North Yorkshire and York Specialist Eating Disorder Service Joanie Barber Bee, Nicola Birkin and Liz Hill Specialist Practitioners; Eating disorders

Not everyone is for us: what to do: BMI higher than 17.5 Normal bloods Bulimia with no physical problems Binge Eaters with no physical problems Refer to Primary Mental Health Worker attached to the GP surgery Counsellor attached to the GP surgery

Aim of service Service commissioned by NYYPCT Dec 2007 to: Improve the quality and effectiveness of services in North Yorkshire & the City of York for people with eating disorders Decrease the length of time between the onset of eating disorders and access to appropriate help Limit the physical and psychiatric morbidity, social disability and mortality caused by eating disorders

Who Are We? Lesley Hudson: Team Secretary Bootham Park Hospital tel 01904 721173 Dr Mark Willis: Consultant Psychiatrist X 3 sessions per week Bootham Park Hospital Nicola Birkin: Specialist Practitioner York & Selby

Who Are We? Joanie Barber-Bee: Specialist Practitioner : Scarborough, Whitby & Ryedale Tony Brownbridge: Specialist Practitioner Harrogate, Ripon & Craven Liz Hill: Specialist Practitioner Ripon, Hambleton & Richmondshire

Who Are We? Bernadine McDonald: Advanced Dietitian Harrogate, Ripon & Craven Hambleton & Richmondshire Elaine Sargeson: Advanced Dietitian York & Selby Scarborough, Whitby & Ryedale

Service Remit Our service is directed at working with clinical cases which represent a moderate to severe eating disorder presentation: severe purging (severe bulimic episodes resulting in physical signs and symptoms) and/ or rapid rate of weight loss (25% body weight in 6 months) and/or low BMI (<17). Essentially these are cases where there is a high probability of interface with specialist in-patient services and community services.

Service remit cont’d Less severe physical presentations would typically be seen within primary care services, although it is acknowledged that such cases often represent similar levels of complexity. Primary care cases would usually have a BMI of 17 or over and the compensatory weight control behaviours would not put them at immediate risk. We are happy to offer consultation to primary care services.

Who do we work with ? Work collaboratively with: Service Users/Carers CMHT Local Mental Health inpatient units CAMHS Primary Care Medical units Tertiary services Specialised Commissioning Group Other agencies

Information needed at referral Weight, height & Body Mass index Information about eating patterns and frequency of binge/ purge behaviours Information about associated mental health problems Information about additional risk factors such as diabetes, pregnancy or substance misuse.

Information needed at referral Results of blood tests/physical monitoring and medical risk Information about any previous interventions/admissions Information re aim of referral and level of motivation

Service user journey Referral to be sent to CMHT initially Joint assessment undertaken by CMHT/Seds CMHT take on role of Care Coordinator Outcome of assessment sent to GP and often service user; with summary of risks, management plan and recommended physical monitoring. The GP remains responsible for physical monitoring; we recommend monitoring in line with Kings College Guide to Medical Risk Assessment for Eating Disorders

Service user journey If presenting with very low BMI/high medical risk medical admission may be indicated May need admission to specialist eating disorder unit May need to consider use of MHA if resistant to treatment and presenting as high medical risk

Service user journey In less severe case; management plan may include: Joint working with CMHT Alternate sessions with Seds Practitioner/ Dietician /CMHT Individual work with Seds Practitioner Individual work with CMHT supervised by Seds Practitioner

Service user journey Many service users on caseloads for several years Some require several inpatient admissions Some not ready to change; discharge from service if no response to motivational enhancement Some drop out of treatment; often re-present at a later stage

Service user journey Tragically, but very rarely some die; in our experience this has been with other complex co-morbidity Some move on to other areas Some reach “safer BMI” then either drop out or mutual decision to discharge Some engage very well and complete treatment

What Is My Role as Specialist Practitioner? Devise care pathways for people with ED Offer specialist skills & interventions as part of care package working with CPA care co-ordinator Offer specialist supervision to CPA care co-ordinators, CMHT’s, GPs. Additional advise can be offered to PCMHW’s and counsellors.

What Is My Role as Specialist Practitioner cont? Individual work with a small amount of clients considered as within the more severe range of ED Offer training/educative role and provide evidence based research across all stakeholders Maintain regular contact with tertiary service support transition in and out of care – access tertiary care after conducting assessment Promote and maintain multi disciplinary involvement in all aspects of patient care

Role of the Dietitian? To work as an integral part of the ED team to offer advice and support in all aspects of nutrition to both staff and clients. To provide psycho-education sessions around nutrition to clients. To ensure optimal nutrition is achieved throughout all parts of treatment. To work with the client to plan the step by step recovery process and challenging beliefs around food issues.

Limitations of service Office space not available in all localities Difficulty accessing clinical space in some localities No IT system available for clinical notes/data other than York & Selby locality Specialist Consultant Psychiatrist only available in York & Selby locality Limited dietetic availability to cover large geographical area.

Limitations of service Early interventions not available within service remit. Limited Support Worker availability within localities to work more intensively with service users Reluctance of some GP’s to complete physical monitoring

A few stats:

Not everyone is for us: what to do: BMI higher than 17.5 Normal bloods Bulimia with no physical problems Binge Eaters with no physical problems Refer to Primary Mental Health Worker attached to the GP surgery Refer to a Counsellor attached to the GP surgery

Not everyone is for us: what to do cont: If under 18 years of age then you can refer to the Castlegate Counselling Service. If the client is a York University student then they can be referred to the ‘Open door’ facility at the University Offer the self help material outlined