Lorna Collins, Agnes Ayton, and David Viljoen discuss how a collaborative approach to healthcare has been developed and accelerated in the context of covid-19, for eating disorders patients in Oxford Health NHS Foundation Trust.  

The adult eating disorder service in Oxford and Buckinghamshire has been developing a multi-step cognitive behavioural therapy for eating disorders (CBT-E) treatment model. [1,2] It provides an integrated, evidence-based, multidisciplinary system of care across inpatient, day patient, and outpatient settings.

The problem that eating disorder services are facing is how to deliver the best possible healthcare for patients with an eating disorder in the wake of the covid-19 pandemic. This task is compounded by three further problems: historic and chronic underfunding, reduced capacity in terms of bed and staff availability, and difficulties with telehealth interventions and remote working (which needs high level of cooperation, not just technology).

Covid-19 has intensified the crisis in adult eating disorders services. Since the emergence of the pandemic, clinicians have been reporting an increasing number of patients presenting with acute emergencies needing hospitalization due to extreme malnutrition or other severe complications. Eating disorders thrive in isolation, and the lockdown had a major impact on some patients’ mental health.

At the same time, the pandemic has posed unprecedented challenges to the delivery of mental health services, including specialist eating disorder services. Since 23 March 2020, the NHS has directed that, where possible, all workers should work from home, and we have since seen a rapid reorganisation of services. Specialist outpatient eating disorder services have been able to carry out the majority of appointments remotely. [3] However, the pandemic has placed additional strain on the capacity of these chronically underfunded services. Underfunding of adult eating disorder services is a long standing problem, which was highlighted in the PHSO report in 2017. [4] The NHS Five Year Forward View plan promised more funding in 2018/19, but this never materialised. Following the PACAC report, NHS England produced new commissioning guidance for adult eating disorder services, as part of the NHS Long Term Plan. Eating disorder clinicians are uncertain whether the necessary investment will reach the frontline, given the impact of covid-19 on the wider NHS and the economy.

The risk of infection from covid-19 poses additional challenges for inpatient services, as inpatient treatment carries the risk of hospital transmission to both patients and staff. Cotswold House Specialist Eating Disorders Unit in Oxford (like many other inpatient mental health facilities) is not fit for purpose for the management of patients during a pandemic of a highly infectious respiratory virus. It only has one en-suite room (the rest have shared bathrooms), and narrow corridors. Reducing the risk of nosocomial transmission required rapid changes. Newly admitted patients are now initially quarantined in the en-suite room, until two negative PCR tests are confirmed. Groups run remotely (e.g. patients use their own devices in their rooms), using MS Teams. Staff members work in separate offices, or from home to ensure social distancing. This has also been found to save costs and time. 

Embracing digital technology and being creative and flexible, has helped us so far to keep the ward safe for patients and staff. This became possible by using a multidimensional approach, based around reducing physical contact, accelerated use of video consultations and remotely facilitated groups, reducing the number of staff entering the building, and using level 1 personal protective equipment (PPE). Since these changes the ward has been covid-19 free—no patients have tested positive.

The treatment model in Oxford is a multidisciplinary, stepped care approach based on enhanced cognitive behavioural therapy (CBT-E) for eating disorders. A detailed “formulation” is created in collaboration between patients and the multidisciplinary team. Crafting their formulation enables patients, with the help of staff, to map their illness and the factors that maintain the eating disorder (e.g. body image issues, dietary rules, malnutrition, perfectionism, low self-esteem, interpersonal difficulties), then initiate a treatment plan with the aim of sustained recovery. The formulation charters a patient’s mental health difficulties, in a historical, present and future sense, by laying down a map of where the illness came from, expressing how it presents now for the individual, and identifying goals, skills and strategies to create a new, recovered life.

Collins’ own treatment and recovery was guided by her CBT-E formulation, with which she was able to shift from 20 years of being a revolving door patient, towards developing insight and creating a new, recovered life. Now, Collins is part of the team, as a Peer Support Worker. She co-presents groups for patients and staff, and uses her own formulation experience to build a co-produced, comprehensive approach across the model of care in Oxford, where patient voices come first and are an integrated part of service delivery. 

