Issue 12

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INSIDE THIS ISSUE:

1) Foreword from the editors

2) Foreword from the Chair

3) Feedback on EDSECT strategy day and work plan 2013/14

4) Reflections on being the Psychiatric Trainee Committee Rep on EDSECT

5) The EDSECT Annual Conference: feedback form a bursary winner

6) Update from the Academy of Eating Disorders

7) Provision of services for people with EDs and Type 1 Diabetes

8) List of Executive Members of EDSECT

If it seems a while since the last newsletter, circulated back in May, that’s due to a new system introduced this year in which the newsletter will be published only twice a year. Hopefully the Spring/Summer and Autumn/Winter editions will still give plenty of scope to capture and communicate the work of the Section and report the progress made with our objectives each year.

At the end of June the EDSECT Committee met and reviewed the progress made with our 2012/2013 work plan and developed the aims for the coming year. A summary of the work plan for 2013/14 and progress to date are described within.

Some EDSECT members have moved on this year as new members have joined and Carol Wilson as the Trainee representative is one of those whose enthusiasm and hard work for the section will be missed. As Carol takes on the role of Vice Chair of the Psychiatric Trainee Committee she has given some reflections on her time on EDSECT and in particular her thoughts on the challenges that we face in encouraging trainees into the specialty.

The annual EDSECT conference in November was a great success and presented delegates with a range of speakers including some from beyond the usual boundaries of eating disorders psychiatry. Several bursary winners attended, one of whom has written a very thoughtful piece on their experience on the conference and the questions raised by the presentations.

As Dasha Nicholls leaves her post as President of the Academy of Eating Disorders she reflects on the ICED in Montreal earlier this year and the newly honed objectives and goals of the Academy, as well as looking ahead to the ICED in New York next year for AED’s “coming of age “ 21st birthday celebrations.

Finally we have included a request from Sylvia Dahabra for EDSECT members to respond to a survey on the current provision of services for patients with Eating Disorders with Type 1 Diabetes. Please do find the time to complete the survey before the end of November.

Wishing you all a happy and healthy festive season and New Year

Rebecca CashmoreIrene Yi

EditorCo-Editor

@sabp.nhs.uk

The medical profession and Royal Colleges are currently assimilating the Francis Report.

It would be tempting to adopt a defensive posture built on lack of resources and management structures.

However, this would not address the need for compassionate care, collaborative care and dignified care.

These are issues that permeate the eating disorder specialism, as we strive to balance risk management with patient autonomy, vast demand against finite resources and bureaucracies that may override clinical judgment.

Eating disorders services have had their fair share of Staffordshire scandals, based around abuse of power.

But the Francis Report also offers opportunities. Patient safety is now at the forefront of policy, with medical leadership integral to its attainment.

Acute hospitals remember their compassion when psychiatric input becomes properly integrated, as seen through MARSIPAN groups.

By taking ownership and accepting responsibility of the challenges laid out in the Francis Report, eating disorder services can rightly assert the importance of medical leadership, compassionate and collaborative care and added quality of a psychiatric presence in the acute healthcare trust.

These are issues that are likely to gain further prominence in the next year, as the Academy of Royal Colleges grasps the nettle.

John F Morgan

The Executive Committeemet at the end of June and after reviewing existing priorities agreed that the following themes continue to be important to the work of the Section:

  • Commissioning
  • Training
  • Models of care
  • Co-morbidities
  • Risk/mortality

In order to focus our minds on what might be new areas on which to focus our attention; Exec members worked in small groups to consider the following question:

“What difference would we want to see in the Eating Disorders world?”

Following these discussions the Committee members agreed the following 4 statements which reflect the vision for improving specialist services, educating and supporting allied professions who may an individual’s first point of contact and broader public health messages which could influence the development of eating disorders.

1) There should be equality in the quality and availability of services across the UK

2) Patients should receive an integrated and well informed model of care that works

3) EDSECT should promote the message that “Dieting doesn’t work”

4) EDSECT would work to promote the message that “It’s OK to talk about an eating disorder to anyone”

The Committee members considered the steps that would be required in order that the above could be achieved:

1) To improve the quality and equality of services across the UK required:

  • Mapping the provision of services to established networks
  • Influencing commissioning structures
  • Informing the QED process
  • Training and supporting carers across the UK
  • Dissemination of information
  • Include MARSIPAN guidance in Core training
  • Developing an implementation/training in MARSIPAN working group – working with GPs, medical students, physicians, paediatricians, nurses, dieticians, psychiatrists and student health professionals.
  • Improved audit of Outcome

2) Patients receive an integrated and well informed model of care that works

  • Working with carers across the age range
  • Hosting MARSPIAN training
  • Supporting the exploration of novel care pathways
  • Qualitative research
  • Joint conference with the Faculty of Medical Psychotherapy (eating disorders and personality disorders)
  • Developing a New to Eating Disorders Training Programme Working Group (working with EEATS).

