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Eating disorder services: Charting the way forward  

By Niamh Cahill - 27th Jan 2025

Eating disorder

While progress has been made in developing HSE eating disorder services, significant deficits remain.
Niamh Cahill examines current provision

In January 2018, a national plan for eating disorder services was launched by the HSE.

The Eating Disorder Services HSE Model of Care for Ireland set out a strategic vision for provision of eating disorder services in Ireland in the future.

More inpatient beds were promised. Community outpatient teams would be launched. A complete and accessible national service was envisaged. The existing paucity of services would be no more.

It is now seven years since the model of care was published. Eleven of 16 agreed national community teams for adults and children/adolescents are in place.

Across the system, awareness and education among healthcare workers has improved and there are more clinicians dedicated to treating patients with eating disorders than ever before.

However, despite considerable progress, there are concerns that not enough investment has been made to fully develop services. The pace of developments has also been questioned.

In November, the College of Psychiatrists of Ireland’s eating disorders special interest group (EDSIG) advocated for increased resources for treatment, particularly to address the “lack of availability of essential community services and access to inpatient and day patient treatment in many areas of the country”.

Based on the 2016 census population, an estimated 188,895 people in Ireland would experience an eating disorder in their lifetime. The EDSIG noted that the population had since grown dramatically and recent studies indicated the rates and severity of cases had risen significantly, particularly among young people.

“The consequences of untreated eating disorders can be devastating, leading to severe physical and psychological health issues which can be life-threatening, as well as significantly damaging to social and occupational wellbeing.”

In regard to the model of care, the group stated: “While new teams have been created, these have often been understaffed and under-resourced, and there has been a failure to fund all of the necessary teams. Even starker is the lack of progress in the availability of inpatient and day programme treatment options.”

In December, the College of Psychiatrists warned that resourcing for eating disorder services was in a “perilous state”. The College called for the immediate and full implementation of the model of care. It stated that the HSE had fallen short of its targets, “leaving patients and their families suffering”.

Model of care

Evidence shows that eating disorders have the highest morbidity and mortality within mental health.

Before the publication of the HSE model of care and the establishment of the National Clinical Programme for Eating Disorders, there were no specialist community eating disorder services in Ireland.

According to Dr Michelle Clifford, Consultant Child and Adolescent Psychiatrist and HSE National Clinical Lead for Eating Disorders, it is important to remember “where we came from” when reviewing services.

In an interview with the Medical Independent (MI), Dr Clifford stated that while a lot of work has been undertaken to develop services since 2018, further developments are required.

She also confirmed that a planned review of the model of care would hopefully take place “within the next year”.

“Before the model of care, we had no community eating disorder services in Ireland,” she noted. “We had probably less than five clinicians dedicated to eating disorders. Eating disorders were always looked after within general community mental health teams within CAMHS [Child and Adolescent Mental Health Services] and adult mental health teams. While [patients] would often receive very good evidence-based care, it was pockets of services and initiatives… there was no joined network or standardisation of care or national training programme.”

Dr Art Malone is Chair of the EDSIG in the College of Psychiatrists and Consultant Psychiatrist with the adult eating disorder service at St Vincent’s University Hospital, Dublin.

Speaking to MI in his capacity as Chair of the EDSIG, Dr Malone remarked: “Four or five years ago we were the only adult eating disorder team in the country…. There will be a whole cohort of people who, at the age they developed an eating disorder, had no access to treatment at all.”

Because of the dearth in services, the HSE has initially focussed on developing community services. It has stated that the most effective treatment setting for eating disorders is usually in the community, although a small number of people require more intensive treatment.

But Dr Malone is worried that community efforts are eclipsing an urgent need for more inpatient beds.

“My concern is that if the focus is on establishing community teams, which is a necessary step, it will be years down the line before there is a single new bed available under the current plans,”
Dr Malone said.

“From a HSE strategy point of view, the goal has been to put a service in every area and then to look at inpatient beds. Inpatient beds is a massive issue to develop. Going from zero to putting beds in hospitals is a huge undertaking and involves negotiating with hospitals, a lot of which are already oversubscribed in terms of their beds….

“At the moment there is no strategy for where the beds are going to go, who can access them and who is going to govern them…. Once a plan is in place it will then take years to implement.”

There are currently three adult inpatient beds dedicated to treating patients with eating disorders at St Vincent’s University Hospital. The beds serve patients in the surrounding catchment area.

These beds pre-date the model of care and no new adult inpatient public beds have been delivered to date. The model of care, which had a five-year implementation plan, proposed developing a further 20 adult inpatient beds.

To make up for this deficiency, the HSE regularly purchases inpatient beds from private units such as St John of God Hospital, Dublin, and St Patrick’s University Hospital, Dublin. The HSE Treatment Abroad Scheme (TAS) is another way for patients to access inpatient care. Since 2020, 14 people have accessed treatment for an eating disorder via the TAS, according to the Department of Health.

Patients unable to access a specialist eating disorder bed are also admitted to medical beds in public hospitals. However, this is not regarded as the most appropriate place for treatment, as the required level of psychological and social support cannot be provided in this setting. In 2023, some 485 patients with an eating disorder diagnosis were treated in public hospitals according to data from the Hospital Inpatient Enquiry system (which collects data on day patient and inpatient activity in all acute public hospitals).