Collins uses her lived experience to coordinate co-production for the eating disorder team at Oxford Health. New methods of care had to be developed rapidly during lockdown restrictions. Following their training, all members of the multidisciplinary team understand how to support each patient with goals and strategies to address the unique maintaining mechanisms of their eating disorder. The formulation has expanded to become a collaboration between the patient and the whole multidisciplinary team, in the name of supporting patients, at whichever stage of their recovery journeys.

During recent groups, patients reported a preference for attending formulation groups on their own devices, in their own room (rather than with their peers, in the group room). In this case telehealth has become an advantage: patients can interact with staff and their peers, while also having their own private space, when working remotely on their highly personalised formulations. Virtual working has also meant that after discharge from inpatient treatment, patients can continue to attend the group programme remotely without having to travel. Post-pandemic this will offer new opportunities for patients who live geographically too far to attend the day programme. 

People with eating disorders often criticise inpatient admissions for a disproportionate focus on weight restoration rather than psychological change. Consequently, during ward rounds, the intention is for patients’ weight graphs and formulation profiles to be discussed, juxtaposing and incorporating physical and psychological approaches into a holistic approach to care. Collaborating with staff across a horizontal (rather than a top-down) model of care, patients inform their own treatment programme, working with members of the multidisciplinary team, to enable an individualised approach to treatment and recovery. Treatment is done with rather than to patients.

There is a strong risk that covid-19 will endure, and continue to be a threat in the long term. With this in mind, and to create a progressive healthcare system in our service for eating disorders, our aim is to review the whole service. We need a new hospital and new facilities, designed for infection control—the first priority, so everything else can follow. 

In the meantime, the team in Oxford will continue to advance its co-led initiatives. We want to expand the mapping of patients’ coinciding physical and mental health concerns and use the whole multidisciplinary team across the care pathway to help patients to develop skills and strategies to overcome the mechanisms that keep their eating disorders going. Another task is to consolidate and develop our step-down day hospital, using remote technology, so more patients will have the opportunity to receive care. This will nourish our vision of community “stepped care”, so we can find a safe and sustainable way of caring for our patients. 

Despite the vast challenges, covid-19 has allowed us to initiate new forms of care. Not only is CBT-E suitable for remote delivery, but it is potentially possible to reach larger numbers of patients in virtual group formats than in 1-1 or face to-face group sessions. [6]

Lorna Collins, Peer Support Worker and former patient in this service. @sensinglorna 

Agnes Ayton, Consultant Psychiatrist, Cotswold House Specialist Eating Disorders Unit, Oxford. @agnesayton

David Viljoen, Consultant Psychologist, Cotswold House Specialist Eating Disorders Unit, Oxford. 

Competing interests: The authors work for Oxford Health NHS Foundation Trust.

References:

1. Fairburn CG. (2008) Cognitive Behaviour Therapy for Eating Disorders. London: The Guildford Press.
2. Dalle Grave R. (2013) Multistep cognitive behavioral therapy for eating disorders: Theory, practice, and clinical cases. New York: Jason Aronson. 
3. Waller G, Pugh M, Mulkens S, et al. (2020) ‘Cognitive-behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face-to-face meetings are not possible’ in Int J Eat Disord. doi: 10.1002/eat.23289 [first published online: 2020/05/10]
4. Parliamentary and Health Service Ombudsman. (2017) ‘Ignoring the alarms: How NHS eating disorder services are failing patients’. London.
5. Department of Health and Social Care. (2019) Government response to the recommendations of the Public Administration and Constitutional Affairs Committee’s Seventeenth Report of Session 2017-19: ‘Ignoring the Alarms follow-up: Too many avoidable deaths from eating disorders’. London.
6. Murphy, R., Calugi, S., Cooper, Z., & Dalle Grave, R. (2020) Challenges and Opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19. The Cognitive Behaviour Therapist, 1-31.