3) The message that “Dieting doesn’t work”

  • Influencing and promoting relationships with public health/obesity professionals
  • Develop a College position statement

4) The message that “It’s OK to talk about an eating disorder to anyone”

  • Joint work with RCGP
  • Making the first encounter with a health professional count (working collaboratively with BEAT)
  • Develop/collate a transition guide (including university students).
  • Develop good practice guidelines (transitions)

In the months since the Strategy day,work in these areas has been progressed by various working groups. Examples of the work still ongoing with the named leads include:

Dr Jessica Morgan is leading on the work to map services, initially trying to secure funding for this substantial project.

Drs Ayton and Sharma are the Exec committee members liaising with Dr Paul Robinson on the training and implementation of the MARSIPAN guidelines across different professional groups.

Dr Crockett is liaising with Prof Kam Bhui (College Lead for Public Health) to consider how to promote the public health messages important to EDSECT.

Dr Morris is leading the working group on the development of a “New to Eating Disorders” pack for those clinicians who are new to eating disorders or working in allied professions and seeking education in the area of eating disorders.

Rebecca Cashmore


From 2012-2013 I sat on the Eating Disorder Section (EDSect) of RCPsych as their representative from the RCPsych Psychiatric Trainees’ Committee (PTC). The PTC has approximately 40 elected trainee representatives and we are in the unique position of having members sitting on almost every committee within the College. Having just completed a 6 month outpatient eating disorder post in Edinburgh I was immediately attracted to EDSect. Of my core training years, this 6 months was where I learned most about psychotherapeutic approaches, formulation and, seemingly at odds with that, where I found myself most immersed in physical medicine. Being relatively inexperienced in the former but feeling increasingly unfamiliar with the latter when I had started that post, I recalled the apprehension of those early days. In my view we do not hear enough about eating disorders during our core training but the one thing we do get reminded of, starting in medical school, is the mortality rate associated with Anorexia Nervosa. I approached the post feeling a bit of fear and self-doubt: I suspect many of my peers have felt similarly. With supervision I gradually gained confidence and whilst working alongside some truly skilled therapists I undoubtedly developed as a psychiatrist.

It would not be an honest account of my experience on EDSect if I denied that my first meeting was a nerve wracking experience. For all PTC representatives, our first meeting on our first College committee may be the first time we have ever stepped into the College building (our initial PTC meeting is often held elsewhere). I found myself joining a group full of established professional relationships, mutual respect and huge collective experience. Extensive and detailed discussions took place related to the NHS reforms in England. I searched in vain to find something useful to say. However, during the first meetings I learned to understand the challenges facing the Section, its members and the wider eating disorder community. The provision of care to those with eating disorders is provided across NHS and many non-NHS organisations. If ever the term ‘post-code lottery’ was relevant to a patient group, my sense was that the committee feared it was here. How do we move further towards more standardised and evidence informed care when we don’t even have a complete map of where the services are and what they do?

The training that psychiatrists receive in eating disorder psychiatry is acquired across core training, child & adolescent higher training, general adult higher training or as CPD for non-training grades. A psychiatrist could feasibly take up a post within an eating disorder service for the first time in their career at any of these grades and as such there is no clear curriculum that will have been followed and no assumptions that can be made about the psychiatrist’s previous experience.

Within the committee there seemed to be a consensus that there were too few trainee psychiatrists currently in eating disorder posts and a concern about what this could mean for the future workforce. Efforts were being made to promote eating disorder psychiatry to medical students and trainees by offeringbursaries for travel to the Section’s Annual Meeting and by inviting applicants to the Section’s Poster Prize: some very high quality entrants highlighted that the interest, enthusiasm and capability the future of the service needs is out there. Why then does there seem to be a dearth of core and, particularly, higher trainees in these services?

In June 2013EDSect held its annual strategy day. The Chair, Prof. John Morgan, facilitated an enthusiastic discussion aimed at identifying the main areas of focus for EDSect for the year ahead. During a wide ranging conversation emphasis was repeatedly placed on the importance of high quality training to good services. We also considered whether any factors ‘pushed’ trainees away from eating disorder services. Might it be that psychiatric trainees are just put off by the need to get their stethoscopes, BP cuffs, needles and tourniquets to hand on a regular basis? The early jitters of my own involvement with eating disorder services came to mind. It had, in fact, been an initially very daunting and very different experience to work in an eating disorder service. With no assurance of an adequate induction programme I believed it was this unfamiliarity and self-perceived lack of competence that deterred some trainees. We agreed this training gap was a problem and that the Section should address it.

