Response 50418609

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Beat

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Questions

1. Our framework sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities?

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If no, what priorities do you think will deliver this transformation?
Beat is the UK eating disorders charity. We work for a future in which no life is blighted by or lost to eating disorders. Eating disorders are a range of serious mental health conditions that affect people physically, psychologically and socially. Anorexia Nervosa has the highest mortality rate of any mental illness and the mortality rates for the other eating disorders are also high (Arcelus et al, 2011; Crow et al, 2009). Over 725,000 men and women in the UK are affected by eating disorders (PwC, 2015). The 2014 Health Behaviour in School-aged Children survey found concerning rates of unhealthy weight control behaviours and body dissatisfaction amongst Scottish school children (Currie et al, 2015). Although serious, eating disorders are treatable conditions and full recovery is possible. We know at Beat from our daily contact with people affected, they can and do make a full recovery – their lives no longer dominated by a fear of food. The sooner someone gets the treatment they need, the more likely they are to make a full recovery. Research shows the importance of early intervention in improving prognosis, reducing relapse and preventing the escalation and development of severe and enduring eating disorders (PwC, 2015; Franko et al, 2013; Carter et al, 2012; Treasure and Russell, 2011). In principle we welcome the priorities included in the consultation document, although we would like to suggest some additional priorities and these are listed below. We recommended making a change to priority 6. This priority should be extended to apply to all people with mental health problems and not just those with a ‘Severe and enduring’ condition. If this qualification is retained the final strategy should clarify and explain how ‘severe and enduring’ is to be defined. The inclusion of a priority about ‘supporting mental health in primary care’ is welcome, however we believe that there should be considerably more focus on primary care within the strategy. This is reflected in our response to Question 2 in particular. SUGGESTED ADDITIONAL PRIORITIES: • Mental health services, training and mental health policy-making is guided by the views and experiences of people with mental health problems and their families. • Support for families (and other carers) of people with mental health problems. • Delivering accountability/transparency through the collection and publication of robust data • A commitment to a well-resourced and supported workforce. [Please note: hyperlinks for the references cited are available on request as these links were automatically removed by the online survey tool].

2. The table in Annex A sets out a number of early actions that we think will support improvements for mental health.

Are there any other actions that you think we need to take to improve mental health in Scotland?
COMMENTS ON KEY ACTIONS LISTED IN THE CONSULTATION DOCUMENT AND RECOMMENDATIONS FOR ADDITIONAL ACTIONS AGAINST SOME OF THE 8 DRAFT PRIORITIES: Priority 1: The key actions listed under Priority 1 should include a focus on eating disorders. Clinical experts recommend that women should be screened for eating disordered cognitions and behaviours during pregnancy and where necessary referred for a specialist assessment. Priority 1 – Key action 1: These ‘Managed Clinical Networks’ should include social workers (including mental health social workers), children’s services and experts from other non-clinical professions that can be essential to the early recognition of mental health problems in the perinatal period. Priority 2 - Key action 1: This action refers to supporting “key vulnerable populations of infants, children and young people”. Infants, children and young people who have a sibling, parent (or other relation) or friend with a mental health condition should be included within this group – acknowledging the distress that caring for someone with an eating disorder can cause. When referring to “young people” it would be helpful to know how this will be defined. Priority 2 – Key actions 1,2,5,6: If these programmes of work will be purely about prevention then they should incorporate what has been learned about potential environmental risk factors for the development of an eating disorder. This includes educating young people about positive body image, promoting self-esteem and media literacy. Efforts to reduce obesity should be focussed on health rather than weight, promote a balanced approach to diet and exercise and avoid stigmatising representations of people who are overweight or obese. Guidelines on the delivery of responsible ‘health promotion’ interventions have been published by the Academy for Eating Disorders and can be accessed here. Priority 2 – Key action 4: It is notable that this key action is specifically about the improvement of early intervention for Psychosis services. This represents the only condition-specific key action (or priority) in the document. The same rationale that supports the need for early intervention in psychosis also applies to the treatment of people with eating disorders. Early intervention (with evidence-based treatments) for patients with eating disorders is strongly associated with improved prognosis and recovery rates and reduced relapse