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On 29 June 2023, the House of Lords is due to debate the following motion tabled by Baroness Parminter (Liberal Democrat):

To ask His Majesty’s Government, further to the publication of the report by the Parliamentary and Health Service Ombudsman ‘Ignoring the alarms: How NHS eating disorder services are failing patients’, in December 2017, what progress has been made in relation to NHS eating disorder services.

1. What are eating disorders?

The NHS states that eating disorders are mental health conditions where people use the “control of food to cope with feelings and other situations”. The NHS states that eating disorders include:

  • anorexia nervosa: trying to control your weight by not eating enough food, exercising too much, or doing both
  • bulimia: losing control over how much you eat and then taking drastic action to not put on weight
  • binge-eating disorder (BED): eating large portions of food until you feel uncomfortably full
  • other specified feeding or eating disorder (OSFED): an eating disorder with symptoms that do not exactly fit the other disorders

The eating disorder charity Beat has estimated there are 1.25 million people in the UK with some form of eating disorder. 75% of those are women. OSFED is the most common type of eating disorder. Anorexia is the least common, but it has the highest mortality rate from medical complications associated with the disorder and from suicide. Eating disorders can start at any age, but they are most common in young people between 12 and 20. Eating disorders can be associated with other mental health conditions, such as depression and anxiety.

Treatment for eating disorders varies depending on the disorder. It often involves some form of talking therapy, such as cognitive behavioural therapy, in addition to medical checks and weight monitoring.

2. NHS eating disorder services

Most funding for local mental health services (including eating disorder services) is not ring-fenced, meaning that each local NHS area determines its own mental health budget from its overall funding allocation. The 2019 ‘NHS long term plan’ included a commitment that investment in mental health services would grow faster than the overall NHS budget. It introduced a new ringfenced local investment fund for mental health services “worth at least £2.3bn a year by 2023/24”.

During the coronavirus pandemic there was an increase in demand for mental health services, including eating disorder services. There was a particular increase in demand for eating disorder services for young people. Since the pandemic, concerns have been raised about issues related to access to mental health services, waiting times to start treatment, and staff shortages in the sector.

2.1 NHS children and young people’s eating disorder services

The NHS publishes specific statistics on children and young people’s eating disorder services. Since 2020, the NHS has had a national waiting time target for children and young people with an eating disorder. The target is that 95% of urgent cases should receive treatment within one week and 95% of routine cases should receive treatment within four weeks.

Figure 1 shows the percentage of referrals to children and young people’s eating disorder services within the target time from 2016–17 to Q4 2022–23. The data shows that the target has never been met and there was a significant decline in the proportion of waiting times being met during the pandemic. In the latest data for Q4 2022–23, 78.7% of urgent eating disorder cases started treatment within one week, and 82.5% of routine cases started treatment within four weeks.

Figure 1. Waiting times for children and young people referred to eating disorder services in England (percentage of referrals receiving treatment within target time)

Figure 1. Waiting times for children and young people referred to eating disorder services in England (% of referrals receiving treatment within target time)

(NHS England, ‘Mental health: Children and young people with an eating disorder waiting times: CYP ED waiting times timeseries: Q4 2022–23’, accessed 21 June 2023. Note: data for Q2–Q4 2022–23 is imputed, due to a cyber incident affecting some providers.)

Figure 2 shows the number of children and young people with an urgent eating disorder referral and how long they were waiting to start treatment. During the coronavirus pandemic there was a significant increase in the number of young people waiting for urgent treatment and an increase in how long they were waiting.

Figure 2. Children and young people’s urgent eating disorder referrals waiting for treatment, by week

Figure 2. Children and young people’s urgent eating disorder referrals waiting for treatment, by week

(NHS England, ‘Mental health: Children and young people with an eating disorder waiting times: CYP ED waiting times timeseries: Q4 2022–23’, accessed 21 June 2023. Note: data for Q2–Q4 2022–23 is imputed.)

In Q4 2019–20, prior to the onset of the coronavirus pandemic, there were 18 young people waiting to start treatment for an urgent eating disorder, with most waiting between one and four weeks. The latest figures for Q4 2022–23 showed that 132 young people were waiting to start treatment, of which 59 (45%) had been waiting for 12 weeks or more.

2.2 Lancet study on young people’s eating disorders during Covid-19

On 20 June 2023, a study of eating disorders and self-harm among young people during the coronavirus pandemic was published in the Lancet. It analysed the health records of over 9 million patients aged 10 to 24 in the first two years of the pandemic and compared them against the decade prior. It found that between March 2020 and March 2022, the incidence of eating disorders among girls aged 13 to 16 was 42% higher than expected, and 32% higher than expected for girls aged 17 to 19. For boys in all age groups the incidence of eating disorders was similar to expected rates.

The study found that the higher incidence of eating disorders and self-harm in girls was “largely attributable to increases within less deprived communities”. The authors said that in the 10 years before the pandemic, incidence of eating disorders in girls was also higher in least deprived areas and this trend increased during the pandemic. In contrast, the authors said that overall rates of mental health conditions among young people were usually higher in deprived areas. The authors speculated that the increase in eating disorders in the least deprived areas may have been due to an “increased willingness among individuals from more affluent areas to seek clinical treatment and better access to healthcare services in these neighbourhoods”.

