Community Eating

Disorder Service (CEDS) Operational Policy

Version: 4 Executive Lead: Exec Director Quality and Safety Lead Author: Professional Lead Community Eating Disorders and OCD/BDD Services Approved Date: 19th December 2014 Approved By: East and North SBU Quality and Risk Meeting Ratified Date: 11th August 2015 Ratified By: Policy Panel Issue Date: 17th September 2015 Review Date: 17th September 2018

Target Audience: Staff and users of the Eating Disorder Service This Policy must be understood by: Users of the Eating Disorder Service Any related service which may make referrals to the Service All staff dealing with this Care Group

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P1 - Version Control History:

Version Date of Issue Author Status Comment

V3 9th December 2010 Service Manager Superseded

V4 11th August 2015 Professional Lead Community Eating Disorders and OCD/BDD Services

Current Updated, including Care Act Update.

P2 - Relevant Standards:

a) NICE Guidance for Eating Disorders b) B-EAT Standards c) QUALITY ASSURANCE FOR EATING DISORDERS ROYAL COLLEGE OF

PSYCHIATRISTS d) Care Act 2014 e) Equality and RESPECT: The Trust operates a policy of fairness and RESPECT

in relation to the treatment and care of service users and carers; and support for staff.

P3 - The 2012 Policy Management System and the Policy Format: The PMS requires all Policy documents to follow the relevant Template

Policy Template is the essential format for most Policies. It contains all that staff need to know to carry out their duties in the area covered by the Policy.

Operational Policies Template provides the format to describe our services ,how they work and who can access them.

Guidance Template is a sub-section of the Policy to guide Staff and provide specific details of a particular area. An over-arching Policy can contain several Guidances which will need to go back to the Approval Group annually.

Recovery Care Pathways (RCP) are documents that describe a clear route from assessment, through intervention to recovery.

Symbols used in Policies:

RULE =internally agreed, that this is a rule and must be done the way described

STANDARD = a national standard which we must comply with, so must be followed

Managers must bring all relevant policies to the attention of their staff, where possible, viewing and discussing the contents so that the team is aware of what they need to do.

Individual staff/students/learners are responsible for implementing the requirements appropriate to their role, through reading the Policy and demonstrating to their manager that they understand the key points.

All Trust Policies will change to these formats as Policies are reviewed every 3 years, or when national Policy or legislation or other change prompts a review. All expired and superseded documents are retained and archived and are accessible through the Compliance and Risk Facilitator Policies@hpft.nhs.uk

All current Policies can be found on the Trust Policy Website via the Green Button or

http://trustspace/InformationCentre/TrustPolicies/default.aspx

Preface - concerning the Trust Policy Management System (PMS)

mailto:Policies@hpft.nhs.ukhttp://trustspace/InformationCentre/TrustPolicies/default.aspx

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PART: Content Page:

Preface Preface concerning the Trust Policy Management System: P1 - Version Control History P2 - Relevant Standards P3 - Policy Management System and Document Formats

PART 1 Preliminary Issues: 1. Flowchart Community Eating Disorder Care Pathway 2. Summary 3. Purpose 4. Definitions 5. Duties and Responsibilities

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PART 2 What needs to be done and who by:

6. The Community Eating Disorder Service 7. Core Service Objectives 8. Aims of Impact on Service user 9. Values 10. Team Membership 11. Team Locations and Hours of Operation 12. Eligibility for Services 13. Referral Process 14. Assessment Process 15. Medical Responsibility 16. Admission and Discharge from Hospital 17. Advance Decisions 18. Working Practices 19. Care pathways, transitions and interfaces between services and

agencies 20. Treatment Options and Treatments 21. Discharge Guidelines from CEDS 22. Missed Appointments 23. Disputes Resolution 24. Services for Carers 25. Induction, Supervision, Performance Management and Training 26. Quality, Audit and Practice Governance 27. Communication 28. Capacity to Consent 29. Deprivation of Liberty Safeguards 30. Records Management, Confidentiality and Access to Records 31. Electronic Patient Records 32. Comments, Complaints and Compliments 33. Freedom of Information 34. Access to Records 35. Health and Safety Risk Management 36. Access to healthcare for people with a learning difficulty 37. Practice Governance 38. Embedding a culture of Equality and RESPECT 39. Process for monitoring compliance with this document

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PART 3 Associated Issues

40. Version Control 41. Archiving Arrangements 42. Associated Documents 43. Supporting References 44. Comments and Feedback

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Appendices List 32

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1. Community Eating Disorder Care Pathway

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PART 1 Preliminary Issues:

Back to GP / referrer and/or signpost to

another service

- Routine assessment offered within 28 days - Urgent assessment offered within 4 working days

Suitable

Triage

Referral (Direct/SPA/Other MH or Wellbeing teams)

Teams)

Suitable for CEDS

Service User full agreement

Complete symptom remission

Partial symptom remission

No or very little symptom relief

Discharge back to GP / referrer

Review leading to: - More therapy sessions - Different kind of therapy - Parallel family work - Break in therapy - Medical monitoring - Other interventions

Routine: Placed on waiting list for therapy / other interventions (< 18 weeks) Psycho-education provided. Interim appointment offered every 4-6 weeks or more

frequent if indicated High risk/low weight: offered support/therapy, Intensive Community Management or

referral to inpatient unit

Service User ambivalent to

change low risk

Unsuitable

Psychotherapy e.g

Guided self-help (6 contacts over 3 months)

CBT (20/40 sessions +1/2 follow up)

IPT (16/40 sessions +1/2 follow ups)

CAT (16/40 sessions +1/2 follow ups),

Family Therapy (16 sessions +1 follow up)

Group Therapy (12 sessions +1 follow up)

Psychiatric Input / Medication

Medical monitoring

Specialist nursing

Dietetic support

Support working

Tertiary (e.g. in-patient) and Secondary Care (e.g. STT, TTT, CDAT, CATT) referrals made as and when appropriate.

Service user ambivalent to change high risk, GP unwilling to hold alone

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2. Summary

This document details the operational functions of HPFTs Community Eating Disorder Service. The service is offered to all Hertfordshire residents who have a moderate to severe eating disorder and a Hertfordshire GP.

3. Purpose

This document has been written in line with Trust practice and procedure in order that all those working in or with the Community Eating Disorders Service understand the procedures, practices and functions of the service and are able to work within them.

4. Definitions

STANDARD STT - Support and Treatment Team TTT - Targeted Treatment Team CDAT - Complex Depression, Anxiety Trauma Team CATT - Crisis Assessment Treatment Team CEDS - Community Eating Disorder Service CAMHS - Child and Adolescent Mental Health Service MDT - Multi-Disciplinary Team DNA - Did Not Attend PBs Personal Budgets JCT Joint Commissioning Team BP Blood Pressure BMI Body Mass Index ECG - Electro-Cardiogram 5. Duties and Responsibilities

RULE

Professional Lead this is the team manager responsible for HR functions within the team, the postholder is the budget holder, needs to ensure meeting of Trust KPIs and accountable for team function to the Service Line Lead. The post holder also works closely with the Consultant Psychiatrist and Lead Psychological Therapist to ensure their functions operate smoothly. Consultant Psychiatrist responsible for the overall clinical function of the service Lead Psychological Therapist responsible for the psychological and psychotherapeutic provision by the team Leadership and Management Group membership are the three staff members above plus Clinical Nurse Specialist and the two senior psychologists. This group is a back up to the functions of the above team members and ensures team development. Team meeting occurs weekly and includes monthly practice governance meetings, weekly review of high risk service users, recording of clinical improvements of service users and

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Team is then made up of

Team Secretaries and administrative assistant

Psychologists, Eating Disorder Therapists. Clinical Nurse Specialists and Nurse Practitioners who provide therapeutic and clinical management for the service users

Support workers who support the clinical function and provide social care support and carers assessments

Dietician who advises on dietetic plans and nutrition for service users who need it

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6. The Community Eating Disorder Service The Community Eating Disorder Service has existed in Hertfordshire Partnership University NHS Foundation Trust (HPFT) since 1998 but was fully commissioned by the Joint Commissioning Team (JCT) in April 2010. The service specification has been agreed with the JCT. From 2013 the team specification forms part of the Herts NHS contract along with other HPFT mental health service provision. 7. Core Service Objectives

To offer assessment and treatment to service users with moderate to severe eating disorders usually defined as: Anorexia Nervosa; Bulimia Nervosa and Binge Eating Disorder and atypical presentations of these.

