CONNECT: West Yorkshire and Harrogate Adult Eating Disorder Service – Leeds & York Partnership NHS Foundation Trust – Winners – #MHAwards18 & #MHAwards19

The CONNECT service is the first adult eating disorders service of its size in the UK to offer a consistent and integrated pathway of care offering a multi-tiered approach to treatment in line with the newly revised NICE and MARSIPAN guidelines (2017, 2014). In addition to this it is one of only two adult eating disorders NHSE New Care Models initiatives trialling devolved commissioning as a means of delivering cost-effective, high quality care. Since CONNECT went live in April 2018, the service has been able to offer evidence-based and equitable community and inpatient treatment to patients outside of Leeds who the vast majority had previously been unable to access to a level which was required to meet their complex needs. We have already received overwhelming positive feedback from service users, carers, GPs, secondary mental health services, commissioners and other stakeholders.

https://www.leedsandyorkpft.nhs.uk/our-services/services-list/connect-west-yorkshire-harrogate-adult-eating-disorders-service/

WINNERS - #MHAWARDS18 & #MHAwards19

Co-Production

  • From start: No
  • During process: Yes
  • In evaluation: Yes

Evaluation

  • Peer: Yes
  • Academic: Yes
  • PP Collaborative: Yes

Find out more

 

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

Prior to the development of CONNECT, service provision for adults with eating disorders across the West Yorkshire and Harrogate footprint was extremely varied with significant inequalities noted with regards to availability of integrated evidence-based community care, significant delays in accessing care and long distances required to access treatment. Moreover regional eating disorders care pathways lacked a cohesive framework meaning that service commissioning, design and provision were often disjointed across in-patient and community pathways resulting in potentially avoidable treatment delays, increased hospitalisation to out-of-area placements, poor clinical outcomes and service user and family dissatisfaction. The CONNECT service aims to provide: • a consistent and integrated pathway of care across the West Yorkshire and Harrogate footprint which spans a number of tiers including specialist adult community-based eating disorder services and specialist tier 4 adult eating disorders in-patient beds (ward 6, Yorkshire Centre for Eating Disorders, Leeds), with links to local mental and physical health providers, Universities, colleges and third sector/ voluntary agencies. • an improved, joined-up system approach to the care and treatment of adults with eating disorders across the West Yorkshire and Harrogate health system and wider services, resulting in improved service user outcomes and experience and improved transitions between services. • high quality treatments as recommended by the National Institute for Clinical Excellence (NICE) guidelines on eating disorders (NICE, 2017) to facilitate positive change in individuals with eating disorders. • a multi-disciplinary team (MDT) approach to care and treatment which allows individuals to develop and achieve personal growth whilst promoting autonomy and investment in shaping their own treatment. • consistent and equitable access to the same level and standard of care and services across the West Yorkshire and Harrogate footprint. • a significant reduction in length of stay within tier 4 in-patient services and out of area placements with admission only occurring when this is absolutely clinically necessary. • maximised use of digital and other technological approaches (e.g. tele-consultation, therapeutic apps, online chatrooms) to enhance service delivery • a consistent, coordinated and strengthened approach to the delivery of ‘Management of Really Sick Patients with Anorexia Nervosa’ (MARSIPAN) (RCPsych, 2014) in partnership with acute hospital partners across the region. • enhanced links and accessibility of advice and support to local mental health services (both adult and CAMHS), primary care, acute providers and third sector organisations across the region. • Tailored support for families and carers of individuals with eating disorders and involving key people in treatment where appropriate

 

What makes your service stand out from others? Please provide an example of this.

The CONNECT service is the first adult eating disorders service of its size in the UK to offer a consistent and integrated pathway of care offering a multi-tiered approach to treatment in line with the newly revised NICE and MARSIPAN guidelines (2017, 2014). In addition to this it is one of only two adult eating disorders NHSE New Care Models initiatives trialling devolved commissioning as a means of delivering cost-effective, high quality care. Since CONNECT went live in April 2018, the service has been able to offer evidence-based and equitable community and inpatient treatment to patients outside of Leeds who the vast majority had previously been unable to access to a level which was required to meet their complex needs. We have already received overwhelming positive feedback from service users, carers, GPs, secondary mental health services, commissioners and other stakeholders.

