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NICE urges GPs to refer for suspected eating disorder 'without delay'

GPs should refer anyone with a suspected eating disorder to specialist services ‘without delay’ and not wait to see if symptoms progress, under new draft recommendations published by NICE.

NICE experts said this approach may help to prevent delays in treatment where a GP feels uncertain and does not want to add to already long waiting lists – and avoid situations where people are told they are not ill enough to be referred.

The advice, outlined in new provisional guidance on recognition and management of eating disorders, comes as doctors and charities warned children in England are being sent to Scotland for treatment because eating disorder services are so over-stretched, and reports that some eating disorder clinics will not treat people for anorexia until they lose weight to hit referral BMI thresholds.

The draft recommendations state that if GPs suspect an eating disorder after initial assessment they should ‘refer without delay to: a community based, age-appropriate eating disorders service for an assessment and treatment (if possible); or day patient or inpatient services for people with clinical signs in the concern or alert ranges’.

It added that when deciding whether to use day patient or inpatient care the GP should take into account:

  • 'the person’s BMI or weight, and whether either are below the safe range and rapidly dropping (for example more than 1 kg per week);
  • whether several medical risk parameters (such as blood tests, physical observations and ECG have values and/or rates of change in the concern or alert ranges);
  • the person’s current physical health and whether this is declining;
  • [and] whether the parents or carers of children and young people can support them and keep them from significant harm'.

The guidelines committee said the term ‘without delay’ highlights to GPs ‘that they should not “wait and see” if the symptoms progress’ and that this will ‘also mitigate instances where patients are told that they are not ill enough or that they need to lose more weight before they are eligible for treatment’.

The group added: ‘Also, GPs may delay referral because they think waiting lists are long and they are not sure how serious the eating disorder is.’

However advisors stressed that they used the term 'without delay' instead of 'immediately' because 'the latter may result in GPs referring patients the same day or a four hour triage assessment, which is not usually required'.

Members of the guidelines committee acknowledged that community based eating disorder services are not always available locally for GPs to refer to, but said ‘they wanted to recommend it in the hope that it would improve services across the country’.

Dr Andrew Green, chair of the GPC clinical and prescribing subcommittee, said he welcomed the move.

Dr Green said: 'The suggestion from NICE to refer without delay is to be welcomed. The assessment of eating disorders is complex and requires skills and time which most GPs will not have.

'This is one area where low referral rates are not a sign of good practice, and GPs must be care navigators and not care gatekeepers.'

Key recommendations – eating disorder referral

The draft guidelines say GPs should think about the possibility of an eating disorder in people who, for example, have an unusually low or high BMI for their age, show signs of dieting or restrictive practices, show disproportionate concern about their weight – for instance, about weight gain as a side effect of contraception – as well as those with menstrual or other endocrine disturbances, and dental erosion.

They should also be particularly alert to the potential problem in people who take part in certain high-risk activities, such as professional sports, dancing and modelling.

If an eating disorder is still suspected after the initial assessment, refer without delay to:

  • a community based, age-appropriate eating disorders service for an assessment and treatment (if possible) or
  • day patient or inpatient services for people with clinical signs in the concern or alert ranges*.

* for example severe electrolyte imbalance, dehydration or signs of incipient organ failure. 

Source:NICE draft guidelines - Eating disorders: recognition and treatment


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Readers' comments (11)

  • cuckoo-land. Locally there are no specialist services to refer to, no referral form and no pathway

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  • I would love to see NICE come up with these plans along with clear details covering all areas with what one needs to do and publish in very public forums what the waits actually are, number of staff available etc. As it stands GPs are presented as simply not doing enough to support any patients.
    We have a 47 week wait until first Dermatology OPA (though I believe there is an official waiting list and a hidden list before you get on the waiting list to keep NHSE waiting time targets happy) Rapid eating disorder service - Please NICE tell me where and when?! Yet more utter nonsense.

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  • Refer directly top Scotland maybe.

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  • how will referring without delay 'mitigate' against the referrals being bounced by an overstretched clinic for not meeting their severity criteria to be accepted?? Though from a defensive point of view better we refer and the clinic reject rather than us failing to refer.

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  • refer to a non existent service. Nice one Nice

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  • AlanAlmond

    Refer immediately ...who to? Ok so this is what we should about we talk about want we CAN do? There's no one to refer to - these services don't exist to the extent needed. Who's to blame ..GPs??

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  • To where?

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  • Will NICE also stipulate time by which secondary care will see these patients ???.
    Average waiting time is anything from 12 weeks to 40 weeks. There is no point in telling GPs to refer immediately, NICE better direct their words toward Secondary care/Govt and ask them to provide services

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  • Council of Despair

    1. where to?
    2. waiting lists?
    3. what to do when the family comes back because the waiting time is 6 months and nearest facility is in France?

    same problem for ... (mental health services, dementia care, etc etc)

    identifying the problem is only part of the issue and i'm tired of taking the blame for the rest of the system being in meltdown. at least if we worked in private care you will know that when you make a referral your patient will be seen promptly. the NHS has become unsafe because of the poor decisions of politicians of all sides.

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  • When I was training in public health there was a Venn diagram with three overlapping circles:
    * need - defined as the ability to benefit from an intervention
    * demand - the amount of clamour from patients or the population for an intervention
    * service provision.

    We would discuss the extent to which the need and the provision overlapped. Occasionally there would be a service for which there was a demand, but no need (little or no evidence of efficacy); if this was provided by a new clinic there would be a rush of referrals, and sometimes we would (perhaps dismissively) refer to provider-led demand.

    We also discussed how a new clinic could uncover previouisly unmet demand - if there's nowhere to refer a patient to, there are no referrals. Systems assessing needs based on the number of referrals don't work if referring practitioners know there's no service to refer to...

    In the case of child and adolescent psychiatry in general - and possibly easting disorders in particular - there has been a lot of publicity recently about "parity of funding" and stigma. We know that services are appallingly underresourced. We know that if young people were dying of accident or other diseases at the rates they die of mental health related problems there would be an outcry - but the stigma associated with mental health allows people to distance themselves and blame the victims.

    I've no idea what to do about this!

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