Appendix 1: Mapping services for eating disorders and ...



Appendix?1: Mapping services for eating disorders and consultations with Health BoardsThis document presents data on services mapping and scoping, building upon the information collected by the Mental Welfare Commission for Scotland (MWC) during their themed visit from 2018-2020. Outlined below is the context of this data; the MWC data and additional information provided to the Services Review Team regarding referral numbers, pathways and staff mix organised by health board; details of discussions with Chief Executives of health boards organised by geographical context; and details of 3rd sector organisations in Scotland.Table of Contents TOC \o "1-3" \h \z \u Appendix?1: Mapping services for eating disorders and consultations with Health Boards PAGEREF _Toc71812035 \h 1Ayrshire & Arran PAGEREF _Toc71812036 \h 3Borders: PAGEREF _Toc71812037 \h 4Dumfries & Galloway PAGEREF _Toc71812038 \h 8Fife: PAGEREF _Toc71812039 \h 9Forth Valley PAGEREF _Toc71812040 \h 14Grampian: PAGEREF _Toc71812041 \h 15Greater Glasgow and Clyde: PAGEREF _Toc71812042 \h 20Highland: PAGEREF _Toc71812043 \h 28Lanarkshire: PAGEREF _Toc71812044 \h 33Lothian: PAGEREF _Toc71812045 \h 37Orkney and Shetland: PAGEREF _Toc71812046 \h 38Tayside: PAGEREF _Toc71812047 \h 40Western Isles: PAGEREF _Toc71812048 \h 43Discussions with Health Boards/Health & Social Care Partnerships PAGEREF _Toc71812049 \h 44Rural and semi-rural areas PAGEREF _Toc71812050 \h 44Semi-urban and urban areas PAGEREF _Toc71812051 \h 51Third sector organisations in Scotland PAGEREF _Toc71812052 \h 56Index of text boxes, figures and tables: PAGEREF _Toc71812053 \h 57?Context of the Scoping and Mapping??The Mental Welfare Commission for Scotland (‘the Commission’) carried out a themed visit in relation to people with eating disorders from 2018 to 2020. They found that access to general and specialist treatment and support could vary across the country. This Appendix will combine the findings of the Commission (report ‘Mapping of eating disorder services across Scotland’, September 2020, which can be found at: with our findings from our own scoping and mapping activity, to provide a fuller picture of services provided by each Health Board. We asked for meetings with the Chief Executive Officers of every health board; and also asked for the following information from each health board:Population size?Staff numbers/mix that work with eating disorder patients?Number of referrals of eating disorder patients?Referral criteria/pathways?Waiting list/times (if applicable)?Our mapping, which was a smaller exercise done less than a year after the Mental Welfare Commission, had similar findings. The additional information in response to our questions, where provided, are found after the Mental Welfare Commission mapping information in this appendix. The discussions with the CEOs and health board leads added considerable depth of understanding about the local contexts and constraints, they are provided at the end of this appendix, grouped by the geographic context of each health board footprint.In summary, the findings were:That there is wide variation across Health Boards in terms of what services are available to people with eating disorders and their families and carers, in both child and adolescent mental health services and adult services;That there is wide variation in pathways to treatment as described to the Service Review team;That there is wide variation across Health Boards in terms of the level of expertise and specialism of staff looking after people with eating disorders and supporting families;That there is a lack of data and information regarding staffing numbers, patient referrals and outcomes, and even nature of treatments provided, particularly when patients with eating disorders are not being seen at specialist services.Ayrshire & Arran Text box 1: Mental Welfare Commission mapping report on Ayrshire & ArranMental Health Inpatient facilities: Specialist adult: The Priory Glasgow General Adult (18 yrs+): Ward 9, Woodland View. A small team of staff have been trained to manage stabilisation in order to facilitate discharge into community. Child and Adolescent mental health services CAMHS (under 18 yrs): Skye House Regional Adolescent Unit, Stobhill Hospital, Glasgow. Community facilities: Specialist Eating Disorder Service Across Age range: Community Eating Disorder Service (CEDS) is a pan Ayrshire service that provides comprehensive treatment for individuals with either Anorexia Nervosa or Bulimia Nervosa who are 12 years and older based on NICE guidelines. The service is not a stand alone service but works with primary mental health care teams (PMHCT), community mental health teams (CMHT), CAMHS and inpatient services. Operational Guidance documentation outlines the role of CEDS and adult or CAMHS teams and provides an overview of pathways between services. Generic Adult Service: Primary Care Mental Health Teams and Community Mental Health Teams based in North East and South Ayrshire. Generic CAMHS Service: CAMHS based in North, East and South Ayrshire. Day Patient Adult facilities: NoneDay Patient CAMHS facilities: NoneSpecialist Network to discuss Complex Cases: None Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Generic Paediatric beds in Crosshouse Hospital. Junior Marsipan group exists with Paediatrician attending from Crosshouse Hospital. 16+ Medical Admissions: Generic Medical Ward with no designated beds or designated medical staff for patients above the age of 16 with an eating disorder. Borders:Text Box 2: Mental Welfare Commission mapping report on BordersMental Health Inpatient facilities: Specialist adult: Regional Eating Disorder Unit (REDU) at St John’s Hospital, Livingston. The Eden Unit in Aberdeen can be funded if necessary. General Adult (18 yrs+): Huntlyburn Inpatient Unit, Borders General Hospital, Melrose CAMHS (under 18 yrs): Young People’s Unit, Royal Edinburgh Hospital, Edinburgh Community facilities: Specialist Eating Disorder Service Adult: Borders Eating Disorder (BED) team comprises a specialist dietician and psychologist specialising in eating disorders who work with CMHTs with individuals whose primary diagnosis is an eating disorder. Care pathways are currently in development. Specialist Eating Disorder Service CAMHS: Access to BED team dietician for all ages and BED psychologist for 16-18 year olds where individual psychological therapy is indicated. Specialist Eating Disorder Service Across Age range: See above. Generic Adult Service (18 years +): CMHTs East and West based at Huntlyburn house, CMHT South based in Hawick. Generic CAMHS Service (under 18s): Andrew Lang Unit, Selkirk. Care pathways in development. Day Patient Adult facilities: None Day Patient CAMHS facilities: None Specialist Network to discuss Complex Cases: South East Scotland network meets quarterly and complex adult cases may be discussed there. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Paediatric ward, Borders General Hospital, Melrose 16+ Medical Admissions: General Medical Ward, Borders General Hospital, Melrose Information provided to Service Review Team from Borders:Things are set up a bit differently in Borders with no eating disorder service and a Clinical Psychologist (0.6WTE) and a Dietitian (was 0.8WTE now 0.3WTE) offering specialist input to a small number of eating disorder cases that are otherwise treated in the Adult Community Mental Health Teams (CMHTs).??Because of this it is not possible to extract numbers of those patients with an eating disorder who don’t meet the threshold to be seen by the clinical psychologist or dietitian, but who are treated by the general CMHTs, as CMHTs don’t record diagnostic information. Recent data on referral numbers to the clinical psychologist and dietitian over the last 2 years is provided below. The dietitian covers child and adult and the clinical psychologist predominantly covers adults but would also pick up those over 16 who need a more adult approach rather than a more Family Based Therapy CAMHS model.????Table 1: ED referrals Nov 2018 – Oct 2019?& Nov?2019 – Oct 2020?in BordersAdult referrals to ED TeamAccepted Referrals ED PsychologyAccepted referrals ED DieteticsRejected referrals ED TeamCAMHS ED referrals1/11/18-31/10/19241319161/11/19-31/10/20302123611??Figure 1: Adult referrals by month Nov 2018 - Oct 2020?for Borders??Table 2: Number of inpatient bed days between Nov 2018 – Oct 2019 & Nov 2019 – Oct 2020?Bed days Nov 2018 – Oct 2019Bed days Nov 2019 – Oct 2020Huntlyburn258127BGH (adult)3833BGH (CAMHS)1835REDU/EDEN225456YPUNo data336TOTAL539987Figure 2: Borders Eating Disorders Referral Pathwayleft19576Dumfries & GallowayText Box 3: Mental Welfare Commission mapping report on Dumfries and GallowayMental Health Inpatient facilities: Specialist adult: None unless the post of full time dietician is vacant. General Adult (18 yrs+): Midpark Hospital, Dumfries with support from the Eating Disorder Inpatient team (EDIT). CAMHS (under 18 yrs): Skye House Regional Adolescent Unit, Stobhill Hospital, Glasgow. Community facilities: Specialist Eating Disorder Service Adult: Specialist Eating Disorder Service (SEDS) is based within Mountain Hall Treatment Centre, Dumfries and comprises a Consultant Psychiatrist, Specialist Consultant Psychologist, Specialist Dietician, staff nurses and additional health care support workers who have specialist training in Eating Disorders. An integrated Care Pathway describes care provision and standards for adult patients with anorexia nervosa or bulimia nervosa from time of referral including primary care responsibilities and criteria for various inpatient medical and mental health resources. Referrals are made from CMHT to SEDS which provides specialist treatment for a period of up to 6 months. Specialist Eating Disorder Service CAMHS: None Specialist Eating Disorder Service Across Age range: None Generic Adult Service: Wigtownshire, Stewartry, Dumfries, Nithsdale and Annadale CMHTs are supported by SEDS in order to provide support for adults with an eating disorder. Each of the CMHTS have an identified nurse with specialist training provided via SEDS. The SEDS Consultant Psychologist has a separate ED clinic for supporting treatment of people with ED who are managed by the CMHT. The SEDS Consultant Psychiatrist will also see and review CMHT ED patients if requested by CMHT. Generic CAMHS Service: CAMHS is provided across the region and in addition to community teams CAMHS has an Intensive team (CITS) which works intensively with young people. CAMHS has 1 family based therapist who works with families. Day Patient Adult facilities: Mountainhall Treatment Centre provides facilities which include day-based care and meal support for four days a week. This is supported by SEDS or identified nursing staff who have been trained through our SEDS for the following groups of patients: (i) adults with anorexia nervosa (AN) who are at high risk (ii) adults with AN not responding to CMHT input (iii) adults in early stage of AN for whom early intervention may be helpful (iv) adults with severe and enduring eating disorders (SEED) (v) adults with severe bulimia nervosa. Day Patient CAMHS facilities: NoneSpecialist Network to discuss Complex Cases: None. