Out Of Hours

by Francesca Baker
out of hours

Theresa May has yet again come under fire, this time for ‘demanding’ GPs surgeries open longer hours, based on the Director of acute care for NHS England Professor Keith Willett’s estimate that 30% of those attending A&E would be better cared for elsewhere in the system.

Whether its GPs, dentists, community care or other support services, I think there’s huge value in operating in the evenings and weekends – and this can be particularly relevant for mental health, based on my own experience of an eating disorder.

Illnesses don’t happen between the hours of 9-5, but treatment for them does. For those working or with families the choice can therefore either be to give those up and have full time care, stay in work and with family and friends, and potential risk to exacerbating the illness. Having to choose to be either a patient or a functioning person is hugely detrimental to self esteem and wellbeing, as well as putting treatment out of reach of many due to practical reasons.

Out-of-hours are fairly medically-oriented, so lend themselves towards symptoms requiring medical treatment. But there could be services that help for someone with ED in emotional distress, or with less-acute symptoms, such as needing support to managing meals during a tough time. Many people have asked for more day centres with extended hours including evenings and weekends. This can be hugely powerful as a preventative measure, when an illness is less entrenched and will not require acute medical care. But it’s also important for aftercare.

Too often patients are discharged with no support and quickly relapse. The relapse rate for eating disorders is ludicrously high – 63%. More ongoing care that does not end as soon as a person reaches a healthy weight or leaves hospital is key. It’s not only early intervention for diagnosis but early intervention for relapse. For more than half suffer the recurring cycle (of waiting, treatment, recovery and relapse requiring repeat treatment), lasting for more than 6 years.

By solely focusing on clinically-urgent cases, the system forgets those at risk of becoming one, or relapsing –  what we are seeing is a lot of people repeatedly coming back as clinically-urgent cases, making it plainly inefficient in the long-term. It might be that ongoing support requires services collaborating with other social-support-services so that as someone progresses through their recovery, they may receive less ED-specific support, but the overall level of community support is not pulled from underneath them too soon.

Services need to be more creative and ambitious with how they engage with patients, and there are some great apps and podcasts out there that the NHS could learn from. For example, can we better utilise email and phone call support in order to reach more people whilst increasing efficiency?

Accountability and human contact are really valuable to maintain recovery, but they don’t always require a 30min appointment. Sometimes a simple exchange of emails can resolve a relatively minor anxiety such as ‘I haven’t quite managed my plan today, should I have an extra glass of milk.’ Some trusts operate home visits, whilst others may refer patients to support lines. Practical meal support is vital, and social eating groups would be helpful for many. Eating disorder recoverer and advocate of Family Based Therapy for adults Tabitha Farrar is now running online meal support groups. Some clinicians will check in through meal records and motivation tools like Recovery Record, but there’s still so much more that can be done. 

A recent pilot from South London and Maudsley and NIHR looks at whether a programme called Self Help Aid and Recovery guide for Eating Disorders (SHARED) is a useful addition to standard treatment and whether guided self-help (SHARED using recovered patients to provide support via email/phone in the initial 6 weeks of treatment) is superior to pure self-help, where the resources and vodcasts are offered without the weekly check ins with peer supporters.

It might be that we have to embrace that other political bomb – the Shared Society. If services work laterally with other community services to help people either prevent chronicity or move through the latter stages of recovery they can focus on those more acute cases, at the same time as offering holistic, patient centred support in an environment that suits the individual. Working with organisations in the whole social and healthcare landscape to help provide the resources and support a person needs – be that creative arts, health professionals, job centre, volunteering etc – is part of collaborative model that can be life changing and self-sustaining for all involved.

Whatever the political outcome of May’s comments and the new government plans, it’s clear that if the NHS is to live up to its promise of providing a service to all at the time of need, it must recognise that need can occur at any time of day, and respond to the lives of the people who use it. Both patients and the NHS can recover and flourish – but something has to change.

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