A hospital trust has used an evidence briefing and service review to inform the redesign of its service for adolescents with eating disorders. Heather Holmes explains
Translating Research into Practice in Leeds and Bradford (TRIP-LaB) is part of the NIHR Leeds, York and Bradford Collaboration for Leadership in Applied Health Research and Care.
TRIP-LaB is an alliance of academics, clinicians and policy makers from York, Leeds and Bradford. As part of the TRIP-LaB programme, the centre for reviews and dissemination at York University provides a free knowledge translation service to support evidence-informed decision making by local commissioners and decision makers.
Before August 2011, NHS Airedale, Bradford and Leeds commissioned out-of-area placements involving long-term inpatient admission for a small number of adolescents with eating disorders. The basic cost of these placements varied from £454-£750 per bed day. Patient preference was for more local treatment.
Need for inpatient stays
Typically, inpatient stays occurred where the patient was unable to maintain their meal or care plan, in response to parental or carer requests or because more support was required. This contributed to inconvenience and distress to families and young people through separation from family and friends, difficult travel arrangements and disruption to education.
To support a possible reorganisation of services by commissioners, the York University researchers carried out a literature review to evaluate the evidence base for inpatient admission compared with other models of service provision.
An evidence briefing, Alternatives to inpatient admission for adolescents with eating disorders, indicated that it might be possible to offer services currently provided by inpatient admission in a specialist outpatient setting.
Following the evidence briefing, the commissioners agreed that it would be helpful to carry out a review of the eating disorders service to ascertain how the service could be improved through clinical and provider innovation to best meet the needs of the local population.
The service review included an audit of baseline data on patient demographics, treatment, outcomes and the economics of the current service and feedback from service users.
‘The eating disorders team embraced the review as an opportunity to evaluate the service, make improvements where indicated and redesign the service’
The eating disorders team embraced the review as an opportunity to evaluate the service, make improvements where indicated and redesign the service taking into account the views and opinions of service users.
The audit data was analysed and the results were encouraging. Notably, the results indicated that the service was effective in increasing the body mass index of patients from admission to discharge (mean BMI was 16.3 on admission and 17.5 on discharge).
The service also had a positive influence on the psychological and social functioning of the young people. This was demonstrated through analysing the mean child global assessment scores on entry to the service and on discharge. The mean CGAS scores increased from 51.7 (first reading) to 64.1 (final reading).
Patient feedback was obtained through four face-to-face interviews, five telephone interviews and two paper questionnaires. Of the 11 patients surveyed, nine were still attending school and all stressed the importance of not missing school and accessing therapy out of school time. There was also significant support for more family involvement in treatment (10 out of 11 respondents reported this).
Significantly, of the seven patients who had experience of being an inpatient, five reported that more intensive support and monitoring might have prevented them from requiring admission to an inpatient unit.
The evidence briefing and the service review were used as tools by the commissioners to redesign the eating disorders service. It was re-configured and a new service, SPEEDIHT (specialist eating disorder and intensive home treatment service), which avoids out of area inpatient episodes, was developed and launched on 1 August 2011.
Prior to this, the local NHS provider trust and the primary care trust agreed a specification for the new service and, crucially, an innovative risk-share agreement that provides reassurance for commissioners and incentive for the providers. An understanding was also reached that with this low-volume/high-cost patient group there may be exceptional years when spend will necessarily exceed budgets.
The eating disorders service recently received national recognition when the team was announced as a finalist at the Beat Awards, which recognise people who have shown an outstanding commitment to the cause of eating disorders.
The successful redesign of a more effective and accessible service, meeting the needs of patients and carers, demonstrates the productive relationship that can occur when the NHS engages with research colleagues to ensure that evidence is used to inform service redesign.
Heather Holmes is TRiP-LaB facilitator writing on behalf of the Research and Innovation Team NHS Airedale, Bradford and Leeds and the TRiP-LaB research team