Mersey Care's Eating Disorder Service has worked hard to enhance their relationship with the professional referring into the service and this has meant a positive attitude towards the mental health difficulties that contribute to people eating difficulties has been fostered. One area that the service has worked hard to support is the endocrinology department within Aintree University Hospitals NHS Foundation Trust.
What We Did
Mersey Care Foundation Trust is a provider of mental health services. Mersey Care’s Eating Disorder Service has worked hard to enhance their relationship with the professional referring into the service and this has meant a positive attitude towards the mental health difficulties that contribute to people eating difficulties has been fostered. One area that the service has worked hard to support is the endocrinology department within Aintree University Hospitals NHS Foundation Trust. As a result of this, professors, medics, dieticians and physiotherapist within the service have become more psychologically aware of the potential needs and vulnerabilities that the patients referred into the service may present with.
As a result of this improved relationship, our service was asked to support the newly established weight management service, something we have now been doing for over 10 years.
It seemed right then to be included in a collaborative partnership to provide a comprehensive bariatric service to residents living in Merseyside, Lancashire, Lancaster and Cumbria (and the Isle of Man).
This partnership successful won the tender to provide services and so a joint provision of care that integrates both the physical and mental health aspects of bariatric care was established.
This approach is supported by a House of Commons Committee report on Obesity that was published in 2004 in which it states that “all those receiving treatment for obesity should have access to psychological support provided by an appropriate professional”. The integrated care provision described here draws from the experience of working within eating disorder, weight management and general psychiatry. It was quickly established that if care was to be truly integrated then there needed to be a psychological understanding held within the whole team. The lead psychotherapist drew from a cognitive analytic therapy (CAT) perspective, a relational therapy that focused on relationship and helps to identify problematic patterns and procedure. CAT is an evolved integrative psychotherapy that has an emphasis on building up collaborative relationships between patient and therapist and on a systemic level, between teams.
It could be seen that to truly care for our patients, we needed to work in a more psychologically informed way.
The full team comprises of surgeons,anaesthetists, endocrinologists, dieticians, nurses (including both qualified staff and health care assistants) physiotherapists, administration officers and of course psychological therapists (Consultant psychotherapist, Clinical psychologists, cognitive behavioural therapists, psychotherapists, assistant psychologists and trainee Doctorate Clinical psychologists)
The provision of care within this service is at several different levels.
* A psychological understanding is supported amongst staff groups with consultation and supervision offered at very level.
* Psychological therapy staff attend all meetings (MDT, Operations Meeting, Business meeting, Case conferences)
* Offer individual assessment both pre and post operatively
* Offer individual psychological therapy (including CAT, CBT, CFT, Motivational Interviewing). Formal therapy is offered and also, one off support sessions, monitoring sessions and motivational enhancement sessions are provided.
* Offer a psychological therapy support group (CAT group)
The post operative CAT psychological therapy support group is a group not run anywhere else in the country (to my awareness). It offers individuals psychological support accessing a relational therapy for up to 9 months in duration.
Wider Active Support
Our formal partners in this service are:-
Mersey Care NHS Foundation Trust
Aintree University Hospitals NHS Foundation Trust Pheonix Health Care
The psychological element of the service is also maintaining effective relationships with patient and professional support groups within the voluntary sector – these being The WLS (Weight Loss Support service, a patient support and training group) and the ASO North West (Association for the Study of Obesity)
In addition to attending all meetings, senior psychological therapy staff make themselves available to support the wider team. This often involves having lunch with junior staff and fostering a collaborative relationship that supports staff.
We have also had wider active support from a member of Parliament who has a special interest in mental health services. At the point of writing this application I was awaiting confirmation that she is happy for me to provide her details.
We have service user involvement. Within the eating disorder service weekly clinical meetings are held and any clinical issues raised within the bariatric service are raised there.
Staff also input into twice monthly Multi Disciplinary meetings and also input into Monthly Operations Meeting.
Looking Back/Challenges Faced
Initially we offered post surgery assessments four weeks following surgery. We quickly recognised that this was not an ideal time to assess patients recovering from surgery. At this point in time a number of both physical and psychological factors were in play that prevented us gaining a true picture of how someone may recover post operatively. Another area for development and to try and gain additional commissioned services for is longer post operative support. Current post operative bariatric support is offered for up to two years post operatively. We have recognised that for many people, they struggle with weight maintenance and their own psychological wellbeing at around the 2 years post operative position. Here psychological interventions can play a crucial part in helping someone maintain the benefits of the bariatric surgery they have received.
We found that many people had not had a comprehensive psychological assessment prior to attending the new patient clinic (a multi disciplinary clinic where the patients is assessed by and anaesthetist, a surgeon, a dietician, medical screening and psychology). We found that patients were guarded within the psychological assessment fearing that this may be the one assessment that prevented them progressing to surgery. In order to manage this we altered the psychological nature and emphasis within the assessment. We now present a positive attitude to the decision they have made and ask the patient to consider ways in which we are able to help them make good use of surgery and support them postoperatively. We also developed an initial screening assessment tool that patients complete prior to the assessment.
Post operatively, we were initially offering follow up assessments too soon. Patients were in a euphoric position having physically recovered from the first physical effects of the surgery and were noticing obvious dramatic weight loss. Difficulties were then noticed much later so, we now offer post operative assessment at around 3 – 4 months post operatively.
Demand for the service was high so we developed a cost effective method of delivering high quality psychological therapy, drawing from the earlier work we had done with weight management services. We offered a Cognitive analytic therapy post surgery support group. This is an open therapy group and our patients are offered therapy within the group for up to 9 months.
In order to ensure that the service is sustainable we have invested in training, supporting staff to attain addition therapy qualifications in cognitive analytic therapy, cognitive behavioural therapy and compassion focused therapy.
I have been able to allow multiple different staff to work within services so that we are able to successfully sustain the positive service contribution we have made. This has been fully supported by Mersey Care NHS foundation trust.We recognise that this is an on going project and will require on going commitment to managing and maintaining the high level of care given.
We are currently in the process of trying to evaluate our service.
This is being done using a range both qualitative and quantitative tools. It is an area that to date we have not fully covered and is a challenge for the future development of the service.
We intend to set this as a DCLin project for one of our trainee clinical psychologists. We will use patient satisfaction surveys and will also evaluate the use of CAT through a qualitative look at goodbye letters following therapy completing. We will also examine attendance rates and compliance with therapy.
In addition we are also using the CORE 10 to collate pre and post therapy health measures.
We are happy to share information with other services and have presented (and continue to look for opportunities to present) at local and national conferences. (Local WLS groups, ASO groups and the National Association for Cognitive analytic therapy conferences)
We are also involved with our surgical colleagues helping to collate information to inform research in attachment style (with Mr Connor Magee – surgeon) and also a research project looking at psychological factors influencing weight gain and age of onset.
Is there any other information you would like to add?
This is an exciting service to work in, one in which there is a real value for looking after peoples mental health in conjunction with major physical health care/ surgery.
Our anaesthetists, surgeons and dieticians value the psychological interventions and view this as integral to the service. It is a prerequisite for patients to have a psychological assessment and to ensure that there are no psychological factors that would hinder or act as a contraindication to pursue bariatric surgery but within our service this goes a stage further. All members of the team recognise that successful outcome is dependent on a change of lifestyle and failure to address issues including psychological factors will result in a poor outcome. “Surgery itself generates a huge change in lifestyle and recognising the major effect this can have on a persons mental health is essential” (a quote from our resident anaesthetist )