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Paediatric ward at Dumfries and Galloway Royal Infirmary. 16+ Medical Admissions: Dumfries and Galloway Royal Infirmary. ICP outlines criteria for medical as opposed to mental health admission and dietetic support and psychological provision while an inpatient. No information was received by the Service Review Team. We are due to meet with the chief executive on 1st April.Fife:Text Box 4: Mental Welfare Commission mapping report on FifeMental Health Inpatient facilities: Specialist adult: REDU (regional eating disorder unit) at St John’s Hospital, LivingstonGeneral Adult (18 yrs+): General Adult beds in relevant sector ward.CAMHS (under 18 yrs): Young People’s Unit, Royal Edinburgh Hospital, Edinburgh Community facilities: Specialist Eating Disorder Service Adult: Anorexia Intensive Treatment Team (ANITT) is a small specialist multidisciplinary team originally designed for people with severe anorexia nervosa. ANITT is based in Stratheden Hospital, Cupar but covers the whole of Fife. ANITT is currently under review and is to be resigned to broaden the team’s remit to increase joint working with CMHTs and to facilitate more consultancy. Specialist Eating Disorder Service CAMHS: None Specialist Eating Disorder Service Across Age range: None Generic Adult Service: Patients with less severe eating disorders are seen by CMHTs and/or general adult clinical psychology with input, if needed, by a dedicated dietician for mental health. Generic CAMHS Service: Psychologists within community CAMHS teams have training in CBT-E and multidisciplinary staff across Fife CAMHS have training in FBT. The generic CAMHS Intensive Therapy Service (ITS) provides community based intervention for young people with severe mental health difficulties and are responsible for managing CAMHS patients diagnosed with Anorexia or where physical presentation is causing concern. Day Patient Adult facilities: None Day Patient CAMHS facilities: None Specialist Network to discuss Complex Cases: South East Scotland network meets quarterly and complex adult cases may be discussed there. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Paediatric Ward, Victoria Hospital, Kirkcaldy 16+ Medical Admissions: Generic Medical Ward, Victoria Hospital, Kirkcaldy. Liaison psychiatry have developed relationships with gastroenterology to facilitate MARSIPAN guidelines. Information provided to the Service Review Team: ?Population size?Total?Fife Population: Approximately 378,000??Fife under-18 population: Approximately 83,000??Staff numbers/mix that work with eating disorder patients?Adult Services:??Within the adult?mental health?services the majority of cases?are seen by?Clinical Psychology Service and?the Community Mental Health Teams (CMHT’s).?Fife has?a small specialist resource available for complex?tier?3 cases?(Eating Disorders Advanced Intervention Team). This resource is currently under review alongside the development of an Eating Disorder pathway for Fife. The Pathway will?ensure adult patients experience a consistent joined up approach to?treatment, delivered across psychology services, CMHTs and the EDAIT resource.??The redesign of the specialist resource will focus?their skill set on consultation, supervision and direct support to the CMHTS allowing?enduring patients with no active needs and stable risk to be transferred to community teams. In?addition?they will provide intensive input and?quicker access to patients?who present with significant needs.?EDAIT consists of:?0.2 DCC Consultant Psychiatrist?1 WTE Nurse Specialist?0.5 WTE?Clinical?Psychologist?0.5 WTE?Specialist Dietician?0.8 WTE psychology assistant?0.8 WTE dietetic assistant?0.6 WTE admin support?CAMHS Services?Eating disorders within Fife CAMHS are managed initially by the East & West Core?generic?Teams. These multi-disciplinary teams provide intervention for children and young people with?initial?presentation of eating disorder and disordered eating.??Children and young people who present with more severe eating disordered behaviour are managed by the CAMHS Intensive Therapy Service (ITS). This adopts?a?home-based?treatment model primarily delivered as FBT alongside CBT-ED and other therapies as required. In addition to severe eating disorders, the CAMHS ITS also works with children and young people who present with a range of severe and complex mental issues that require intensive intervention?and?those?who would potentially require hospital admission?CAMHS?ITS consists?of:?4.0 WTE Senior Nurse Therapists?0.4 WTE Clinical Psychologist?0.6 WTE Specialist Dietician?0.8 WTE Therapy Support Worker??Number of referrals of eating disorder patients?Adult services:??21 referrals to EDAIT from 2020-2021??The ability to provide accurate eating disorder referral data from the wider Adult mental health services is under development through the introduction of?Trakcare?and Morse electronic records, both introduced in Jan 2021.???CAMHS Service:??Average total referral numbers to CAMHS 2018-2020: 2,499 per annum?The service is unable to report the number of young people who presented with eating disorder/disordered eating at point of referral.??25?children &?young people referred to the?CAMHS?Intensive Therapy Service with an eating disorder in 2020.??Referral criteria/pathways?Adult services:??Draft pathway is under development. Attached for reference.??CAMHS Service:??Fife CAMHS Eating?Disorder Resource & Pathway attached for reference.??Waiting list/times (if applicable)?Adult services:?EDAIT provide urgent phone advice on the same day as referral if required.?Consultation?and intervention?is?provided within 5 working days. No waiting list?exists?for specialist intervention.?Redesign of CMHT’s and the eating disorder pathway within Fife Mental health services have been undertaken to ensure that waiting times for first assessments?are equitable and a?single?point of access,?through the CMHT’s, is designed to achieve this. Currently referrals for eating disorders reach various services resulting in variable waits.?Referrals are triaged to identify those who require an urgent or priority assessment.?Input from CMHT is within 6-8 weeks. Input from?AMH Psychology service patients?are?normally assessed within 12 weeks of referral. Routine waiting times for patients assessed as requiring the most highly specialist?psychological?interventions are the longest and in this part of the service exceed 100 weeks.???CAMHS Service:?Children and young people presenting with symptoms of disordered eating/eating disorder are seen as priority referrals. Waiting times for priority referral is less than 6 weeks.?Children and young people referred to the CAMHS?ITS are?seen on the same/next working day.??Figure 3: Fife CAMHS Referral PathwayFigure 4: Fife CAMHS Referral Pathway (continued)Forth ValleyText Box 5: Mental Welfare Commission mapping report on Forth ValleyMental Health Inpatient facilities: Specialist adult: Regional Eating Disorder Unit (REDU), St John’s Hospital, Livingston General Adult (18 yrs+): Mental Health Unit Forth Valley Royal Hospital if complex comorbidity otherwise do not use CAMHS (under 18 yrs): Skye House, Stobhill Hospital, Glasgow Community facilities: Specialist Eating Disorder Service Adult: Eating Disorder Service based at Stirling Community Hospital and area wide. The service comprises a multidisciplinary team of specialist psychiatry, nurse therapists and dieticians who work with individuals with moderate to severe anorexia or bulimia nervosa. Operational guidance for the role of service is available and the psychiatrist attends monthly meetings with CAMHS. Specialist Eating Disorder Service CAMHS: None Specialist Eating Disorder Service Across Age range: None Generic Adult Service: Individuals with less severe eating disorders or where there is complex comorbidity are cared for within the community mental health teams based across Forth Valley. Generic CAMHS Service: CAMHS teams are based in Falkirk and Stirling. In addition to generic skills some nurses and psychologists have been trained in FBT and CBTe and the service has access to specialist dieticians. In addition to the regular intensive (tier IV) iCAMHS meetings monthly eating disorder meetings are held within CAMHS which the specialist eating disorder adult psychiatrist attends. The CAMHS Eating Disorder pathway is currently under review and a draft pathway is available. Day Patient Adult facilities: None Day Patient CAMHS facilities: None Specialist Network to discuss Complex Cases: South East Scotland network meets quarterly and complex adult cases may be discussed there. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): paediatric ward Forth Valley Royal Hospital. Ongoing work to incorporate work undertaken by Marsipan group to include paediatric admissions. 16+ Medical Admissions: Medical Unit at Forth Valley Royal Hospital if over 16. Marsipan pathway. Patients are admitted via 2 of the GI physicians with special interest and expertise in ED. No meeting with, or information received by Service Review Team. The meeting with the Chief Executive and General Manager was postponed due to urgent clinical issues in Forth Valley.Grampian:Text Box 6: Mental Welfare Commission mapping report on GrampianMental Health Inpatient facilities: Specialist adult: The North of Scotland Eating Disorder Unit (Eden Unit), Royal Cornhill Hospital Aberdeen. 10 bedded specialist ED unit. General Adult (18 yrs+); Crathes Ward, Royal Cornhill Hospital CAMHS (under 18 yrs): Dudhope House, Dundee Community facilities: Specialist Eating Disorder Service Adult: Grampian has a specialist 18-64 (adult) eating disorder out-patient service (EDS) based at Royal Cornhill Hospital in Aberdeen but covering the whole of Grampian. EDS also provides a service to adults in Orkney and Shetland. The majority of outpatients with an eating disorder are managed within EDS which provides MDT based assessment and intervention for patients with Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and atypical presentations/EDNOS. EDS is an outpatient, hospital based clinic service in Aberdeen and comprises psychologists, psychiatrists, nurse therapists, a dietitian, a physiotherapist, a Physician Associate and a team secretary. Specialist Eating Disorder Service CAMHS: (see generic CAMHS entry below) Specialist Eating Disorder Service Across Age range: None Generic Adult Service: Patients with comorbid mental health problems may be seen in community mental health teams (CMHTs) in addition to the Eating Disorder Service. Patients with ED symptoms that are less severe or secondary to other mental health problems may be seen only in CMHTs or in NHS Grampian's specialist Psychotherapy Service. In such cases EDS can provide advice and consultancy in managing the ED symptoms. Consultancy is also provided to Older Adult services. Generic CAMHS Service: NHS Grampian CAMHS has a specialist CAMHS Eating Disorder Team, hosted within the generic CAMHS service. The CAMHS Eating Disorder team provides input for those aged 0 - 18 living within the NHS Grampian area. The team is not specifically resourced rather is a specialist care pathway that has been developed within CAMHS. The team covers all of the NHS Grampian area from the 2 CAMHS bases, one at the Links Unit in Aberdeen and the other at the Rowan Centre in Elgin. Day Patient Adult facilities: Day patient facilities may be provided at the Eden Unit for Grampian patients. Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: The North of Scotland Managed Clinical Network is based in Royal Cornhill Hospital, Aberdeen and comprises 3 mainland Health Boards (Grampian, Tayside, Highland)& 3 Islands Boards (Shetland, Orkney, Western Isles (in discussion)). Monthly VC meetings hosted by the North of Scotland MCN involving EDS are available which provide consultation between MCN Eating Disorder adult specialists and local adult mental health clinicians from around the network. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): generic paediatric beds are supported within a local joint multidisciplinary Junior MARSIPAN pathway between Paediatrics/ Dietetics/ Nursing and CAMHS in terms of an agreed admission protocol as and when required. This has involved training across services and ongoing quarterly meetings / joint case reviews. 16+ Medical Admissions: ward 104 in Aberdeen Royal Infirmary is a Gastroenterology ward. The North of Scotland network, MCN has supported the development of a carepathway between outpatient, the regional inpatient unit (Eden Unit) and medicalservices (Gastroenterology in Aberdeen Royal Infirmary). The collaboration is respected nationally in the care of anorexic patients at high medical risk. In 2015 a joint project between the Eden Unit Team and their Gastroenterology colleagues was recognised with a prestigious SAGE Award. This award led to the production of Springer’s Handbook of Multidisciplinary Management of Eating Disorders (2018) and the development of the companion website Anorexiabytes, free to all clinicians (to be launched summer 2020).Information provided to Service Review:?NHS Grampian’s Eating Disorder Service?(EDS)?offers specialist assessment and intervention?for sufferers of Anorexia Nervosa, Bulimia Nervosa and related disorders,?including Binge Eating Disorder,?age 18-64,?on an out-patient basis.?The service has the following staff:?1.0WTE Consultant Clinical Psychologist?&?Service Team Leader?0.4WTE Consultant Psychiatrist?0.9WTE Advanced?Dietitian?2.63WTE Nurse Therapists?0.5WTE Principal Clinical?Psychologist?0.4WTE?Highly Specialist?Physiotherapist?0.3WTE Physician Associate/Intern?1.0WTE Medical Team Secretary?EDS provides a service across the NHS Grampian region?and to NHS Orkney and NHS Shetland, utilising videoconferencing technology when appropriate. Referrals?are received?primarily from GPs and mental health professionals.?Referrals are typically around?265?per year.?Total population figures are:?Aberdeen City – 207,932?Aberdeenshire – 261,470?Moray – 95,520?Orkney – 21,670?Shetland – 23,200?Total – 609,792 ?EDS, in line with the existing evidence base and best practice guidance,?provides a psychological therapy driven service,?based on?a range of psychological?therapies. The staff involved in the delivery of?psychological therapy are?2.63 Nurse Therapists?and 1.5WTE Clinical?Psychologists. The following psychological therapies are currently available:First Steps Group (4 x 1 hour?psychoeducation?group followed by individual review)?Steps to Change Group (Introduction to CBT.?7 x?2 hour?sessions?followed by individual review)?Advanced Steps Group (Development of CBT skills?and?self-formulation.?7 x 2 hours followed by individual review)?Compassion Focused Therapy Group (10 x 2 hours followed by individual review)?Contemplation Group (motivational enhancement group for patients?who are contemplative regarding change.?10 x 2 hours followed by individual review)?Systemically Informed Intervention Clinic (involving parents, partners, siblings. Not time limited)?MBT group (weekly?2 hour?6 month?duration group?for patients with comorbid EUPD)?Individual Therapy (utilising?a range of?therapies?e.g.?CBT, Compassion?Focused?Therapy, Schema Therapy, Interpersonal Psychotherapy,?Mentalization?Based Therapy. Mix of time limited and longer-term interventions based on patient need)??Review Clinic is for patients with severe and enduring eating disorders where multiple attempts at change have not been successful but discharge from the service is not appropriate due to ongoing risk. The clinic provides risk monitoring and has a focus on promoting self-management and improving quality of life.?Development of the psychological therapies programme is an ongoing, evolving process. All groups are?transdiagnostic?therefore all patients?have access to the same stepped care model of interventions in the service. This?has the?aim of fewer patients requiring?extended?individual therapy and being able to offer individual therapy on a?needs-led basis.?Below is a diagram of the service’s group programme. Patients who prefer not to engage in the group programme are offered individual contact.?Figure 5: Grampian pathway and group programme for eating disorderscenter1460500??In addition to psychological interventions, psychiatric assessment and interventions are available via the service’s consultant psychiatrist (and psychiatric trainees when on placement). Specialist physical assessment and monitoring is offered by the Physician Associate resource. Specialist dietetic assessment and intervention is provided by the service’s advanced?dietitian, including group-based nutrition education in addition to individual work. The service’s highly specialist physiotherapist provides assessment and intervention for exercise management, body awareness and body image work, both on an individual and group basis.?Waiting times to access the service are typically 6 weeks from referral. The service offers triage assessments to assess risk, need and to plan care. Priority triages?and interventions?are available based on?clinical?need.?The service also provides consultancy and supervision to other services where?appropriate. The local eating disorder charity, North East Eating Disorder Support (Scotland) receives supervision from clinicians in the service.??Enclosed is the service operational policy document and patient information leaflets regarding interventions offered.?(Documents obtained).A meeting with the Chief Executive was postponed due to urgent matters within the Board at the time of the arranged meeting.Greater Glasgow and Clyde:Text Box 6: Mental Welfare Commission mapping report on Greater Glasgow and ClydeMental Health Inpatient facilities: Specialist adult: 4 specialist eating disorder beds in general adult psychiatry ward (Armdale) in Stobhill Hospital, Glasgow. Beds are supported by AEDS psychiatrist and dietician (see below) and AEDS keyworkers join reviews meetings. Ward nurses receive specific training and supervision for patients with Eating Disorders. General Adult (18 yrs+): Adults who do not require specialist inpatient beds are treated within their local mental health inpatient treatment facility (Stobhill Hospital, Leverndale Hospital, Gartnavel Hospital, Dykebar Hospital and Inverclyde Royal Hospital). AEDS clinicians including a psychiatrist are to provide support to these admissions. CAMHS (under 18 yrs): Skye House, Stobhill Hospital, Glasgow Community facilities: Specialist Eating Disorder Service Adult: Adult Eating Disorder Service (AEDS) is a specialist multidisciplinary service that has been recently reviewed and service specification is not yet available. AEDS has historically cared for individuals with moderate to severe eating disorder using a stepped care model and support CMHTs with individuals with mild to moderate eating disorder. Specialist Eating Disorder Service CAMHS: GGC has a hub and spoke model whereby Connect- ED (eating disorders specialist team) provides specific evidence based therapies and patients are often treated within generic CAMHS teams (including intensive teams) where they access psychiatry and other supports. The team provide evidenced based therapies, Family Based Treatment (FBT) and Cognitive Behavioural therapy for eating disorders (CBT-ED).Connect ED central base is at Templeton but clinics also held close to sectors. Generic Adult Service: The 19 Community mental health teams across the area look after individuals with less severe eating disorder or where there is complex comorbidity. Generic CAMHS Service: 8 generic community CAMHS teams (North, South, East, West, East Renfrewshire, Renfrewshire, Inverclyde and West Dunbartonshire) provide elements of the care of many young people with eating disorder in conjunction with Connect ED. The Intensive team (ICAMHS) supports those with more severe eating disorders. Day Patient Adult facilities: AEDS provides day programme which involves groups as well as supported meals. Proposals to develop a community based Intensive Day Unit (6 places) to support treatment in the community are in the early stages of development. Day Patient CAMHS facilities: NoneSpecialist Network to discuss Complex Cases: None Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): ward 3 A Royal Hospital for Children. Connect- ED work collaboratively with the paediatric team, Liaison Psychiatry and Intensive CAMHS throughout the admission. Ward 3A staff have received ED-specific training. Liaison Psychiatry provide on-site support to the paediatric ward team. A pathway outlining admission clarifying roles and processes is available. 