What about expertise flowing in the other direction? An inpatient SEDU may well be managing a severely ill patient with AN, and the team may require the expertise of a medical unit. Here experience is a patchwork. In some SEDUs, there is an excellent relationship with a named physician with a special interest in the area, often one with special expertise in nutrition. The physician can be contacted whenever serious medical problems arise in a patient’s care and may be willing to see the patient and consult with the team. This happy arrangement does not, however, apply everywhere. Approaches to the gastroenterology department may be fruitless because the established special interests of all the consultants fail to include nutrition. If this occurs, we suggest that mental health and acute medical commissioners and providers should make the solution of the problem a priority. It may involve 1–2 h/week of a physician’s time to provide support to the eating disorder service. Sometimes, the problem is solved in the wake of the avoidable death of a young patient with AN. We suggest that waiting for such as occurrence comes close to sacrificing a young life through neglect. It is the responsibility of those providing and commissioning services to address this problem in advance of an untoward incident.

The equivalent models for young patients under 18 are more variable. In some areas, paediatric and mental health services are well integrated, and patients receive comprehensive care without the need to transition services as their risk increases and decreases again. In other areas, the majority of eating disorder expertise is held by child and adolescent mental health services (CAMHS), who support paediatric wards when admissions of acutely unwell young people occur. The same may not be true in reverse—not uncommonly, patients are admitted to general psychiatric units without the means to provide nasogastric feeding or perform and interpret ECGs, and even the monitoring of pubertal development and bone density is far from routine. By contrast, in some countries, e.g. the USA and Australia, expertise in managing eating disorders may be held by paediatric services, often Adolescent Medicine teams, to whom mental health services are adjunctive or become available to patients on discharge from paediatric care. The risk in this scenario is that the patient just needs to lose weight again to escape the psychological treatment that is so challenging and difficult, and a “revolving door” of repeat admissions process begins. Figure 7.2 illustrates the times of particular risk in transitions between mental health and paediatric care for young people with eating disorders and between inpatient and outpatient care where these services are structurally independent. These risks can be effectively overcome with integrated mental health and paediatric care and with clear decision-making processes, seamless transition and collaborative working, linked to key agencies, as shown.

We have concentrated on the problems introduced by the gaps that can appear between physical and mental health services. The other dimension is that of age. At the age of 18, when many patients with severe eating disorders are still unwell, it is thought wise to transfer their care to a completely new service with different staffing and ethos. As we have said, we doubt that this is actually the best way to treat young people with eating disorders and, for that matter, any disorder that is likely to continue into adulthood. Like the brain-body split, we live with (in most services) the child-adult chasm. The chasm can cause a great deal of damage unless much care is taken. Good practice suggests that the move should be anticipated well in advance. A specialist adult service should be identified if possible although referral to the general community service may also be appropriate. If the adolescent is an inpatient, it may be wise to transfer to an adult eating disorder bed. In all cases the process of handover needs to include the child and adolescent practitioners who know the patient and the general and specialist adult practitioners who will be taking over care. The general practitioner should also be involved if practicable. The patient and carers should be involved and a care plan for transfer agreed by all and circulated to all, including a current risk assessment and crisis plan.

The same principles apply if a seriously ill patient, including one who has recently been discharged from hospital, moves to another part of the country. This is not uncommon, as patients sometimes leave for university as soon as they have finished intensive treatment for AN. This is, we suggest, often inadvisable, and may represent what has been termed a “flight into health”. Usually a period of stabilization for, perhaps, a year, should precede such significant changes. Transfer of a patient of any age to a service in another town demands exactly the same care as described above. A patient in the year after discharge from hospital is recognised as being highly vulnerable, and the NICE guidelines for eating disorders advise regular outpatient therapy following discharge for at least a year (National Institute for Health and Care Excellence 2004).