Clinician perspectives of the implementation of an early intervention service for eating disorders in England: a mixed method study

Background The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has been shown to reduce the wait for care and improve clinical outcomes in initial evaluations. These findings led to the national scaling of FREED in England. To support this scaling, we conducted a mixed method evaluation of the perceptions and experiences of clinicians in the early phases of scaling. The Normalisation Process Theory (NPT) was used as a conceptual lens to understand if and how FREED becomes embedded in routine practice.Methods The convergent mixed method evaluation included 21 semi-structured interviews with clinicians from early adopter sites and 211 surveys administered to clinicians before, immediately after and 3 months after the FREED training. The interview guide and survey included questions evaluating attitudes towards early intervention for eating disorders (EDs) and NPT mechanisms. Interview data were analysed using an inductive thematic analysis. The NPT was applied to the inductively derived themes to evaluate if and how NPT domains impacted the implementation. Survey data were analysed using multilevel growth models.Results Six themes and 15 subthemes captured barriers and facilitators to implementation at the patient, clinician, service, intervention, implementation and wider system levels. These interacted with the NPT mechanisms to facilitate or hinder the embedding of FREED. Overall, clinicians were enthusiastic and positive towards early intervention for EDs and FREED, largely because of the expectation of improved patient outcomes. This was a considerable driver in the uptake and implementation of FREED. Clinicians also had reservations about capacity and the potential impact on other patients, which, at times, was a barrier for its use. The FREED training led to significant improvements in positive attitudes and NPT mechanisms that were largely maintained at the 3-month follow-up. However, negative attitudes did not significantly improve following training.Conclusions Positive attitudes towards early intervention for EDs increased enthusiasm and engagement with the model. Features of the model and its implementation were effective at developing adopter commitment and capabilities. However, there were aspects of the model and its implementation which require attention in the future (e.g., capacity and the potential impact on the wider service). First Episode Rapid Early Intervention for Eating Disorders (FREED) is an early intervention service for 16-to-25-year-olds who have had an eating disorder (ED) for three years or less. Studies have shown that FREED can reduce the length of time that people wait for treatment and that it improves outcomes. However, it was unclear what it was like for clinicians trying to deliver the service. We used questionnaires and interviews with clinicians who were preparing to or already delivering FREED to understand what they thought about it and their experiences of delivering it. Overall, clinicians were positive and enthusiastic about early intervention for EDs and FREED because they believed that it could improve patient outcomes. This enthusiasm and features of the FREED model and support facilitated its delivery. However, clinicians were worried about their ability to deliver FREED with limited resources and the impact this might have on patients who are not eligible for the service. Resources were a major barrier to providing treatment as quickly as possible. This study suggests that FREED was well-received by those delivering it and that many parts of the service and support were helpful, but resource issues need to be addressed in the future.