Adult Eating Disorder Specialist Inpatient Services

Provision Option Appraisal

Background

The Welsh Health Specialist Services Committee (WHSSC) commissions specialist inpatient eating

disorder services on behalf of the 7 local health boards and their resident populations in Wales. Tier-

4 services are currently provided by services in England; Cotswold House1 in Marlborough for

residents of South Wales and South Powys, and Oaktrees Unit2 in Cheshire for the residents of North

Wales and North Powys. A recent audit by the Aneurin Bevan Health Board discovered individual

Health Boards were also carrying cost pressures for admissions for inpatient stabilisation and

refeeding. Although admissions for emergency medical stabilisation and highly specialized treatment

in Tier-4 ED services is low volume, it is also high cost with variable outcomes apparent. This

variability of admission venue closely mirrors the situation in CAMHS (Glaze 2012i). Further concerns

centre on the variable adoption of Standard 5 in the Eating Disorders Framework for Wales 2009ii,

which describes the arrangements to be made for the provision of a range of acute and general

medical treatment services. Clinical concerns centre on the financial and practical burdens on

patients and families of being treated many miles from their home-base, alongside difficulties in

coordinating care and discharge planning. First-language Welsh patients are disadvantaged by the

lack of availability of therapies in their preferred tongue, and linking with social services support and

housing for aftercare is also hampered. Though Oaktrees cases are commissioned on a cost per case

basis, the service agreement with Cotswold House is due to end on 31st March 2013, making this a

good time to review Tier-4 ED Service provision for Wales with respect to cost, value and quality and

arrangements more generally for Emergency Medical Care.

The Project Team and Options Appraisal Task

This Options Appraisal has been prepared by a task and finish group (the Project Team) consisting of

the Tier-3 Eating Disorder Clinical Leads, a Senior Representative from WHSSC, Service User and

Carer Representation via B-Eat Cymru, a Consultant Physician, a CAMHS representative, Senior

Representation form 1000 Lives Plus, the Chair of the All-Wales Eating Disorders Clinical Network

and a Dedicated Project Manager. The Project Team has also established close links with the CAMHS

National Expert Reference Group (NERG) and the Mental Health Clinical Directors Forum.

The Project Team has duly examined the feasible options for both acute re-feeding beds and Tier 4

Services for the population of Wales to ensure the highest quality services are commissioned within

1 Cotswold House Specialist Eating Disorders Service, Savernake Hospital, Wiltshire. The service is hosted by

the Oxford Health NHS Foundation Trust and is situated east of Marlborough town centre on the A4 London Road and can be easily reached from the M4. See http://www.cotswoldhouse.nhs.uk/ for further details. 2 Oaktrees Eating Disorder Unit, Springview Hospital, Clatterbridge Road, Bebington, Wirral CH63 4JY. The

service is hosted by the Cheshire and Wirral Partnership NHS Foundation Trust. For further information see http://www.youtube.com/watch?v=h6s6vglQQUw and http://www.cwp.nhs.uk/services/244-eating-disorders.

the resources currently available to ensure optimal outcomes for patients and carers with best

value. This has included a baseline assessment of existing service provision and a determination of

costs to establish existing spend, alongside a thoughtful review of options for future service

provision. Affordability and practicality with respect to geographical differences has been a key

consideration with differing solutions plausible for North versus South Wales.

This Report

This report sets out descriptions of Emergency and Tier-4 ED Service Care, a financial analysis of

historical costs, a summary of option groups, a list of specific proposals, a for-and against analysis of

the specific proposals and a summary conclusion.

Definitions

Emergency Medical Care

Careful attention to physical care is required throughout the assessment and treatment

process of care with eating disordered patients. Standard 5 of the Framework for Wales sets

out some of the components of necessary provision for acute and general medical

treatment services. These include organizations specifying their arrangements for the

provision of:

Appropriate diagnostic and treatment responses from

o Paediatric

o Adult General Medicine

o Dietetics

Other appropriate medical specialties according to specific individual circumstances

The extent of medical services’ responsibilities for providing direct intervention into

psychiatric settings, and direct treatment in non-psychiatric settings, both need to be

defined. It is expected that Specialist Tier-4 ED services will be competent to diagnose and

manage a range of physical consequences of severe eating disorders and guidance on these

issues is comprehensively described in Junior MARSIPAN: Management of Really Sick

Patients under 18 with Anorexia Nervosaiii, Choosing treatment settings for adolescent

anorexia nervosa: admission to the paediatric ward in context and MARSIPAN: Management

of Really Sick Patients with Anorexia Nervosaiv.

