Clinicians in the UK are unable to offer their best service as a result of overwhelming demand and reduced staffing

When NHS Digital released data^[1] showing that hospital admissions for eating disorders had reached a peak in the year to April 2017, these figures were widely reported with alarm. The number of admissions with a primary or secondary diagnosis of an eating disorder almost doubled from 7260 in 2010-11 to 13 885 in 2016-17. We are treating more patients than ever before, but this is not necessarily a dreadful thing. My specialty came into this millennium conscious of huge unmet need, and, slowly, we may be making some headway in addressing that need.

When our service opened in 2009, our average patient was in their 30s or 40s. With the use of modern treatments, provided early, the prevalence of eating disorders in older people has diminished. Many of our remaining patients have entered a stage of illness where the disadvantages of admission outweigh the benefits and they want the improved quality of life that is possible in the community. Now, most patients on our adult ward are in their late teens and 20s. Sure enough, these latest statistics from NHS Digital suggest that there are substantially more admissions in younger patients, with admissions for anorexia among patients under 19 almost doubling, from 1050 to 2025 over the same period. Yet early intervention is proven to improve outcomes, so it’s good to see that this happens and that patients are receiving treatment at a young age.

In Germany and elsewhere, all eating disorders are treated in a residential setting, but in the UK NICE^[2] regards inpatient care as a “last resort.” In urban areas, many clinicians restrict inpatient admissions to brief, life saving interventions in a partner medical ward, which means that intensive outpatient, day patient, or outreach services are needed. One conclusion to draw from the rise in hospital admissions is that current outpatient treatment isn’t working well enough.

Improved outpatient resources would certainly prevent unnecessary admissions and minimise the risk of relapse after necessary hospitalisation. When one Scottish health board implemented family based treatment for teenagers with anorexia, outcomes improved, admission rates fell, and money was saved.^[3] However, it took substantial initial investment to do this, which involved expensive training and intensive planning.

Sadly, excellent eating disorder clinicians in the UK are unable to offer their best service as a result of overwhelming demand and reduced staffing. Colleagues speak of having to ration therapy that takes place in the community, and being obliged to discharge patients from outpatient services prematurely. This causes a “revolving door” of repeated treatments and relapses, leading to chronicity and despair.

Why are inpatient places more readily available while investment in outpatient care is cut and has even been withdrawn in some areas? It may be that perverse financial incentives are at work in a climate of commissioning. Inpatient care is costly, and anorexia patients characteristically stay for many weeks and months, providing a reliable source of income to providers. Outpatient clinics, however, are a far less profitable prospect.

I don’t want to demonise inpatient care altogether. It can provide unrivalled intensity of assessment and treatment. And sometimes geographical considerations make community care impossible. The remote Highlands and islands of Scotland, the wildernesses of Wales, and the extremities of England can’t realistically deliver intensive community based treatments: inpatient treatment far from home is the only option.

Yet when inpatient care is the only option, it’s misguided for hospitals to offer mere “refeeding,” then discharge the patient facing their worst fear—weight gain. Inpatient treatment should teach patients alternative ways to cope with distress, life stress, and other people so that they don’t relapse. Above all, we need to actively manage the transition back into the community—and all other transitions—as was outlined in a new report from the Royal College of Psychiatrists.^[4]

Clinicians’ impressions—and a growing evidence base^[5]—testify to the dangers of social media and the selfie culture in triggering and maintaining disorders. But new electronic forms of communication can also help to avoid hospitalisation and support necessary transitions. Northern Scotland effectively uses video conferencing to provide therapy sessions, link up with patients’ GPs and families, and train and supervise clinicians. Berkshire Healthcare Trust has developed a well moderated online therapeutic community called “SHaRON.”^[6] This service is available to patients during and after their treatment sessions, and uses peer support to promptly address small lapses. Clinicians from Glasgow and London have developed online treatment for bulimia nervosa,^[7] which can be used with minimal telephone support, allowing patients to recover without setting foot in a clinic.

Both the fascination and frustration of working in my specialty is that the disorder grows and evolves, becoming resistant to whatever treatments we develop, and throwing up new challenges. Treating an eating disorder is a constant battle of chess, and we must collaborate with our patients to outwit the illness with all our combined cunning and creativity.

Jane Morris trained in Cambridge and London, but has spent nearly all of her working life in various Scottish cities. She has higher psychiatric training in medical psychotherapy and in child and adolescent psychiatry. She now specialises in eating disorders, chairing the Faculty of Eating Disorders for the Royal College of Psychiatrists in Scotland.

Competing interests: I am accredited in various psychological therapies and teach and supervise these.

References
1. Marsh S. Eating disorders: NHS reports surge in hospital admissions. The Guardian. 12 February 2018. https://www.theguardian.com/society/2018/feb/12/eating-disorders-nhs-reports-surge-in-hospital-admissions
2. NICE. Eating disorders: recognition and treatment. May 2017. https://www.nice.org.uk/guidance/ng69
3. Oakley, C. Implementation of Family based treatment for anorexia nervosa. Doctoral Thesis, Caledonia University, 2017
4. Royal College of Psychiatrists. Managing transitions when the patient has an eating disorder. 2017. http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr208.aspx
5. Mabe AG, Forney KJ, Keel PK. Do you “like” my photo? Facebook use maintains eating disorder risk. Int J Eat Disord 2014 47: 516–523. https://www.ncbi.nlm.nih.gov/pubmed/25035882
6. Support Hope and Recovery Online SHaROn Berkshire NHS Healthcare Trust https://www.sharon.nhs.uk/
7. Overcoming Bulimia Online (OBO) Media Innovations Ltd, reviewed and summarised at https://beacon.anu.edu.au/service/website/view/221/19