Averil Hart

Dear Mr Horstead Regulation 28: Report to Prevent Future Deaths The details of the tragic circumstances of Averil Hart’s death are upsetting to read. I extend my sincere condolences to Averil’s family and to other families affected. You list four key concerns in your report. As the Medical Director and Director of Education and Standards at the General Medical Council, I can respond to the first (Inadequate training of doctors and other medical professionals re eating disorders) and also your fourth key concern about the impact of the COVID-19 pandemic. The provision of consistent, comprehensive medical education and training on eating disorders (ED) remains an important issue for us since the Parliamentary and Health Service Ombudsman (PHSO) identified concerning themes in their 2017 ‘Ignoring the Alarms’ report. I appeared before the Public Administration and Constitutional Affairs [Select] Committee in 2019 to give evidence about our progress towards the PHSO’s recommendation that we review training for all doctors. The written evidence I submitted may be helpful as it details our regulatory role, our requirements for doctors, and our early actions in response to the PHSO report. Since then, we’ve used our regulatory powers and influence to find solutions to inconsistency in training to address patient safety concerns. I will summarise our role as a regulator and how it relates to the education and training of doctors around ED, and then describe the actions we’ve taken since the PHSO report. Our role as a medical regulator Our powers in medical education, as set out in the Medical Act 1983, are two-fold: to set the outcomes for graduates of UK medical schools leading to entry on to the medical register, and to approve the curricula for postgraduate training of doctors. We quality assure both aspects of medical training against our standards for the management and delivery of medical education and training. The principle of patient safety drives our work.

Medical education must adapt to the needs of society and be appropriately responsive to patients and the public. We keep our standards and requirements for medical education up to date with timely revisions to make sure they reflect changing patient needs as well as contemporary medical practice, scientific basis, and professional behaviours. We review our guidance to make sure it keeps up to date with new information and developments in healthcare. Undergraduate education We determine and publish the high-level outcomes all medical students are required to demonstrate in order to graduate. We updated our ‘Outcomes for graduates’ in 2018 after extensive consultation. Our powers don’t extend to mandating specific content in undergraduate curricula, but the outcomes do describe relevant key themes around mental health, nutrition, and vulnerable groups. We required schools to embed the new outcomes in undergraduate curricula for all students commencing academic year 2020/21. However, many schools had already introduced changes to their curricula for current student cohorts. To keep driving improvement, we’re introducing a new way of assessing medical students, as well as international medical graduates, that will ensure they meet a common and consistent threshold for safe practice before they’re licensed to work in the UK. The Medical Licensing Assessment will be based on a comprehensive content map which sets out the range of skills and knowledge that students will be required to have and could be tested on. The content map is available on our website. It includes eating disorders. All students graduating from UK medical schools from the academic year 2024/25 will need to pass the new assessment, which will also replace our current test for international medical graduates in early 2024.

Foundation Programme All doctors enter the two-year Foundation Programme after graduating from medical school. It trains graduates to develop a range of essential interpersonal and clinical skills for managing acute and long-term conditions. The Academy of Medical Royal Colleges (AoMRC) develops the Foundation Programme curriculum, which describes specific outcomes all Foundation doctors should demonstrate on completion of the programme. Our regulatory role is to approve the curriculum. It requires doctors to show skills including: recognising eating disorders, referring to specialist services, addressing nutritional needs, and communicating these during care planning, formulating recovery plans, and investigating and managing weight gain. Specialty training The curricula for postgraduate specialty training are set by individual medical royal colleges and faculties. We approve them against our standards for postgraduate curricula. In 2017 we published new standards requiring curricula to be mapped against our framework of shared generic and specialty-specific outcomes. Our ‘Generic professional capabilities framework’ sets the essential capabilities which underpin professional medical practice and are a fundamental part of all postgraduate training programmes. The capabilities include mental health, nutrition, safeguarding vulnerable groups, communication, leadership, and multidisciplinary team (MDT) working. Most specialty curricula have now been mapped to the new outcomes. Specific

requirements for identifying, assessing, and safely managing patients with ED are specified in a number of relevant specialty and GP curricula.

Changes we’ve made to the training of doctors re eating disorders You highlight that there is a widespread and continuing lack of training, knowledge, or experience on the part of doctors and other healthcare staff. The provision of education and training on ED is evidentially inconsistent and sometimes insufficient to prepare all doctors to recognise and manage or refer patients with ED. Since the PHSO report, we’ve taken actions in collaboration with others to strengthen education and training around ED. Crucial to preventing future deaths is for all doctors to have skills to recognise ED and support care, including the recognition and management of emergencies such as life-threatening nutrition. Patients may present to doctors in various contexts with other symptoms and complications, which could include: diabetes, abdominal issues, fertility problems, suicide attempts, and multiple others. Every interaction with patients is an opportunity to identify and act on these signs. The earlier they are picked up, the more treatable the underlying ED. Doctors’ capabilities in ED should become progressively more complex as their responsibility for, or level of exposure to patients who have eating disorders, increases.

