PROPOSAL TO DEVELOP A NORTH OF SCOTLAND EATING DISORDER IN-PATIENT UNIT
Report by Dr Annie K Ingram, Director of Regional Planning & Workforce Development, North of Scotland Planning Group and Derek Leslie, Director of Planning & Performance
The Board is asked to:
· Agree to develop a Tier 4 inpatient unit for the North of Scotland, with preferential access for patients from NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles, based at the Royal Cornhill Hospital.
· Approve the potential capital/revenue requirement in 2008/09 and to confirm that the approvals required to meet this within the NHS Board are in place.
· Approve the proposed methodology for cost sharing.
· Agree to the development of an intermediate/outreach service to support improved patient care.
1. Purpose of the Report
To ask North of Scotland NHS Boards to seek the approval of the appropriate Group within each NHS Health Board of a proposal to develop a specialist Eating Disorder In-Patient Unit for the North region and to seek the necessary capital and revenue funding requirements from NHS Grampian, NHS Highland and NHS Tayside to support this.
2. Executive Summary
This proposal would see the development of a tier 4 facility of adults with a severe eating disorder for the North of Scotland and would allow the mainland NHS Boards to save significant costs from current spend and improve the quality of care provided by inpatients services.
This facility will augment locally based services and provide specialist treatment for those most at risk. It is intended that there will be 10 places for North patients.
Through the NoS MCN for Eating Disorders the unit will have a clear North identity and work within clinical pathways of care agreed by the North clinicians.
NHS Boards will need to invest £437.5k capital towards ward upgrade and equipment and a recurring investment of £1146.5k for the In-Patient Unit. There are potential additional recurring staffing costs of £176.6k associated with the implementation of the Intermediate Care facility.
The costs will be shared on the basis of historical usage share with the private sector. See sections 8.2 and 8.3 of the paper for apportionments.
This will allow the mainland Boards to release circa £2.1 million from current spend with the private sector and achieve significant savings in the region of £1m.
3. Background
The North of Scotland Planning Group (NoSPG) is a collaboration of six NHS Boards including Grampian, Highland, Orkney, Shetland, Tayside and Western Isles. Argyll & Bute became part of NHS Highland in 2006 but, for the purposes of this proposal, patients from Argyll & Bute will continue to access services in Glasgow or elsewhere, as required.
In 2005, the North Boards established a Regional Network for Eating Disorders and subsequently appointed a Lead Clinician and Network manager. The Network was established under the Principles for a Managed Clinical Network, as summarised in HDL (2002) 69 and was asked by NoSPG to undertake a review of the needs of all patients from Community level to more specialised care, including support for primary care to help with early identification and intervention and the development of improved capacity in local generic mental health teams to deal with eating disorders. In addition, the network completed a review of the best means of addressing the needs of those patients who require hospital treatment. This detailed proposal is based on that work.
At the meeting of the North of Scotland Planning Group (NoSPG) on 20th April 2007 a proposal to develop an inpatient unit for adults with a severe eating disorder was approved in principle, subject to preparation of more detailed financial planning for approval by partner NHS Boards.
There are currently no NHS inpatient facilities for adults with an eating disorder in Scotland, with these services currently being provided by the private sector. Two private facilities exist: The Priory in Glasgow, which will admit patients aged 16 and above and The Huntercombe, which will admit younger patients. The costs of accessing care in the private sector have continued to rise for each of the mainland Boards since 1998, with a total spend in the three years to 31st March 2007, reaching £6.426m.
The following table (1) summarises key information relating to this service, including patients treated, bed days and costs to each board for each of the last three years.