To take a whole systems approach to CEDS together with Acute Inpatient services, Acute Day Treatment Unit, Support and Treatment Teams (STTs), Targeted Treatment Teams (TTTs) and RAID, jointly offering an integrated acute, crisis and long term service provision. We are not a crisis team, basically offering interventions between 9 am - 5 pm but we ensure our service users know about out of hours help provided by the Trust and NHS more broadly.

To offer a multi-disciplinary, pro-active and comprehensive service to people suffering from moderate to severe eating disorders who require assistance from a specialist service which includes attention to their social care needs where appropriate, their physical health and their financial and occupational wellbeing where affected by or affecting the eating disorder. The social care, financial, accommodation and occupational needs may be addressed directly by CEDS or the service user may be signposted to other resources and services.

8. Aims of Impact on Service user

Facilitate the service users engagement with the treatment system,

Enable service users to make choices designed to improve their health and quality of life,

Prevent physical and psychological deterioration and promote physical and mental well-being,

Increase stability and quality in the lives of service users and their carers/families,

Provide support to help clients reduce life threatening behaviours,

Improve interpersonal and social functioning,

Promote the service users participation in their own recovery,

Assist the service user in accessing educational support and work activities,

PART 2 What needs to be done and who by

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Help service users locate psychological treatment appropriate to the individual and informed by the current evidence base if they are assessed not to have an eating disorder or if they would prefer not to work with Hertfordshire CEDS.

Provide such treatment with the aim of aiding recovery if the service user has a diagnosis of an eating disorder

9. Values The Trusts values - to be welcoming, kind, positive, respectful and professional - are central to the team ethos. We strive to practice them in all our working relationships. CEDS is also committed to the Trusts anti-discrimination statement and policy. The intrinsic values of Recovery Approaches in Mental Health, collaborative working, openness and honesty also underpin the work of the service. 10. Team Membership CEDS unites specialist psychiatrists, psychologists, psychotherapists, nurse specialists, a dietician, support workers, an assistant psychologist and administrative staff within two team bases and a single management structure (Please see Table 1 for CEDS establishment). Table 1

Post WTE: CEDS establishment

Consultant Psychiatrist 1

ST4 - ST6 ST2

0.4 0.4

Clinical Nurse Specialist band 7 1

Psychologist Band 8B 1

Psychologist Band 8A 1.6

Psychologists/psychotherapists Band 7 5

Psychological Therapists/Nurse Practitioners Band 6 3

Assistant Psychologist Band 5 0.87

Dietician Band 6 0.52

Professional Lead (Team Manager) 0.8

Administrator Band 4 Administrative Assistant Band 3

1.6 0.63

Senior Support worker Band 4 2

11. Team Locations and Hours of Operation

CEDS central office is in Welwyn Garden City Rosanne House Parkway Welwyn Garden City AL8 6HG Telephone 01707 364006 Fax 01707 328744 Email ceds@hpft.nhs.uk

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Services will be delivered from other HPFT buildings within the county to ensure that provision is as close to as many service users as possible whilst providing adequate staffing and meeting quality standards. Currently CEDS provides interventions in Bishops Stortford. Hitchin, Cheshunt, Welwyn Garden City, St Albans, Watford, Borehamwood and Hemel Hempstead. CEDS working hours are between 9.00 am 5.00 pm Monday to Friday. Some team members have flexible working hours and can offer individual, couple, family or group sessions outside of regular hours (e.g. at 8:00 am; 17:00 18:00 pm). Out of hours cover Outside these hours, advice is available from the Trust Mental Health Helpline, CATT Teams, GPs, A&E and other crisis support services, like the Samaritans and the Beat helpline. When the office is closed the team base has an answer phone message giving details of emergency procedures. These are also contained in information packs given to all service users and carers. 12. Eligibility for Services CEDS will offer assessment and treatment for adults (18 years +) in the population for which Hertfordshire Clinical Commissioning Groups and Local Authority hold responsibility. Services are provided to all service users with a Hertfordshire GP (including those who reside in neighbouring counties). Service users with moderate/severe eating disorders (e.g. Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Atypical Eating Disorders or Other Specified Feeding and Eating Disorders, OSFED) which significantly impact on their social, occupational and other areas of functioning, and/or physical health could access CEDS based on the following criteria:

People with eating disorders that significantly affect their physical health and/or their mental and social functioning.

People with moderate/severe eating disorders with high clinical risk including diabetes and pregnancy.

In cases where staff in primary and secondary care lack the knowledge and expertise to treat the service user (despite possible supervision and guidance from, and joint working with the CEDS).

All service users with a diagnosis of Anorexia Nervosa as there is little evidence for the treatment of this disorder in primary care.

Service users who fail to respond to evidence based psychological therapies provided over an appropriate period of time in primary and secondary care.

Service users with severe and enduring eating disorders with complex needs requiring continuing care from multiple agencies (including CEDS).

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Service users who have been discharged from inpatient treatment should receive psychological/ psychiatric treatment for at least 12 months post- hospitalisation (NICE, 2004).

Service users requiring admissions to specialist ED in-service user services and service users that have been sectioned through provisions of the Mental Health Act (i.e. CEDS fulfilling its gatekeeper role).

Exclusion criteria

Mild eating disorders which do not cause significant distress, considerable physical risk or impairment in the service users social, occupational and other important areas of functioning. These individuals would be most appropriately referred to the Wellbeing teams.

Individuals with loss of appetite, psychogenic disturbance of appetite or other conditions that involve significant weight loss but which are due to physical illness or other psychiatric conditions such as anxiety disorder

Morbid obesity (i.e. in the absence of an additional diagnosis of an eating disorder such as Binge Eating Disorder or Bulimia Nervosa). Psychological issues related to morbid obesity could be addressed by the Well-being Team

13. Referral Process Referrals come into the service through HPFTs Single Point of Access. SPA will triage if possible within 72 hours and will then pass on to the team, whether triaged or not. SPA will book the service user into an assessment slot with CEDS within 28 days of referral, and if no slots are available will pass to the team to organise an extra slot. Referrals are also accepted either for consultation or as a full referral from other HPFT teams such as the STTs, TTTs, Wellbeing, CAMHS and RAID. These will be processed in a timely manner in negotiation with the referring team but are not part of the 28 day KPI.

Referral Screening

Referrals are screened by Single Point of Access (SPA) and then by the CEDS clinician on triage duty every weekday.

SPA will request recent blood test results from the GP if none have been provided, (i.e. urea, electrolyte, phosphates, protein, FBC), ECG, and general health like BP, pulse as well as current BMI.

SPA will give a preliminary classification to referrals as routine or urgent. SPA will regard referrals as urgent if they have a BMI below 15, have significant changes in blood profiles, or have lost a lot of weight in a short period of time. SPA will forward the details of urgent referrals to CEDS as soon as possible and CEDS triage clinicians will contact the service user and referrer/GP to determine if indeed the referral should be regarded as urgent and seen within 4 working days. If SPA regard the referral as routine, they will attempt to triage the service user over the phone and if possible book them into an assessment appointment within 28 days. If they cannot do this within 72 hours, they will pass it over to CEDS to arrange the assessment appointment.