It is acknowledged that early intervention for ED is crucial to successful treatment. This means doctors have a pivotal role to play in identifying the potential that a patient presenting to them with varying symptoms may have an eating disorder. We are asking education providers to reach an agreed core set of knowledge and skills for all doctors to be able to draw on in critical meetings with patients, although enforcing exactly what education providers teach is not within our remit. Survey of medical schools

To build a better picture of coverage in undergraduate curricula, I sent a letter to all medical schools in 2019 raising the issue and requesting details of teaching in ED. All 35 medical schools responded with helpful detail on how students are taught about ED. The survey identified some good practice but also areas where education and training could be improved. There was variability across schools in coverage, in links between teaching on mental and physical health, and in exposure to patients with ED. We are working with schools to ensure coverage is improved and especially the link between physical and mental health. We reported our findings to schools, highlighting both good practice and gaps, and suggesting schools work together to develop a shared approach. We’re currently working with schools, in collaboration with Beat, the eating disorders charity, to address these gaps and bring consistency to undergraduate education on ED.

Training resources We supported Beat, the eating disorders charity, in their development of new all-encompassing training resources, with expertise from the Royal College of Psychiatrists’ Faculty of Eating Disorders, which are available to use as of March 2021. They introduce students and Foundation doctors to the knowledge, skills, and tools they need to identify, diagnose and treat or refer patients. We’re working with representatives from the UK Foundation Programme as well as the

Medical Schools Council and education and curriculum leads from individual medical schools to develop implementation plans for the new resources. Although there are pressures on space in the curriculum, encouragingly, education providers have expressed enthusiasm to make use of this helpful resource. We hope that teaching on ED will be embedded in their teaching programmes. We’ll include this in our quality assurance of medical schools in 2022 to ask about changes they implemented, or if they need further support. We hope that this will give schools time to embed the new training resource. Data from the e-Learning platform will help us to monitor uptake of the training and consider what further work is required. Shared learning across postgraduate specialities We are working with the AoMRC on the details for a process to identify and develop areas where key learning can be shared in postgraduate training across the various specialties and subspecialties. The aim of this will be to ensure high standards in core clinical areas. We have asked that one of the case studies to test the shared learning process must be ED. As the shared learning work develops, we will feed into the AoMRC’s work that these skills are needed. The process to identify and develop shared learning across specialties will consider post-qualification development as part of a programme of lifelong learning across a doctor’s career. We expect this work will begin later in 2021. Health Education England (HEE) and NHS England/Improvement (NHS E/I) have developed intensive ‘whole team’ adult eating disorder training with expertise from the Royal College of Psychiatrists’ Faculty of Eating Disorders, where specialist ED or non-specialist e.g. GP practice team members jointly acquire the knowledge and skills to enable the safe and effective management of patients with ED. We welcome the initiative by HEE and NHSE/I, and we’re actively following HEE and NHSE/I’s work. As it matures, we will consider ways to showcase this whole team ED training as good practice, and as part of our lifelong learning strategy to enable doctors to develop throughout their career. Progress towards the PHSO recommendation I hope this assures you that we have already taken significant actions within our powers to address the concerns you raise. I have also identified areas where we can take further actions and have indicated timelines for these. Shortage of ED specialists The final point you raise as part of the first concern is that there is a serious shortage of ED specialists. We’ve heard evidence of a continuing shortage of ED specialists across the country, with many trusts finding it difficult to fill vacancies. These shortages inevitably impact on the level and quality of support available to primary care providers and other specialists. Your report evidences this staffing crisis, whereby heavy workloads with insufficient staffing compounded failings in Averil’s care. Although workforce issues are not specifically within our powers, we are working with the workforce bodies and health care providers across the UK to identify and implement solutions.

