Ignoring the Alarms follow-up: Too many avoidable deaths from eating disorders Contents

2Training of doctors and other medical professionals

Box 1: PHSO Recommendation One

The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.

Source: Ignoring the Alarms: How NHS eating disorder service are failing patients, Parliamentary and Health Service Ombudsman, December 2017, p 15

Background to the recommendation

10.The PHSO’s report described how training for doctors on the serious and complex subject of eating disorders is limited “to just a few hours”.6 GPs are often the first port of call for people with eating disorders seeking help and therefore “should be equipped with enough knowledge of the illness to know what steps to take next, including when and where to refer a patient to another service.”7 The report continued that medical professionals in acute settings needed to understand both “the nature of anorexia nervosa and the behaviours that sufferers may display.”8

11.In written evidence to this inquiry the PHSO said that the amount of training received by most doctors was “not enough” and repeated the point about GP training in particular:

GPs, often the first port of call for people with eating disorders who seek help, should be equipped with enough knowledge of the illness to know what steps to take next, including when and where to refer a patient to another service.9

The lack of training that doctors receive in medical schools about eating disorders was a consistent theme in the evidence to this inquiry. A study published in 2018 found that less than two hours is spent on eating disorder teaching in medical schools and that “Postgraduate training adds little more, with the exception of child and adolescent psychiatry” and concluded “given the risk of mortality and multimorbidity associated with these disorders this needs to be urgently reviewed to improve patient safety.”10

12.Beat carried out surveys in 2017 and 2018 of medical schools and junior doctors. Their written evidence reported some stark comments from respondents:

Extremely limited education on ED [eating disorders] during medical school. No training whatsoever as a junior doctor (Junior Doctor: Foundation Year 2, 2017).

We have been told about eating disorders briefly in one lecture I believe, along with other disorders like body dysmorphic disorder. We weren’t told who to refer these patients on to. (Year 5 student, 2017).

I have encountered a number of problematic, stereotypical opinions of patients with eating disorders being spread through medical training and have not felt comfortable countering these. Additionally I have found myself having to educate my fellow students about different aspects of eating disorders because of a lack of education from our tutors, which I feel is inappropriate. (Year 4 student, 2018).

The theory is adequately covered but [we] don’t get any clinical skills experience so that would be useful (Year 4 student, 2018).

Source: Beat IDF0012

13.Miss Hope Virgo, the leader of the #DumpTheScales campaign, told us that many clinicians were still using BMI to determine whether people could access treatment and support.11 This is contrary to NICE guidelines that recommend not using single measures such as “BMI or duration of illness to determine whether to offer treatment for an eating disorder.”12 The Eating Disorders Health Integration Team in Bristol echoed this, telling us that in relation to young people with eating disorders, GPs were overly reliant on low BMI as an indicator of an eating disorder.13 This point of over reliance on BMI was further raised in the discussions we had in our informal seminar, attendees likened gating treatment for eating disorders behind BMI as akin to suggesting a cancer patient should not receive treatment until the cancer had spread throughout their body.

14.In the report, the PHSO stated “The failure of staff in both Averil’s and Miss E’s case to recognise the nature of their illness and seek appropriate advice about treatment could have been easily remedied with some additional training and awareness of the relevant guidance.”14 Rethink Mental Illness argued there should be greater training for all junior doctors on eating disorders15 and Family Mental Wealth suggested that adequate learning about eating disorders should be made a mandatory part of medical education within medical schools and subsequent continuing professional development.16 In the informal seminar we heard the stark example of a GP who was concerned that a person with an eating disorder may die but believed they “could not section them because they were not suffering from a mental illness”. This example demonstrates that some GPs do not appreciate that an eating disorder is a mental illness.

15.Attendees to our informal seminar also told us about how, in their experience, some GPs had used triggering language when discussing their condition with them, such as suggesting another patient was more deserving of treatment because they were thinner. This suggests GPs need more training not just on recognising eating disorders but also in how they communicate with people who have eating disorders.

16.We conclude that there is a serious lack of training for doctors about eating disorders and the treatment of eating disorder patients, as evidenced, for example, by GPs relying on BMI as a sole indicator of whether people can access treatment for eating disorders, contrary to published guidance. This is particularly important because preventing patients from receiving treatment for eating disorders by reference to single measures such as BMI prevents the access to early treatment which can help prevent a patient from becoming seriously ill. While the number of hours spent in training does not on its own determine the competence of clinicians, two hours of training on such a complicated topic is insufficient.

