The CAMHS Durham and Darlington Eating Disorder Team (EDT) are passionate and committed to improving access and care for young people with eating disorders. Since inception, the EDT has shown commitment to innovating the service to improve the experience of service users. In July 2016 with the aim of making access quicker and easier, the team accept self-referrals and direct referrals from any partner agency. This allows rapid assessment and treatment, in line with access and waiting time standards.
What We Did
The CAMHS Durham and Darlington Eating Disorder Team (EDT) are passionate and committed to improving access and care for young people with eating disorders. Since inception, the EDT has shown commitment to innovating the service to improve the experience of service users.
1. Examples of innovation leading to positive improvements in clinical practice:
• We have developed resources to support young people and families in meal support; this has now been expanded to include a booklet for paediatric staff caring for young people with Eating Disorders who are physically unwell.
• The team piloted a day service in summer 2012 which ran two days a week for six weeks. Six young people took part and evaluation showed positive outcomes for dietary intake, weight restoration and therapeutic engagement.
• In 2013 we began to develop the Social Eating group. This has been delivered and the team have worked with young people towards this becoming more recovery focused and goal based. Outcomes have shown that this intervention is effective in normalising eating behaviours and reducing purging behaviours.
• The team have taken part in developing protocols and care pathways in collaboration with other Eating Disorder teams in the trust, helping to ensure safe, high quality and consistent care for young people and families as well as identifying training needs within the workforce.
• The team has engaged in CYP-IAPT programmes to improve access to psychological therapies, focus on transformation of services and embed an outcome focused approach which involves young people and families. These programmes have also helped to strengthen leadership within the team and support induction of new staff.
• EDT also support raising awareness and development of other teams, delivering teaching and training ranging from a target audience of undergraduate staff through to established ED teams. EDT’s practice has been chosen as a case study as an exemplar to teams in development.
2. Changes to service structure:
With arrival of the funding for CYPS-ED, the EDT has expanded to include nursing staff from physical and school health backgrounds and healthcare assistants from A&E, to improve the quality of physical health care within the mental health setting. This has been further improved by close working with local paediatric colleagues through developing a paediatric pathway. This aims to improve not only the transitions between physical and mental health services, but improving the quality of medical support for young people with physical complications secondary to eating disorders. Furthermore, this has strengthened working relationships and allowed training needs in Paediatric colleagues to be identified and addressed.
EDT have established regular family clinics, delivering high quality evidence based interventions. This includes Maudsley Family Based Therapy, CBT and guided self-help. This allows for meeting of access and waiting time standards, but also individual choice. Multi-Family Therapy was introduced in 2017, further improving patient choice of evidence based interventions. We have run two cohorts and in feedback from these both young people and families have provided a 100% recommendation to others.
In July 2016 with the aim of making access quicker and easier, the team accept self-referrals and direct referrals from any partner agency. This allows rapid assessment and treatment, in line with access and waiting time standards.
The team work closely together and are highly motivated to provide the best possible care. New ideas and quality improvement is embedded in the team culture. A Royal College of Psychiatrists Quality Network for Community Eating Disorders (QNCC-ED) review in April 2017 allowed reflection on progress and ideas for further improvement to be explored, the informal feedback from which was very positive.
Wider Active Support
We are in the process of developing a robust multi-disciplinary pathway with our Paediatric colleagues for those young people who require a medical admission to maintain their safety. This has identified training needs and we have so far offered two training sessions to paediatric nurses and have plans to attend a medical staff education day. This pathway will also include development of service user information, written by a service user. Paediatric nurses were also involved in the service re-design event in November 2015 which looked at how the service could transform to meet Access and Waiting Times standards and were involved in recent Royal College of Psychiatrists Quality Network for Community Eating Disorders (QNCC-ED) peer review.
In March 2017 we held a Stakeholder event, inviting partners from school health, education, local authority, commissioning, Investors in Children, locality CAMHS, Single Point of Access team, GP practices and paediatrics, as well as young people and families. This allowed communication of the national picture and drivers for change, the team’s response, the shape of the current EDT service and the new referral pathways.
Unfortunately GP practices were unable to attend however the team are currently working with the Trust GP engagement team to explore other methods of engaging them in the transformation. We currently have good working relationships with the practices where young people on our caseload are registered with regular GP update letters and invitation to reviews as part of routine practice.
We have worked closely with locality CAMHS to ensure clear pathways between services and offer consultation and joint assessment in order to prevent duplication of assessments for young people and identify how best to meet individual needs. The development of the Single Point of Access team in locality CAMHS has meant we are able to liaise closely and quickly accept referrals received through this service, as well as accepting direct referrals and offering consultation to wider agencies where a concern is present about a young person.
Service-user and carer involvement is integral to EDT quality improvement. Feedback is encouraged, reviewed, responded to and actioned on a monthly basis. An audit by the trust Quality Improvement Team provided excellent feedback on EDT’s processes for responding to service-user feedback.
Meaningful engagement with service users is integral to the team. Due to the regularity and close working with young people and families, they are engaged in providing input and feedback. Young people and parents/ carers are involved in participation groups, participation events, and service development. The service stakeholder event (March 2017) included presentations from service users, and opportunities for stakeholders to speak to young people and families about their experiences of using the service. The Royal College of Psychiatrists Quality Network for Community Eating Disorders (QNCC-ED) review (April 2017) included service user involvement. Service users, parents and carer are viewed as being central to further development and the team has three participation champions who link with locality CAMHS participation groups.