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There are two CEDS triage clinicians on duty each working day. The CEDS triage clinicians will screen all referrals, routine and urgent, to ensure that no referral has been wrongly classified. Where necessary, the CEDS triage clinician will re-classify an urgent referral as routine or vice versa and then ensure that the service user is correctly allocated to the assessing clinician. Where necessary the CEDS clinician will contact the service user before sending out an appointment letter.

All standard referrals will be seen in 28 days and urgent will be seen within 4 working days. Any recommendations for action before assessment will be communicated to the GP or referring team.

Internal referrals should have an up-to-date comprehensive assessment of health and social care needs, Risk Assessment and a Care Plan on the EPR. The referral to CEDS should be documented in the Care Plan and the service user should be aware of the referral. If insufficient information is available then CEDS may have to write back to/contact the referral for more information. Level of priority: routine versus urgent referrals

Routine referrals are defined as to service users with moderate to severe eating disorders.

Urgent referrals are those of service users with severe anorexia nervosa with either BMI < 15, rapid weight loss and/or evidence of system failure. It also includes critically ill service users who are medically unstable (e.g. unable to perform 'squat test') and requiring urgent medical attention. Where possible, urgent referrals will be co-managed with the referrer (e.g. telephone advice and guidance to the GP/STT/TTT/Wellbeing regarding the need for further blood and ECG tests and possible admission to medical wards) from the point of referral received. CEDS will also provide consultation to the process of re-feeding and possible subsequent transfer to a specialist in-service user unit.

When the urgency is related to suicide risk or self-harm, service users should be assessed through their local STTs or Crisis Assessment and Treatment Teams and considered for admission to a mental health unit. CEDS will provide advice regarding management of the eating disorder.

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14. Assessment Process Once a referral has been received, service users will be screened by the triage clinician who will also check that if SPA has booked an assessment appointment it is within 28 days of the referral. If there is an unclear presentation or a high risk, the clinician will contact the service user by phone to conduct a triage assessment and establish urgency and appropriateness of need. If the referral is clear and the referral routine but does not have an assessment appointment, the CEDS triage clinician will book them into an assessment slot within 28 days of the date of receipt of the referral and ask the secretaries to send out an appointment letter. Text reminders will be sent to service users where possible to remind them of assessment appointments. Assessment appointments take place at the CEDS main base and other HPFT buildings. Unusually but where appropriate home visit can be arranged and will always involve two members of staff. Attempts will always be made to see the service user close to their home but we may have to ask them to travel for the assessment with the assurance that should they work with us in ongoing therapy, this will be in a building of their choice. Where appropriate, CEDS will offer assessments/consultation to service users and staff on medical, psychiatric and specialist eating disorder wards. Assessment procedures CEDS will complete a comprehensive assessment of eating disorder symptoms primarily based on an Assessment Interview Schedule (please see Appendix C). In the assessment the assessor will discuss recommended therapies for the service users presentation and where there are several options for the type of therapy that might help, will discuss the different options with the service user. Psychiatric co-morbidity and health and social care needs will also be assessed. Service users and their carers will always be involved in the assessment and the treatment plan will be jointly agreed. CEDS will complete relevant documentation on Paris including needs assessment, risk assessment, Fair Access to Care Framework and HONOS. CEDS also send out the CIA, CORE and EDE-Q which are used for outcome monitoring for team use and to show progress in the clinical work.

Assessment may need to include issues around the protection of vulnerable adult and children. CEDS will involve other resources in these circumstances if needed and operate within the Safeguarding Adult and Childrens policies. CEDS clinicians will complete a social care screening assessment and a full social care assessment for anyone who meets the criteria following screening. In some cases the assessment will extend over more than one meeting. All carers known to the team will also be offered a carers assessment.

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Safeguarding Throughout all our interventions with service users and carers we will be alert to safeguarding concerns relating to children and vulnerable adults. All staff members will follow Trust policy in reporting and acting on concerns and be involved in interventions to manage those concerns. Assessment Outcomes Following an assessment, each service user will have a plan of care. Complex cases will be presented at the next CEDS weekly team meeting for an assessment outcome decision. An assessment letter including the content and outcome of the assessment will be sent to the service user, GP and referrer within 10 working days of the assessment outcome decision being made. When CEDS offer ongoing input, an initial care plan will be outlined in the assessment letter, which will include:

Detail of input the service user has been offered.

Recommendations for psycho-education and self-help literature.

Responsibility for physical and medical monitoring.

When CEDS ongoing input is offered, the service user is allocated to the appropriate care level (i.e. standard or CPA) and the assessor is their named Care Coordinator.

If CEDS services are not appropriate then again this will be communicated to the service user where appropriate immediately after assessment and the referrer notified within 10 working days. All service users will be signposted where relevant to other services and recommendations communicated to referrer. Social care assessments will lead to signposting of the service user to resources in the wider community and supporting them to access these or using a personalised budget to meet the social care need. Care Programme Approach The CEDS will observe the Care Coordination procedures. Care Coordination responsibility for any referral from another secondary care team will be negotiated at the point of referral. In cases where the needs are complex and additional input from other services is required, or where services that cannot be duplicated by the CEDS are already available in a local team, CEDS and the referring team may agree which service will hold care coordination responsibility whilst the other service provides additional services. Transfer of Care Coordination responsibilities This is a known time for increased risk when responsibility is transferred and needs to be handled according to a recognised process. CEDS will take over the

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Care Coordination role from another service only at a CPA review attended by both teams, if the service user is on CPA. Transfer of a service user on CPA from CEDS to another service or when CEDS require the involvement of another service will again be arranged through a CPA review attended by both teams. Service users on standard care will still be transition in a timely and careful way. CPA documentation The CEDS will request that in the case of referrals from other secondary care teams, all CPA documentation is completed by the referring team before transfer of responsibility to the CEDS, except where the only service to have been involved has been a gateway service, like a duty worker. Assessments under the Mental Health Act Service users being Care Co-ordinated by the CEDS who require assessment under the MHA will be co-ordinated through the Consultant Psychiatrist within CEDS and the care co-ordinator liaising with the sector AMHP. All elements of care and process will be in accordance with relevant polices and local agreements. CEDS will provide advice regarding management of the eating disorder and might co-manage until the emergency has passed or is averted or the service user is sectioned under the MHA. 15. Medical Responsibility When the CEDS is care-coordinator for a service user the Consultant Psychiatrist attached to the CEDS will be the Responsible Consultant. When CEDS involvement terminates and further treatment and support is required by mental health services, this responsibility will be transferred, following communication and agreement and if appropriate a review with the relevant services. Should a service user require in-patient admission during their period of care with CEDS medical responsibility will be agreed between the CEDS Consultant and the Ward Consultant. This will be subject to local agreements. If a service user receiving treatment from CEDS does not require the medical support of the CEDS Consultant, the medical responsibility remains with the GP. It is the responsibility of the Care Co-ordinator to ensure the GP is aware there is no HPFT medical input involved in the treatment. In accordance with the shared care agreement on physical health monitoring GPs will do physical health assessments for service users on an annual basis and or when necessary. Copies of the most recent annual physical health assessments should be forwarded to CEDS. The responsibility for physical health monitoring (including regular blood tests, BP, pulse, temperature, ECG and any additional tests/investigations including bone scans) in accordance with the Kings College Medical Guidelines will remain with the GP practice. The GPs will alert CEDS when abnormalities occur. The CEDS will proactively liaise with GPs for this information.

