Mental Health Matters: A life and death situation

Sobering analysis on what is arguably one of the most widely misunderstood mental health conditions – with the risk of deadly physical consequences – has shone an uncomfortable light on continuing gaps in knowledge and training.

Hospital admissions for eating disorders leapt up by as much as 84 per cent in the past five years, reaching a total of 24,268 admissions in 2020-21, according to the Royal College of Psychiatrists.

While the increase is clearly devastating, the numbers will come as no great surprise to acute hospital leaders, who are caring for more people with eating disorders now than ever before.

Eating disorders are the single service mental health CEOs have been losing the most sleep over – with one executive telling HSJ in March a 34 per cent increase in referrals for child inpatients was “keeping them awake at night”.

And yet professional understanding of the conditions, from ward to board, remains seriously inadequate.

Several times a year, avoidable deaths crop up in coroner reports, one of the most recent detailing the case of Nichola Lomax from anorexia who was seen by 30 medics and just one had “extremely limited” knowledge of emergency guidelines.

Last year a coroner investigating five deaths in the east of England warned that failures to protect the women risked being repeated without action.

Such gaps in knowledge mean signs someone with an eating disorder is dangerously ill are often missed, to the detriment of their care and treatment, and sometimes resulting in deaths – which experts say are wholly preventable.

A life and death situation requires an emergency solution. Therefore, alongside research on hospital admissions, the Royal College has also drawn up new medical emergencies in eating disorders guidelines, endorsed by the Academy of Medical Royal Colleges and informed by an expert reference group of professionals and patient representatives.

‘Not just domain of specialists’

Replacing MaRSiPAN (Management of Really Sick Patients with Anorexia Nervosa) due to the food-related acronym and to incorporate all ages and recognised disorders, the new guidelines provide advice on assessing conditions which can lead a patient into a state of clinical emergency. They also outline how to manage patients’ physical, nutritional and psychiatric care.

Among key recommendations are for medical and psychiatric ward staff to be aware patients with eating disorders admitted to a general ward may be at risk, despite appearing well and having normal blood parameters.

Another is that where specialist eating disorder units are not available, general psychiatric units should be supported to provide specialist care, including input from liaison psychiatry and eating disorder services to prevent delay in discharge.

Commissioners and managers should also be aware of gaps in local resources and be willing to support referral to national centres for advice and treatment when necessary.

And knowledge and training about the content of the overall guidance should be required for all frontline staff, experts suggest.

Dasha Nicholls, of Central and North West London Foundation Trust, helped to develop MEED. She told Mental Health Matters the guidelines are not just the “domain of specialists”.

She added: “It needs to be everyone’s knowledge. The key thing is for all doctors who are likely to encounter somebody with an eating disorder to be familiar with how to recognise severity, how to manage an emergency situation, and to realise it is not just about someone’s weight.

“We know, sadly, from a number of coroner’s reports into deaths of people with anorexia nervosa that the most seriously unwell aren’t always recognised as being malnourished, and that the [knowledge] problem is across the board – from primary care to emergency departments.”

Meanwhile, head of the college’s eating disorder faculty Agnes Ayton said MEED’s recommendations to commission additional nursing support in hospitals should be an especially important consideration for CEOs, systems and commissioners.

Developing higher quality specialist services without extensive waiting lists should also be a prioritised medium to long-term goal for commissioners, she added.

Such aspirations will undoubtedly have resource implications, and will almost certainly require additional funding.

But Dr Ayton stressed: “If we were implementing high quality and accessible eating disorder services already, that would make this guidance redundant, because you’d have less people presenting in a crisis.

“Guidelines are one thing, but unless you have the workforce to implement them and training, nothing is going to happen.”

Professionals from commissioners to frontline staff are urged to read and implement MEED – this appendix contains checklists for each area of medicine.

A Department of Health and Social Care spokesperson said: “Eating disorders can be devastating for people living with them, and we are focused on improving services so that everyone has access to the right support.

“We are investing an extra £2.3bn per year by 2023-24 to transform mental health services – this includes almost £1bn in community mental health care for adults with severe mental illness, including eating disorders, as well as £53m per year in children and young people’s eating disorder services. This will increase capacity in 70 community support teams across the country.

“We have also launched a public call for evidence to support the development of a new cross government 10-year mental health plan, which will include eating disorders.”