16+ Medical Admissions: Patients may also receive care in the acute sector in one of four hospitals (Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven Hospital and Royal Alexandria Hospital). AEDS provides psychological input to those inpatients and the specialist AEDS Link Nurse offers expert advice and training and attends ward rounds where possible. The service has a well-established Marsipan group and is currently working to implement a MARSIPAN protocol and to limit the number of hospitals for inpatient treatment to two as part of its ongoing review. Information provided to Service Review:GG&C population = 1.2 million Average total number of referrals to AEDS per annum = 70-80 Staff mix = Clinical lead/ Consultant Clinical Psychologist 1.0 WTEConsultant Psychiatrist for inpatients 1.0 WTETeam Lead 1.0 WTEAdministrator 1.0 WTEClinical Psychologists 1.6 WTESenior Eating Disorder Practitioners 7.0 WTEDietitians 1.2 WTEOccupational Therapist 1.0 WTEGeneral Practitioner 0.4 WTEAssistant Psychologist 1.0 WTE Admissions to inpatient beds (data from 2020) = 11 admissions to AEDS Armadale beds (3 of which were transfers from locality beds).15 admissions to locality beds (2 of which were to the Glasgow Priory).GG&C Adult Eating Disorder Service (AEDS) Referral Pathway The Greater Glasgow and Clyde Adult Eating Disorder Service sees patients with moderate to severe eating disorders across Greater Glasgow and Inverclyde. It employs a stepped care approach as recommended in the NHS QIS document (Eating Disorders in Scotland 2006). AEDS is a multidisciplinary service that offers input across the four tiers. Due to the complex nature of eating disorders and the often severe and enduring course of the illness, all patients referred to the service must have a Consultant Psychiatrist and key worker. Patients are physically monitored by their General Practitioner. The AEDS traffic light system illustrates the referral criteria and service response time. Patients with mild to moderate eating disorders are managed within their primary care team or community mental health team. AEDS offers consultation and training to all staff working with eating disorders across Glasgow and Clyde. Patients at amber risk (moderate level eating disorder) are managed within the CMHT, if this input has not resulted in recovery patients may be referred to AEDS for joint assessment and potential intervention. This joint assessment takes place within a month. It is important that there is sufficient information from the referral to enable the service to assess the risk of the case and allocate efficiently. This is why a referral should consist of a referral letter, AEDS Indicator Form, Glasgow Risk Screen and the SSA.Patients with severe eating disorder who are at high risk may be referred urgently to AEDS. These referrals are usually accompanied by a phone call to provide further information. This may include inpatients in hospital, or patients at risk of a hospital admission. Urgent cases are assessed within 10 working days but usually significantly sooner. All cases receive a two-session multidisciplinary assessment, ideally the first with the referrer. They may then be offered a month trial with the service in order to complete a comprehensive psychological formulation and treatment plan and establish the stage of motivation and commitment to recovery. In addition to outpatient appointments, AEDS offers a day patient programme for patients requiring intensive intervention and may provide inpatient treatment for patients requiring an inpatient stay. It has four beds on a General Psychiatric Ward (Armadale Ward) at Stobhill Hospital. Patients are offered a time limited individually tailored multidisciplinary intervention from the service before they are discharged back to the care of the CMHT. Intervention from the specialist service may be one to two years.Figure 6: GG&C Adult Eating Disorder Service (AEDS) Traffic Light Screening ToolConnect-eating Disorders Team InformationThe Connect-ed team works within GGC CAMHS providing evidence-based therapies for children and young people with eating disorders. Referrals /Requests for assistance. There are no specific thresholds we require to work with a young person who is in GGC locality CAMHS. Risk management for all young people with eating disorders.There is a pathway for low weight eating disorder patients. In addition, there is the Face Eating Disorders Schedule (FEDS) that requires completion. Dietetic assessment from the Connect-ed Dietitians is required as part of the medical assessment for all young people with eating disorders including those with bulimia nervosa presentations. In addition there is a pathway with Royal Hospital for Children CAMHS pathway which aims are: physically stabilise those who are admittedto enable them to be safely discharged to the community for treatment to continue within the Child and Adolescent Mental Health Service (CAMHS).To enable stabilisation essential 2 approaches are required:paediatric, to physically manage and stabilise the patient and psychiatric, to manage the eating disorder behaviours to allow for the process of medical stabilisation. CAMHS staff support all meals and supervision periods and start to skill parents. Admissions are for 14 days for all under 16 years. Treatment – based on best research evidence.Eating disorders treatments are summarised within the CAMHS care packages. There are 2 evidence based therapies which are provided for young people with eating disorders. These therapies were given the highest grade of evidence within the 2017 NICE guidelines, and within the Scottish Psychological MATRIX 2016, for both Anorexia and Bulimia Nervosa presentations. The one with the best evidence is Family Based Treatment (FBT) and the one with next best evidence is CBT for eating disorders (CBT-ED).Approximately 20-30 % of cases who undertake FBT go onto require CBT-ED and 90% of these patients meet recovery thresholds. Treatment – outside the best evidenced therapies. A small proportion of patients have either exhausted the evidence based therapies or they or their families have not opted for them. These young people, approximately 10% of all referrals, are therefore being treated outside the evidence base by clinicians experienced in working with young people with eating disorders. See flow chart.Summary of other aspects of Connect-ed service: Act as a resource, support patient and carer involvement, provide training and supervision and audit and governance. Connect-ed Permanent Staffing1 wte Clinical Lead Band 8a (Dietitian) 1 wte Clinical Nurse specialist / CBT therapist band 7 1 wte Dietitian band 7 2.6 wte FBT band 70.6 wte Administration band 3Figure 7: Number of referrals to the Connect-ed Team ?2017201820192020Number of referrals to the NHS GGC Connect-ed team90102139191% Change over the previous year?13 %36 %37 %Increase in referrals and severity in 2020-21In common with all CAMHS services in Scotland, Connect-ed has not only seen an increase in number of young people with eating disorders coming into treatment but also an increase in severity at first referral during the Covid-19 pandemic. Normally there are 1 – 3 patients admitted to the RHC CAMHS pathway per year. However, in 2020 there were 13 admissions and in the first 2 months of 2021 there were 7. center-23201200-327660000Figure 8: Connect-ed PathwayHighland:Text Box 7: Mental Welfare Commission mapping report on HighlandMental Health Inpatient facilities: Specialist adult: North of Scotland Eating Disorder Unit (Eden Unit) Royal Cornhill Hospital, Aberdeen. General Adult (16/1718 yrs+): New Craigs Hospital, Inverness CAMHS (under 16/17/18 yrs): Dudhope House, Dundee Community facilities: Specialist Eating Disorder Service Adult: Highland Eating Disorder Service (HEDS) is an outpatient specialist eating disorder service based in Inverness and serving the Highland Council area (not Argyll and Bute). HEDS receives referrals for all patients with eating disorders and may co- manage individuals who have other comorbid conditions within their CMHTs if appropriate, generally using the Care Programme Approach to co-ordinate care. Specialist Eating Disorder Service CAMHS: None Specialist Eating Disorder Service Across Age range: None Generic Adult Service: NHS Highland has CMHTs with a number of bases covering the north (Caithness, Sutherland), south (INBS, Inverness, Nairn and Ardersier, Badenoch and Stathspey), mid (Mid Ross, East Ross) and west (Skye & Lachalsh, Wester Ross, Lochaber) of the region. Argyll and Bute has a CMHT based at Helensburgh for Helensburgh and Lomond areas provided by NHS Greater Glasgow and Clyde. Generic CAMHS Service: Eating disorder referrals are triaged and managed within the generic service. Physical monitoring of patients is mostly requested of GPs. Some members of the multidisciplinary team have been trained in Family Based Treatment for Anorexia Nervosa (FBT), and some psychology colleagues have CBTe (CBT for Eating Disorders) training also. Day Patient Adult facilities: Mealtime lunch support and training programme provided for two days a week at New Craigs Hospital, Inverness. Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: Monthly VC meetings hosted by the North of Scotland MCN are available which provide consultation between MCN Adult Eating Disorder specialists and adult mental health clinicians locally. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): generic paediatric beds are available supported by CAMHS outreach team to support families and paediatric staff during admission. 16+ Medical Admissions: Ward 7c Raigmore Hospital, Inverness. Local MARSIPAN group comprised of medical (Gastroenterology consultant), specialist nutrition dietetic and nursing colleagues meets for regular review and organised training and updates for nursing and other staff. Information received by Service Review Team:CAMHS Eating Disorders – North HighlandPopulation size :235500 for North Highland as per Council stats (note NHS Highland also covers Argyll and Bute but that is a separate team from the one reporting here)?Staff numbers/mix that work with eating disorder patients:?we currently do not have designated staff dedicated to working with young people with eating disorders; the time is taken from within provision for core and Tier 4 CAMHS staff;?therefore?due to increased demand, the service is stretched in order to respond urgently for such a clinically risky patient group.? We do have a?multidsciplinary?team available?though?