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16. Admission and Discharge from Hospital Service users who require admission to hospital need the full support of community staff during the inpatient episode. Ensuring that the service user and relevant carers receive appropriate support is seen as high priority by CEDS staff. Admission to hospital for service users with eating disorders only occurs when the clinical picture indicates extremely high risk if the person remains at home. Admission is typically arranged to a specialist Eating Disorder Unit outside Hertfordshire. A referral letter (often summarised in the Patient Placement Notification Form (PPNF) needs to be included which provides comprehensive information on the nature of the eating disorder, its history and any other information relevant to the service users mental health and risk should be included. Care programme approach (CPA) documentation should be included where appropriate. If admission to a specialist placement is not available admission may be considered to a local Mental Health Unit or if physical risks are high, to the local General Hospital. (Please refer to section 24 for those service users requiring assessment under the Mental Capacity Act and Deprivation of Liberty Safeguards). Support during a hospital admission is particularly important for those suffering with eating disorders and the Care Coordinator/CEDS clinician will ensure regular contact occurs. This may be in person or on the phone depending where the service user has been admitted. If the service user is admitted to a local acute/medical ward the Care Coordinator/CEDS clinician will attend the multi-disciplinary ward round discussion whenever possible. If the service user is admitted to a specialist unit outside the local area the Care Coordinator/CEDS clinician will ensure the service user is visited or telephoned in hospital regularly and at least once every 2 weeks. When contact is made by telephone a personal visit will occur at least every 8 10 weeks if possible taking into consideration geographical constraints. The Care Coordinator/CEDS clinician will also discuss progress with the Named Nurse at 2 weekly intervals and attend CPA reviews in person or by conference call held in the in-service user base. Prior to the planned discharge date a CPA Review Meeting will be convened and CEDS will attend if possible and/or necessary and relevant carers invited. If the unit is a long way away, this might take place on the phone. All follow up appointments after inpatient admission will occur with 7 days of discharge (planned or unplanned) in accordance with the HPFT Policy Follow up after discharge from Mental Health Inpatient Units. 17. Advance Decisions and Advance Statements Service users will be encouraged to complete an Advance Decision and Statement according to the literature and procedures for advance decisions where appropriate.

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According to the Marsipan (Management of really sick service users with anorexia nervosa) Guidelines (2010), the question of the validity of an advanced decision to refuse treatment (e.g. not to NG feed) needs to be evaluated with psychiatric, medical and legal assistance as the issue arises. 18. Working Practices

Service users are allocated to identified team members for Care Coordination and to others for specified areas of support if necessary.

Care plans and progress is monitored regularly

There is a daily triage rota

All clinical staff participate in an assessment schedule.

All staff participate in weekly team meetings.

All staff participate in regular clinical, professional and managerial supervision.

Support and advice is offered to both other colleagues within the Trust and elsewhere who are working with service users with eating disorders

Information from Executive and Senior Management is cascaded to all levels of staff as outlined in the Communications Strategy

Liaising and working with other statutory and voluntary agencies (e.g. Housing Department, Police, and Employment Services) is promoted.

Vulnerable people are worked with taking regard to Vulnerable Adult Policies and Procedures

Standardised measures are used to measure outcome e.g. Eating Disorder Examination Questionnaire (EDE-Q); CORE; HONOS; Clinical Impact Assessment Questionnaire (CIA), as well as considering other factors such as weight, BMI, menstrual status and recovery outcomes (e.g. returning to work/college). Service user and carer satisfaction with the service will also be evaluated (e.g. Having your Say).

Staff communicate their whereabouts using an electronic shared diary and mobile phones. Staff who do regular home visits will be supplied with lone worker devices

19. Care pathways, transitions and interfaces between services and agencies

a. Please see Appendix D for transitions between CEDS and primary healthcare.

b. CEDS and CAMHS transitions and interface

Service users with anorexia nervosa, especially those with the bingepurging sub-type, are at increased risk of self-harm and suicide, particularly at times of transition between services or service settings (NICE, 2004). Close cooperation and good communication between the CEDS and CAMHS and/or the Advanced Practitioners in Eating Disorders are therefore essential. Young people aged below 18 years will be eligible for a service from CAMHS, however where appropriate CEDS will offer advice, consultation and an on-going dialogue with CAMHS and jointly manage the transition process from the age of 17 years onwards.

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The transition process can happen over a year period, up to six months either side of the young persons 18th birthday. CAMHS should initiate the transition process and make a written referral to CEDS when service users are aged 17 years. Service users with co-morbid difficulties and risks to themselves (e.g. self-harm or suicide risks) or others should be referred to both CEDS and the local CMHT. It is accepted that in some cases it might be in the interest of the service user if s/he remains open to CAMHS for a few months after their 18th birthday (e.g. where the service user turns 18 a few months before they go to university; when turning 18 during an in-service user admission, etc.). If service users are being held by CAMHS after their 18th birthday, CAMHS needs to discuss any concerns about deterioration or possible admissions with CEDS. The transition will allow the service user to retain key relationships with existing therapists whilst developing new ones with staff in CEDS. Sometimes a long transition can be problematic as in cases where anxiety is high and there is a need for clarity over who is responsible from a clinical point of view and clinicians should be sensitive to this. The formal transfer of care and handover of clinical case responsibility from CAMHS to CEDS will only happen after a service users 18th birthday. The handover as a minimum standard will involve at least one (ideally 2-3) meeting(s) with the service user and representatives of the CAMHS and/or the Advanced Practitioners in Eating Disorders and CEDS (including RMOs where relevant from the respective teams) as well as the service users family/carers. The STTs would be involved for service users who apart from their eating disorder pose a risk to themselves (e.g. history of self-harm and suicidal attempts/ideations) or other comorbidities. The transition process could be aided by the provision of written or online materials which the service user and family can read prior to any face to face appointment with CEDS. 20. Treatment Options and Therapies All treatment options offered by CEDS are informed by NICE guidelines and tailored and reviewed to individual formulation of clinical need. In brief the range includes:

Psychological therapies namely Cognitive Behavioural Therapy (CBT), Cognitive Analytical Therapy (CAT), Interpersonal Psychotherapy (IPT), focal psychodynamic therapy and family interventions

Psycho-education for Service users and Carers

Dietetic support

Family and Friends groups

Ensuring physical health needs are addressed

Appropriate medication and psychiatric management

Assertive engagement if required

Occupational support

Support with social care needs if indicated in referral or following assessment

Referral for substance use issues

Assistance in accessing suitable accommodation

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Information regarding Direct Payments if eligible

Information regarding Advocacy Services

Compulsory interventions using the Mental Health Act 1983

Regular reviews

Fulfilling a gate keeping role and facilitating inpatient admissions and discharge in accordance with commissioning arrangements for in-service user treatment.

Long term support and monitoring of people with severe and enduring eating disorders where appropriate.

21. Discharge Guidelines from CEDS Discharge from the CEDS will normally be to the individuals GPs care following a care review, and will be supported by a Care Plan incorporating guidance addressing relapse prevention, risk management and contingency planning. Where service users wish to maintain a supportive relationship with secondary mental health services, and have eligible needs, a transfer of care to another service can be facilitated by CEDS, after discussion with the individual, their carers and other potential services. Discharge/exit routes Following discharge from CEDS service users may follow a number of pathways in line with a model of stepped down care. The decision as to which pathway is most appropriate will be made according to the clinical needs of the individual service user:

When a service user has made sufficient progress and it is felt appropriate by all involved in their care they will be discharged to primary (e.g. GP) or secondary services (e.g. STT, TTT etc.) as most appropriate.

When alternative services have been identified as more appropriate to meet a persons needs the service user will be referred on.

When a person moves out of the providers locality referral to other services will be made in line with Care Programme Approach (CPA) policy if the service user wishes and it is clinically appropriate.

CEDS will routinely discharge and transfer the care of service users who relocate to attend universities and colleges across the country. In these cases service users will remain under the care of the University/College GP or eating disorder units when they return to Hertfordshire for holiday breaks. In some cases, however, a request can be made through the Hertfordshire GP, for support from CEDS for the service user during their holiday breaks. Care will be transferred back to the team/GP local to the University when the holiday ends.

When a service user continually chooses not to engage with services and does not pose a risk to themselves or others and to which continuing to attempt to engage would be a violation of human rights (Human Rights Act 1998). A discharge visit or letter/care plan would explain how the service user (and carers if appropriate) can access future care and support. The service user would then be discharged to their GP for medical monitoring. However, their carers would be entitled to ongoing care.

