What the Professional Adviser had to say
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The Adviser said that this case was complex as Miss S lived in south Wales and was registered with a GP there, but after she went to stay with a friend in the south west of England she became unwell. The Adviser noted that Miss S came under the care of the local (English) psychiatric service from 28 September 2006 and was admitted to hospital on 27 October 2006. He said that as time went on, the need for assessment and treatment by a specialist eating disorder unit emerged. He noted that in the NHS as currently organised, payment between different NHS bodies would be required for the specialist treatment, and that the body liable would not be the PCT (as Miss S was resident in Wales), but HCW.
The Adviser noted that Miss S had not had any contact with clinicians in her home area, and although the Welsh Consultant was identified as the relevant consultant for that area, he had never seen her. The Adviser noted that HCW’s procedure suggested that a local (Welsh) consultant should assess any need for specialist treatment, recommend the treatment, and produce a follow-up plan; in this case the request for funding failed because none of this had been done. He noted it was not sufficient from HCW’s point of view for the Welsh Consultant to give his full support to a detailed request for funding from the English Consultant.
The Adviser noted that when Miss S had been admitted to hospital she had weighed 47kg; after two months she weighed 40kg and had a BMI of 14. He said that, in his opinion, Miss S’s physical condition had become sufficiently grave to warrant urgent transfer for re-feeding, either to an eating disorder unit, or to a medical ward in a general hospital if there was a ward and consultant physician (often a gastroenterologist) available who was experienced in managing such patients. The Adviser said that even if it could not be said that a transfer was essential at that point, it would be unreasonable to hope that Miss S would suddenly turn a corner and start to gain weight where she was.
The Adviser said that in the longer term Miss S might, after she had regained some weight, also have needed a period as an in-patient in an eating disorder unit for psychological management of her psychiatric condition. He noted that management in a general psychiatric ward had failed, albeit that it was theoretically possible that a placement in a different ward might have succeeded.
The Adviser said that in his experience, a Trust manager would discuss a case such as this with a ‘home’ clinician when funding for a specialist out-of-area service was requested. The Adviser commented that it did not appear reasonable to insist that a home clinician undertook a long journey to see a patient personally when there was already a valid and detailed opinion available; any additional information could be obtained by telephone or email, and plans for aftercare discussed. The Adviser said that in the unlikely event there was a clinical question which could not have been answered in this way, the Welsh Consultant should have been prepared to assess Miss S, and if necessary travel to do so. He could not see that it was reasonable to expect the Welsh Consultant to have been familiar with HCW’s procedures, as this could have been explained to him by a Trust manager.
The Adviser noted that the English Consultant wrote to the Welsh Consultant on 31 October 2006, a few days after Miss S’s admission, asking him to take over her care; this request was apparently declined by telephone, although there is no contemporaneous record of this. The Adviser said that if the Welsh Consultant honestly felt that he did not have the resources to manage Miss S, even for a short period, he would have had reasonable grounds to decline; however, at that date, when Miss S’s depression was more prominent, and before it seemed that she had a difficult case of anorexia nervosa, she would not have appeared an unusual patient, and should have been thought to be manageable in the short term on the ward. The Adviser noted that in a later letter to HCW dated 14 December 2006, the Welsh Consultant stated ‘we feel that Miss [S]’s needs can no longer be met from within the generic adult psychiatric provision’. This implied that the Welsh Consultant recognised Miss S’s needs might, earlier, have been met in a general ward. That said, the Adviser commented that it would have been difficult to assess Miss S’s best interests overall, which may have been to remain in the south west of England where she had more support available from family and friends.
The Adviser said that by December 2006, when the Welsh Consultant was again asked to take over Miss S’s care, it was clear that his resources would not have been suitable to care for Miss S in the state she had reached (albeit that if she had simply arrived home by some means or other, he would have had to take her and make whatever arrangements were necessary). The Adviser noted too that, at some point, it appeared Miss S became unwilling to return to Wales.
The Adviser said he sympathised with HCW’s role of safeguarding public money, particularly given its stated previous experience of losing the benefits of expensive in-patient treatment because of inadequate follow-up. In terms of follow-up arrangements, the Adviser said that a responsible clinician should be identified (in normal circumstances someone who knew the patient) who would keep in touch with his or her progress on an in-patient unit and develop a plan as requirements became clearer. He said that in a case like Miss S’s, only a very sketchy plan, of nominal value, could have been produced at the outset: it would have been unreasonable to insist on a fully worked-up plan. The Adviser thought it questionable that Miss S’s own uncertainty about where she would live in the future was used as a reason for withholding treatment.
The Adviser said that the Welsh Consultant could, nevertheless, have produced a plan, if it had been made clear that HCW insisted on one. If Miss S improved, and then decided to return to Wales, the plan could have been elaborated or amended. He also said that if, alternatively, it transpired that Miss S intended to stay in England, the PCT could have liaised with the EDU and prepared a different plan.
The Adviser said that eating disorders are very common and every Trust should make provision for managing such patients, and should have a smooth pathway in place for referring on those who require more specialist treatment, such as in-patient care (which the Trust did not itself provide). The Adviser said he was surprised by the apparent low level of provision for eating disorders at the Trust; he would have expected a higher level of resource given its status and the large population it serves (around 500,000).
The Adviser said it is normal for community mental health teams to provide the mainstay of psychiatric treatment, and usually they have back-up available within a Trust through advice from a specialist team or person with a special interest in eating disorders. He said it was not clear in this instance whether the members of the Trust’s steering group were willing or able to provide such support, and he doubted that the monthly staff support group was an adequate alternative.
The Adviser said that in its comments on the complaint, HCW had outlined sensible plans for making its systems known to local services, and for establishing points of contact. He noted, however, that difficulties will remain in the case of Welsh patients, admitted to services elsewhere in the United Kingdom, who do not want to be repatriated.
In conclusion, the Adviser said that he felt the outcome in this case was unreasonable: from a clinical view, Miss S should have gone to an eating disorders unit paid for by the NHS. Miss S’s health was at risk, not because she might be admitted without a document specifying that ‘in Wales/England she will be followed up on discharge by Consultant A/B and his/her team’, (to conform with the NICE guidelines), but because she was very ill with a pressing need for admission. More effort should have been made to cover the two alternative discharge locations in simple plans that could have been reviewed and revised later.