Discussing the possible reasons for the increase in eating disorders among girls during the pandemic, the authors said the causes were uncertain. However, the authors stated that:

Disruption in education and daily routines, social isolation, familial stress, food insecurity, and concerns for Covid-19 infection in the initial months of the pandemic could all have had an adverse effect on young people’s mental health.

The authors noted that social media use by young people increased during the pandemic. While social media use can be associated with “social support and connectedness”, the authors noted that it has also been linked with “elevated risks of body dissatisfaction, low self-esteem, eating disorders, and psychological distress, particularly among adolescent girls”.

3. Calls for improvements in eating disorder services

In 2012, 19-year-old Averil Hart died from severe anorexia. Averil’s father, Nic Hart, complained to the PHSO about the care his daughter received at four NHS organisations.

The PHSO published its subsequent report ‘Ignoring the alarms: How NHS eating disorder services are failing patients’ in 2017. The report concluded that Averil’s death “would have been avoided if the NHS had cared for her appropriately”. It also found “inadequate coordination and planning” between service providers. The PHSO said the investigation had uncovered “serious issues that require national attention”.

The report made five recommendations, which included that:

  • the General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders
  • the Department of Health and NHS England should review the existing quality and availability of adult eating disorder services to achieve parity with children and young people’s services
  • the National Institute for Clinical Excellence (NICE) should consider including coordination in its quality standard for eating disorder services

In 2019, the eating disorder charity Beat published a report on NHS adult eating disorder services in England. It concluded that patients faced a “postcode lottery” in service provision, with “alarming discrepancies” in access to specialist treatment, waiting times and staffing levels at eating disorder services.

Also in 2019, the House of Commons Public Administration and Constitutional Affairs Committee published the report of a follow-up inquiry on the PHSO’s 2017 report. The committee investigated what progress had been made on each of the PHSO’s recommendations. The committee welcomed the steps taken by some organisations, but its overall conclusion was that “further action” needed to be taken under each recommendation. Its comments included:

  • There was a “serious lack of training” for doctors about eating disorders. It also said there was a “shocking” lack of precise information on the prevalence of eating disorders in the UK. It recommended that the NHS should commission a national survey to assess how many people have an eating disorder.
  • The committee found it “disturbing” that the government had claimed that the PHSO’s recommendation of achieving parity between adult and young people’s eating disorder services had been achieved, when “it is clear that this is not the case”.
  • It confirmed that NICE had implemented the recommendation of including coordination in its quality standard for the assessment of eating disorder services. However, it said that “further work was necessary” to embed the standards.

The report said that the Department of Health and Social Care should “play a leadership role” in driving progress against the PHSO’s recommendations. The committee asked the department to set out timelines for improvements in its response to the report.

4. Government statements and developments since 2019

Boris Johnson’s government published a response to the committee’s report in August 2019. It said that improving eating disorder services was a “key priority” for the government and that it was “working closely with our arm’s length bodies and stakeholders, who have been referenced in the committee’s inquiry, to implement the PHSO recommendations”.

On the training of doctors, the government said that the GMC was “driving forward” work across the organisations involved in doctors’ training. The government said the GMC would “look at ways of increasing trainee doctor exposure to eating disorders” to develop their knowledge and skills.

Addressing the committee’s points on the quality of adult eating disorder services and parity with children and young people’s services, the government acknowledged that parity had not been achieved, but it said that “further action is in train”. The government claimed that improvements to services would be implemented through the mechanisms set out in the NHS long term plan.

The government response concluded that while there had been “substantial improvements” since the PHSO had published its report, the government acknowledged that “there is still further to go”. The response said the government was “committed to implementing and completing” the PHSO’s recommendations.

Since the government’s response to the committee’s report, the PHSO has criticised the pace of improvements in eating disorder services. In February 2023, the PHSO stated that in the six years since its 2017 report there had been “little progress” on implementing the report’s recommendations. It said people with eating disorders were still being “repeatedly failed” by the system and that “radical changes” needed to be made to “prevent further tragedies”. The PHSO acknowledged there had been some progress in “scaling up early intervention services” and improving the training of doctors. However, there were still “unacceptable recurrent issues” with eating disorder services, which led to poor care and “avoidable deaths”. The PHSO said that since 2019 it had received 234 complaints relating to eating disorder services.

In June 2023, the current government set out how it was supporting mental health services in England. It reiterated that £2.3bn a year would be spent by March 2024 to “expand and transform” NHS mental health services. The government said this investment would mean 2 million more people would have access to mental health support.

Specifically on eating disorder services, the government stated that it was investing £1bn in improving community mental health care for adults with severe mental illness, including eating disorders. On services for children and young people, the government said an extra £53mn per year had been invested from 2021/22 to increase capacity at children and young people’s community eating disorder services. The government also said it was “expanding the number of trainees and skilled professionals” who provide care for people with eating disorders.

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Cover image by Annie Spratt on Unsplash.