rates and would therefore lead to significant cost savings - for the NHS, other public services, individuals and their families (Treasure and Russell, 2011; PwC, 2015). Therefore, within this priority we strongly argue for the need to include a programme of work aimed at improving the early identification and treatment of eating disorders. Priority 2 – additional recommended actions: The symptoms of eating disorders often begin in adolescence. There is also recent evidence about high rates of body dissatisfaction and unhealthy weight-control behaviours amongst Scottish school children (see Currie et al, 2015). Training should be provided for teachers and other school staff to help them notice the signs and symptoms of mental health problems (including eating disorders), know how to approach students in a compassionate and non-judgemental manner and what action they should take. One of Beat’s trustees, Dr Pooky Knightsmith, has published some important work on how schools can be supported to facilitate early intervention for students with symptoms of an eating disorder (Knightsmith et. al., 2014a; Knightsmith et. al., 2014b). Education about mental health conditions including signs and symptoms should feature within the curriculum from primary school age onwards (adjusted for developmental level). Further and Higher Education (University) medical/health services, student unions, sports clubs and academic schools should be required to meet a ‘mental health support standard’ - proving that their policies and practices facilitate and support early intervention and recovery for students with mental health problems (including eating disorders). Priority 3 – Key action 1: The models being tested and evaluated should include the provision of training and supervision for GPs and primary care nurses in the treatment of patients with mental health problems (including eating disorders). They should consider the time required for GPs to be able to compassionately and professionally deal with complex consultations. The Royal College of GPs in Scotland has called for action to improve the capacity of GPs to be able to offer extended appointments when they are seeing patients with mental health conditions (RCGP in Scotland, 2015). We welcome their focus on this issue and support their call for future primary care workforce projections to account for this need. A consistent approach to the medical monitoring of patients with eating disorders in primary care must be ensured. In some areas GPs have refused to provide this service. The NHS Healthcare Improvement Scotland (2006) clinical guideline for the management and treatment of eating disorders states that: “There should be a clear and preferably written agreement between the patient, the GP and the secondary care service about the nature and frequency of monitoring” (p.28), however in practice there is often no such written agreement. Priority 3 – Key action 2: We would recommend that NHS Scotland reviews the evidence which is already available about Crisis Response and Home Treatment teams (CRHTs) in England, without waiting until 2020 to make decisions about the provision of these services. This could include Mind (2011); CQC (2015), University College London’s CORE study and learning from the ‘Bristol model’. McCrone, Knapp and Hudson (2007) estimate that an acute mental health service making full use of CRHT services in appropriate cases costs approximately £600 less per crisis episode than one in which CRHT is not available. Where Community-based crisis response is available, NHS Scotland should consider introducing a waiting time target to ensure parity (see Priority 7) with those experiencing a physical health emergency, who are covered by the A&E 4 hour waiting time target. Similarly to CRHT teams, in Scotland there are currently two ANITT (Anorexia Nervosa Intensive Treatment Team) services, which can provide an alternative to hospital admission for some patients (Royal College of Psychiatrists in Scotland, 2013). These services offer the opportunity for some severely ill patients to be treated safely via intensive outpatient treatment or in their own homes. As with general CRHT, treatment teams who specialise in eating disorders and are able to offer intensive, home-based treatments should be available across Scotland. The decisions over which patients should be treated by these services should be based on holistic assessment of the severity of patients’ illness, motivation, suicidality, their medical stability and medical risks etc. and not simply on their BMI or weight. Priority 4 – Key action 1: These self-help resources should include ‘Guided self-help’ as this can be more effective in some cases where the patient is initially ambivalent about treatment (as with some patients with eating disorders). Some self-help resources for patients with eating disorders, should be considered for inclusion, these may include ‘Overcoming Bulimia Online’ which is aimed at patients with Bulimia Nervosa and ‘Overcoming Anorexia Online’ which is aimed at the family members (or other carers) of people with Anorexia Nervosa. Both of these resources were developed by Professor Chris Williams of the University of Glasgow and colleagues. (Overlapping with Priority 3) - A charity called the ‘Reading Agency’ runs a scheme with libraries across England and Wales called ‘Books on prescription’. This scheme has helped many people in England and Wales to access self-help books about mental health problems. NHS Scotland should consider introducing such a scheme in Scotland. Priority 