Emergency Medical Care is any care that may be required to assess or treat medical issues

that are severe, unexpected or unexplained and of a nature and degree that could lead to

the death of the patient. It will always be necessary for life saving and highly specialized

medical treatments to be available for these patients from time to time. However these

interventions are usually brief and time limited aimed at restoring physical parameters back

to a healthy range, or undertaking the initial 7-10 days of refeeding in severe cases of

malnourishment where there is a very high risk of refeeding syndrome developing. The

medical environment is not generally suitable for substantial renourishment, or the

management of necessary psychiatric care for the Eating Disorder itself, or indeed other

psychiatric Comorbidity particularly around suicide or absconsion risk.

Nasogastric (NG) tube feeding is something that can easily be done in a medical setting,

however the psychiatric intervention for a resistant or ambivalent patient would not be

readily available (ie. 1-to-1 nursing for supervision and support) to support this. NG feeding

is rarely possible on an adult psychiatric ward, and treatment and prevention of refeeding

syndrome is not possible on a psychiatric ward. As we have seen, long-term nasogastric tube

feeding on the medical ward is not usually appropriate. CAMHS inpatient units do vary, but

both of the units in North and South Wales are comfortable with nasogastric tube feeding

and this prevents unnecessary toing and froing between the paediatric and psychiatric

settings.

Tier-4 ED Service Care

Tier 4 eating disorders services provide intensive specialist psychiatric care for eating

disorder psychopathology, and any coincident comorbidity (eg. depression with suicidality,

self-harming behaviours, substance misuse, borderline personality disorder), and fairly

intensive physical support consequent on the renourishment task and the physical problems

caused via starvation or purging behaviours. This will certainly include structured meal

planning, intensive group and individual programmes of psychological interventions, dietetic

interventions, occupation therapy interventions, family therapy, mealtime support at the

table for eating, regular blood monitoring for bone marrow suppression, liver failure,

electrolyte disturbances, hypophosphataemia and dehydration. These units will usually be

able to perform ECGs and will be proficient at nasogastric tube feeding. Medical assessment

may also include less frequent measurement of other parameters including bone-density,

pelvic ultrasound and brain MRI. This may require transport off-site, making proximity to

comprehensive medical facilities essential.

Lengths of stay are typically much longer than on acute medical wards and may range from

a few weeks through to many months depending on the extent of the starvation prior to

admission, comorbidity and the patient’s ability to resume independent eating.

Financial Analysis of Historical Costs

A baseline assessment was conducted for the years 2010-2012 in order to establish the number and

cost of admissions for patients presenting with an eating disorder to both an acute medical bed and

an out of area inpatient bed. The total number of admissions and cost of those admissions is

outlined below in table 1. The data presented is for adults and is for the whole of Wales. As is

highlighted in Table 1, the cost and number of patients over this time period have remained very

similar, however the average cost per bed day has decreased from £603 to £449.

A full analysis of the placements by LHB is found in appendix 1 and 2.

Table 1

Total no. of

Inpatient

admissions

Total no.

Medical

admissions

Cost of

inpatient

admissions

Cost of

medical

admission

(av. £300 pbd)

Total cost

2010 –

2011

36 31 £1,453,705

(av. £603 pbd)

£225,280 £1,678,985

2011 -

2012

38 31 £1,393,006

(av. £449 pbd)

£212,023 £1,605,029

OPTION OUTLINES FOR SPECIALIST INPATIENT SERVICES FOR

ADULTS WITH EATING DISORDERS IN WALES

Options are outlined below for consideration with respect to three areas of service provision which

comprise, or impact directly upon, the provision of specialist inpatient services for adults with eating

disorders in Wales. These include:

a) specialist inpatient treatment for eating disorders;

b) specialist medical settings for the treatment of severe medical sequelae of the initial

refeeding process for cases of severe malnutrition or other medical instability such high risk

potassium levels due to purging arising directly from an eating disorder;

c) intensive home support for patients who would otherwise be requiring inpatient services as

within services (a) or (b) as above.