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22. Missed Appointments Service users who fail to attend the Initial assessment and/or follow up appointments will receive an immediate telephone call if the information the CEDS/STT hold suggests that there is an urgent physical risk. When this is not the case the service user will be sent a letter asking them to contact the team to arrange a convenient time to attend. Risks should be reviewed by the therapist and the Multidisciplinary Team (MDT) and the GP must be informed.

Failure to attend two consecutive appointments must be reviewed in supervision or discussed by the Multi-Disciplinary Team. It is accepted that for some service users irregular attendance will be part of the therapeutic process. A decision regarding further action following 2 failed appointments should be taken based upon assessed risks to self or others and the team DNA and cancellation policies. If the decision is to discharge, the service user and the GP will be informed immediately. 23. Disputes Resolution Any comments made by professionals, service users or their carers that are about failures in the consistency, quality, availability, and range of service, or indeed any other issue, will be handled according to the Trusts various current policies on Complaints, Adverse Incidents or Whistle Blowing. All staff are obliged to respond to issues reported orally as well as written ones, and must make the relevant complaints policy available to people who may need it, without prejudice to their support, and will advise on the availability of independent advocates. In accordance with the complaints procedure, any issues raised will be responded to in an informal way, at a local level in the first instance in order to bring satisfaction for all involved. These issues will be reported even if satisfactorily resolved. Only in the event of this not working however, will the issue be raised at another level, for further enquiry. Disputes that do not constitute complaints or grievances but which may be simple enquiries about clinical and management decisions made within the service should be directed in the first instance to the person perceived to have made the decision, with whom clarification and reconsideration can be sought. An instance of such a decision, for example, may be the non-take-up of a referral to the team. These decisions are communicated back to the referrer by a range of people within the service, and reasons will be given. However reconsideration may be requested if accompanied by additional information or appropriate reasons for such a step. 24. Services for Carers Wherever possible CEDS will actively involve carers in assessments and on going support work. Carers can include family and friends. All efforts will be made to explain the importance of this to service users in order to foster an environment of openness and honesty. This is in recognition that ill health usually impacts upon a

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whole group or network, not just one individual, and that the network is usually instrumental in the recovery from illness. If any individual, whether carer or service user actively chooses not to engage in this, CEDS may engage with the carers and service users separately, whilst still observing the confidential nature of the relationship between the service, the service user and the carer.

CEDS will try to support carers by assisting in the development of situation specific strategies to support the recovery of the individual and the family group. This involves using psycho-educational materials and therapeutic methods. The service will endeavour to start this process from the point of referral. All carers who are known about will be offered an assessment of their own needs (Care Act 2014) and offered a Carers Pack. They will be offered appropriate services within resources available and will have a written care plan, which will be reviewed no less than once annually. Carers can attend Family and Friends groups which will run at two venues in the county per month. 25. Induction, Supervision, Performance Management and Training Staff development and training is a high priority for HPFT and it is the responsibility of the Trust and CEDS to ensure that services are delivered by appropriately trained staff. The professions of psychiatry, nursing, psychology, dietetics and social work each have specific structures for the continuing professional registration and professional development (CPD) of its practitioners. It is a requirement of the Trust that these are observed. Mandatory training is identified by the training section of the Trust and is the responsibility of the Team Leader and the individual team members to ensure they are up to date with mandatory training requirements. Specialist skills training is actively pursued by CEDS and specialist training courses on eating disorders are accessed whenever possible/feasible. Further specific information about any individuals training, or the skills mix in the service will be made available if requested. Each member of staff has an annual appraisal, performance agreement and a Personal Development Plan identifying training needs. Regular staff support is offered through supervision, team meetings and also by access to external HPFT counselling for members of staff if required. All staff receive management, clinical and professional supervision (as appropriate) given by a more senior member of staff. Sessions are recorded, are held at least monthly (six weekly for managerial), and offer an opportunity to focus upon the professional role, workload and clinical practice. When a supervisor is from a different profession the supervisee will have an identified person from the same profession

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from whom to seek further clinical advice when/if this is required. This will be in accordance with HPFT Supervision Policy. Professional groups may also access relevant professional support / peer supervision groups within the wider Trust. All newly appointed staff undergo a comprehensive induction programme in line with HPFT policy. The programme commences with an intensive induction during their first week of work. Further induction is planned over the following three months of employment. There is also a corporate induction organised by the Human Resources Department. It is the responsibility of the line manager to insure the induction is signed off on the Induction Check List During the first week of employment it is the CEDS Managers responsibility to ensure the new member of staff is registered for the use of EPR and undertakes the mandatory training in order to be competent in its use. All staff, including bank and agency staff are required to have an induction. This may be locally agreed according to the length of time they are expected to be employed Training courses form an integral part of every Personal Development Plan. Training Bulletins are issued regularly by the Trusts Training and Development Department. Mandatory courses, such as risk assessment, child protection, health and safety and coping with violence, must be attended and regular bank staff will also be expected to attend. All CEDS staff directly working with service users are required to achieve basic competencies in working with families, CBT techniques, welfare rights and safeguarding children from abuse and neglect. Training courses to acquire these competencies are made available. Within the CEDS there are a regular number of students from all disciplines 26. Quality, Audit and Practice Governance Every effort will be made to provide services of high quality. SBU Practice Governance Groups meet monthly to review, reflect, prioritise and learn the lessons identified from practice issues such as serious incidents, near misses, complaints and compliments. A member of CEDS will attend these meetings. Audits will be conducted regularly within the CEDS in collaboration with the Trusts PACE department and presented at the teams practice governance meetings. 27. Communication Effective communication with the service user should meet the individuals communication needs, for example, people with additional needs such as physical, sensory or learning disabilities and people who do not speak or read English. The assistance of an advocate, carer or relative may be required with the service users permission.

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Where there are specific cultural/religious practices which affect compliance with treatment the service user should be given the opportunity to discuss and agree adjustments or alternatives to enable treatment to go ahead. If the service user, relatives or carers do not have sufficient understanding of English and the member of staff does not speak their language, an interpreter should be available to assist when giving information. The telephone interpreting service Language Line is available to all Trust staff for short conversations or face to face interpreters can be arranged through the Cross Cultural Services Advisor, Trust Head Office. If a sign language interpreter is required this can also be arranged through the Cross Cultural Services Advisor. It is not good practice to use families, especially children aged 16 and under, to act as interpreters for healthcare information. (See HPFT Policy Communicating with Service Users from Diverse Communities (including Translating and Interpreting Services). 28. Capacity to Consent The Mental Capacity Act 2005 provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves. Everyone working with and/or caring for an adult who may lack capacity to make specific decisions for themselves, must comply with this Act when making decisions or acting for that person. The same rules apply whether the decisions are life changing events or everyday matters. (Please refer to the MCA Code of Practice and the Hertfordshire policy on mental capacity for further information). 29. Deprivation of Liberty Safeguards The Mental Capacity Act contains procedures for authorising the deprivation of liberty in hospitals of some people who lack capacity to consent to being detained in a hospital. These procedures must be taken into account when making decisions to admit to a unit. As part of the Mental Capacity Act and Deprivation of Liberty Safeguards, the Trust is legally required to apply for a standard or urgent deprivation of liberty authorisation before admitting a service user without the required capacity. For further information refer to Deprivation of Liberty Safeguards Code of Practice, which is a supplement to the main Mental Capacity Act 2005 Code of Practice MHA Deprivation of Liberty Safeguards Procedure for Managing Authority and the Herts County Council, Deprivation of Liberty safeguards Supervisory Body Policy and Procedure. 30. Records Management, Confidentiality and Access to Records All NHS employees (including seconded staff) are responsible for all records that they create or use in the course of their duties. This responsibility is defined both in law and in other professional guidelines covering the handling of records. For example, the Public Records Act 1958, the Data Protection Act 1998 and the

http://trustspace/InformationCentre/TrustPolicies/Lists/Policies/DispForm.aspx?ID=197&Source=http%3A%2F%2Ftrustspace%2FInformationCentre%2FTrustPolicies%2FPages%2FMentalHealthPolicy%2Easpx