5 – Key action 1: The mental health outcome framework should include outcome measures which are specific to the symptoms of eating disorders (such as the EDE-Q). For these patients it would not be sufficient to rely solely on general anxiety and depression outcome measures. Priority 5 – Key action 3: There is a need to address both the capacity of services offering treatment for patients with eating disorders and also their waiting times. This work should not just focus on CAMHS services but should apply to patients of all ages. In the case of the treatment of patients with eating disorders improving their access to mental health services will require action to remove referral criteria which is based solely on BMI/weight. Barriers such as this, are the antithesis to early intervention and also contradict clinical guidelines and medical evidence about the complex assessments required to safely determine severity in eating disorders. It is not acceptable that the 12-week referral to treatment waiting time target for outpatient treatment in Scotland does not apply to patients who are referred for mental health treatment. This is a clear breach of priority 7 which must be brought to an end as soon as possible. In 2013 it was reported that under 18s with eating disorders occupied the majority of CAMHS inpatient beds in Scotland (Royal College of Psychiatrists in Scotland, 2013If quick access to evidence-based treatment was more widely available for people with eating disorders, then these patients need for inpatient treatment would be significantly reduced). There is a compelling case for greater investment in specialist eating disorders services (Royal College of Psychiatry, 2012). This was recognised recently by NHS England through the allocation of £150million over the next 5 years to improve access to evidence-based eating disorders treatment (NCCMH/NHS England, 2015). There is a lack of training on eating disorders within medical degrees and psychiatry training (Jones et al, 2013). Patients with eating disorders experience complex psychological symptoms which can create barriers to identification and treatment. Services which are dedicated to the treatment of eating disorders can help to facilitate the multi-disciplinary approach to treatment recommended by clinical guidelines and act as a hub of expertise for local health and social care systems (Royal College of Psychiatry, 2012; Gowers et al, 2010; Currin et al, 2007). For patients with eating disorders treatment in a mental health service which specialises in the treatment of eating disorders is more cost effective than treatment in a generic/non-specialist mental health service (Gowers et al, 2010; Byford and Barrett, 2007). The operation of a specialist eating disorders service within an area improves the identification of eating disorders by local GPs (House and Schmidt, 2012), leads to better clinical outcomes and reduces hospital admissions (House and Schmidt, 2012). They provide better continuity of care (House and Schmidt, 2012) and are highly valued by patients and carers (Gowers et al, 2010; Escobar-Koch et al, 2010). Although the situation has improved in Scotland over the last few years, there are still a number of areas with no such services and in areas where services are available these services are often lacking in capacity (Royal College of Psychiatry in Scotland, 2013). These programmes of work should be informed by the views and experiences of experts by experience and clinical experts. Beat would welcome the opportunity to help inform the development of new access and waiting times standards for the treatment of eating disorders in Scotland, perhaps through membership of an expert reference group. Beat recently played an important role as a member of the Expert Reference Group which was convened by the National Collaborating Centre for Mental Health (NCCMH) to develop the commissioning guide ‘Access and waiting times standard for Children and Young People with an eating disorder’ on behalf of NHS England. Priority 5 – Additional recommended actions: In order to improve access to mental health services work will need to be carried out beyond efforts to improve capacity and reduce waiting times: • This should include commitments to open-up access to CAMHS through clear referral pathways from schools, further education colleges/sixth forms (and other youth groups), Universities, the voluntary sector and self-referral. Often people with eating disorders are unable to secure the referral they need from their GP. • There should be a collaborative approach between CAMHS, schools/colleges/Universities, GPs (and other professionals within primary care) and families. • Transitions between services is an area of particular concern for patients with eating disorders. Often there is little or no communication and coordination between CAMHS and adult mental health services, between inpatient and outpatient services or between services in different parts of the country (particularly for University students). Transitions between services are often difficult for patients and can be dangerous – with the risk of patients falling between the gaps (Treasure, Schmidt and Hugo, 2005). The age of transition from CAMHS to adult mental health services varies across Scotland, although it is often based strictly on the date of the patients 16th or 18th birthday. The system should show flexibility so that transitions between these services are based on the developmental stage and circumstances of the young person, rather than an arbitrary age boundary. Due