The options outlined here are to be considered for each of these three service areas in turn, and a

single preferred alternative option to the current model of provision is to be identified in each of the

three areas of provision. Every effort is to be taken to ensure that the preferred options within the

three service areas are complementary and form a unified and clinically coherent model of specialist

service provision for eating disorders in Wales.

a) Specialist Inpatient Treatment For Eating Disorders

Option 1: No Change

Specialist inpatient treatment for eating disorders continues to be provided by services external

to Wales within North and/or South Wales regions, under the oversight of the Eating Disorders

Policy of the Welsh Health Specialist Services Committee.

Option 2: Dedicated Specialist Eating Disorders Unit (SEDU) Inpatient Service

A service would be established that was dedicated to the provision of specialist eating disorders

inpatient treatment, where patients are medically stable to the point of not requiring the

intensive medical treatment as would be provided by a medical team on a medical hospital

ward. Such a service would comprise provision for weight restoration treatment and support

and intervention targeted at addressing the complex behavioural and psychological aspects of

eating disorders. Patients would be referred to the dedicated specialist eating disorders service

rather than to the LHB’s generic adult mental health inpatient services where the level of

complexity of behavioural issues and/or medical issues are deemed to exceed what can be

support appropriately within a generic adult mental health ward. Patients would be admitted to

the dedicated specialist eating disorders inpatient service either to achieve weight restoration

and/or medical stability only, where the patient is not motivated to achieve full recovery from

the eating disorder, or full treatment to a healthy weight, where the patient is motivated to do

so. This service would be established to serve either the whole of Wales or on a regional basis

for North and/or South Wales.

Option 3: Hybrid Model

Local specialised eating disorder beds would be established in a designated side ward of a local

generic inpatient adult mental health units within a Health Board. There would be continued use

of out-of-area specialist eating disorders unit(s) (SEDU’s) for the more complex patients who

require highly specialised inpatient treatment. The local designated ED beds should be

earmarked and kept as eating disorders beds and the “mini unit” set up in such a way as to be an

enhancement on what currently is provided for eating disorder patients on local psychiatric

inpatient units. This option has the potential to address issues of accessibility, applicability, and

acceptability.

The hybrid option model would comprise:

For a region of Wales- Local specialist eating disorders psychiatric beds on a side ward of a centrally positioned generic mental health inpatient unit, preferably on the site of a local DGH and same site as agreed local ED medical beds (if this arrangement for medical services provision for eating disorders continues). Number of beds dependant on the demand and need in that particular region.

Individual bedroom beds in a private and special area of the unit set up specifically for ED patients and staffed by specially trained staff, to be agreed as local specialist ED beds and kept for local ED patients.

Tier 3 ED teams to co-ordinate training up of inpatient staff and inpatient staff on going CPD.

Tier 3 ED Teams monitor all local inpatient cases.

In reach and close liaison by local community Tier 3 ED Team and CMHT clinicians with patients and staff in the local ED beds.

There would be a cost implication for extra staffing including 1:1 nursing and any additional facilities, although cost effective use of existing resources would also be utilised.

Arrangements would still continue to be made by local Tier 3 Teams for transfer to out of area SEDU if appropriate for a particularly complex patient (but likely to be less due to use of local beds).

b) Specialist Medical Settings

Background

Medical services are considered to be those services which provide physical care of individuals with

an eating disorder and mainly focus on the delivery of inpatient services, which cannot be provided

in other locations. This often involves the treatment of patients thought to be at high risk of the

refeeding syndrome, where electrolyte abnormalities, such as low blood levels of potassium and

phosphate are common and often require close physical monitoring and the administration of

intravenous drugs and fluids. Nasogastric feeding can be commenced on a medical ward, where this

facility is not available elsewhere. Such admissions typically should last 1-2 weeks but are often

longer. Shorter admissions are commonly required for treatment of electrolyte abnormalities such

isolated low blood potassium levels in a patient who is vomiting and or using laxatives.

Currently in Wales, these services are provided with variation in terms of ease of access and relevant

medical and nursing expertise. This is for both outpatient advice, to potentially prevent hospital

admission and also with respect to providing care as a medical inpatient. Inpatient services are

currently provided at the patient’s local district general hospital and outpatient services are mainly

provided by primary care with variable input from secondary care across Wales.

Option 1: No change

Medical services will continue to be provided by each Health Board on an individual basis.

Option 2: Local Provision Enhancement

Services within the Health Boards will be enhanced in order to meet the requirements of the Wales

Eating Disorders Framework (2009, Welsh assembly Government). Typically this will require at least

1 consultant session per Health Board, and the development of local nursing expertise (including the

provision of 1 to1 nursing care) with a dedicated environment for the treatment of patients with

eating disorders, such as a bed on a medical ward, with access to outpatient opinion and close links

to local Tier 3 eating disorders service.

