Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

Abstract

Background: Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

Overview of paper: This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Keywords: Adolescent; Care pathway; Child; Eating disorders; Evidence based practice; Expert community-based treatment; Multi-disciplinary team; Service transformation.

Fig. 1

Child and adolescent EDs services in London boroughs in 2010. CAEDS—Dedicated community-based Child and Adolescent Eating Disorders Service. Mini-ED CAMHS—Mini eating disorder teams within generic CAMHS. CAMHS—Generic Child and Adolescent Mental Health Service

Fig. 2

Direct healthcare cost by care pathway

Fig. 3

Average outpatient and inpatient costs by care pathway

Fig. 4

Putative impacts of a specialist service context on specific and non-specific therapy factors