Looking Back/Challenges Faced
The biggest challenges the team has faced were presented when the team engaged with the IAPT clinical programme which required three team members to attend. This left a less experienced team to manage the caseload over this period. This was most effectively managed by flexibility on the part of the trainees to support the team where possible alongside their training requirements. Although this was a significant challenge, without accessing the training in this way we could not have been in the position to meet the demands of the access and waiting times standards and provide the high quality of evidence based interventions we are currently able to do so.
Further challenges have been ensuring robust induction of all staff as the staff team doubled in the year 2016 as a result of access and waiting times standards. There has been a great deal of energy focused upon the induction and development of new staff, who have varied backgrounds and experience. This challenge has presented opportunities though, to share knowledge and learn from each other, diversifying the skill set of the team.
All staff within the team have been involved in developing the vision of the team and have an understanding of the drivers for this. This is included in staff induction. The team are participating in the national training programme (delivered by the Maudsley) to further embed theses values, skills and knowledge. The team are engaged in on-going training and development both in-house and external to further support availability of psychological therapies.
There is wider support from the Trust via the ED steering group and information department produce Unify weekly reports to support monitoring of waiting times for both assessment and NICE concordant therapies.
The therapeutic model of systemic practice is central to the team who are engaged in team supervision and a weekly reflection slot to further enhance this.
Protocols and Pathways have been developed both clinical and organisational to ensure consistency of approach and seamless care.
Perhaps most importantly though, the team culture has developed into one of continuous improvement involving all staff, who each act as leaders of smaller projects which contribute to the transformation. This shared culture of continuous improvement, combined with the real passion to provide the best care possible, should act to support ongoing development regardless of individual leaders.
Evaluation (Peer or Academic)
The team have worked to evaluate service developments and pilots. The evaluation of the Day service showed positive outcomes for dietary intake, weight restoration and therapeutic engagement. The social eating group evaluation showed that young people all made progress toward their individual goals, with more sessions yielding improved results. Goals were around eating socially, ordering from menus, normalising eating behaviours and avoiding purging behaviours. Two Multi Family Therapy cohorts have now begun, with follow ups planned over the next six to nine months and two further cohorts planned to commence in the next six months. Evaluation of the first four days has been extremely positive, gaining feedback regarding specific activities and the intervention as a whole. Importantly 100% of those who attended would recommend the intervention to others.
The team was included in the Investors in Children CAMHS service review conducted in 2015 for the local CCG. The comments relating to the team were very positive regarding individualised care and support.
Anne O Herlihy (National IAPT Lead) conducted a service visit in September 2016 which allowed us to reflect on challenges and achievements in service transformation. She provided very positive feedback regarding the team’s enthusiasm and commitment to transforming services.
QNCC-ED peer review took place in April 2017. The team are awaiting final report but informal feedback was positive, with particular notice being given to access times and team transparency and team cohesion.
NHS England Case study has recently been conducted and included review of service evaluations and feedback from service users to inform the study.
The team are engaged with CYP IAPT and are utilising outcome measures within therapy. The process of embedding these into supervision to maximise their benefit is ongoing, with supervisors being provided with training to support this and a ROM’s champion being identified within the team. We continually seek feedback regarding experience through formal and informal channels including experience of service questionnaires and feedback from specific interventions.
The patient experience feedback collected through the trust patient experience department is confidential and we encourage families and young people to engage with this, reviewing regularly and feeding back actions we have taken as a result. Free text comments have themes around a supportive, friendly team, individualised care, with trusting relationships supporting recovery and motivation.
Feedback from recent Multi family therapy interventions provided 100% recommendation to others; with young people identifying that the group helped them to realise what life could be like and to feel closer to recovery, parents highlighting a greater sense of understanding and development of strategies to support recovery. Young people and parents reported feeling that meeting others with similar experiences was supportive and helpful. The groups have not completed follow up as yet so more formal outcome measurement is planned at this time.
The social eating group is an example of the use of goal based outcome measures to facilitate recovery focused care and measure outcomes. These are also used routinely in meal support and have been used within multi family therapy and single family therapy.
The team have over the past few years made efforts to share their practice both locally and nationally. We have visited local CAMHS teams and Paediatric wards to share plans for transformation, new referral routes and have supported training of the wider workforce about Eating Disorders through the Primary Mental Health link workers. In March 2016 we presented at the Quality Network for Community Eating Disorders (QNCC-ED) launch event, followed by a presentation to cabinet ministers in April 2016. In September 2016 we presented a poster evaluating the social eating group at the RCN nursing research conference. In October 2016 we presented at the regional Eating Disorder Network event, sharing practice regarding access and waiting times standards. In April 2017 we organised a stakeholder event and also presented a workshop at the national Children and Young People’s Mental Health Conference.
We have also offered several training sessions to paediatric colleagues and offer supervision for staff when young people are being nursed n the ward.
The team also had nursing representation on the curriculum development group for the national training programme.
Is there any other information you would like to add?
The team philosophy is one of providing the best possible care and we are flexible to meet individual needs. We are continually working to improve the service we provide and are passionate in supporting young people and families towards recovery.