Some of our main achievements include: • Successful delivery of the regional clinical model and care pathway • Repatriation of all pre-existing out of area placements • 24% reduction in hospital bed days • £515k savings accrued (Apr-Oct 2018) to be re-invested into community services • Integrated the FREED (First Response Early Intervention in Eating Disorders) pathway into our community teams on the back of acting as a partner site in the FREED-UP research trial • Development of a group therapy protocol for delivering MANTRA (The Maudsley Model of Anorexia Nervosa Treatment for Anorexia) which is being used for a multi-site RCT planned for 2020 • CONNECT MARSIPAN ‘hub and spoke’ model has been used as the basis for the new national RCPsych national MARSIPAN dissemination strategy • The CONNECT appeal process regarding ‘patient choice’ for inpatient treatment has been used as a template for other regional Integrated Care System Initiatives

 

How do you ensure an effective, safe, compassionate and sustainable workforce?

We rely heavily on input from service user representatives in our recruitment and selection processes. The CONNECT service provides a diverse training, supervision and support programme for its staff members which is anchored in the wider values of the service (see above). We believe that by providing safe, compassionate, individualised and high quality training, supervision and support, our workforce will feel safe and supported such that individual growth can be achieved which in turn will help the service to grow and flourish in the future. Examples of this include: • Regular reflective practice sessions for each of the four CONNECT teams, facilitated by an external consultant • Regular clinical, professional and line management supervision • Regular staff development training sessions – development of an in-house training programme which includes various topics from basic eating disorder awareness to training in specific therapeutic models, as well as enabling personal reflection • Regular team formulation sessions are facilitated to enable quality discussion about clinical material, allowing the team to share any difficulties they are experiencing, recognising emotional responses to the work and supporting them to continue to hold a compassionate understanding of individuals, with a clear care plan being developed as a result.

 

This is an example of supporting staff and service users simultaneously • Employing 2 peer support workers across the service (1 peer support worker per community team) to enhance the support provided to service users and carers within the service. • Regular organisational development workshops (e.g. away days) to promote team working and shared visions. • Developing service champion roles within the service to ‘devolve’ responsibility such that service development initiative do not solely lie within the senior management team and also providing a platform for individual growth, career progression and continuous professional development across the workforce. • Exit interviews for all staff leaving the service to help future service developments and promote workforce retention and sustainability. • A training budget to accommodate individual and service level training needs. • Provision of trainee/ student placements across the range of professions contributing to the MDT (medics, nursing, OTs, dieticians, psychologists/ therapists) • Apprentice scheme for health support worker • Supporting staff to develop in their career whilst in post e.g. supporting access to nursing course, advanced practitioner, nurse prescribers, NHS leadership and management training • Contributing to teaching on local training courses with the aim of contributing to the development of newly qualified staff and allowing students/ trainees to consider working in the field of eating disorders

 

Who is in your team?

Across the two community teams we have the following staff: Consultant Psychiatrist 2.0wte Specialty doctor 2.0wte Lead psychologist 8b/ 8c 1.0 wte Band 8a clinical nurse lead 1.0 wte Band 8a psychologist 2.0 wte Lead for early intervention/ therapist band 7 0.6 wte Band 7 CTM 2.0wte Band 7 therapist 1.8 wte Band 7 dietician 1.0 wte Band 6 social worker 1.0 wte Band 6 mental health practitioners 8.6 wte Band 6 dietician 2.0 wte Band 3 health support workers 5.0 wte Band 3 peer support workers 2.0 wte Band 3 admin support workers 4.0 wte Total 36.0 wte

 

How do you work with the wider system?