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Freedom of Information Act 2000. The Trust's Records Management Policies give full details of those responsibilities and the standards that need to be met. 31. Electronic Patient Record Paris is the electronic service user record used by HPFT. Staff are required to record all contacts with the service user on Paris. Paris training is a mandatory requirement for all staff including bank staff 32. Comments, Complaints and Compliments All comments, compliments and complaints should be dealt with in accordance with the HPFT Complaints Policy. This requires all verbal or written complaints to be acknowledged within two working days with copies forwarded to the appropriate line manager and the Complaints and Service Experience Manager at 99 Waverley Road, St Albans. Comments and Compliments, once responded to, should be sent for information to the Complaints and Service Experience Manager also at Trust Head Office. (For more information contact the PALS and Complaints Team on 01727 804629 or look at the HPFT Compliments, Concerns and Complaints Policy and Procedure) 33. Freedom of Information The purpose of the Freedom of Information Act (FOI) is to allow greater access to non-clinical information held by public authorities and potentially every document (that is not about an individual e.g. service user) can be scrutinised by the Public. The Act gives the Public the right to be told whether a piece of information exists and the right to receive it if requested. The FOI Act DOES NOT supersede the Data Protection Act 1998 and information about an individual (and described as personal data) WOULD NOT be disclosed under the FOI Act. 34. Access to Records Members of staff have a statutory duty (Data Protection Act 1998) to inform services users that information is being held by the Trust which records details of their health and social care assessment, treatment and progress, and that these records are identifiable. Service users must also be informed of the right to request access to their records. This information should be given verbally and by offering the service user the relevant information leaflet. The mental health professional should inform the service user that all information is confidential but may be shared on a need to know basis. Application for access to records has to be made in writing and can be sent direct to the CEDS Team Leader. There are special rules regarding legal access to records. If any case arises where legal access is requested staff within CEDS should refer to the Access to Records Policy and discuss with the Service Line Lead.

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35. Health and Safety/Risk Management Members of staff have a duty of care to themselves and to others with whom they come into contact in the course of their work as laid down in the Health and Safety at Work Act 1974 and any subsequent amendment or legislation. All staff are required to participate in the Trusts accident/incident reporting systems and to comply with the Trusts procedures and techniques for managing risks.

36. Access to healthcare for people with a learning disability HPFT have a responsibility to ensure that all people with a learning disability access appropriate services and that they receive the best treatment available in line with good practice and legal frameworks. Therefore all services will ensure that

Reasonable adjustments are made to ensure that each person has the same opportunity for health, whether they have a learning disability or not. (Equality Act 2010)

Assume that each person presented to the service has capacity. If assessment shows they dont, a decision must be made in their best interest. (Mental Capacity Act 2005)

Everyone has a right to expect and receive appropriate healthcare. (Human Rights Act 1998)

Adjustments will include:

spending time with the individual to gain an understanding of their preferences for treatment

To ask them where they would prefer to be treated,

To provide additional support to assist with communication, this support will be available via easy read material/and/or audio equipment. Templates for appointment letters and easy read information leaflets are available via the Performance page on the intranet.

If an individual continues to have difficulty understanding their treatment it is the responsibility of the staff to refer them to a specialist learning disability service for additional support

All people with a learning disability may have a Health Action Plan or Purple Folder and all HPFT staff will ask for permission to see these and contribute to the plan when appropriate

To value and welcome the contribution of the relative/carer/advocate 37. Practice Governance

The service is held within the North and East SBU and the Professional Lead and Clinical Nurse Specialist attend the monthly practice governance meeting covering East and West SBU community services. The team holds a local monthly Practice Governance meeting Quality improvement measuring

Service User and carer experience

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The team uses the Trust Having Your Say forms as well as Focus Groups and Patient Satisfaction Surveys to ensure they are aware of the service user and carer experience

Clinical Effectiveness Outcome questionnaires are administered at the start and end of treatment and midway if the intervention is 40 weeks. In the weekly team meetings outcome indicators are recorded such as return of periods, return to work or study etc. These are then collated by the assistant psychologist.

Safety High risk service users are discussed weekly in the team meeting in order to monitor their risk. The Consultant Psychiatrist or other senior members of the team will always be present for these discussions. All staff are aware of the physical risks associated with eating disorders and will ensure that the service user is monitored regularly through blood tests, ECG and general physical health monitoring such as temperature and blood pressure checks and dental visits.

38. Embedding a culture of Equality & RESPECT

The Trust promotes fairness and RESPECT in relation to the treatment, care and support of service users, carers and staff. RESPECT means ensuring that the particular needs of protected groups are upheld at all times and individually assessed on entry to the service. This includes the needs of people based on their age, disability, ethnicity, gender, gender reassignment status, relationship status, religion or belief, sexual orientation and in some instances, pregnancy and maternity. Working in this way builds a culture where service users can flourish and be fully involved in their care and where staff and carers receive appropriate support. Where discrimination, inappropriate behaviour or some other barrier occurs, the Trust expects the full cooperation of staff in addressing and recording these issues through appropriate Trust processes.

RULE: Access to and provision of services must therefore take full account of needs relating to all protected groups listed above and care and support for service users, carers and staff should be planned that takes into account individual needs. Where staff need further information regarding these groups, they should speak to their manager or a member of the Trust Inclusion & Engagement team. Where service users and carers experience barriers to accessing services, the Trust is required to take appropriate remedial action. . The following table reflects specifically for this policy how the design of the service and processes involved has given consideration to all protected groups so ensuring equality and dignity for everyone.

Service user, carer and/or staff access needs

All buildings used by the team have accessible entrances and clinic rooms for staff and service users. Staff have available adjustable chairs and adjustable workspaces including computer screens and

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(including disability) desks. The team has leaflets which help those with learning disabilities understand their eating disorder and the treatment to be offered. We can provide more non-verbal therapy using the arts if required. The team has access to an interpreter if the service user or carer is not sufficiently fluent in English.

Involvement Service users attend interview panels Service users have helped us present to the Trust public board Peer support group enables service users to be involved in the service beyond discharge We have a database of service users willing to help others

Relationships & Sexual Orientation

All staff are aware that there are different types of relationships and people may express their sexuality in different ways. The team prides itself on valuing all its staff members.

Culture & Ethnicity

Our dietician is very aware of cultural differences in terms of food and will alter her meal plans accordingly As mentioned earlier, we have access to an interpreter if necessary The team respects all cultural and religious holidays where necessary.

Spirituality All service users will have their spirituality respected and the support workers in particular will ensure they are in contact with people who can support them spiritually if they would like this.

Age The service treats everyone with respect whatever their age. We will liaise with CAMHS, STT, TTT and the older peoples service to ensure we are acting in a way that supports the person at their age.