- psychiatry, psychology, nursing, family therapy (no dietician) which includes FBT and CBT-ED trained staff??Number of referrals of eating disorder patients:?2020 ED referral numbers recently provided for BEAT from NHS Highland CAMHS (north Highland team) for past year:?2019/2020 Q4 - 14 referrals?2020/2021 Q1 - 10 referrals?2020/2021 Q2 - 11 referrals?2020/2021 Q3 - 14 referrals??Total = 49: we do not have data previously, but anecdotally this was around 15/year.????Referral criteria/pathways:?attached, work ongoing to develop further?Waiting list/times (if applicable):?we currently do not have patients waiting for Eating disorder specific interventions, all Eating disorder referrals are seen initially as a priority and allocated due to high clinical risk.?Figure 9: Referral Pathway for 0-18 years in North Highland-3684901950500Adult Eating DisordersHighland Eating Disorder Service served Adult patients 18+ or 16/17 if they have left school across the Highland Council area - 'North' NHS Highland which has a population of around 250,000 spread over a wide geographical area.??Our department is made up of 0.8WTE (whole time equivalent) Consultant Psychiatrist, 0.5WTE Speciality Doctor/Medical Psychotherapist, 1.6 WTE Band 7 Nurse Specialist and Cognitive Behavioural Therapists, 0.3 WTE Specialist Dietitian, 0.2 WTE Band 6 Secondment Nurse Therapist, 0.3 WTE Band 4 Eating Disorder Assistant. We work as a multidisciplinary team to provide a range of medical, psychiatric, nutritional and psychological therapies in line with national guidelines.???The service was developed to manage a referral rate of 100 patients/year and at this rate of referrals was able to remain within the?18 week?referral to treatment target, usually within 12 weeks even for routine patients, however we have had gradual increase in referrals over the last 5 years, with a dramatic increase since October 2020 as noted in most Eating Disorders Services. This is resulting in our breaching?18 week?referral to treatment targets. There is also an increase in the number of higher risk patients who need to be seen as - 'Urgent' (within 7 days), or 'Soon' (within 4 weeks). Please see the graphs below.??Projected referrals?If previous rate of increase maintained, we would have around 130 referrals in 2020/21.?If rate of referrals from Oct 2020 is continued, we would receive around 145 referrals over the same period.??Figure 10 & 11: Referrals to Highland adult eating disorder services??The Highland referral pathway and other departmental information is available at:? Box 8: Mental Welfare Commission mapping report on LanarkshireMental Health Inpatient facilities: Specialist adult: the Priory, Glasgow if specialist Eating Disorder admission is required General Adult (16/17/18yrs+): Adult mental health wards (Ward 19 - 25 beds & Ward 20 - 25 beds).University Hospital Hairmyres (Ward 1 - 23 beds & Ward 2 - 23 beds) in University Hospital Wishaw. CAMHS (under 16/17/18 yrs): Skye House, Stobhill Hospital, Glasgow Community facilities: Specialist Eating Disorder Service Adult: The specialist Eating Disorder Community Team (TESS) is a Lanarkshire wide service based in Buchanan Centre, Coatbridge. The service is multidisciplinary and provides direct clinical input to those individuals (and their families) with a severe eating disorder resulting in the person having complex needs. Where required, intensity can be up stepped in the community and meal support can be offered (up to three times a day Monday - Friday for limited periods of time) alongside their MDT input. TESS also operates an early intervention approach (and thus has an adapted criteria for direct clinical work) for individuals with an eating disorder in late adolescence (approximately 16-21 years). Young people who are in education are seen by CAMHS. Specialist Eating Disorder Service CAMHS: none Generic Adult Service: All Community Mental Health Teams and Psychological Therapy Teams in Lanarkshire provide input for people with an eating disorder if they don’t meet the TESS criteria (Airdrie, Bellshill, Coatbridge, Cumbernauld & Kilsyth, Motherwell, Wishaw, Camglen, Clydesdale and East Kilbride). Generic CAMHS Service: CAMHS in Lanarkshire provide input for people with an eating disorder if they don’t meet the TESS criteria (Airdrie, Bellshill, Coatbridge, Cumbernauld & Kilsyth, Motherwell, Wishaw, Camglen, Clydesdale and East Kilbride). CAMHS operates a local eating disorder tiered pathway within CAMHS teams, with escalation/internal referral to specialist FBT (Family Based Treatment for ED) Clinician and Specialist Dietetic Post, supported by a network of Trained FBT clinicians and CBTe clinicians within the locality CAMHS. Specialist supervision/ case discussion structures form part of the ED/FBT pathway. Transition guidance is available to support transition into TESS from CAMHS. Day Patient Adult facilities: none Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: There is no specialist network to discuss cases Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): generic paediatrics ward 16+ Medical Admissions: There are no designated acute medical beds for individuals with an eating disorder. Information provided to the Service Review Team by Lanarkshire TESS team which sees patients over 16 years of age:Population size - 661,900Clinical Psychologist 2.4 WTENurse Therapist 1.0 WTEDietitian 1.4 WTENurse 1.0 WTENursing Assistant 1.0 WTEConsultant Psychiatrist 0.6 WTEOccupational Therapist 1.0 WTEAdmin 1.5 WTENumber of referrals from 01/04/2020 - 31/01/2021 = 78-58737531432500Figure 12: Tertiary Eating Disorder Specialist Service Adult Referral Criteriaright47752000Figure 13: Tertiary Eating Disorder Specialist Service Young People’s Referral CriteriaLothian:Text Box 9: Mental Welfare Commission mapping report on LothianMental Health Inpatient facilities: Specialist adult: Regional Eating Disorder Unit, St John’s Hospital, LivingstonGeneral Adult (18 yrs+): Royal Edinburgh Hospital, Edinburgh. St John’s Hospital, Livingston. CAMHS (under 18 yrs): Young People’s Unit, Royal Edinburgh Hospital, Edinburgh Community facilities: Specialist Eating Disorder Service Adult: The Cullen Centre provides outpatient and small amount of community treatment across the Lothians. It is based at the Royal Edinburgh Hospital. Specialist Eating Disorder Service CAMHS: Non-clinical Eating Disorder Development Team has no clinical responsibilities but has a role to increasing skills and education and undertake research on eating disorders in young people. NHS Lothian CAMHS are grant holders for a number of national ED innovations such as CARED (web based support) and have received Scottish Government funding with BEAT to deliver and evaluate online peer support for under 25s and the national delivery of ECHO a parent support intervention. CAMHS are also piloting and designing a number of school base preventative programmes. Generic Adult Service: The Cullen Centre Service work with all the generic mental health teams across Lothian and other specialist services such as Substance Misuse to do joint assessments and joint treatment as appropriate. The Cullen Centre is currently undergoing a service review. Generic CAMHS Service: Across Lothian there are five generic outpatient CAMHS Teams (North, South, East Lothian, Midlothian and West Lothian teams) who regularly provide assessment, support and treatment for children and young people with an eating disorder. The main treatment focus in the outpatient setting is Family Based Therapy (FBT) or CBT–E, with specific eating disorder pathways and specialist supervision. Day Patient Adult facilities: None Day Patient CAMHS facilities: Lothian CAMHS patients have access to either the Day programme at the YPU, Edinburgh or the Day unit at Willowgrove, St John’s Livingston . All Lothian CAMHS tier 4 services have an eating disorder programme inclusive of cognitive remediation therapy, a motivation group, a body image group and a parent’s support group. Specialist Network to discuss Complex Cases: Adult: South East Scotland network meets quarterly and complex cases may be discussed there. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Royal Hospital for Children, Edinburgh or St John’s Hospital, Livingston 16+ Medical Admissions: REDU have an agreement with Medical Assessment Unit for medical admissions and REDU MDT staff provide liaison and support with care and treatment plans. Orkney and Shetland:Text Box 10: Mental Welfare Commission mapping report on Orkney and ShetlandOrkney:Mental Health Inpatient facilities: Specialist adult: North of Scotland Eating Disorder Unit (Eden Unit), Royal Cornhill Hospital, Aberdeen. Aftercare when patients are discharged back to Orkney is supervised by both VC meeting with Eden Unit, support from NHS Grampian Eating Disorder Service and the local mental health team on Orkney*. General Adult (18 yrs+): Royal Cornhill Hospital CAMHS (under 18 yrs): Dudhope House, Dundee Community facilities: Specialist Eating Disorder Service Adult: None on isle. NHS Grampian EDS clinicians may accept some referrals on a case-by-case basis and participate in assessment and formulation of some cases, sometimes using VC with patient and family/carers as well as discussion between clinicians. In the past, NHS Orkney has also funded travel for patients to visit Aberdeen in person for thorough assessment and discussion*. Specialist Eating Disorder Service CAMHS: NoneSpecialist Eating Disorder Service Across Age range: no information provided Generic Adult Service: CMHT based in Kirkwall, Orkney looks after most patients with eating disorders of lower risk by generalist Community Mental Health Clinicians, led by senior Psychologists and Psychiatrists, and including several nurse therapists who also have the evidence-based skills to treat them. When patients require greater intensity of care or more highly specialist treatment, they are referred to NHS Grampian’s Eating Disorder outpatient service. NHS Orkney is visited on an annual basis by MCN staff.*. Generic CAMHS Service: no information providedDay Patient Adult facilities: no information provided Day Patient CAMHS facilities: no information provided Specialist Network to discuss Complex Cases: Monthly VC meeting hosted by the North of Scotland MCN which provides consultation between Adult Eating Disorder specialists and adult mental health clinicians on isle*. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Balfour Hospital, Orkney 16+ Medical Admissions: Balfour Hospital, Orkney * information provided by NHS Grampian’s response outlining North Of Scotland Managed Clinical Network (MCN). Shetland:Mental Health Inpatient facilities: Specialist adult: North of Scotland Eating Disorder Unit (Eden Unit) Royal Cornhill Hospital. Aftercare when patients are discharged back home is supervised by both VC meeting with Eden Unit, support from NHS Grampian Eating Disorder Service and the local mental health team on isle*. General Adult (18 yrs+): Royal Cornhill Hospital, Aberdeen CAMHS (under 18 yrs): Dudhope House, Dundee Community facilities: Specialist Eating Disorder Service Adult: None on isle. NHS Grampian EDS clinicians may accept some referrals on a case-by-case basis and participate in assessment and formulation of each case, sometimes using VC with patient and family/carers as well as discussion between clinicians*. Specialist Eating Disorder Service CAMHS: none Specialist Eating Disorder Service Across Age range: none Generic Adult Service: Shetland CMHT covering all islands and based in Lerwick, Shetland. Generic CAMHS Service: Generic CAMHS team covering all islands and based in Lerwick, Shetland. Day Patient Adult facilities: none Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: Monthly VC meeting hosted by the North of Scotland MCN which provides consultation between Adult Eating Disorder specialists and adult mental health clinicians on isle*. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Paediatric Ward, Royal Cornhill Hospital, Aberdeen 16+ Medical Admissions: no information provided. * information provided by NHS Grampian’s response outlining North Of Scotland Managed Clinical Network (MCN). Tayside:Text Box 11: Mental Welfare Commission mapping report on TaysideMental Health Inpatient facilities: Specialist adult: North of Scotland Eating Disorder Unit (Eden Unit), Royal Cornhill Hospital, Aberdeen General Adult (18 yrs+): Carseview Centre, Dundee CAMHS (under 18 yrs): Dudhope House, Dundee Community facilities: Specialist Eating Disorder Service Adult: NHS Tayside Eating Disorder Service (TEDS) is based in Dundee, with peripheral clinics in Angus and Perth and Kinross. Operational guidance outlines TEDS and pathways between services in Tayside and specific guidance is available for primary care outlining primary care responsibilities. TEDS is a multidisciplinary services for individuals with significant eating disorder symptoms. Specialist Eating Disorder Service CAMHS: (see generic CAMHS entry below) Specialist Eating Disorder Service Across Age range: None Generic Adult Service: 8 CMHTS across Tayside (three in Angus, two in Dundee, three in Perth and Kinross) look after patients where the eating disorder is not the primary issue. Area wide psychology service and psychotherapy service. All may refer into TEDS. Generic CAMHS Service: Some staff within generic CAMHS community services have designated time to deliver a Tayside-wide outpatient CAMHS eating disorders team which is mostly provided from the Dundee base. This team is multidisciplinary with a consultant psychiatrist, specialist dietitian, family therapist, CBT psychotherapist and 2 nurses and is for young people whose primary difficulties relate to an eating disorder. The service may work with the assertive outreach generic CAMHS locality nurses and the North of Scotland network liaison nurse if there is a clinical need for more intensive community support, support or when a young person is admitted to paediatrics or a medical/gastroenterology bed and when there is poor progress with outpatient treatment or admission to inpatient care is looking likely. The CAMHS eating disorder team also provide advice and consultation to generic CAMHS teams. Operational Guidance provides information about the service and interface with generic CAMHS teams. Day Patient Adult facilities: none Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: Monthly VC meeting hosted by the North of Scotland MCN which provides consultation between Adult Eating Disorder specialists and adult mental health clinicians locally. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years):Ward 29 (paediatrics) Ninewells Hospital, Dundee. Operational guidance is available outlining the standards and processes relating to paediatric admission. 16+ Medical Admissions: Gastroenterology ward of Ninewells Hospital, Dundee Information received by the Service Review Team from NHS Tayside Outpatient CAMHS ED team:Population size?NHS Tayside 2017/2018 Population?416,090?16% Children - 66,574???Staff numbers/mix that work with eating disorder patients?1x Consultant Psychiatrist- No dedicated job planned time for ED.??0.5 WTE Dietitian?1x Systemic family therapist- 3 sessions (1 session= 1/2 day)1x Senior Psychotherapist- 3 sessions (1 session= 1/2 day)?0.5 WTE ED Specialist Nurse (Leaving Service end March 2021)?0.5 WTE ED Specialist Nurse (Post vacant since Sept 2020)?Nursing assessment and physical monitoring- 6 sessions (Secondment ending March 2021)?Hoping to recruit 2x New WTE specialist ED Nurses this year?Number of referrals of eating disorder patients?2016 – 31?2017 – 41?2018 – 39?2019 – 42?2020 – 56?2021 – January data only – 7??Referral criteria/pathways?Please see attached current Standard Operating procedure for the service. This is unfortunately out of date due to multiple staff members leaving the team in the past year. We have recently merged with our intensive outreach nursing team to increase capacity for assessment and physical monitoring but not evidence-based treatment due to lack of appropriate training.??Waiting list/times (if applicable)?We currently do not have a waiting list for ED assessments.?Urgent ED referrals are assessed within 5 working days and Routine referrals within 4 weeks?Figure 14: Tayside CAMHS eating disorders pathway-56769025908000Western Isles:Text Box 12: Mental Welfare Commission mapping report on Western IslesMental Health Inpatient facilities: Specialist adult: Western Isles is currently in discussion in relation to inpatient provision. General Adult (18 yrs+): Western isles Acute Psychiatric Unit, Western Isles Hospital. CAMHS (under 18 yrs): Western Isles is currently in discussion in relation to inpatient provision. Community facilities: Specialist Eating Disorder Service Adult: none Specialist Eating Disorder Service CAMHS: none Specialist Eating Disorder Service Across Age range: none Generic Adult Service: Stornoway CPNs (Lewis and Harris) Balavanich CPNs (Uists and Barra) Generic CAMHS Service: NHS Western Isles CAMHS Stornoway, Western Isles Balavanich, Day Patient Adult facilities: none Day Patient CAMHS facilities: none Specialist Network to discuss Complex Cases: Western Isles is currently in discussion in relation to possible provision. Medical Inpatient facilities: Paediatric Medical Admissions (0-16 years): Western Isles Hospital, Stornoway 16+ Medical Admissions: Western Isles Hospital, Stornoway The Service Review team have not received any additional information.Discussions with Health Boards/Health & Social Care PartnershipsRural and semi-rural areas‘Rural’ Health Boards (Orkney and Shetland and Western Isles) and ‘Semi-Rural’ Health Boards (Health Boards with a mixture of semi-rural and rural geography - Forth Valley, Highland, Fife, Ayrshire and Arran, Dumfries and Galloway, Borders): Discussions with Health Board leadsHealth Board 1:Biggest challenges:?Delivering consistent care across geography?CAMHS service – no specialist team and long waiting times (this is seen as a priority). Specialism needed in CAMHS but no funding streams.?Spike in referrals to adult services (pre and post Covid)?Government messages re healthy weight and exercise?‘Diagnostic creep’ i.e., ARFID currently don’t provide services for and it would be a stretch (capacity wise) to do so.???Idea of a National Managed Clinical Network (MCN) – concerns/anxiety around this. This health board is part of a strong regional group – would a national group?be a gain? Or loss from regional? Bigger group might mean it is harder to be heard.?CAMHS aren’t currently in an MCN??This NHS health board covers neighbouring rural health board for some things, may need joint working with another neighbouring rural health board too.?Have good cross linking between services, however, CAMHS don’t currently have capacity for medical management?as well.?Discussed the idea of Investigation and Treatment Centres (ITRs) for enhanced observations, these are a one-stop shop for medical monitoring on behalf of GP practices. The medical responsibility lies with whoever asked for the investigations. ?Training, staff retention & recruitment:?National NES training is very reliant on adult services?Need for online training?Clinical network – cross support with other Boards?Need for networks of training and supervision??Transitions:?Need for stronger relationships between CAMHS and adult services for a ‘proper’ transition??Intensive treatment:?Need for intensive working into homes – the more we can do at home the better?This Board area has tried day centre model – it did not significantly reduce admissions to inpatient beds and was not perceived to be as beneficial as working in people’s homes.?But this could have been due to how this service was set up.?Implementation considerations:?Workforce issues?Funding is neededEquity of service is a major issue (due to geography challenge)?Home first model/ assertive outreach?idealRight people doing the right job?Specialist/expertise important – front load services for future?Pressure of amount of work coming through?- waiting?lists on top of developing new services is tricky.?Prioritised?based on risk.??Covid reflections:?Can’t just have one model. Consideration of vulnerable groups, cautious about risk and patient choice.?Deprivation & IT?Wifi?connectivity issues – some people are having to travel to get better access to?wifi?Online groups as a positive??Binge eating disorder – groups and guided self-help initially then develop more intensive intervention later?SUMMARY:?Training and development?neededCAMHS specialism?neededDiagnostic creep?Long term impact of Covid & population?Implementation & design guidelines?neededHealth Board 2:This health board includes a wide range of geographic settings, ranging from very rural isolated areas to towns where there can potentially be more specialist teams. This is a major challenge. There are challenges to deliver specialist treatment face to face within the Health Board. There are solutions that might work well for the challenges of treating eating disorders in the community – for example there are highly effective cancer networks which very effectively deliver high quality treatment across the entire health board, by taking a regional approach to having highly expert specialists, combined with more locally based staff.How do we develop/deliver equitable services for everyone in?Scotland??The health board covers islands and a rural community.?Poverty & deprivation makes accessibility to services challenging.?Travel & transport is the single biggest issue when accessing services.?Digital technology is a positive way of connecting/engaging with people. However,?have to consider digital inclusion issues. Access to digital?technology may be more difficult for people in poorer communities. They may also not have safe spaces within their homes.?Long term strategy:?to have hubs?to allow access to digital spaces. Role of partners such as community centres and?3rd?sector. To learn from Covid & think creatively about how we can provide support in the community.Barriers:?Recruitment and retention of specialist staff in a rural community is a major issue.?“Highly specialist skills” much more challenging to recruit and retain staff as well as maintain skills in a rural area as don’t have the numbers.?Despite rurality, we should deliver treatment as close to home as possible.?Networking as a way to enable this – an ability for specialists to work across boards and attend joint appointments/create multi-disciplinary teams.?This needs the right cultural conditions, which values?disciplinary and skill mixing.?Joint appointments with specialists within networks?should be possible. This needs the “Right place, right time, right people”.Regarding implementing change:?Change should be planned & structured – with reform and better use of existing resources.Acknowledged that more work is needed to marry up physical and mental health sectors. Emergency room staff/acute staff need to get more support?as currently have lack of knowledge/understanding. Physical and mental health staff need to do more joint working.?Clinicians to come together?