Disorders (2004, England & Wales) ØIt was intended that further research based evidence would continue to inform training, and indeed that training would encourage Scottish contributions to the body of available research It was also a founding principle that training should be Ø multi disciplinary, multi agency and Øacross the age range ACROSS THE AGE RANGE The average age of onset for eating disorders is around 15, and the average time taken for someone with severe anorexia to reach recovery is about 6 years, spanning transition from CAMHS to adult services halfway through the recovery process. The publication of the Scottish Ombudsman s Report on the death of a young woman from anorexia nervosa highlighted the contribution of so many transitions to the tragedy, and proved a driver in attracting resources for Scottish Eating Disorders services FINANCES EEATS was grateful to HeadsUp Scotland THE EEATS ACCREDITATION syllabus, for a pump priming grant leading to leading to more substantial funding from NHS Education Scotland (NES). This has provided administration expenses, allowed the establishment of the accreditation, financed our new website, paid for free training days for both clinicians and supervisors, and continues to subsidise NHS clinicians applications for accreditation. CORE GROUP members represent : Ø the major geographical areas & Health Boards across Scotland Ø mental health and other disciplines & professions Ø different tiers of intensity and severity, and Øthe range of self help, voluntary, private, public, NHS, General Practice, Educational and research services, which are indispensible to service provision in the current climate. We also arrange Øuser and carer representation whilst providing protection from exploitation or distress to these much appreciated volunteers. LINKS WITH SEDIG The Scottish Eating Disorders Association (SEDIG) is a well established organisation made up of professionals (NHS & private), volunteers, users and carers, and with national and international affiliations which make it an ideal associate. Its 6 monthly training days allow EEATS to draw on its networking opportunities so that SEDIG has provided a mutually helpful reference group for EEATS. SEDIG is working to provide maximum benefit from the resource which BEAT (the Eating Disorders Association) proposes to invest in Scotland in 2010 11 32 allows individuals of any discipline to acquire, maintain and demonstrate their competence in evidence based practice in Eating Disorders. Input from a KSF trainer makes the syllabus highly sympathetic to Agenda for Change. Candidates register and then work their way through the pack over a period of up to 3 years. Previous experience may be included in the submitted portfolio, allowing experienced clinicians to achieve the qualification swiftly. The accreditation pack has been designed in such a way that professionals can adapt it to suit the needs of their own speciality. All professionals cover a core syllabus, including diagnosis, ethics, the Mental Health Act & risk management, but there is also a tailormade section to allow each discipline to pursue appropriate expertise under the guidance of an experienced supervisor.. Accreditation submissions are scrutinised and approved by the core group or constructive feedback encourages successful resubmission. www.eeats.co.uk WEBSITE created by RHINO, offers an electronic version of the training pack, together with guidance, news and notices of forthcoming training opportunities approved by EEATS. A bank of MCQs provides an online theory test which can be taken as often as required to ensure basic knowledge is in place. SUPERVISION Experienced eating disorders clinicians from all disciplines are selected on the basis of their CVs and invited to participate in supervision workshops and regular meetings to support their provision of high quality supervision and quality assurance for the accreditation programme. EEATS supervisors are the backbone of the entire accreditation programme.