Progress made on the recommendation

The General Medical Council’s review

17.The General Medical Council (GMC) said in their evidence that it was unable to undertake the review envisaged by the PHSO because it is limited by the scope of its powers afforded by the Medical Act 1983. Its role is purely one of oversight and it does not write curricula.17 It could not, for example, prescribe the number of hours of teaching on a subject or the precise nature of that teaching. Instead its powers are limited to quality assuring the medical schools against broader educational skills, knowledge and outcomes they expect undergraduate medical students to achieve.18

18.Individual medical schools and other training establishments set their own curriculum. For undergraduate education, the GMC set the outcomes which UK graduates must meet for entry to the medical register, and this includes several specified practical procedures. The GMC said:

The outcomes that we set are, by definition, broad in nature. We do not believe it would be practical for us to include all possible presentations or conditions that a newly qualified doctor could expect to encounter.19

19.The GMC approves curricula for the Foundation Programme, a two-year programme all graduate doctors are required to undertake to achieve full GMC registration. The curriculum for the Foundation programme is set by the Academy of Medical Royal Colleges (AoMRC) and the GMC’s regulatory role is to approve that curriculum. This approval is not subject to the inclusion of specific content but rather the GMC sets “out a process that the AoMRC should follow to ensure that appropriate consultation is undertaken and appropriate medical expertise is brought to bear in its development.”20

20.Following completion of the foundation programme, a doctor may elect to pursue a specialist field. The GMC explained that there are 65 recognised medical specialities in the UK, each of which has a specific curriculum. These curricula are formulated by 25 medical royal colleges and faculties.21 Under Sections 34H–34M of the Medical Act 1983, the GMC has powers to approve these curricula as well as the assessment systems attached to them. The GMC does not base this approval on the inclusion of specific treatments or the diagnosis of individual conditions. Rather, the organisations must show how they have determined the content of their curricula.22

21.Despite this, the GMC suggested it had done everything it could to progress the recommendation, including writing to every medical school in the UK seeking information on:

how eating disorders are currently taught and covered in curricula;
the relationship between teaching on eating disorders and teaching in mental health, nutrition and physical health; and
the exposure medical students get to eating disorders as part of their clinical attachments.

The GMC has also asked royal colleges and faculties to identify where there are overlaps between specialities and where curricula content could be shared. The Academy of Medical Royal Colleges is coordinating a discussion between relevant specialities and colleges on sharing resources and best practice.23

22.Beat expressed frustration at the lack of progress made under this recommendation:

The General Medical Council (GMC) has not, to the best of our knowledge, agreed to conduct the review recommended by the PHSO.24

23.The CEO of Beat, Mr Radford elaborated further on this point in oral evidence:

We are unhappy with the progress made by the General Medical Council. It seems to have taken it a long time to get going and I have not heard any public statement that it is going to take the action the PHSO recommends it takes. There seems to be a certain amount of deflecting of responsibility going on there and I hope that you will scrutinise that point later. Clearly its mandate has its limits but I feel, when we look at some of the other things the GMC has done in the past, it is pulling back on this issue and it could push harder and take more responsibility.25

24.Professor Colin Melville, Director of Education and Standards in the General Medical Council, told us that he absolutely accepted the “need for change”26 and explained in more detail the steps GMC had taken with medical schools:

We have written to medical schools. We can now go back to them, once we have heard from them all, and talk about where we think some of those changes are. We can work in partnership with the Royal College of Psychiatrists and its eating disorders faculty. We have indicated that we would be keen to help it support the development of curricula content across all the colleges. Ultimately, we need the colleges to accept that they are willing to allow that.27

25.Dr Melville also explained to us that the prevalence of eating disorders was now higher than schizophrenia and that the balance of teaching should reflect that change.28 Dr Meville offered to provide to us a summary of the GMC’s findings once it had received all the responses from the medical schools.29

26.In relation to postgraduate training, Dr Nicholls, the Chair of the Faculty of Eating Disorders in the Royal College of Psychiatrists, told us about the difficulty of getting a question on eating disorders into the psychiatry curriculum:

