In 2008, our practice team was becoming increasingly conscious of the ever-rising numbers of students with an eating disorder presenting at our university health service. Studies estimate prevalence in the general population to be 0.5% for anorexia and 1% for bulimia in females.
An average practice, therefore, with 10,000 patients (5,000 female) would have about 25 patients with anorexia and 50 with bulimia – many of whom would be unknown to primary care.
In 2005, we had 55 students with an eating disorder and in 2008 we had 87. Today we have 153 (143 female) out of a total of 14,000 patients, a 175% increase in six years. Known prevalence is 2% in our 17- to 24-year-old age group (some of our patients are older). Many more are likely to be suffering, but have yet to come forward.
The waiting time to see a specialist in 2008 could be months, and we were often left trying to support guided self-help within normal GP appointments. Our nurses were using 200 appointments a year for weighing and blood tests. Some 500 GP appointments a year were used to care for these 87 patients, whose academic studies were often completely derailed by the illness and the wait for treatment. With prognosis worse the longer intervention is delayed, something had to give.
What we did
It seemed obvious that many of our patients could be cared for in a primary care setting by an appropriately qualified therapist, although for more complex cases we would still need secondary and then tertiary care input.
After significant research and discussion with other primary care-led clinics for eating disorders, we designed a service that would best address our patients' needs: led by primary care, with rapid access, integrated with the GP team, bookable in the practice, with clear referral criteria and geographically convenient (hopefully ensuring fewer DNAs). We wanted to remove as many barriers as possible to readily available, clinically excellent psychological treatment. It would also save the NHS money by avoiding expensive referrals to secondary or tertiary care.
We carried out an audit, identified a clear gap in provision and then the practice and local eating disorder service together designed a better pathway that our PCT, NHS Bristol, commissioned us to provide. Joint working with secondary care led to the practice hosting the service and the local mental health provider providing the post, management and clinical supervision.
In 2009 we wrote a business case and successfully applied for innovation bid funding. We were commissioned to provide a 15-month pilot of the new service, to run in our practice, with a review of outcomes at 12 months.
We interviewed for a psychologist who would be able to provide two days a week of cognitive behaviour therapy for eating disorders, and appointed Dr Will Devlin, with a view to extending the service if it proved its worth clinically and financially.
The initial plan was to see about 30 eating disorder patients a year, based on previous figures, but as the word spread in the student community, numbers presenting at the health service increased steadily and in total Dr Devlin was referred 94 patients in the first 12 months.
We kept the referral criteria simple. A GP could refer any patient with bulimia or anorexia for assessment if their BMI was over 17. Referral criteria are evidence-based and reflect NICE guidance. The more unwell patients were referred to secondary care for onward referral to our regional hospital-based eating disorder clinic. The steps in our process were not complicated, but bureaucracy slowed us down. This needs to be addressed if the future of commissioning is to be successful.
Prior to first assessment, to facilitate and speed the process, primary care patients who were referred in-house completed health questionnaires to measure mood, self-esteem, eating disturbance and clinical impairment. These were repeated at the end of treatment to assess outcomes. They also completed a feedback questionnaire on ending their programme of care.
What we found
A review of our outcomes after one year demonstrated excellent value for money and clinical care. The pilot suggests that primary care-based delivery of specialist treatments for people with less complex and severe forms of eating disorder is both feasible and cost-efficient. Opportunities exist to develop the model to provide a primary care assessment and treatment service, which could reduce costs while enabling seamless onward transfer into secondary and specialist services where warranted.
In the first 12 months of service:
- Ninety-four patients were referred to the service and 91 (96.8%) had been offered a service.
- Seventy-seven patients (84.6%) were offered an appointment within 28 days of seeing their GP.
- Some 83% of appointments were attended, and a total of 329 hours of face-to-face contact with patients was provided.
- Twenty-five patients (27.5%) had attended a pre-triage assessment appointment only (comprising psychometric assessment, risk assessment, advice, information and signposting), six of whom (6.4%) were awaiting full therapeutic assessment.
- Fifty-nine patients (64.8%) completed a therapeutic assessment comprising a pre-assessment triage (as above) plus full assessment including case file review, full history, problem manifestation and psychological formulation.
- Some 36 packages of treatment were offered and 24 were completed (66.7%).
Treatment options were CBT-based and included active change therapies and socialisation/contemplation therapies. Treatment adherence was markedly lower for active forms of therapy than for other interventions (45% versus 100%). Service user satisfaction scores and reports were overwhelmingly positive. All patients who completed an active change treatment experienced positive benefits.
At a total cost of £25,000, the pilot demonstrates how a comparatively modest investment can provide an effective, accessible and cost-efficient primary care service. The service also added value by enhancing allied service provision through training, consultancy, service development and networking activity.
On the basis of our findings, our PCT decided to widen the service to the whole of the city of Bristol. The neighbouring PCT, Bath and North East Somerset, has followed suit with Avon and Wiltshire Mental Health Partnership Trust commissioned to provide the new primary care community eating disorder service from April 2012.
Other local PCTs are reviewing their own provision and local GPs are raising awareness of a model that works and their desire to have access to something similar.
Pressure from front-line clinicians is needed to emphasise the importance of commissioning services for patients not covered by the QOF and whose voices are often unheard. All primary care professionals are advocates for patients – not just in the consulting room or on an individual basis, but at population level.
Commissioning is not a process that had ignited my passion previously, yet I found myself getting involved with local service redesign and I really believe that this is a way for primary care to make a difference – as long as we don't get dragged down in bureaucracy and stay focused on the clinical services we know will make a real difference to people's lives.
The service's impact
A card sent by a service user, summer term 2010
‘Thank you SO much for all your help this year. I know it was your job, but I feel like a different person now and I couldn't have done it without you. I really am so grateful and I'm sure I will keep you updated on my progress. Thanks again, you really have made such a difference.'
Dr Will Devlin, clinical psychologist
‘Working in the practice enables me to treat people right where they live, and working in such close partnership with my GP colleagues while maintaining strong links with the specialist service ensures that clients get a high level of joined-up clinical care. But redesigning the clinical care pathway hasn't just improved the patient experience; it's also really good value for money.'
Dr Dominique Thompson is director of service at the University of Bristol Students' Health Service and a GP in Bristol