– to be clear about the added value?and work in partnership not in silos.Regional networks?to coordinate care?are a way forward for rural health boards, utilising a?hub & spoke model of?delivery.?The regional?cancer?care group for the West of Scotland works well and could be examined as a model to follow –A regional groups brings together clinical leads across regions as well as managers.??Data, standards, quality & audit?can be standardised.Discussion of emerging evidence can enable the group to make recommendations to chief executive groups.A connected network for decision making.?Early intervention:?Needed in primary care, schools and universities. Training and supporting other professionals who worry they don’t have the skills to have these?initial?conversations.?Create a wraparound from specialist services?for primary?care.??People have to be sign-posted to the right service/right advice?NHS inform etc./3rd?sector?Recognition that early intervention is wider than the NHS and goes beyond what the NHS does – people tend to interact with?NHS?later?in their journey.?Ensuring people are directed to reliable information and?resources.Health Board 3:Lessons from Covid:?Increase in?prevalence?in eating disorders?Importance of early identification?Digital first approach, however there are some issues around geography and connectivity/broadband?Covid has meant school closure & the potential impact of children not being able to speak to each other or school nurses etc.???Early intervention needs:?Close working with universities/colleges is needed?MDT within primary care?suggestedOngoing/embedded wider?education in schools and school nurses?is needed.?Primary care:?Current state of affairs – physical issues seen as needing to be ruled out before considering diagnosis of eating disorders. By the time this happens the eating disorder presentation is more?embedded and challenging.?Role of primary care practitioners has to be clear. Recognition that everyone has easier access to primary care (specialists tend to be centralised).??Challenges/barriers at a local level in the health board:?Waiting times at CAMHS?are longBias around early detection of eating disorders in males?Workforce capacity – training to be accessible to all staff groups, need for MDT working??Training/awareness & supervision:?The health board has an informal Managed Clinical Network (MCN) with neighbouring large health board that works well. If national MCN happens, how will this be hosted and managed??Need for training/awareness programmes for medical staff.?Public health approach should include every profession and how to manage eating disorders. Everyone should take?responsibility?regardless of?occupation.??Recruitment/ retention:?This health board is sandwiched between larger health boards so staff get pulled in?the direction of those boards, and as a result recruitment and retention is an issue.?Considerations for implementation:?Balance ambition with what’s realistic i.e., money & staff?Time-limited funding as a barrier – needs to be recurrent?Longer terms concerns re increase in prevalence in eating disorder cases & the impact of Covid??Third sector:?Need to liaise with local charities and utilise the third sector?This health board is working closely with Linda Tremble Foundation and this is helpful??Service delivery:?Home setting & family focus?is key.?Health Board 4:Challenges to consider:?Equitable services across geographies. In Holland, equitable services?are?written into the law.?For example, no matter where you live you can’t be more than an hour away from a?stroke?clinic.?Enormity of travel in the health board footprint - they?are funded by population rather than geography?Can’t manage a severely ill eating disorder patient on a remote island, we need an innovative model that promotes health/wellbeing in 1st?instance?Skill set of remote areasClinicians are known in the community, no anonymity & adds layer of pressure?Expectations are higher in an island community??Lessons from Covid:?Need for remote therapy moving forward, especially to help manage remote areas?Barrier to engage young people in Near Me, need social media messaging to tackle this?Cancer standards:?Need for a model like cancer models at a regional and national level?The health board has a contact for quality standards?Early intervention:?Need pre-emptive model that prevents acute presentation and can direct to the right services?Access to rapid support??Current model in the Health Board/ joint working:?Current routes/links with neighbouring health board work really well?- have links with specialism and a Community Psychiatric Nurse on the ground for support and medical management?Funded travel to nearest regional inpatient unit in a city is providedThere can be value of consulting expert clinicians as the health board would struggle to fill a clinic for their population size?Networks aren’t as effective in moving early and quickly??Recruitment/retention:?Staff are often having to do 2/3 jobs?Level of?resilience?in staff is lower due to numbers?Struggle to recruit/retain?staff?particularly?in mental health?Have to make positions very attractive & opportunities for career progression?Innovative?recruitment?– a rotation with neighbouring health board?Nurse leaders in islands, nurse prescribers??Roles:?Consultants shouldn’t have sole?responsibility?to detain patients?“The Law needs to catch up” with mental health strategies??Implementation considerations:?Commissioning services?“For a population of...they need...”?Outcome focussed??Model hospital?& model mental health hospital?Guide to the Model Hospital?: Board 5:Needs in the health board - There is a need to upskill staff for instance in Community Mental Health Teams. There needs to be the right training and realistic pathways locally, and there is a wish to maintain skills locally.?Making recommendations about specialist teams for Scotland is challenging because this is a small health board. So the challenge is: What are the functions that a patient should expect and how can they deliver that in their (existing) structures??A regional unit different compared to other health boards areas is requested by health board. Tertiary level intervention from?that regional eating disorder unit would be needed to provide assistance to deliver specialist treatment in the community.Developing specialist teams in small board is challenging, a shift in responsibility amongst staff can be dangerous for patients. There is a risk of fragmentation and lacking skills elsewhere in mental health.?There is a need for larger boards to support smaller boards with expertise. Alternatively, there should be funding to replicate the services of larger boards. How would single pathways such as strategies for co-morbidities be delivered in smaller boards??Workforce – there needs to be precision about what aspects of skills add value for this population. What are the things that are really evidenced to work? This would need to be delivered in general teams. Training in the right places & knowing what "good" looks like is important. This has implications for early intervention.?Having a clear vision is important – this could be similar to perinatal. There needs to be Continuing Professional Development, networking and training in specific therapies, in order to continually up skill the CMHT.?Requests and suggestions from the health board:Community treatment to combat need for?inpatient admission?Need for more than one named person?for eating disorder treatment deliveryNeed for good governance and joined up approach, including psychological therapies working together across adult services.?The regional unit could deliver training to?CMHT?psychologists & the wider team. Ongoing supervision with the regional unit with up skilling from psychology perspective. CAMHS – the current cut off 16 years for psychological therapies and there is an increase of referrals in CAMHS?- Psychological therapy provision in CAMHS, but this is not well resourced. This needs to be funded.?NHS Education Scotland could provide agreed training of?evidence based?therapies & regional support around this?Length of stay data in inpatient services has increased in recent years.?The local Young People’s Unit proportion of patients with eating disorders has increased indicating that demand going forward is great.People are being admitted to less adequate setting – this needs good data collection to report on this creation of better solutions for beds/extra capacity.?Binge eating disorders - need for psychological input at higher weights. A link between weight management services and ED services?is needed.Semi-urban and urban areas‘Semi-Urban’ Health Boards – Health Boards with a mixture of urban (large towns and small cities) and semi-rural geography - Lanarkshire, Grampian, and Tayside, and,‘Urban’ Health Boards – Health Boards with a mixture of urban (large cities and towns) and semi-rural geography - Greater Glasgow and Clyde and LothianHealth Board 1:Challenges in the health board:?Pressures on services, regional inpatient unit is primarily providing beds for one particular health board. Conversely, another health board finds they don’t have to use these beds – what are they doing differently? More effective community treatment??‘Revolving door’ admissions?Unsettled transitions (child to adult services)?Seasonality of students & impact on referrals to service is challenging to manage?Extent to which GPs are willing to support management is?variable?Question of appropriateness of mixed ED and personality disorder units???Joint working:?Need for more joint working, especially in regards to services involved in young?person's?care?Relationship between acute medicine and gastroenterology described as having ‘ups and down’?Need for developed pathway?for?gastroenterological medical issues?Engage wider network for care planning?Regional specialism???Workforce capacity/retention/recruitment:?MDT capacity – therapy?is?not matching medical/dietetic and nursing staff. Need for more staff trained in therapy.?Struggle to recruit psychiatrists??Need for innovative recruitment?– Nurse Consultants to lead rather than do a management role,?physician assistant role?& non-medical prescribers?Skills & competency before profession??Service delivery:?Improve community services?– more?resourced?intensive?home treatment (with rapid response) to avoid admissions??Primary?care:?More resources for primary care in how to support people (including severe and enduring)??Lessons from Covid:?Near Me as the new normal?The health board has invested in laptops for clinicians???Perinatal review:?Perinatal review deemed as?appropriate?model for this service review?Health Board 2:Inpatient provision?Lack of specialist inpatient beds one of biggest challenges?Need for a regional eating disorder unit rather than admitting to inpatient beds in general psychiatric wards. This?would also be better for staff development, staff?flexibility?and training etc.?Built for/made for environment including appropriate kitchen and groups.?Dedicated unit with day services attached to it?and community treatment (all housed under one roof)?Shorter admissions and support in people’s own homes?Language used is important I.e.,?step-up step-down approach to care, escalate and de-escalate, alternative to hospital treatment???Community?Assertive outreach?Family?work?Geography?Geography as a challenge in this mixed health board – Attend Anywhere is helpful in addressing this?Challenging in delivering intensive home treatment??Need for equity across Scotland???Joint-working?Opportunities for strategic leads in this health board to feed into other?health boards?Access to specialist consultations?This health board has a specialist networks.Relationship encouraged between services.?More regional support for medical responsibility – challenge for smaller areas to recruit consultant psychiatrists?Network approach??Comorbidities?Recognition of complex, comorbid needs e.g., personality disorders??The health board is currently rolling out MBT and DBT to all community teams (evidence base?for personality disorders)?Challenges of patients with mixed needs in inpatient treatment.??Covid?Intensive community step-down approach been a challenge due to Covid?Also, community issues such as kitchen space for social distancing?If short term, 12-month funding delivered due to Covid, this may be useless from an organisational point of view. Takes too long to recruit and train people?