Patients under the age of 18 have access to 20 beds nationally via CAMHS. The development of this capacity has meant that no patients under-18 had accessed the TAS since 2018. “We’ve been able to meet that need in Ireland now,” outlined Dr Clifford.

She also stated that a review of adult bed capacity was underway. “That will include a review of the data we have on bed usage in the HSE, the private placement and the treatment abroad. That will inform plans in terms of how best to develop and deliver beds required for adults with eating disorders,” Dr Clifford said.

“We’re fully aware that [the number of adult beds] has not changed. That is an area of need and that does need to be developed.”


At the moment there is no strategy for where the beds are going
to go, who can access them and who is going to govern them

Investment

In 2023, the HSE spent €8.1 million on eating disorder services under the clinical programme.

Around 100 posts have been funded. Some 85 clinicians including 10 consultant psychiatrists are now treating people with eating disorders. A further 26 posts are in recruitment, Dr Clifford advised.

The model of care set out plans to develop eight adult and eight CAMHS community outpatient teams.

To date, five consultant-led CAMHS teams and six adult teams have been established. Recruitment to deliver three more teams is underway.

In Budget 2024, funding was announced for five posts within HSE South West Dublin, West Wicklow, and Kildare to commence an adult eating disorder team and two full-time posts for a CAMHS team in the Wicklow, Dun Laoghaire, Dublin South East region.

Investment under Budget 2025 will deliver a new CAMHS team in Clare, Limerick, North Tipperary/East Limerick and an adult team covering Laois, Offaly, Longford, Westmeath, Louth, and Meath.

Funding under Budget 2025 will also enable adult teams in Community Healthcare Organisation (CHO) 5 [South Tipperary, Carlow/Kilkenny, Waterford, Wexford] and CHO 7 [South West Dublin, West Wicklow and Kildare] to “deliver a service across their large catchment area and avoid a postcode lottery within these CHOs”, according to a programme update from the clinical programme in December 2024. “Fully resourced teams across full catchment areas are necessary to ensure early intervention and to ultimately improve clinical outcomes and reduce costs in the long-term.”

Dr Clifford commented: “We’re really trying to focus on rolling out the adult services and under-18 services in tandem so that it works. In order for inpatient services and day programmes to work efficiently, you have to have the foundation of the outpatient services.

“When people are discharged from specialist eating disorder beds, they need to be able to be discharged to outpatient eating disorder services. For the stepped model of care to work, you have to have all steps available, that’s why you need the community eating disorder teams because actually they are the ones who will facilitate discharge from inpatient beds and medical beds.”

However, Dr Malone of the EDSIG commented: “The consequences of having no bed capacity is that first of all sick patients don’t disappear, they have to be treated somewhere. So there’s three choices. One is the HSE buys beds off private services….So they are spending money on beds, they are just outsourcing the money privately. In some cases, they treat patients abroad. Patients are sent off to the UK for treatment, which is funded by the HSE.

“The third choice is that actually for whatever reason, a person is unable to make use of those options, and they just continue to remain unwell. What we know about eating disorders is that the longer they remain untreated the more severe they become and the longer it takes for people to recover when they do engage with proper treatment. In some cases, a person’s eating disorder can become severe and longstanding and people get into cycles of repeated medical admissions and generally being unwell in the community without the relevant supports needed to treat them.”

While recognising the need to develop inpatient services, Dr Clifford told MI that most people with an eating disorder can be treated effectively in the community. She stated that most eating disorder cases are GP referrals into outpatient teams.

“The sooner we can see [the patients] the better. With early intervention the idea is you prevent the progression to more chronic and severe eating disorders.

“People who need specialist inpatient care are those who are severely underweight, unresponsive to evidence-based treatment in the community, or if there is psychiatric comorbidity.”

Regarding the TAS, Dr Clifford said that it was rarely used and only for the most severe presentations.

Between 2022 and 2024, the HSE spent more than €12.7 million on inpatient care for adult patients with an eating disorder through the TAS, according to data released under Freedom of Information law. In 2022, the cost was over €3.1 million. This figure rose to more than €4.6 million in 2023 and over €4.9 million in 2024. Less than 10 patients accessed the TAS during this period.

Demographics

Eating disorders predominantly affect a young section of the population. According to Dr Clifford, 90 per cent of patients presenting are under 25 years of age.

Eating disorders are more common in females. However, males would be expected to comprise 25-to-30 per cent
of presentations.

“But in our service it’s one-in-20. That means there is a very large number of men who are either not looking for treatment or not being referred for treatment,” said Dr Clifford.

“Certainly, it’s a large gap in terms of a group of people we really don’t see as many of as we would expect to. There is the stigma men might feel about looking for help, there is the stigma that maybe clinicians might have, if a man presents maybe not even thinking that treatment for an eating disorder is appropriate or an option. We don’t discriminate in terms of referrals coming into us. It doesn’t matter what their gender is, but referrals of males just don’t come our way in the numbers we would expect.”