Option 3: Regional Medical Eating Disorders Service + Local Medical Services

Assuming the establishment of a Welsh dedicated specialist eating disorders unit (SEDU) inpatient

service, enhance the provision of local medical services within the individual Health Boards in

addition to developing a regional service which is co-located on the same site as the SEDU. This

would likely require less consultant input and less nursing development required for local services,

but greater nursing and consultant input required by the regional service.

Option 4: Regional Service Alone With No/ Very Limited Provision of Secondary Care Local Medical

Services

Assuming the establishment of a Welsh dedicated specialist eating disorders unit (SEDU) inpatient

service, establish a regional medical service which is co-located on the same site as the SEDU to

undertake all inpatient medical intervention in relation to eating disorders, with little or no provision

from individual Health Boards.

c) Intensive Home Support

Option 1: No change

There are currently no Intensive Home Support services for eating disorders in Wales.

Option 2: Intensive Home Treatment Service to Prevent Inpatient Admissions

A service would be established to provide home based care, treatment and support to those people

with an eating disorder that are likely otherwise to require admission to an inpatient eating disorder

unit and who do not require medically managed refeeding in the Health Board’s general hospital.

Support would be delivered intensively at the person’s home with the aim of weight restoration and

treatment of the complex behavioural and psychological aspects of the eating disorder. The service

would be available to those that wish to achieve weight restoration to a healthy weight and to those

that are not motivated to full recovery but who require this level of intervention to stabilise their

presentation and reduce the level of risk associated with their eating disorder.

Option 3: Intensive Home Treatment Service to Prevent Inpatient Admissions & Prevent Relapse

Following Discharge From Inpatient Services

Weight loss during the first 28 days following an admission for weight restoration in Anorexia

Nervosa is the primary marker for relapse in this group of patients. In order to mitigate against this

occurring, the Intensive Home Support could facilitate transition from inpatient services to the

community by providing intensive support in the home to maintain weight and behavioural changes.

CONSULTATION STRATEGY

This options report will be utilised for consultation purposes within Health Boards, and to serve as a

framework for a stakeholders' event. The outcome of this consultation process will be a final options

report in September 2013.

Appendix 1

Adult medical bed admissions

(Based on bed occupancy not patient episodes )

Cwm Taf Total no. of

admissions

Average length

of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 3 28 £16,200 £5,400

2011 - 2012 2 40 £19,500 £9,750

Cardiff & Vale Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average

cost per

admission

2010 – 2011 4 44 £13,200 £3,300

2011 - 2012 4 17 £21,900 £5,475

ABMU Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average

cost per

admission

2010 – 2011 7 15 £32,100 £2,140

2011 - 2012 10 24 £67,500 £6,750

Hywel Dda Total no. of

admissions

Average length

of stay

Total cost of

admissions

Average

cost per

admission

2010 – 2011 7 36 £110,200 £15,743

2011 – 2012 7 20 £54,300 £7,757

ABHB Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average

cost per

admission

2010 – 2011 2 20 £27,154 £13,577

2011 - 2012 1 35 £29,023 £29,023

Specialist Inpatient treatment

Adult Out of

Area

Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 36 71 £1,453,705 £40,381

2011 - 2012 38 89 £1,393,006 £36,659

SW CAMHS

Unit

Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 10 101 £579,436 £57,944

2011 - 2012 16 141 £1,325,016 £82,814

NW CAMHS

Unit

Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 11 191 £967,840 £87,985

2011 - 2012 13 101 £605,880 £46,606

BCUHB Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average

cost per

admission

2010 –2011 8 Tbc £26,400 £3,300

2011 - 2012 7 Tbc £19,800 £2,828

Adult total Total no. of

admissions

Average

length of stay

Total cost of

admissions*

Average cost

per

admission

2010 – 2011 31 39 £225,280 £7,267

2011 – 2012 31 34 £212,023 £6,839

CAMHS OOA Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 5 214 £1,139,787 £227,957

2011 – 2012 10 164 £1,298,697 £129,870

CAHMS total Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 26 168 £2,687,063 £103,349

2011 – 2012 39 135 £3,229,593 £82,810

Inpatient total Total no. of

admissions

Average

length of stay

Total cost of

admissions

Average cost

per

admission

2010 – 2011 86 144 £4,140,768 £48,148

2011 – 2012 108 124 £4,622,599 £42,802

(The figures are based on approximate costs of bed days and reported lengths of stay)