& some posts already remain unfulfilled during Covid.?May be better to deliver funding for kitchen?space, dedicated ADL kitchen in the inpatient ward,?or?recruit assistant psychologists.?Procurement issues to be considered if going down the route of 3rd?sector support?Staff burn/out and exhaustion – already carrying over extra leave. Promote leave little and often.?Accessing digital self-help for ED – less trained staff can support that (almost peer led). Carefully supervised?– link with?Universities?over summer.??Medical?responsibility?Increase RMO time in the community?Named medical responsibility/ medical lead?Medical lead acute side – MARSIPAN group?Staffing?AEDS currently under resourced?Could utilise peer support workers. Benefits such as quicker recruitment, however, concerns re individuals being well enough to take on the role. Could use?carer consultants for family support, however would need to be sufficiently distanced from own situation.?Advanced nurse practitioners for ED service – an attractive role??Non-medical prescribers?Nurse Consultant roles – these are not difficult to recruit to?However, emphasise that the evidence base is psychological therapy. What we need are trained therapists. Everyone should be training to deliver therapies. This?should be part of core competencies of role.?Roles shouldn’t be blurred I.e., nurse therapists taking bloods?General nurses important for physical?aspects?of ED?Health Board 4:There is an MDT team for adults with eating disorders, utilising a person-centred approach?Joint working across CMHTs occurs, with training in wider community?Gaps have been identified for mild/ moderate cases – there are inconsistencies of care across localities.Short duration of illness/ mild cases?should be?seen by specialists based on emerging evidence about early intervention.Inpatient provision – the Health Board still relies?on Priory (private hospital) for some admissions and?locality general adult psychiatric unit beds?A MARSIPAN group?is running.There are limited psychiatry resources and major recruitment issues??Focus on prevention?- where to pick up early intervention??Inpatient provision – regional working?needed?rather than local health board – individual health boards struggling to maintain?any inpatient provision.MCN for ED services favoured – a structured network to progress and improve standards?Networking – communication with different partners, third sector, universities etc?Training – helpful but difficult with high staff turn-over –?staff?feel de-skilled and unconfident?and training would need to be on a rolling basis.Importance of meal supports – more assistant practitioners?are needed for this.?Also?need more staff for monitoring of bloods/weights etc. Staff from psychology, nurse therapists?currently?having to pick up the monitoring for cases.?Medical monitoring – don’t know what management is like outside their service,?particularly in CMHTs, question of how to use localities.?CAMHS should engage with education at schools for joint working such as meal support staff?Need more work on how to best support families.Public health and obesity – suggest links with high schools; Psycho-education in high schools needed about how we look after ourselves?How do we stop people needing TESS in the first place?Healthy?schools?framework – weight management services should be involved as well.Tech can be used for remote?medical?monitoring?depending on risk. Scottish Government’s ‘Hospital at Home’ concept can be explored: . Single wearable for patient.?Importance of MDT –?we need to ascertain the right staff mix for community ED servicesMeal supports via attend anywhere?-?COVID?Inpatient environments not always the best place for this population – personality disorders etc.?How best to support people at home – younger patients?Recognition that it can be difficult to?engage in?therapy on a screen?Scotland as big geographical area – attend anywhere good for capacity?But Zoom fatigue??Early intervention online supports – sign post to right resources??Right support at right times – not severe?enough for certain services – shouldn’t?just focus on tertiary needs?How do we break down barriers and make sure people get the right support at the right time? Training, education – staff knowing how to manage at early stage.?Building staff confidence?Step matched care model??Public health, primary care and education – wider general information sharing?Pointers – where do you go in first instance – pre-emptive strategies don’t exist?Link nurses?needed?within specialist teams?Role for something before secondary and tertiary services – link nurse at this stage/interface?More close working with third sector – no local physical third sector presence and for carers support?in?Lanarkshire?Bariatric care? How do we provide the right support – range of patients that sits between service gaps?Health Board 5:Considerations from Chief Executive perspective:Concerns re report already being written and thoughtfulness about being named participantIJBs is responsible for commissioning services and need to be involvedRegional infrastructures are not formalised, they are dependent on good willStrategic planning sits with IJB's - fearful that report may be missing that inputMaintaining specialists' skills with increased volumeNeed for preventative measures that can be put in place as well as specialist treatmentCritical – creating different profile of the importance of mental health services Issues specifically relating to the health board ED servicesWhat they do wellWell established eating disorder team in the health board Inpatient unit serving a region of ScotlandLarge geographical area, outpatient services cover remote locations. Have been using remote technology i.e., video consultations for 20 years. Clinics set up in GP surgeries to support remote delivery of medical monitoring. Initially struggled to persuade clinicians to use this type of technology as opposed to patients.Day patient programme for those who have been inpatients, stepped care model, but only available to people who can attend in person. Has recently been remobilised during COVID.Good relationship with GI consultant.Current model of CAMHS team - special interest within generic CAMHS works well, headed by psychology. Well established at collecting data. Team is split between two sites. CAMHS MDT working - schools, social work other disciplines etc.Use of CAPA (Choice and Partnership Approach) has meant waiting times have been well managed.People tend to be interested in eating disorder roles and in this health board we tend not to have gaps in recruitment. ChallengesAdult services - COVID has resulted in a gap in group treatments. What are safe digital platforms to use? Sometimes more beneficial to do groups i.e., it provides peer support. Different health boards using different platforms.Peak in referrals, there has been an increase in adults but approximately 280% increase in child services (national issue). Their health board have highest numbers referred during the peak of Covid for CAMHS. Uncertain why particularly high in these areas but conducting research on this.Remote areas and physical monitoring – support from GPs (historically been an issue), have team medic as well.Their health board do not have a CAMHS inpatient unit and the closest one (in a city) is always full. Have had to take young people into adult mental health wards previously. The local adult eating disorder unit generally always full as well. If no NHS beds, use the Priory (not that common). Pressure of inpatient beds more focussed on CAMHS. Issue of sending young people out of area for treatment.Sourcing of IT an issue i.e., long waits for laptops.Recruitment - easier to recruit into CAMHS but harder to recruit into psychiatry, use of locums. However, staff leave from one service to work in other areas that pay more, everyone is "fishing in the same pond".Third sector organisations in ScotlandTable 3: List of eating disorder Third Sector stakeholder organisations in ScotlandLinda Tremble Foundation UK Line Scotland Health Foundation Fellowship Recovery Network in Mind Scotland Action Scotland@VA_ScotlandYouth Scotland Scotland Scot Bulimia Care (ABC) Youth health and wellbeing’t have twitterMens Health Scotland sport Trans alliance Autism – Scottish Womens Autism Network of text boxes, figures and tables:Text box 1: Mental Welfare Commission mapping report on Ayrshire & ArranText Box 2: Mental Welfare Commission mapping report on BordersTable 1: ED referrals Nov 2018 – Oct 2019?& Nov?2019 – Oct 2020?in BordersFigure 1: Adult referrals by month Nov 2018 - Oct 2020?for BordersTable 2: Number of inpatient bed days between Nov 2018 – Oct 2019 & Nov 2019 – Oct 2020?Figure 2: Borders Eating Disorder PathwayText Box 3: Mental Welfare Commission mapping report on Dumfries and GallowayText Box 4: Mental Welfare Commission mapping report on FifeFigure 3: Fife CAMHS Referral PathwayFigure 4: Fife CAMHS Referral Pathway (continued)Text Box 5: Mental Welfare Commission mapping report on Forth ValleyText Box 6: Mental Welfare Commission mapping report on GrampianFigure 5: Grampian group programme for eating disordersText Box 7: Mental Welfare Commission mapping report on HighlandFigure 6: Greater Glasgow & Clyde Adult ServiceFigure 7 & 8: Connect-ed service data and pathwayFigure 9:Referral Pathway for 0-18 years in North HighlandFigure 10 & 11: Referrals to HighlandText Box 8: Mental Welfare Commission mapping report on LanarkshireFigure 12: Tertiary Eating Disorder Specialist Service Adult Referral CriteriaFigure 13: Tertiary Eating Disorder Specialist Service 16-21 year Referral CriteriaText Box 9: Mental Welfare Commission mapping report on LothianText Box 10: Mental Welfare Commission mapping report on Orkney and ShetlandText Box 11: Mental Welfare Commission mapping report on TaysideFigure 14: Tayside CAMHS eating disorders pathwayText Box 12: Mental Welfare Commission mapping report on Western IslesTable 3: List of eating disorder Third Sector stakeholders in Scotland ................
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