The impact of the COVID 19 pandemic You identify a concern that the pandemic increases the risk of further deaths because it has impacted all aspects of care, including training. The pandemic has impacted on training across all countries of the UK and in different ways for the differing specialties. A lot of teaching was moved online, but the clinical experience was inevitably affected. We are working with medical schools, the MSC, the national education bodies and service providers to re-establish all training opportunities as quickly as possible. We continue to work with education providers to ensure students and doctors in training can meet their outcomes and progress safely, and we’re reviewing the impact of the pandemic on training. The pandemic also impeded our plans for this work in 2020. We had planned to follow up with medical school Deans one year after our 2019 survey, but we decided to postpone this measure since schools faced significant disruption. Instead, we communicated with schools in other ways, by contributing to a letter HEE sent to schools encouraging uptake of the new training resources, as well as communicating directly with medical school education leads and the Medical Schools Council. Final reflections Thank you for highlighting these important issues in your report. Better care for ED is so important, especially considering its growing prevalence. We’re committed to providing workable solutions to address the risk of insufficient training, knowledge, and experience of doctors. We believe the changes we’re making to enhance medical education and training will contribute to improved patient outcomes, and we will monitor progress to ensure they are effective. I’m extremely grateful for the efforts of our partners in this work who’ve collaborated to achieve significant goals in better care for people with eating disorders.

Department of Education and Quality 2nd Floor Stewart House Russell Square London WC1B 5DN

30th April 2021 I write in response to your report of 3rd March 2021, made under the Coroners (Investigations) Regulations 2013 (“the Regulations”). May I begin by extending my sincere condolences to Miss Hart’s family following her tragic death from Anorexia Nervosa (AN). Every death is a tragedy and whilst your report is difficult reading, we have shared it widely in our organisation so that our staff can see the impact on families and ensure our focus remains on working with partners and families to improve Eating Disorder services. Your report raises concerns regarding the training of doctors and other medical professional regarding eating disorders (ED). As you note, the 2017 Parliamentary Health Service Ombudsman (PHSO) Report, Ignoring the alarms, made recommendations regarding training for doctors about eating disorders. This recommendation was more recently reiterated in the Public Administration and Constitutional Affairs Committee (PACAC) Follow-up Report, published in
2019. Whilst there are many reports detailing widespread issues for patients and families, many in HEE have experience of services as clinicians who are working on solutions and have contributed to this response. To respond to your concerns, I will first clarify Health Education England (HEE)’s role, and how we work with partners to plan, recruit, educate and train the health workforce. I will also provide an update on the measures that HEE has taken in response to the PHSO and PACAC recommendations regarding education in eating disorders. Health Education England (HEE) is the executive non-departmental public body responsible for promoting high quality education and training for the healthcare workforce in England. We fund and manage the highest quality education and training to deliver high quality health professionals who work effectively in multi-disciplinary teams for the benefit of patients. As well as planning for and training our future workforce, we are committed alongside employers and other stakeholders to the development of the current NHS workforce. The standards for medical education in the UK are set by the independent professional regulator, the General Medical Council (GMC). Each individual medical school sets its own undergraduate medical curriculum, which must meet the standards set by the GMC, who then monitor and check to make sure that these standards are maintained. The curricula for postgraduate specialty training are set by individual royal colleges and faculties, and the GMC approves curricula and assessment systems for each training programme.

By Email:

Sean Horstead, HM Assistant Coroner, Cambridgeshire & Peterborough

HEE funds clinical placements for undergraduate doctors and pre-registration healthcare students, and commissions postgraduate medical training in England. We set our expectations for the quality of the educational environment in our multi-professional Quality Framework. The overarching objective of Framework is to promote inter-professional learning and to support and facilitate service transformation that meets current and future patient needs. We also have a key role in supporting service development and delivery of the NHS where key priorities, including ED, require additional post qualification training and education support to the system. We have several mechanisms to do this, including system transformation, workforce development funding and continual professional development (CPD) programs. Doctors in training Our Postgraduate Deans and Foundation School Directors manage the quality of postgraduate medical education and work with employers to design training programmes that equip doctors with the skills they need to provide high-quality patient care. Since the publication of the PHSO and PACAC reports, HEE has introduced changes to medical education to improve mental health awareness across the medical profession. This includes HEE commissioned learning resources for medical students and Foundation 1 and 2 doctors provided in partnership with BEAT and the Royal College of Psychiatrists.