Information gaps are another challenge. According to Dr Malone, the number of deaths from eating disorders is unknown as the coroner service does not keep a database of this information.

“The coroner service in this country is under-developed and under-resourced in terms of being able to give data like that….  In our service we’ve had a number of deaths over the last few years.”

Demand

Demand for services has grown significantly. With the development and availability of new services, where none existed previously, more people can now access treatment in the community.

St Vincent’s University Hospital, where a team has been in place for nearly 30 years, has recorded a rise in referrals.

In 2022, the service had 65 referrals. As of late 2024, there had been 109 referrals. In the years preceding 2022, referrals were about half of what they were in 2022, according to Dr Malone.

“Our numbers represent an increase in referrals. The reasons for that are many-fold. The population is growing. Awareness is growing too. There would be a reduced stigma as well in terms of people asking for help and in terms of clinicians knowing there is a service there and what the referral pathway is. Whether it’s related to Covid-19 and the unique circumstances that caused, or other things occurring around the time of Covid like increased social media [is not yet known]… but it’s a population increase and increase in incidence as well,” Dr Malone said.

Dr Clifford told MI that a steep rise in presentations occurred during the pandemic. “Even though that sharp increase has dropped, demand is about one and a half times higher now than it would have been prior to the pandemic,” Dr Clifford noted.

The peak for referrals was in mid-2021. In 2023, there were 669 referrals to the community teams. Some 449 assessments took place and 385 eating disorder diagnoses were made, according to HSE data. Some 343 patients were discharged to their GP in 2023.

Twice as many people accessed an assessment with an eating disorder team in 2023 compared to 2022. During 2023, 368 people started treatment for an eating disorder and 406 children, adolescents and adults were attending eating disorder community teams at the end of that year.

In 2023 about 77 per cent of patients accessed an assessment within eight weeks of referral to a HSE community team.

For the first time, in 2023, an eating disorder was the main diagnosis for child/adolescent admissions to psychiatry units and hospitals, according to data published by the Health Research Board (HRB). Of the 322 admissions of children/adolescents that year, 24 per cent were for eating disorders.

The HRB report found the number of inpatient admissions for under-18s with eating disorders had increased by 43 per cent in the last five years.

Recovery

Dr Clifford stressed that recovery for many people with an eating disorder is possible.

“It is important to say that recovery is absolutely possible. I think it is a myth that if someone has an eating disorder that it is lifelong and will become chronic, but that’s not the case at all. Up to 75 per cent will get full or partial remission and will have a really good quality-of-life and then 25 to 50 per cent may develop a more chronic illness.”

This is why, she said, early intervention is so crucial. It leads to faster recovery, reduced relapse rates, shorter hospital stays, and shorter duration in outpatient treatment.

While acknowledging that more work remains to be done, Dr Clifford highlighted positive developments over recent years.

An eating disorder self-care app for patients and families was launched in 2020. A sense of collegiality among clinicians has been fostered through the development of an annual national webinar, which takes place during eating disorder awareness week every February. All clinicians meet twice every year to share learning and developments.

Furthermore, Dr Clifford welcomed the introduction of two half-time paediatrician posts and two half-time gastroenterologist posts to the eating disorder service.

“The model of care recommends that every community eating disorder team has, depending on the age group, either got paediatric consultant sessions or gastroenterology sessions. We now have funding for two paediatricians with two teams, one in Dublin and one in Cork, and we have two gastroenterologists recruited. They are half-time posts. They have dedicated, protected time for eating disorders now, which never has happened in the past,” Dr Clifford said.

“We have worked really hard to increase education and awareness within the acute hospital system,” she added. “That is really important because there can be a lot of clinician apprehension and anxiety around managing eating disorders, especially if there hasn’t been any education or training. Eating disorders wouldn’t have been on the curriculum of medicine in colleges or dietician courses so we’re really trying to increase that education and awareness and build clinicians’ confidence and knowledge in assessing eating disorders.

“That’s a big culture change and takes time. That’s really starting to come through and we really feel that. I definitely feel that on a day-to-day basis as a clinician on the ground when I’m linking in with acute hospitals and staff, there are huge improvements.”

A Department of Health spokesperson told MI that both it and the HSE remained “firmly committed to enhancing specialist services for eating disorders, including improved access and shorter waiting lists”.

The draft Programme for Government commits to  further development of eating disorder services in terms of community and inpatient provision.

Further information and support:

www.hse.ie/eng/about/who/cspd/ncps/mental-health/eating-disorders/ and

www.bodywhys.ie/

HSE Adult Eating Disorder Teams

  • Sligo/Leitrim (CHO 1)
  • Cavan/Monaghan (CHO 1)
  •  Cork (CHO 4)
  •  Kilkenny (CHO 5)
  •  Dublin South East and Wicklow (CHO 6)
  •  North Dublin (CHO 9)

HSE CAMHS Eating Disorder Teams

  •  Galway (CHO 2)
  •  CAREDS – Cork (CHO 4)
  •  Dublin South East and Wicklow (CHO 6)
  •  Linn Dara community ED service – South West Dublin and Kildare (CHO 7)
  •  North Dublin (CHO 9)

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