to the disruption that an eating disorder can have on a young person’s development, many young patients transitioning to adult mental health services are not ready or prepared for the significantly different approach to treatment which they commonly encounter after transition to the adult service. NHS Scotland should consider whether it would be more clinically appropriate to provide eating disorders services which can see patients up until the age of 25. This would minimise the need for transitions between services. A report from the Royal College of Psychiatrists in Scotland (2013) stated that: “Without continuity of care, people with eating disorders relapse readily. Effective care will not last unless transitions are managed particularly carefully” (p.3). • A commitment to fight stigma across Scottish society, which can constitute a serious barrier to early intervention and access to mental health services. This could involve a long term commitment to the funding of the SeeMe Scotland initiative. The only ‘action’ about stigma mentioned in the consultation document refers specifically to stigma in the workplace. • Perhaps through the ‘Scottish Patient Safety Programme in Mental health’ raise awareness amongst mental health professionals of the need for a cautious and consistent approach to patients who do not attend appointments or engage with treatment. Some patients (particularly in the case of eating disorders) can be ambivalent about engaging with mental health services and treatment, however every possible effort should be made to engage the patient before they are discharged and they should not be discharged without sufficient follow up contacts, liaison with others around them (such as GP, family, school/college/University staff, social workers or others) and guidance about how they can access the service again in future and how they could access help in a crisis (should that arise). • Treatment in specialist eating disorders inpatient units (although these are rare in Scotland) should be accessible to males as well as females. There is anecdotal evidence that policy commitments towards single-sex wards have reduced or prohibited access for males to some of these services in England. • A commitment to end the post-code lottery that exists in terms of access to eating disorders services (and presumably other types of mental health services). The 2013 Royal College of Psychiatrists in Scotland report on eating disorders services in Scotland noted that: “There are particular gaps in service provision in the west of the country and in many remote and rural areas.” (Royal College of Psychiatrists in Scotland, 2013, p.3). • Liaison Psychiatry services in hospitals can increase access to mental health services, as well as improving the experience of A&E treatment for people with mental health problems. NHS Scotland should commit to ensure that these services are available across the country as soon as possible. NHS England has told all acute trusts in England that by 2020 they should “…have in place liaison mental health services for all ages appropriate to the size, acuity and speciality of the hospital.” (NHS England, 2015). A University College London study of four London A&E departments found that people presenting with mental health crises were 6.5 times more likely to have to wait more than 4 hours to be seen than individual presenting with a physical health problem (CQC,2015). There is also a strong cost-effectiveness case for optimal liaison psychiatry services – it is estimated that every £1 invested derives an approximate benefit value of £4 (CQC 2015). A commitment to evidence-based mental health treatment – as well as improving access to mental health services, there should be concerted nationwide effort to ensure that services are delivering high quality treatment and care. These services should be delivering treatment and care in line with best-practice clinical guidelines (although these now need updating in the case of eating disorders). Improvements are necessary in terms of access to Family Based Therapy (FBT) for patients with eating disorders. FBT is empirically supported as a first-line treatment for most children and adolescents with an eating disorder. It is also important that this form of therapy be available for those above the age of 18 where it is clinically indicated, as it can still be effective for some adult patients. Patients should also be offered access to moderated (safe) peer support, potentially through collaboration with voluntary sector organisations such as Beat. Priority 7 – Key action 3: Public health anti-obesity interventions should be carefully designed and delivered so that they are clearly focussed on health rather than weight, avoid a stigmatising representation of people who are overweight or obese and promote a balanced approach to diet (not ‘dieting’) and exercise. Priority 7 – Additional recommended actions: Conduct a review of government mental health spending to ensure that spending on mental health is proportional to clinical need (at least to a similar degree as for physical health conditions). It has been estimated that mental health problems account for 23% of the ‘burden of disease’ in England, but receive only 13% of health funding (Mental Health Policy Group, 2015). The Royal College of GPs estimated in 2012 that mental health was at least part of the reason for nearly 30% of Scottish GP appointments (SAMH, 2014). Such a review would be strengthened by commissioning epidemiological research (see page 7, para. 2) as this would enable