Management of anorexia nervosa revisited

Editor—Russell argues that funding should be more readily available for the private inpatient treatment of anorexia nervosa.¹ She says that “some patients” need inpatient care, but she does not say which patients. This is the crux of the problem.

Inpatient care will continue to be used in some of the most difficult cases, but it should be viewed with caution. I am disappointed that Russell (and her reviewers) did not mention the important paper by Gowers et al, which showed that patients who had received inpatient care did rather worse than those who were treated only as outpatients.² Our own clinical experience reflects this.

We run a child and adolescent eating disorders service for five primary care trusts in north London. The area we cover had previously had between nine and 12 admissions a year to the private sector. With the setting up of our outpatient focused team, the number of admissions has been reduced to one a year, or a total of six admissions over the past six years. This has produced a saving to the local NHS of at least £400 000 a year, while achieving very satisfactory clinical outcomes, and with no formal complaints and no untoward events.

We still work closely with two inpatient units, one NHS and one private, whose contribution we value greatly and to which we will continue to refer patients. But even very good and dedicated inpatient care has not greatly modified the clinical course of some of the six adolescents who became inpatients.

Inpatient care costs perhaps 10 times as much as outpatient care. Clear clinical benefits of inpatient treatment over outpatient treatment have not yet been identified. Furthermore, inpatient care may have some adverse consequences. Therefore, while I will continue to fight for resources to send a minority of my patients to the very best inpatient units, the emphasis now should undoubtedly be on good outpatient care.