The CONNECT dual diagnosis service is a newly established service which provides assessment and treatment for individuals from the West Yorkshire and Harrogate region who have a dual diagnosis of an eating disorder and a substance misuse disorder (as per ICD-10 criteria). This clinic is specifically designed for individuals who meet referral criteria for the service however their substance misuse disorder means that they are not able to access standard community or inpatient treatment and is delivered through the dual diagnosis service in partnership with Forward Leeds. Adult Mental Health Services By developing enhanced links with CMHTs through regular training and supervision CONNECT offers a tier 1 level service (advice and consultation, link workers, guided self-help, support groups) across the region which ensures joined up working along the care pathway in keeping with a stepped model of care.

Child and Adolescent Mental Health Services (CAMHS) CONNECT works in close partnership with local CAMHS services to ensure a smooth transition of care between CAMHS and Adult services in line with NICE (2017) and RCPsych (College Report 208, 2017) guidelines. Primary Care Collaborative working with GPs and primary care health professionals is a crucial aspect of eating disorders treatment and CONNECT works in close partnership with local primary care services to promote early intervention, regular physical health monitoring, MARSIPAN and training helping to ensure that treatment and care pathways are both effective and safe. Third Sector Organisations CONNECT has close links with regional and national third sector organisations and employs 2 community-based peer support workers through local third sector agencies. This enhances the clinical model in numerous ways and brings another dimension to the treatments that we offer. Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) pathways CONNECT provides a consistent approach to MARSIPAN across the region and formalised MARSIPAN pathways and expert working groups have been developed through partnership arrangements with local mental health providers, primary care services and local acute hospital providers

 

Do you use co-production approaches?

‘Connected’ is the service user involvement group which meets regularly and is the mechanism by which service development, delivery and evaluation is co-produced. We currently have a number of current and ex-service users who are actively involved in projects such as recruitment, service evaluation, supporting staff training and development, research projects, and supporting the delivery of clinical interventions and clinical governance. CONNECT also employs two peer support workers, who contribute to all aspects of service delivery, and use their lived experience of an eating disorder to support service users directly and indirectly. We aim to develop the opportunity for formal voluntary posts to complement these roles. Examples of this include service user and carer input into the development of: • The CONNECT clinical model including the newly revised inpatient treatment programmes. • Branding of the service and the service name which was decided by service users at a service user reference group branding workshop. • Service user and carer involvement in recruitment and interviews. • Service user and carer representative included in the membership of the CONNECT clinical governance council. • Development of family and carer champions across the service to help instil a culture of family and carer support and engagement. • Development of service user peer support groups, family and carer peer support groups and family and carer workshops.

 

Do you share your work with others? If so, please tell us how.

CONNECT recognises the huge benefits of sharing work and experiences with others. We provide an array of resources for service users and carers as well as health professionals on our website and regularly publish our work in peer-reviewed journals. We are regularly invited to share our work at local, regional and national learned societies (Royal College of Psychiatrists, Royal Society of Medicine, b-eat, NHSE). In addition several members of our team work as media spokespersons with recent interviews for BBC Panorama, BBC Breakfast, the Guardian, Look North and the Yorkshire Evening Post. We are in the process of contributing to a special issue of the Victoria Derbyshire show which will be filmed from our base in Halifax, and features a number of staff, service users and carers sharing their stories.

 

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

CONNECT monitors service delivery and performance through the collection and evaluation of service users’ experience and satisfaction measures, key performance indicators and validated clinical outcome measures which are measured against national service specification (QED, NHS England and CQC) and standards outlined in NICE (2017) and MARSIPAN (RCPsych, 2014) guidelines. Formal service delivery, evaluation and performance are overseen by the CONNECT Programme Board with input from the CONNECT Service User Reference Group, the CONNECT Carers Reference Group and representatives from regional stakeholders. CONNECT will produce an annual report which will be available on our website so that our performance and experiences can be shared more widely. We are currently undertaking a survey of service users, stakeholders and staff to gather views about experience of the service; this has been designed alongside service user representatives and will be evaluated, published and used to shape further developments. We regularly seek structured feedback on completion of a clinical intervention such as session rating scales (group or individual sessions), feedback from carer workshops etc.