a more accurate estimate of current clinical need. Ensure that local health board’s mental health budgets are protected/ring-fenced and that savings they make from greater investment in early intervention (particularly through any reduced demand for inpatient care in the long term) can be identified and reinvested to lead to further improvements in their community-based mental health services. Priority 8 – Key action 2: Currently calculating the mortality rate of eating disorders is often based on analysis of death certificates. Often if a patient dies due to a physical health problem which has been caused by an eating disorder, the certificate of their death will not provide this information. Death certificates are often limited to only specifying the physical health problem which directly caused the death, (for example a heart attack). This should be reviewed so that we are able to more accurately estimate the mortality rate of eating disorders. Priority 8 – Key action 3: Another action connected to this one, would be to put systems in place to ensure that the treatment of patients with eating disorders who are critically ill is always overseen by a clinician who is experienced in the treatment of patients with eating disorders. Clinicians without this experience are more likely to be misled by patients who may appear lucid and eloquent whilst trying to talk themselves out of being sectioned or force-fed, even if such intervention is ultimately necessary to save their life. SUGGESTED KEY ACTIONS ASSOCIATED WITH THE SUGGESTED ADDITIONAL PRIORITIES: • Mental health services, training and mental health policy-making is guided by the views and experiences of people with mental health problems and their families. Healthcare Improvement Scotland to work with NHS boards and services to ensure that all mental health services are listening to and learning from the views and experiences of their service-users. Healthcare Improvement Scotland to work with NHS Education for Scotland and any other providers of mental health training to ensure that this training is informed by the views and experiences of service-users and their families (and any other carers). The Scottish Government and NHS Scotland to fully involve service-users, families (and other carers) and the voluntary sector in the design, monitoring and evaluation of mental health policy (including this strategy). • Support for families (and other carers) of people with mental health problems. Mental health services should review and improve the support they provide to the families (and other carers) of people with mental health problems. This support should not depend on the patients’ age, condition, severity or the duration of their illness. In the case of patients with eating disorders, their parents (or other primary carer/s) should be provided with information on eating disorders and be able to access ‘collaborative care skills workshops’ modelled on those developed by Professor Janet Treasure and colleagues at the Maudsley hospital and King’s College London. They should also be able to access peer-support, where they can receive support and encouragement from other carers in a similar situation. Training of primary care professionals should highlight the risk of carers themselves developing mental health problems to enhance the likelihood that any problems are identified early. • Delivering accountability/transparency through the collection and publication of robust data Epidemiological research must be commissioned to provide an accurate estimate for the prevalence and incidence of mental health conditions (including eating disorders) in Scotland. It is impossible to estimate clinical need without this data. NHS Scotland and NHS Education for Scotland should ensure that the necessary training is provided and that monitoring systems are in place to improve the accuracy of hospital notes for patients with mental health conditions. A patient may disclose their eating disorder on admission, but this unfortunately does not always mean that this will be recorded on their hospital notes. These notes may only state the physical health problem, such as heart palpitations, without mentioning the eating disorder, even though it was the eating disorder which had led to the heart palpitations. It is important that this information is recorded so that we are able to have a clearer picture of health service-use by patients with eating disorders. All mental health services (including eating disorders services) should be required to collect and make available data on key elements of the service that they provide, including waiting times and clinical outcomes. They should also publish data on the proportion of referrals declined and the reasons for these rejections, to help us to monitor whether harmful barriers to care are obstructing access. Beat hears regularly from patients who have been told that they ‘do not meet the criteria’ for eating disorders treatment as their BMI is ‘not low enough’. Local Health Boards (and any other commissioners) should be required to publish (in an accessible format) data on mental health spending and workforce employed (which can be easily broken down by mental health condition, type of service and other variables if appropriate). Plans for future spending and workforce levels should be published in advance so that they can be scrutinised by stakeholders. • A commitment to a well-resourced and supported workforce. NHS Education for Scotland to use its influence to ensure that Scottish University medical degree curriculum's ensure