Table 1: NoS EATING DISORDERS - 3 YEAR SUMMARY
2004-5 / 2005-6 / 2006-7 / TOTALSNo / % / No / % / No / % / No / %
PATIENT NUMBERS / TAYSIDE / 15 / 41.67% / 17 / 45.95% / 14 / 41.18% / 46 / 42.99%
(TREATED IN YEAR) / GRAMPIAN / 18 / 50.00% / 17 / 45.95% / 16 / 47.06% / 51 / 47.66%
HIGHLAND / 3 / 8.33% / 3 / 8.11% / 4 / 11.76% / 10 / 9.35%
NoS TOTALS / 36 / 100.00% / 37 / 100.00% / 34 / 100.00% / 107 / 100.00%
BED DAYS / TAYSIDE / 1,400 / 35.61% / 1,777 / 43.53% / 1,175 / 32.78% / 4,352 / 37.53%
GRAMPIAN / 2,374 / 60.38% / 1,851 / 45.35% / 2,065 / 57.62% / 6,290 / 54.23%
HIGHLAND / 158 / 4.02% / 454 / 11.12% / 344 / 9.60% / 956 / 8.24%
NoS TOTALS / 3,932 / 100.00% / 4,082 / 100.00% / 3,584 / 100.00% / 11,598 / 100.00%
COSTS / TAYSIDE / 770,274 / 35.62% / 977,598 / 43.54% / 642,112 / 31.82% / 2,389,984 / 37.19%
GRAMPIAN / 1,305,529 / 60.37% / 1,018,184 / 45.35% / 1,197,875 / 59.37% / 3,521,588 / 54.80%
HIGHLAND / 86,796 / 4.01% / 249,500 / 11.11% / 177,816 / 8.81% / 514,112 / 8.00%
NoS TOTALS / 2,162,599 / 100.00% / 2,245,282 / 100.00% / 2,017,803 / 100.00% / 6,425,684 / 100.00%
Notes: For 2004/5 and 2005/6 bed days not collected - bed days therefore calculated by dividing costs by £550 (estimated bed day cost).
In April 2007, a proposal to develop a regional inpatient facility for adults who require inpatient treatment for a severe eating disorder was approved by NoSPG (Item 21/07(i)). It was predicated on the assumption that the cost of such a facility would allow the mainland NoS boards to accrue significant savings and importantly to improve the care that these patients receive.
4. Current Services
Usually patients will be first identified and diagnosed by their general practitioner. However, it is well established that many patients, particularly those with bulimia nervosa and atypical disorders do not present to their general practitioners with an eating disorder. Once identified in primary care patients are frequently referred to mental health services and this happens almost invariably when there is severe anorexia nervosa.
In Highland and Grampian there are specialist multidisciplinary eating disorder services and the patients will often be directly referred to those services. In Tayside, the Western Isles, Orkney and Shetland the first referral will usually be to generic mental health services. In Tayside there is a limited clinical psychology and dietetic specialist provision able to cater for a restricted patient caseload. Tayside are currently implementing plans for a more comprehensive out-patient specialist service. In Orkney and Shetland some patients will be referred on to the Grampian Eating Disorders Service or referred direct to that service which is supported by videoconferencing facilities. Likewise, some Western Isles patients will referred to the Inverness based specialist service.
5. The Role of Inpatient Services
If patients have severe anorexia nervosa and if they are not responding to community based treatment then hospital admission is considered. These patients can be extremely low weight to a degree that there are physiological changes due to starvation. These include very low body temperature, very slow heart rate, low blood pressure, liver failure and kidney failure. To adequately address these severe clinical problems requires expertise from a range of disciplines to correct the nutritional status, manage the physical complications and provide psychological interventions. This normally takes several months. There are no resources in the North of Scotland for providing intensive day patient or assertive home treatment for eating disorders and the geographical spread of patients would make this difficult to provide.
Depending on the clinical situation, patients are admitted to a general medical unit, a general psychiatric unit or to a specialist unit for eating disorders in the private sector. There is no randomised controlled trial evidence to support the benefits of inpatient treatment. However, there are consensus clinical views from the American Psychiatric Association, the NICE Guideline Group and the QIS Guideline Group that inpatient treatment is necessary at least for a small group of patients.