As set out in Stepping forward to 2020/21: The Mental Health Workforce Plan for England, published in July 2017, HEE is working with the Royal College of Psychiatrists (RCPysch) to address the fill rates in psychiatry specialty training. Part of this work has resulted in an increase in the number of doctors in the Foundation Programme working in a four-month psychiatry post to 47% nationally in 2018, and HEE continues to work with the RCPysch to improve on this. HEE is also working to develop and pilot enhancements to GP training. One of the priorities for this reform is to enhance the delivery of the mental health elements of the GP Specialty Curriculum. This includes increasing GP trainee time in General Practice to 24 months from 18months and ensuring that all GP trainees are able to gain enhanced experience in the treatment of mental health in primary care settings. Wider clinical workforce For the wider healthcare workforce, HEE’s National Mental Health Programme has undertaken a project to scope eating disorder training nationally, mapping what currently exists in order to understand existing training and professional presence/skills across the Eating Disorders pathway. We know that all of us in the NHS need to do more to facilitate patient access to high quality safe interventions, particularly between physical and mental healthcare, and between general and specialist services. Stepping Forward to 2020/21: The Mental Workforce Plan for England (HEE 2017) set out a high level roadmap and reflected the additional staff required to deliver mental health service transformation based on best evidence. The December 2020 data, which is the latest available, demonstrates that the mental health workforce has increased by 14,480 WTEs since March 2016, many of whom will be delivering care for eating disorder services across the different pathways. The 2020 Mental Health Implementation Plan (MHIP) builds on the ambition to grow the workforce by a further 27,460 by 2024. In addition to the Stepping Forward and MHIP workforce

growth targets, education programmes are being commissioned to upskill the existing workforce working with children and adults in psychological therapies and eating disorder treatments. This training is provided across the whole of the mental health workforce ranging from specialist practitioners such as in CBT in eating disorders, teams via Whole Team Training and general awareness such as upskilling junior doctors and nurses.

Many of the expanded workforce will be delivering psychological interventions for people with an eating disorder, the growth of which has been complimented by the HEE provision of 4,500 adult Improving Access to Psychological Therapies practitioners. For children and young people we have recruited 700 new practitioners and trained 3,400 existing NHS staff between 2016 and 2021. HEE has also increased the number of clinical psychologists in training by 25% in 20/21 and 21/22. A psychological professions workforce plan is in train which will map the further expansion of, psychological therapies and related roles to guide local workforce planning and education provision. In order to gain a comprehensive understanding of eating disorder education and training needs, in 2019 HEE commissioned an England wide benchmarking report, to inform the planning and discharge of future training commissions and to develop a comprehensive compendium of training., This is now being used to support regional system leaders and local services to manage training in response to local need, drawing on learning resources already available and further training opportunities via HEE commissions. The additional commissions we subsequently made included Cognitive Behaviour Therapy specifically for eating disorders, delivered via whole team training from late 2020. This training covers the whole range of expertise, including ED specialists (70 trained) as well as well as other staff delivering care in eating disorders services (270 trained to date).

To further support the expansion of psychological therapies provision, in March 2021 HEE commissioned the development of a national curriculum and commissioning specification for the Maudsley Model of Anorexia Nervosa Treatment for Adults to enable a nationally consistent approach.

HEE has also commissioned BEAT to develop a programme for all nursing staff to gain confidence to understand, respond compassionately, and appropriately signpost clients with eating disorders.

Further to this, in support of the whole workforce, HEE has developed the ‘Psychological Interventions for People with Eating Disorders: A competence framework in partnership with University College London, which is aimed at all health workers, trainers and supervisors, clinical managers and service commissioners to guide workforce capability development and enhance patient safety. In 2021/22, HEE will be working with NHSE/I to develop physical health check training relating to eating disorder, that is supported by the Physical Health Competency Framework for Mental Health and Learning Disability Settings (HEE December 2020) HEE is currently working with NHSE/I within a joint eating disorder expert advisory group to ensure effective planning for future commissioning activities and determine the workforce requirements of eating disorder services across the demographic. This work will include the urgent development of an education and training commissioning framework agreement.

E-Learning for Health In addition to the above, HEE runs an e-learning platform called e-Learning for Health (e-LfH), working in partnership with the NHS and professional bodies to support patient care by providing e-learning to educate and train the health and social care workforce. HEE has a range of high quality training available via its e-Learning arm, e-Learning for Healthcare, around eating disorders, particularly on its MindEd programme, which is targeted at professionals and their families. This training, which is available nationally and accessible 24/7, includes, but is not limited to:
• Anorexia and Bulimia
• Eating Disorders in Young People
• Combining therapies to support young people with an eating disorder.

These titles include a new programme for medical students and foundation doctors, developed in response to the PHSO investigation into avoidable deaths from eating disorders in partnership with RCPsych and the eating disorder charity, Beat. The programme, launched in March this year, is designed to ensure that all medical students and foundation doctors are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. A full list of eating disorders materials hosted by HEE e-LfH is appended to this response.

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I hope this response provides you with the assurance that HEE is committed to taking the learning from the tragic death of Avril Hart and is working proactively with partners to better equip the healthcare workforce to recognise, diagnose and treat patients with eating disorders, to improve experiences and outcomes and ultimately save lives. This includes work to expand the mental health workforce, to enhance medical education pathways and produce doctors with a greater understanding of mental health and wellbeing, and to develop world-class eating disorders education resources.