sufficient teaching about mental health (including eating disorders) and promote careers in psychiatry or General Practice, to their students. NHS Education for Scotland to develop a long term strategy to deliver training opportunities for a range of health professionals about mental health conditions (including eating disorders) and ensure sufficient clinical supervision. This should include GPs as a priority given their important role as a ‘first port of call’ and gatekeeper. This training should be informed by the views and experiences of people with personal experience of mental health conditions (including eating disorders) and their families (or other primary carers). Those working in specialist eating disorders services should be required to hold or be working towards accreditation under the eating disorders curriculum and accreditation system already developed by NHS Education for Scotland (NES). NES and EEATS (Eating Disorders Education and Training Scotland) should develop re-accreditation and enhanced accreditation schemes for more experienced professionals (potentially incorporating skills in clinical supervision). The Royal Colleges of Psychiatry, Physicians and Pathologists (respectively) have published a set of guidelines called the MARSIPAN (Management of Really Sick Inpatients with Anorexia Nervosa) guidelines due to concerns that “a number of patients with severe anorexia nervosa were being admitted to general medical units and sometimes deteriorating and dying on those units because of psychiatric problems, such as non-adherence to nutritional treatment, and medical complications, such as re-feeding syndrome” (p.6). Hospital staff in Scotland should be made aware of these guidelines (as well as the corresponding Junior MARSIPAN guidelines) and be expected to implement them. Despite their name these guidelines can also be relevant to patients with other types of eating disorder. These guidelines recommend the establishment of local multi-disciplinary MARSIPAN groups to oversee local implementation. A checklist to support implementation is available. There is also a different version of the guidelines which is tailored to the treatment of younger patients known as the Junior MARSIPAN guidelines. Collaboration between NES, EEATS, NHS Scotland, Universities and other partners (perhaps including the Scottish Funding Council) to invest in greater innovation and research into the prevention and treatment of mental health conditions. To help deliver this these organisations should encourage greater collaboration between Scottish academics and leading researchers from other countries. Such collaborations could help to test whether models of care which have significantly improved mental health care in other contexts could be successfully adapted to the Scottish healthcare system. To ensure that SIGN/Healthcare Improvement Scotland has the necessary resources and plans in place to deliver up-to-date clinical guidelines for all mental health conditions. To date it has produced very few guidelines on mental health. As of 05/09/2016 none of the 13 clinical guidelines in development concern the treatment of mental health conditions. A process should be considered to enable Healthcare improvement Scotland to review and adopt NICE clinical guidelines for mental health conditions (perhaps as an interim measure), if there is no SIGN-authored guideline in development on that topic. As part of this SIGN should be instructed to conduct a rapid review of research published on the management and treatment of eating disorders since the publication of the current guideline in 2006, with a view to the publication of an update. NICE are due to publish an updated clinical guideline on eating disorders in April 2017, due to significant new evidence that has been published in the last few years, particularly on the efficacy of Family Based Therapy for children and young people and CBT/CBT-E for adults. Beat frequently hears from service-users who have been refused access to treatment due to their BMI/weight or appearance (commonly they are told that their ‘BMI is not low enough’ for them to ‘meet the criteria’). Any updated clinical guideline from SIGN/Healthcare Improvement Scotland should strongly condemn this dangerous use of BMI/weight/appearance as a sole measure of clinical need and access to treatment and emphasise that all patients with disordered eating should receive a comprehensive assessment of their physical and psychological health, which is then used as the basis for decisions about treatment. Support the development of Managed clinical networks (beyond those promised in the consultation document for perinatal mental health), which can help mental health professionals and commissioners to share best practice, learn from each other and improve continuity of care for patients by working across existing professional and health board boundaries. An inquiry by the Parliament Health Committee in 2005 (see paragraph 114) recommended the establishment of a national Managed Clinical Network for eating disorders to improve communication, continuity of care and management of transitions. Pilot and where successful roll-out initiatives aimed at improving the mental health and wellbeing of health professionals. [Please note: hyperlinks for the references cited are available on request as these links were automatically removed by the online survey tool].

3. The table in Annex A sets out some of the results we expect to see.

What do you want mental health services in Scotland to look like in 10 years' time?