Quantitative outcome measures Key performance indicators • Number of hospital bed days in specialist inpatient eating disorder services including out-of-area placements • Number of hospital bed days to acute trusts • Average length of stay in specialist inpatient eating disorder services including out-of-area placements Clinical • The Eating Disorder Examination Questionnaire (EDEQ) • Clinical Outcomes in Routine Evaluation (CORE) • Body Mass Index (BMI) • Eating Disorders Quality of Life scale • EQ-5D-5l • Rosenberg’s self-esteem inventory • Health of the Nation Outcome Scale (Honos) Qualitative outcome measures Service users • Standardised interview schedules carried out at the point of discharge from the service which assesses service user experience and involvement in their treatment • Annual service user feedback form • Other service user satisfaction tools Family and Carers • Carers satisfaction questionnaire assessing carers’ experience of the service and their ideas about future service developments. Local stakeholders and health providers • Survey of local health providers and stakeholders experience of the service

 

Has your service been evaluated (by peer or academic review)?

The CONNECT clinical model and business case was evaluated by NHSE which led to the initial successful New Care Models (wave 2) bid in July 2017. The Yorkshire Centre for Eating Disorders (YCED), the service from which CONNECT was developed, is accredited by QED (Quality Network for Eating Disorders (RCPsych) and CQC. The service is regularly involved in clinical audit, service evaluation and research with recent examples including: • One of 4 service sites in the UK examining the feasibility of introducing an early intervention model with a community eating disorder service (Multi-centre FREED-UP study). • Service evaluation of the YCED inpatient treatment programmes (2017) • Baseline assessment of CONNECT’s performance against the standards set out in the newly revised NICE guidelines for eating disorders (2018).

 

 

How will you ensure that your service continues to deliver good mental health care?

The CONNECT service works closely with regional and central NHSE commissioners to ensure that the CONNECT New Care Models initiative complies with the agreed standards of care and cost-effectiveness. Through a process of ongoing evaluation and reinvestment of funds saved by reducing out-of-area placement we are able to further develop the service based on performance and stakeholder (e.g. service users, carers, staff, referrers) feedback thus promoting a culture of growth in line with the aims and values of the service. The CONNECT service has also reached an agreement with regional commissioners and the 4 mental health trust stakeholders that if the New Care Models initiative were to come to an end for whatever reason, that there would be a co-commissioning plan to ensure that the new service is sustained and that high quality adult eating disorders care is still provided across the region. Our service user representative group provides on-going feedback on the quality of interventions offered and how well we are meeting their needs. This is fed back to the whole service in different formats; at team meetings, in clinical governance forums etc, and is used to collaboratively shape the service that we are providing. We continually look for opportunities to link in with other mental health providers (as described above) to ensures the smooth transition of care and suitable pathways can be developed and maintained.

 

What aspects of your service would you share with people who want to learn from you?

We regularly share aspects of our service including the challenges we have faced in implementing and delivering specialist adult eating disorders services across the West Yorkshire and Harrogate region. We have also worked in partnership with other NHSE New Care Models initiatives to promote shared learning. We have linked in with other eating disorder services to share working procedures, pathways and our clinical model. We are in a particularly good position to share issues relating to the transition between community and inpatient care, and vice versa, as we are in the privileged position of having both teams in the same service. The CONNECT appeal process regarding ‘patient choice’ for inpatient treatment has been used as a template for other regional Integrated Care System Initiatives. Following the completion of the FREED-UP research project we have been one of the only sites to embrace this way of working as part of our service model, sharing our experience of doing so with other services wishing to develop an early intervention pathway. We have shared our application of MANTRA to a group intervention with other services looking to better use resources and improve patient experiences and outcomes. This has resulted in becoming involved in writing a group MANTRA protocol that is due to be evaluated in a RCT (planned for 2020).

 

 

How do people access the service?