Within psychiatry, there is currently a curriculum review happening, but there are, as ever, a thousand competing demands on that curriculum and in fact the size of the curriculum is being reduced rather than increased. As somebody from the GMC said earlier, nobody ever wants to take a question out of a curriculum, they only ever want to add another one in. We are struggling to get another one in at the moment because we are a minority voice in that dialogue. We are repeatedly making recommendations about what the need is and what the problem is, referring to the recommendations and so on, but I cannot yet say to you that this has resulted in concrete changes to the curriculum.30

27.She also highlighted the need for the inclusion of eating disorders in the curricula of other speciality areas and expressed frustration at the lack of mechanisms for cross-college working:

I would very much like to know what the mechanisms are for effective cross-college working. That is what I am currently struggling with. I have only a few months left in my role as chair but it has been one of the things I have been trying to find my way through for the last year. The approach we have taken from the faculty is to write a position paper based on the recommendations of the PHSO report. That needs to be endorsed internally by the college first and that is pretty much done and dusted, but then I am assuming that the best mechanism is for the Academy of Medical Royal Colleges to take that for cross-college dialogue and engagement around the recommendations. If there are other effective mechanisms that people are aware of, we would be very open to that dialogue.31

28.The steps taken by the General Medical Council (GMC) in support of the PHSO’s recommendation are welcome. While we acknowledge the limits of the GMC’s powers, the GMC has a strong influencing role to play, which would recognise the urgency of taking this work forward. We look forward to receiving a summary from the General Medical Council of the responses they have received from medical schools about the way eating disorders are taught. We recommend the GMC acts on this information and uses the responses received from medical schools to identify examples where education has not been effective, to share best practice where it is identified and overall use its influence to ensure that medical schools improve outcomes in relation to eating disorders. We recommend that the GMC undertakes to write again to medical schools after one year to find out what changes to medical student training have been implemented.

29.We recognise that for eating disorder training to improve postgraduate training is also critical. We agree with witnesses who identified the need for greater cross-college working to ensure eating disorders are included in relevant curricula and support the Academy of Medical Royal Colleges’ work in coordinating a discussion between relevant specialties and colleges on sharing resources. We note that participants in the informal seminar highlighted the importance of training for General Practitioners in this context. We recommend that the Academy should also coordinate the necessary actions arising from this work and report on how the learning from these discussions are implemented.

The MARSIPAN guidelines

30.The Royal College of Psychiatrists drew our attention to the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) guidelines, which were developed by the Royal College of Psychiatrists with the hope of reducing the number of avoidable deaths of patients with severe anorexia nervosa. The guidance “particularly prescribes active communication and consultation between Psychiatric services, including eating disorder and liaison psychiatry, and medical services” and includes for quick reference an all-age checklist for use by clinicians.32 The Royal College of Psychiatrists argued that if the guidelines had been followed then Averil’s death and the deaths of Miss B and Miss E would have been avoided.33 While medical professionals have begun to take on the guidance, the Royal College of Psychiatrists suggested there was a need to monitor and accelerate uptake and suggested one way to improve such uptake would be to include it in undergraduate medical curricula.34 Dr Nicholls explained in oral evidence that the uptake of MARSIPAN guidance, in particular, needed to be improved in relation to non-specialists:

Eating disorder services are all using the MARSIPAN guidance. Where I think it is less clear is whether emergency medicine, acute trusts and primary care are also following that MARSIPAN guidance. It is embedded in all the best practice guidelines. Its reach, penetration and impact outside the speciality is the issue.35

31.Dr Nicholls’ point about the lack of knowledge of the MARSIPAN guidelines among non-specialists was furthered in our roundtable discussions with people with lived experience of eating disorders. Although the guidelines were described as “lifesaving” by participants, they told us that most doctors did not have any awareness of the guidelines.

32.There must be wider take up of the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) guidelines. They are a vital tool to promote active communication and consultation between psychiatric services, including eating disorder and liaison psychiatry, and medical services and includes for quick reference an all-age checklist for use by clinicians. These guidelines are lifesaving for people who have anorexia nervosa. We recommend that Health Education England should work with NHS England to improve uptake of the MARSIPAN guidance by practitioners, particularly practitioners who are not specialists in eating disorders, and the Care Quality Commission should ensure that the MARSIPAN guidelines are being adopted at all levels in NHS England.