Gender & Gender Reassignment

Mental health services often have more female staff than male but all are treated equally. CEDS has a balance of men and women in leadership positions. People with gender reassignment would be treated according the the gender they have assigned to

Advancing equality of opportunity

All recruitment is carried out according to equal opportunities policies. All staff receive annual appraisals in order that they can develop according to their strengths All service users are offered the same range of treatments when clinically appropriate

39. Process for monitoring compliance with this document

STANDARD

Action: Lead Method Frequency Report to: Performance Monitoring Urgent Referrals and Routine Referrals

Tanya Lovett

Part of performance against Annual Plan / KPIs

Monthly / Quarterly

Trust Board

Audits will be conducted regularly within the CEDS in collaboration

Tanya Lovett

Clinical Audit Ad Hoc Practice Governance

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with the Trusts PACE department

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40. Version Control

STANDARD

Version Date of Issue Author Status Comment

V3 9th December 2010

Service Manager Superseded

V4 11th August 2015 Professional Lead Community Eating Disorders and OCD/BDD Services

Current Updated, including Care Act

41. Archiving Arrangements

STANDARD: All policy documents when no longer in use must be retained for a period of 10 years from the date the document is superseded as set out in the Trust Business and Corporate (Non-Health) Records Retention Schedule available on the Trust Intranet A database of archived policies is kept as an electronic archive administered by the Compliance and Risk Facilitator. This archive is held on a central server and copies of these archived documents can be obtained from the Compliance and Risk Facilitator on request. 42. Associated Documents

STANDARD

The Care Act (2014)

Mental Capacity Act

Clinical Risk Assessment and Management for Individual Service users

County Operational Policy for Support and Treatment Teams and Targeted Treatment Teams

County Operational Policy for Crisis, Assessment and Treatment Teams

Cross Service Protocols. Delivering Social Care Across Service Boundaries

Guidance on Sharing Information and Involvement in the Legal Process of Child Protection

Compliments, Concerns and Complaints Policy

Communicating with Service Users from Diverse Communities (including Translating and Interpreting Services

Health and Safety Policies (HPFT)

Hertfordshire and HPFT Child Protection Policies and Procedures

Hertfordshire Area Child Protection Procedures

Hertfordshire Inter-agency Response to Allegation of Abuse of Vulnerable Adults

Information Governance Policy

Mental Capacity Act Advance Decision to refuse Treatment and Advance Statements (HPFT Policy)

Mental Health Act Aftercare of Patients Under Section 117

PART 3 Associated Issues

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Mental Health Act Deprivation of Liberty Safeguards

Mental Health Act Responding to a Request for a Mental Health Act Assessment

Mental Health Act Supervised Community Treatment

Carers Practice Policy

Social Care Funded Placements

Social Care Charging Policy

Integrated Care Programme Approach and Care Management

Learning from Incidents Policy

Lone Worker Policy

Policy Guidance concerning Risk Assessment and Management Procedures

Policy on Access to Records

Policy on Advanced Directives

Policy on Follow Up After Discharge from Mental Health In-service user Units

Policy on the management of Care Records

Policy on Prevention and Management of Violence

Policy, Procedure and Guidance on the Management of Care Records

Post Incident Support to Staff

Whistleblowing Policy 43. Supporting References

STANDARD

British Psychological Societies (BPS, 2001) Service Guidelines for Eating Disorder Services Bell,

DH (2004). NICE Guidelines for the Assessment, Treatment and Management of Eating Disorders

Engaging and changing (2003) Developing effective policy for the care and treatment of black and minority ethnic detained service users.

EOE reference group (2010). Eating Disorder Regional Commissioning Support Paper

EOE reference group (2010). Specialised Tertiary Eating Disorders (Adult) Service Specification

EOE reference group (2010). East of England Adult Eating Disorders Services: Guiding principles and care pathways

Kings College London (2009). A guide to the medical risk assessment for eating disorders.

Mainstreaming Gender and Womens mental health implementation guide 2003

Marsipan Group (2010, 25th May). MARSIPAN: Management of Really Sick Service users with Anorexia Nervosa, Consultation paper.

Mental Health and Social Exclusion (2004)

Mental Health Act 2007

Mental Capacity Act 2005 & Deprivation of Liberty 2009

NICE (2004). Clinical guideline CG9 - Eating Disorders, Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related eating disorders.

NICE (2009). Clinical guideline 78 - Borderline personality disorder: treatment and management

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Refocusing the Care Programme Approach Policy and Positive Practice Guidance (DH, March 2008)

Royal College of Psychiatrists (2000). Eating disorders in the UK: Policies for service development and training. Report from the Eating Disorders Special Interest Group of the Royal College of Psychiatrists.

The Human Rights Act 1998

The National Service Framework (NSF) for adults with mental health problems (1999)

The Specialised Services National Definitions Set (DH, 2002) 44. Comments and Feedback

STANDARD

List of people/groups involved in the consultation.

Consultant Psychiatrist CEDS Complaints and Service Experience Manager

Lead Psychological Therapist CEDS Consultant Social Worker

Managing Director East and North SBU Community Services

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Appendix A CEDS DNA/Cancellation Policy at Assessment Appendix B CEDS DNA / Cancellation Policy during Treatment Appendix C Hertfordshire Community Eating Disorders Service Assessment Interview Schedule Appendix D Transitions and Interface between CEDS and Primary Healthcare

APPENDICES

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CEDS DNA / CANCELLATION POLICY AT ASSESSMENT DNA AT ASSESSMENT Low / medium risk

1. Check no administrative error has occurred. 2. Assessor asks secretary to send standard letter cced to GP asking client to

contact the service within 7 days if they wish to arrange another appointment, or they will be discharged.

3. Clients who contact for another appointment will be booked in within 28 days of their last offered appointment.

4. A second appointment letter will be sent cced to GP advising that second non-attendance will result in discharge.

5. A final discharge letter will be sent to the GP after second DNA. High risk / urgent

1. The client and referrer will be contacted by phone on the day of the DNA and asked to contact CEDS if no answer.

2. If client answers, another appointment will be arranged within 4 working days. 3. If no response from client / client refusing, liaise with GP / referrer and CEDS

Consultant to determine care plan. 4. MHA assessment might be considered as a last resort.

CANCELLATION AT ASSESSMENT

i. Cancellations and a request for another assessment should result in the client being offered another appointment (within another 28 days from the first appointment offered).

ii. Cancellations without a request for another meeting should result in the DNA procedure appropriate for that clients level of risk (i.e. 7 day contact letter / phone contact).

iii. In most cases 2 cancellations should result in discharge for low / medium risk, and prompt further liaison with GP / Consultant in high risk cases.

Appendix A

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CEDS Policy for DNAs / Cancellations during treatment

All DNA letters should be cced to GPs.

All clients should be advised of policy at start of treatment.

Exceptions should be rare and agreed in supervision, or among relevant professionals.

Non-attendance and its meaning should be routinely discussed in treatment

DNAs Low / medium risk clients

1. Check no administrative error has occurred. 2. Clients will be contacted by letter after the first DNA and asked to contact the

service within 7 days if they wish to arrange another appointment. 3. Letters can be therapeutic and include reflections on possible reasons for DNA,

etc. (see examples). They are designed to be warm and engaging while also setting the basic limits and expectations of therapy.

4. Following no response to this, a second letter should be sent to the GP stating that the non-response has been perceived as opting out of treatment and that they will be discharged back to their GP or referring service. Again, this can be therapeutic as required.

5. 2 DNAs should result in discharge. High risk clients (eg BMI < 14, critical physical risk, recent significantly low mood, risk of serious self-harm)

1. Client should be contacted by phone, and if no answer, a message should be left asking them to contact CEDS asap.

2. A DNA of a client with high risk should trigger discussions between clinicians (including CEDS Psychiatrist and the GP where relevant) to establish urgency of situation and necessary level of contact.

3. If deemed not urgent, see guidelines for low / medium risk clients. 4. 2 consecutive or non-consecutive DNAs with a specific clinician should be

discussed between the relevant clinicians including the relevant medical colleagues. This might be followed up with a review or discussions in team or professionals meetings. If clients are to be actively engaged via texts and phone calls, this should be agreed in advance with clients informing them of DNA policy.

Cancellations

iv. Cancellations and a request for another meeting should normally result in the client being offered another appointment by phone or letter.

v. Cancellations without a request for another meeting should result in the DNA procedure appropriate for that clients level of risk (i.e. 7 day contact letter / phone contact).

vi. In most cases (i.e. all but exceptional circumstances), 2 consecutive or 4 non-consecutive cancellations should result in discharge in low / medium risk cases, and prompt a discussion with the wider team in high risk cases as per DNAs.