The CONNECT service accepts referrals from all health professionals and services and has made significant changes to referral criteria in line with stakeholder feedback and NICE (2017) guidance. Previously regional adult eating disorders services had previously used BMI as one of the main gatekeeping measures and often cases were excluded if they were younger than 18 years of age or had a history of substance misuse. With this in mind CONNECT introduced more flexibility in the referral and systems pathway by: • Upscaling the early intervention FREED model which promotes amongst many things the concept that referrals should be prioritised equally base on need and prognosis as BMI and physical risk. Moreover with FREED we have introduced a system whereby service users are contacted within 2 days of receipt of the referral, and assessment is arranged at a time suitable to the service user within 2 weeks of the initial contact and that evidence-based treatment is provided within 2 weeks following the initial assessment. This means that CONNECT aims to provide assessment and treatment within 4 weeks of referral (compared to the national average of 3 years as recently published by b-eat). • Considering referrals for individuals who are 17 years of age with joint working partnerships formed with regional CAMHS services • Developing an online referrals system following feedback from service users, carers and referrers • Developing the dual diagnosis service so that individuals with an eating disorder and a comorbid substance misuse disorder can receive the necessary treatment and avoid significant delays in treatment In future we aim to invest funding into the service so that further flexibility into the regional referral system can be offered in the form of self-referral.

 

How long do people wait to start receiving care?

Individuals accepted to the service are offered a comprehensive biopsychosocial assessment by an experienced member of the assessment team who will assess their individual physical, psychological and social needs in line with NICE (2017) and MARSIPAN (RCPsych, 2014) guidelines. The service offers an assessment within 1-4 weeks for urgent referrals (early intervention cases, inpatient assessment, high physical or psychological risk, pregnancy, type 1 diabetes mellitus) referrals and within 8 weeks for non-urgent referrals. Following assessment evidence-based treatment is offered within 2-4 weeks for urgent cases and within 8 weeks for non-urgent cases. Mean and maximum waiting times from referral to access and treatment is one of our key performance indicators and will be routinely monitored as the CONNECT service continues to develop. Evidence for our FREED study has shown that waiting time from referral to access and treatment has ranged from 4-6 weeks with only a 3% drop out rate (national average ranges between 30-60%) which is well below the national average of 3 years (b-eat). We aim to replicate and upscale this model across the West Yorkshire and Harrogate region.

 

How do you ensure you provide timely access?

The CONNECT service has prioritised timely access and treatment and has introduced a number of initiatives so ensure that assessment and treatment is provided in a timely fashion at a site most convenient for the service user. As part of the FREED study we learned that having a service champion who takes a lead in coordinating referrals and instilling a culture of engagement across the teams when managing referrals that this can quickly lead to reduced drop-out rates, enhanced engagement, better clinical outcomes, reduced waiting times, and service user and staff satisfaction with minimal funding. We have structured our staffing model to ensure all CONNECT teams adopt this model, and are currently rolling this out across the service.

 

What is your service doing to identify mental health inequalities that exist in your local area?

Within the CONNECT service we have three equality and diversity champions who together with service users and carers regularly collect service data (quantitative and qualitative) to ensure that health inequalities are monitored and reported accordingly. Moreover the champions provide regular equality and diversity training to staff in line with trust and national policy. CONNECT works closely with the b-eat, a UK based eating disorders charity, to raise awareness about eating disorders and support their national work in prevention and addressing eating disorders stigma. This work has included support in developing their annual development plan, research portfolio, training of staff, delivery of helpline support and organising their annual conference. The CONNECT research portfolio also includes a number of studies which have examined knowledge and attitudes of health professionals towards individuals with eating disorders which has received public acclaim and has led to the development of training programmes for health professionals on eating disorders aimed at reducing stigma and enhancing system wide assessment and treatment standards for individuals with eating disorders.

 

What is your service doing to address and advance equality?