It is recognised that the options for inpatient provision must be set in the context of comprehensive services. A very important element of this proposal is the provision of transitional care and outreach to bridge the transition from hospital to the community.
To help ensure a comprehensive approach to service provision in 2005 the North of Scotland Health Boards implemented an earlier decision of the North of Scotland Planning Group to set up a Managed Clinical Network. Other components of a comprehensive service being developed include support for primary care to help with early identification and intervention and the development of improved capacity in local specialist mental health teams to deal with eating disorders. The underpinning clinical context is discussed in more detail at Appendix 1.
6. Proposed Service
This proposal relates to the provision of services for patients in NHS Grampian, NHS Highland (excluding Argyll & Bute[1]), NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles for people aged 18 upwards and selected patients between 16 and 18 (16-18 year olds will be assessed for treatment suitability on a case by case basis) including men and women, although less than 10% of patients are male.
Generally these patients’ have severe anorexia nervosa with very low body weight and/or with medical complications. Other patients who may occasionally be considered for admission are patients with severe treatment resistant bulimia nervosa, whose eating pattern cannot be stabilised on an outpatient basis, and patients with an eating disorder co-morbid with severe depression, alcohol or drug misuse or repeated self-harm.
It is proposed that the North Unit will be established in Craigievar Ward in Royal Cornhill Hospital, Aberdeen. This ward is currently unused and requires some upgrading. The costs of the capital refurbishment and equipment are discussed in the Financial Implications section but are likely to be £437.5k. These costs will be 30% capital costs and the balance will be revenue.
It is planned that the unit will be tier 4 facility of 10 beds, with a 6 single rooms and a 4-bedded ward. Tier 4[2] is defined as the level of service required for patients with very severe illness and this mainly referred to inpatient treatment of severe anorexia nervosa. The unit will also include a therapeutic kitchen and dining area, group work area, sitting area and quiet room, in addition to the usual interview and office accommodation for clinical staff.
As noted above, the unit will admit adults with a severe eating disorder. Adults are defined as those over 18. Specialist Child & Adolescent Mental Health Services will provide services for patients under age 16. It has been agreed, in discussion with those responsible for Child and Adolescent Mental Health services that, for patient’s aged 16 -18, services can be provided either by Child & Adolescent Services or by specialist Adult Services for Eating Disorders. Decisions on the treatment for patients aged 16 -18 will be made clinically on a case by case basis aiming to best meet the needs of individual patients.
The unit will be supported by a detailed operational policy; however this is still in preparation by the Project Team, in collaboration with the NoS Network for Eating Disorders. There is a proposal that the unit may also provide an intermediate care/outreach element of care, however this will require further discussion to define the service provide and how the costs will be shared. It is intended that this service would support both the rehabilitation of patients, whilst still resident within the unit and to provide specialised support for patients once they have been discharged. The costs of this care can be shared or can be charged at a specific day rate, if there is not universal agreement.
7. Financial Implications
7.1 Cost Sharing Arrangements
NoSPG has previously agreed that the costs of regional initiatives should be shared on the basis of either a 3-year rolling average of usage share or in the absence of robust data, on the basis of weighted capitation. Despite there being no current NHS facility in Scotland at this time, the mainland Boards of NoSPG have made significant use of the private sector since 1998 and detailed information is available which summarises the use over time. This is presented at Appendix 2.
Table 1 above summarises the activity and costs over the last three years. At NoSPG on 8th November 2007, members asked that this usage data be used to calculate the cost shares between NoS partners. The cost shares between Boards can be calculated on the basis of the percentage use of bed days over the last three years, as follows:
Table 2: Costs Share by NHS Board
NHS Board / %Share
Tayside / 37.53
Grampian / 54.23
Highland / 8.24
NoS TOTALS / 100.00
Projected bed usage for the first year will be developed to allow NHS boards to plan. Usage will be tracked from day one and reviewed at the end of the first year and adjusted on the basis of actual usage. A review mechanism will have to be developed for this purpose.