COMMENTS ON EXPECTED ‘RESULTS’ SPECIFIED IN THE CONSULTATION DOCUMENT: Priority 1: This should also include ‘Better long term outcomes for mothers accessing these services’. Priority 2 – Result 3: This should be extended to include better partnership working between specialist CAMHS in different geographical areas. Continuity of care/integrated care can be essential to delivering early intervention and access to treatment for young people who need treatment away from their usual place of residence (this often includes University students). Priority 2 – additional recommended ‘results’: Other important ‘results’ that could be measured would be (long term) reductions in demand for inpatient treatment and reduced rates of re-admittance to mental health services. Priority 4: Peer support should be facilitated by someone who has received the appropriate training and is able to access supervision so that they can foster a safe and pro-recovery environment. This is particularly important in the case of patients with eating disorders. Peer support can be an important service for people with mental health problems and should be more widely available, however it should not be seen as a potential replacement for specialist treatment. ‘HOW WE SHOULD MEASURE SUCCESS OVER THE 10 YEAR PERIOD’ Page 1 of the consultation document, states that this consultation would like respondent’s views on ‘how we should measure success over the 10 year period’. This is quite different to the wording of this question in the online survey. This distinction is important because transforming mental health care in Scotland will require action and improvement beyond just mental health services. Achieving the goals of early intervention and nationwide access to evidence-based treatments and support will require action across society. Primary care, hospitals and other parts of the health system, the education sector, other public sector bodies (such as those responsible for welfare), the voluntary sector and employers will all have important parts to play and must work collaboratively. All those who work with or care for children (particularly schools) would receive support to help them target the risk factors which can contribute to the development of eating disorders including low self-esteem, perfectionism, body image dissatisfaction and bullying. Any public health interventions aimed at reducing obesity will be carefully designed and implemented so that they are focussed on health (rather than weight), promote balanced approaches to diet (not ‘dieting’) and exercise and avoid presenting a stigmatising representation of people who are overweight or obese. The symptoms of an eating disorder would be routinely identified soon after onset with immediate action taken to help the patient secure the treatment and support that they need. Patients and their families (and other carers) would be treated with compassion and understanding. Parents (or other primary carers) will be informed and supported to help them facilitate treatment and recovery. Strong connections and collaborative working between mental health services and primary care, schools/colleges/Universities, voluntary sector, employers, families and patients will help deliver this early intervention and support these patients to engage in treatment. It would become the norm that very soon after a referral patients will receive a comprehensive assessment of their physical and psychological health and that, if clinically indicated, eating disorders treatment will begin very soon after that initial assessment. This will require an end to the postcode lottery so that eating disorders services (of varying intensity from community-based outpatient to inpatient services) are commissioned in every part of Scotland. The treatment offered would be evidence-based and delivered through clinical teams who have specialist knowledge. Integrated care across geographic and health service boundaries would have become the norm and minimized the disruption which had commonly been experienced during transitions between services in the past. Improved access to (evidence-based) treatment could be expected to result in considerably fewer admissions to intrusive and expensive inpatient or hospital treatment, reduced need to treat patients under section and reduced relapse rates. Those patients who still required inpatient care would be able to access this in appropriate settings – therefore bringing an end to inappropriate out-of-area admissions and children being treated in adult wards. Mental health services would be responsive to the views and experiences of their service-users and their families. They would receive adequate funding and be able to recruit the staff they need. They would prioritise the well-being of their own staff, so that they are able to deliver high quality care for patients. The NHS and Universities in Scotland would conduct more research to help strengthen the evidence-base around optimum forms of treatment and models of service-delivery, which would then inform future planning of mental health services. Commissioners (local health boards) and mental health services would routinely publish data on the services they provide, including spending, waiting times and clinical outcomes to ensure that they are accountable to service-users, their families and taxpayers. COMMENTS ON – ‘MAKING A DIFFERENCE: HOW DO WE KNOW?’ Eating disorders specific outcome measures should be included in this work. Clinicians and academics who specialise in eating disorders, the voluntary sector and experts-by-experience should be consulted when decisions are made about which outcome measures to use. Data should be collected and published in an accessible format so that service-users, their families (or other carers) and taxpayers are able to monitor the implementation and impacts of the strategy. [Please note: hyperlinks for the references cited are available on request as these links were automatically removed by the online survey tool].