Our service covers a large geographical area with an extremely varied demographic profile. We work hard to link in with local communities via third sector organisations and local mental health teams to ensure that we are easily accessible to all, and tailor interventions based on the needs of the current service user cohort. We take steps to provide interventions in non-nhs settings where appropriate to reduce stigma and increase accessibility. We undertake continued holistic assessments to ensure that individual’s faith, cultural and other specific needs are catered for as well as possible. This is particularly important given the range of cultural rituals and preferences around food and eating, which is the core of our work. We are also linked in with local Universities who are exploring issues of inequality in the developing workforce, developing strategies to encourage individuals from under-represented/ minority groups to access professional training.

 

 

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

CONNECT starts to identify individual needs at the point of referral and through our referrals and early intervention pathways we aim to offer an assessment and/or treatment which best suits the individuals needs. Through the newly revised CONNECT referral criteria individuals referred to the service are triaged based on individual need with referrals prioritised on needs rather than physical risk alone in keeping with newly revised NICE (2017) guidelines and service user and carer feedback. All individuals accepted to the service are offered a 2-3 hour comprehensive biopsychosocial assessment by an experienced member of the assessment team who will assess their individual physical, psychological and social needs in line with NICE (2017) and MARSIPAN (RCPsych, 2014) guidelines. Assessments are flexible both in time and site such that service users have at least 3 assessments slots available to them to choose from with the aim of promoting engagement from the point of referral. CONNECT uses a standardised assessment tool which is based on NICE (2017) and MARSIPAN (RCPsych, 2014) standards of assessment which has been developed with input from service users and carers such that assessment is not solely focused on diagnosis and physical risk and includes domains focused on psycho-social needs and the individual’s views on their situation and views on future treatment.

All assessments are brought to the relevant team’s weekly assessment team meeting for further discussion where diagnosis, formulation, mode of therapy and an MDT care plan is agreed taking into account the service users views on treatment and their individual needs. The assessment team is made up psychiatrists, psychologists, senior nurses and senior allied health professionals who are trained in the assessment of individuals with eating disorders and provides a forum for training and monitoring of assessment standards. The assessor writes an assessment letter which is sent to the referrer and the service users GP within 10 working days of the assessment outlining diagnosis, formulation, mode of therapy and the MDT care plan. Service users are encouraged to contribute to decisions about what their treatment looks like, including the timings of interventions. Regular care reviews are offered with members of the team and families/ carers where appropriate. We also aim to involve family members throughout the process, with the consent of the service user, offering joint sessions, carer specific interventions, carer workshops and a carer support group.

 

What support do you offer families and carers? (where family/carers are not the service users)

We routinely offer family involvement in individual’s treatment where appropriate. We do this broadly, and driven by the service user. For instance, recently one service user felt it would be helpful for her flatmate to come to a session so that she could share some of her experiences, and use her friend as a resource in helping her to fight her eating disorder. We have recently developed one day carer workshops, in conjunction with feedback from service users and carers. These were held on a Saturday to enable most people to attend, and were co-facilitated by people with experience of an eating disorder, and carers. We received very good feedback and plan to develop a regular programme of carer workshops that hopefully feed into the regular carer support groups that run each month, allowing families/ friends to be part of an informal network of support.

 

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England):

CONNECT: The West Yorkshire and Harrogate Adult Eating Disorders Service is a new regional adult eating disorders service, part of Leeds and York Partnership NHS Foundation Trust (LYPFT), which has been developed through a New Care Models initiative for Adult Eating Disorders as part of NHS England’s ‘Five Year Forward View for Mental Health’ in partnership with Bradford District Care Trust (BDCFT), South West Yorkshire Partnership NHS Foundation Trust (SWYFT) and Tees, Esk and Wear Valley NHS Trust (TEWV). Development of this new service has involved the expansion and tailoring of existing eating disorders services to significantly reshape both in-patient and community care for adults with eating disorders across the West Yorkshire and Harrogate Health and Care Partnership (HCP) footprint (see Figure 1) which has a collective population of 2.6 million people spread across a wide geographical area.

 

Provided by (e.g. name of NHS trust) or your organisation:  Leeds & York Partnership Foundation Trust

 

 

Population details

Brief description of population (e.g. urban, age, socioeconomic status):

Size of population and localities covered:

2.6 million

 

 

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