At the time of the strategy meeting I was working in a Forensic Psychiatry post at The State Hospital, Carstairs, Scotland. There I had learned of a multi-disciplinary induction programme called ‘New to Forensic’: a joint venture between NHS Education for Scotland and The School of Forensic Mental Health. The programme provides induction material that should be worked through with an experienced mentor. Whilst not providing a formal qualification, a certificate is issued upon completion of the programme.

There was agreement that there was a clear rational for creating a similar programme for eating disorder services. Dr Jane Morris had already created some induction materials for Scotland but these had not currently been conceived to be used at a UK wide level. Dr Morris agreed to lead a working group that would set to work in creating this national induction programme.

As EDSect bids ‘goodbye’ to me it says ‘hello’ to a new PTC representative, Dr Alex Keith, who is an ST5 in General Adult Psychiatry in South East Scotland. Alex was attracted to the exciting opportunity of getting involved in a piece of work that will make it easier for all of the professional people who are taking up posts in Eating Disorder services across the UK to acquire the unique knowledge and skills required in this rewarding but complex area. As I leave EDSect I take on a new challenge as Vice Chair of the PTC. As we welcomed a lot of new members to our committee we encouraged them not to be observers but to recognise that within the Faculties, Sections, Special Committees and Special Interest Groups of RCPsych we can advocate for the needs of the trainees that we represent and we can bring perspectives to discussions that are valued by the more senior psychiatrists, patient and carer representatives that we encounter. My experience within EDSect undoubtedly supports this.

Carol Wilson

ST4 in General Adult psychiatry

Vice Chair Psychiatric Trainees Committee

Whilst learning about the possible aetiological mechanisms that underlie eating disorders during my psychiatry rotation, I couldn’t help but notice that there was a stark resemblance to life as a medical student. It is those same ideals of perfectionism, an eye for detail, and rigidity in following rules set by ourselves that can precede both high achievers and the development of an eating disorder. This sparked my interest, and as a student associate of RCPsych, I was able to apply for a bursary to attend the Eating Disorders Section Annual Meeting.

The thought of attending a conference predominantly targeted towards specialists can feel daunting as a medical student, but in retrospect there was nothing to fear. The conference opened with a presentation by a neurosurgeon on Deep Brain Stimulation (DBS) - he provided a solid introduction as to what DBS was, its use in treating symptoms of Parkinson’s disease, and the result of a trial of its application in improving BMI in patients with anorexia where psychiatric treatment had failed.

Be it my naivety as a student, but it was evident that this exciting research had potential flaws- is DBS treating the underlying anxieties associated with anorexia, or is it just increasing BMI? Why did the inpatient psychiatric treatment that these patients had during the trial before DBS have a significant impact on improving their BMI, if they were treatment-resistant? The discussion forum at the end of the talk was a comfortable environment for me to voice my ideas alongside those of psychiatry consultants and trainees, and it was clear that there were many possible directions for further research in this area. It is exciting to consider that the next generation of psychiatrists may have a role in working alongside neurosurgeons within a multi-disciplinary team to determine the suitability of DBS in specific patients.

This contrasted greatly with subsequent talks on the management of malnutrition and the prevention of ‘refeeding syndrome’- the electrolyte disturbances that can occur when feeding anorexic patients who have been severely malnourished. Here, I realised how important it was for a psychiatrist to have knowledge of general medicine, as acutely unwell patients with anorexia nervosa may have a range of clinical abnormalities- low blood pressure, nutritional deficiencies, electrolyte disturbances and anaemia to name a few; and the same principles of diagnosis and management in clinical medicine are equally applicable in these situations.

All in all, even in a glimpse of a sub-specialty, I was able to witness the variety within psychiatry. The talks were engaging, thought-provoking, and the only essential requirement that you really need is natural curiosity about the subject!

Yathooshan Ramesh

(Year 5, Imperial College London)

My term as President of the AED is now complete, and it was with mixed feelings that I handed over to Professor Pam Keel at the International Conference on Eating Disorders (ICED) in Montreal in May. Mixed feelings because it was not always easy leading a complex network of volunteers and staff at long distance by means of late night teleconferences, trying to keep an eye on the big picture whilst being bombarded with detail and always having to be mindful of risks (although as an ED Psychiatrist this should be familiar territory....). The plus side is the feeling of having contributed something to a vision that I believe in: ‘Global access to knowledge, research and best treatment practice for eating disorders’. The energy of the volunteers is the lifeblood of the AED (over 400 AED members volunteer for the AED in some way!), and I know it is that same energy that keeps EDSECT active and productive. I have likened this to the energy and teamwork what made the Olympics so successful. It’s a good feeling, having made a contribution, and one that will last I think. I hope that’s a spur on to those of you have hesitated about joining the EDSECT executive committee, volunteering for AED, or contributing in your local ED organisations.