Appendix 2

Bed day costs

Average

of Cost /

bed-day Year

Inpatient

/ Other LHB 2009/10 2010/11 2011/12

2012/13 M1-

3 Grand Total

Inpatient Abertawe Bro Morgannwg 539 702 417 879 594

Aneurin Bevan 784 661 417 0 530

Betsi Cadwaladr University LHB 492 559 518 492 505

Cardiff and Vale 600 600 453 442 533

Cwm Taf 584 603 417 442 529

Hywel Dda 775 558 425 442 575

Powys 555 562 417 0 514

(blank) 579 0 0 0 579

Inpatient

/ Other Placement 2009/10 2010/11 2011/12 2012/13 M1-3

Grand

Total

Inpatient Aintree 438 438

Capio 706 706

Cheshire and Wirral Partnership 530 522 492 512

OBMH NHS Foundation Trust 637 577 417 442 515

Priory Altrincham 530 530

Priory Bristol 661 692 733 694

Priory Highbank 587 587

St Georges 879 879

The Huntercombe 640 640

The Retreat York 504 504

Inpatient Total 595 603 449 469 535

Inpatient

Total 595 603 449 469 535

NHS Bed day costs

Cost of an acute medical be day *£300

*Using 2011 / 12 data at present, the ABHB average fully absorbed# cost for a medical bed in the

2010 / 11 financial year was £300. This is also consistent with an average across Wales.

# fully absorbed means that they include direct costs, eg ward nursing costs, plus indirect costs, eg

Pathology costs, plus overhead costs, eg Works and Estates.

(direct costs + indirect costs + overheads = fully absorbed cost)

Bank Nurse costs taken from the All Wales Agency Project (Health Board Bank) cost range from

2010/11

1-1 nursing calculations for 24hr 1-1 RMN used the band 5 range Table below gives rates for AWAP

and the agency rates used.

i Choosing treatment settings for adolescent anorexia nervosa: admission to the paediatric ward in context. Glaze R, Welsh Paed J 2012; 36: 3-10.

ALL WALES AGENCY PROJECT (BANK) RATES AS OF 2010/11

AWAP - BAND & SHIFT Hourly Rate

HhhhhrHOUR

AWAP – BAND & SHIFT Hourly Rate

BAND 3 DAYS (MON-FRI) £15.73 BAND 6 DAYS (MON-FRI) £27.18

BAND 3 NIGHTS (MON-

FRI)

£21.55 BAND 6 NIGHTS (MON-FRI) £35.36

BAND 3 SATURDAY £21.55 BAND 6 SATURDAY £35.36

BAND 3 SUNDAY &

B.HOLS

£27.38 BAND 6 SUNDAY & B.HOLS £43.50

BAND 5 DAYS (MON-FRI) £22.03 BAND 7 DAYS (MON-FRI) £32.48

BAND 5 NIGHTS (MON-

FRI)

£28.64 BAND 7 NIGHTS (MON-FRI) £42.21

BAND 5 SATURDAY £28.64 BAND 7 SATURDAY £42.21

BAND 5 SUNDAY &

B.HOLS

£35.25 BAND 7 SUNDAY & B.HOLS £51.95

AGENCY RATES 2011

ANDOVER AGENCY Hourly Rates THORNBURY AGENCY Hourly Rates

Qualified Qualified

Monday to Friday £22.31 8am – 2pm Mon - Fri £48.95

Sat and Nights £29.00 2pm 8pm Mon – Fri £64.95

Sunday £35.69 Fri from 2pm – Mon 8am £69.45

Unqualified Unqualified

Monday to Friday £13,66 8am – 2pm Mon - Fri £32.25

Sat and Nights £19.67 2pm 8pm Mon – Fri £41.95

Sunday £25.66 Fri from 2pm – Mon 8am £46.45

ii Eating Disorders – A Framework for Wales. Welsh Assembly Government. 2009.

http://wales.gov.uk/docs/dhss/publications/090703eatingdisorderframeworken.pdf iii Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia Nervosa. January 2012. Royal

College of Psychiatrists College Report. http://www.rcpsych.ac.uk/files/pdfversion/CR168.pdf. iv MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa.

http://www.rcpsych.ac.uk/files/pdfversion/CR162.pdf.