Appendix B

HERTFORDSHIRE COMMUNITY EATING DISORDERS SERVICE

ASSESSMENT INTERVIEW SCHEDULE

ASSESSMENT INTERVIEW SCHEDULE Assessment Date: Assessor:

Name:

DOB: Trust No.:

Male/Female:

Age: Ethnicity:

Occupation:

Do you have the correct details (including phone number) for the patient and the GP Yes/No

Current Weight:

Height: BMI:

Presenting problem: Referral and general description of the problem How did the referral originate, who is involved and how does the patient feel about this? What does the patient see as the problem: What bothers them most?

The problem in more detail: What exactly is the problem?

History of eating disorder: Onset, precipitating, perpetuating factors, relapses and remissions, change in the pattern (ie restricting to binge-purge) Childhood relationship with body, weight and shape (i.e. look for teasing, importance of body/weight/shape in family, awareness of physical self, how did this change in adolescence.)?

Appendix C

Eating disorder patterns: Current pattern of eating (e.g. routinised, chaotic; note times/details of food eaten) B: S: L: S: D: S: Nocturnal

Beliefs about food, eating, weight and shape: Preferred foods, forbidden foods?

Dietary rules: Any definite rules/rituals regarding eating (e.g. calorie limits, pre-set quantities of food, timing of eating?)

Binge Patterns (objective/subjective): For BN 2x week for 3 months; Do you get preoccupied with eating and strong compulsions/cravings to (binge) eat (ICD-10, BN)? When you binge eat do you have a sense of loss of control over eating (e.g., a feeling that you cannot stop eating or control what or how much you are eating)? Yes/No

Restrictive Patterns: Over recent months have you consciously tried to restrict or avoid eating any fattening foods in order to lose weight (ICD-10, AN)?

Compensatory Behaviours: Please give details of any behaviour that you use to prevent weight gain or to counteract the fattening effects of food

Frequency per day/week

Past Occurrences

Self-induced Vomiting

Excessive exercising (e.g. 4+ hours per week to lose weight)

Laxative misuse

Drugs (e.g. diuretics, diet pills or appetite suppressants)

Alternating periods of starvation

Body Image Concerns: How does the patient see his/herself? What do they feel about their body/shape, specific parts of the body that they dislike? Do you perceive yourself as being too fat? Over recent months, have you been intensely afraid that you might gain weight (or become too fat) (ICD-10, AN & BN)? Do you have a strong desire to lose weight or to keep your weight at a certain (low) level (ICD-10, AN)?

Any body/weight checking behaviour? Avoidance of seeing body (e.g. in mirrors)? Internet and media (Pro-ana websites, celebrity magazines)

Physical Health Explore whether the client has any of the following symptoms (e.g. history of falling or fainting; weakness in muscles, e.g. difficulty climbing stairs, shortness of breath; dry skin; hair loss; feeling bloated after eating; heartburn; dental problems; heart irregularity; orthostatic hypotension, sleep disturbance, loss of sexual interest or potency in men)? Menstrual history and patterns Smoking? History of pregnancy or terminations?

Current Weight: Height:

Highest Adult Weight:

When?

Lowest Adult Weight:

When?

Desired Weight:

Psychiatric history and co-morbid difficulties: Including Impulsive behaviours, self-harm (current self-harm ideation include suicidal thoughts and attempts, cutting, burning etc)

Mood/Other Psychiatric Symptoms Financial Social Employment/Education

History of psychiatric and psychological treatment

Medical/Surgical History

Current Medical Interventions: Who else is involved in treatment?

Current (previous year) medication

Personal and Family History (Family Circumstances): Who is close to the patient? Genogram to include ages, occupation, history of weight problems, eating disorders, physical or mental health problems. Current alliances, conflicts and patterns relating to family beliefs about food, weight, dieting. Family beliefs about the patient and his/her condition. Family beliefs about how the problem can be solved. Other ED in family. Relevant religious, ethnic, cultural or social aspects of family life.

Emotional Environment in Family Care giving/receiving, competitiveness, abuse, dependency/independence Is the patient a carer? Do they have a carer? Carer details? . Carer assessment offered. Relevant religious, ethnic, cultural or social aspects of family life

Personal History: Current social situations, friends, work, social life, religion, living arrangements; School, college life, relationships, employment and developmental milestones

Premorbid Personality:

Forensic History/Alcohol & Drugs:

MSE 1. Appearance, rapport

2. Speech

3. Mood, affect, suicidal intent

4. Thoughts

5. Perceptions

6. Cognition

7. Insight

Motivation to Change to have an overview throughout the assessment (Include patients description of their motivational stage, current fears, coping strategies for fears, physical, social and psychological, work and financial concerns, areas of hope and optimism).

precontemplation (No intention of changing behaviour) contemplation (i.e. aware a problem exists but no commitment to action) preparation (i.e. intent upon taking action) action (i.e. active modification of behaviour) maintenance (i.e. sustained change where new behaviour replaces old) relapse (i.e. falling back into old patterns of behaviour) stage of motivation.

What is the service user hoping for?

Summary and suggested treatment/care plan

Preliminary Formulations

Treatment offered

Action taken

Bloods requested

CMHT/GP contact

Assessors signature

Date:

Transitions and interface between CEDS and primary healthcare Anorexia nervosa NICE Guidelines (2004) advise that all service users presenting with anorexia nervosa at primary care level should be offered a range of diagnostic tests as part of the initial assessment. The guidelines advise that GPs should take responsibility for the initial assessment and initiate the coordination of care. This assessment should also include the determination of emergency medical or psychiatric assessment. The guidelines recommend as a minimum the following:

Height weight and BMI

Centile charts for age less than 18

Pulse and blood pressure. The guidelines further recommend the following as being helpful in assessing the risk of physical instability:

Core temperature

Examination of peripheries

Cardiovascular examination including postural hypotension

Situp/squat test (a test of muscle power) (Robinson, 2006) Investigations suggested are:

Full Blood Count, ESR, Urea and Electrolytes, Creatinine, Liver Function Tests, Random Blood Glucose, Urinalysis.

ECG: This should be considered in all cases and is essential if symptoms/signs of cardiac compromise, bradycardia, electrolyte abnormality or BMI less than 15 kg/m2. (Or equivalent on centile chart.)

Further tests may be required in more severe cases or to assess complications: Calcium, Magnesium, Phosphate, Serum Proteins, Creatine Kinase (CK or CPK). Tests that may be needed in the differential diagnosis of amenorrhoea and weight loss:

Thyroid Function Tests,

Follicle Stimulating Hormone,

Lutenising Hormone,

Prolactin,

Chest X-Ray

DXA scan for identification of osteopenia/osteoporosis, which may occur after six to 12 months of amenorrhoea. (Although this is not necessarily a primary care level investigation, it has been suggested that it may be helpful in encouraging motivation for change in those not yet ready to accept referral, by demonstrating the real physical consequences of anorexia nervosa).

Appendix D

Bulimia nervosa

NICE Guidelines state that with bulimia nervosa and related conditions, characteristic physical signs have been described for example, parotid enlargement, Russells sign (callus formation on the dorsum of the hand) and dental enamel erosion, which are usually manifestations of purging. In practice these are not seen in the majority of service users presenting in primary care with bulimic disorders, although electrolyte abnormalities are reasonably common, so urea and electrolytes should be routinely obtained. Management guidelines If the service user is:

Severely underweight (BMI 15 or below) or complains of weakness, dizziness or service user looks ill: carry out physical examination, blood tests

Medically unstable e.g. dizzy, weak, dehydrated refer to General Hospital for medical stabilisation and liaise with CEDS

Severely underweight, acute presentation, BMI below 15, but medically stable, refer to CEDS and review on a weekly basis at GP surgery

Medically stable, moderately rather than severely underweight (e.g. BMI 15-17) refer to CEDS and monitor regularly in the GP surgery, whilst waiting to be seen

Mildly ill/mildly underweight or of normal weight, offer advice, support and information about self-help e.g. Eating Disorder Association, Self Help Books, refer to short term Primary Care Counselling Services

Depressed, treat as per Depression Guidelines.