Quality statement 5: Coordinated care across services

Quality statement

People with eating disorders who are being supported by more than one service have a care plan that explains how the services will work together.

Rationale

A lack of coordination of services can cause confusion, add to the burden of the person with eating disorders and their family or carers, and has the potential to delay recovery. A care plan that explains how services will work together ensures that healthcare professionals all know about the person's care needs and their responsibilities for ongoing management. This will help to prevent treatment and support being compromised by poor coordination. This is particularly important when more than one healthcare service is involved because poor communication between services can mean inconsistent messages and management approaches, as well as lack of clarity about clinical responsibilities.

Quality measures

Structure

Evidence of joint working arrangements, including regular liaison and meetings to discuss care plans, between eating disorder services and other services, using formal processes of care planning, such as the Care Programme Approach (CPA).

Data source: Local data collection, for example, contracts and service specifications. NHS England's NHS standard contract for specialised eating disorders (adults) (2013) includes details on care planning and collaborative working using the CPA.

Process

a) Proportion of people with eating disorders who are supported by more than one service who have a care plan that explains how the services will work together.

Numerator – the number in the denominator who have a care plan that explains how the services will work together.

Denominator – the number of people diagnosed with eating disorders who are supported by more than one service.

Data source: Local data collection, for example, local audit of electronic records.

b) Proportion of people with eating disorders who are supported by more than one service and have CPA meetings to discuss their care plan.

Numerator – the number in the denominator who have their care plan discussed in their last CPA meeting.

Denominator – the number of people diagnosed with eating disorders who are supported by more than one service and have a care plan.

Data source: Local data collection, for example, local audit of electronic records.

Outcomes

a) Rate of relapse for people with eating disorders who are supported by more than one service.

Data source: Local data collection, for example, local audit of electronic records.

b) Service user experience of eating disorder services.

Data source: Local data collection, for example, using patient surveys.

What the quality statement means for different audiences

Service providers (such as specialist inpatient and outpatient eating disorder services, community-based eating disorder teams, child and family services, general mental health teams, primary care services or separate healthcare services treating other conditions) ensure that joint working arrangements are in place between eating disorder services and other services as detailed in the agreed care plan.

Healthcare professionals (such as GPs, case managers or care coordinators within a specialist eating disorder service) coordinate care by communicating the care plan to all services involved in care for a person with an eating disorder and mediating between services. There will be a combination of care planning meetings and regular written updates on care needs and how the services will work together to address these. Clear roles and responsibilities will need to be defined for all relevant healthcare professionals involved and shared with the person.

Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that care plans on joint working arrangements for services caring for people with eating disorders are developed, shared and delivered within and across the services involved.

People with eating disorders who are supported by more than one service (such as when moving from one area to another, for example, from home to university) have a care plan that explains how the services will work together to provide the care and support needed. The plan explains clearly the roles and responsibilities of the healthcare professionals involved in the person's care.

Source guidance

Eating disorders: recognition and treatment (2017) NICE guideline NG69, recommendation 1.1.18

Definition of terms used in this quality statement

Care plan

The care plan should be developed in collaboration with the person, their family members or carers (as appropriate), and the services involved.

It should include details of:

  • joint working service arrangements

  • all healthcare professionals and services involved, and their roles and responsibilities

  • preadmission care (including frequency and responsibility for monitoring medical and psychiatric risk)

  • urgent or emergency admission (indications, procedure and location)

  • defined clear objectives and outcomes for inpatient treatment

  • how the person with the eating disorder will be discharged from inpatient care, how they will move back to community-based care, and what this care should be.

[Adapted from NICE's guideline on eating disorders, recommendation 1.11.11 and NHS England's NHS standard contract for specialised eating disorders (adults)]

Equality and diversity considerations

Care planning should take account of the needs of the person with an eating disorder, their families and carers.

Care plans should be supplied in a format that suits the person's needs and preferences. They should be accessible to people who do not speak or read English, and should be culturally appropriate, age appropriate and gender appropriate. People should have access to an interpreter or advocate if needed.

For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.