The FREED project
In September 2024 we will be celebrating the 10th birthday of FREED (first episode rapid early intervention for eating disorders). FREED is a service that provides treatment and care for young people aged 16-25 who are in the early stages of an eating disorder. It is designed to focus on the needs of the individual, taking into consideration their age, life stage and personal circumstances, then tailoring treatment accordingly.
Adolescence into emerging adulthood is the peak period of onset for eating disorders and a time of significant neurodevelopmental, educational and social changes for young people. FREED has evolved from a small local innovation in South London, tested in a single-centre study to a multi-award-winning national programme that has been rolled out successfully in eating disorder services all over England. It has also inspired similar programmes internationally.
How did the journey start?
We started developing FREED at a time when eating disorder services across the UK were struggling with lengthy waiting lists, and young people potentially being hospitalised hundreds of kilometres away from family and friends. We decided we wanted to do something about this desperate situation by delivering early well-coordinated care for young people presenting to treatment for the first time.
In developing FREED, we were inspired by the work of Pat McGorry and colleagues, who had shown that early intervention makes a big difference in the lives of young people with psychosis, with much better outcomes for early intervention than for traditional care up to 10 years later. Pat McGorry is also a pioneer of youth mental health, highlighting the need for making treatments and health services youth-friendly, inclusive, and easily accessible. Finally, we also took on board Jeff Arnett’s concept of emerging adulthood, as a distinct and unique period of development from the late teens through the twenties, characterised by ‘in-betweenness’, (i.e., where the person is no longer an adolescent, but also not yet a fully-fledged adult).
The impact and success of FREED
"I nearly dropped out of university last year when my illness was at its most aggressive. I can only thank FREED for quite literally saving my life"
Research has shown that FREED reduces the duration of untreated illness (time between onset and first evidence-based treatment), improves treatment uptake and dramatically improves clinical outcomes. For example, 60% of young people with anorexia nervosa receiving FREED are fully weight-recovered at 12 months, whereas just under 20% of similar young people (in terms of diagnosis and illness duration) receiving usual treatment were recovered. FREED also reduces the cost to services, by reducing the need for intensive treatments, such as in-patient or day-treatment. Lastly, FREED is highly acceptable to patients and families.
The reason why FREED has been so successful seems to be that it hits a double sweet spot. Firstly, as a model it hits the so-called innovation sweet spot: It is desirable (i.e. it adds value), feasible (i.e. it can be implemented), viable (i.e. it has substantial return on investment, is cost-saving and contributes to long-term growth) and sustainable (i.e. it does not have negative environmental or social impacts). Secondly, at an individual patient level, it also hits a sweet spot, between the person’s emerging motivation for treatment, their strong developmental need for ‘adulting’ and the malleability and less entrenched nature of eating disorder symptoms early in the illness, meaning that key factors for achieving change and recovery are lined up optimally.
The FREED project
‘It is not rocket science’
Some have suggested that FREED is simple "good practice" and that "it is not rocket science". Thank goodness, it is not rocket science: there are no convoluted theories or incomprehensible language needed to understand the principles or practice of FREED. The aim is simply to "get it right the first time", meaning that we intervene speedily, flexibly, and with evidence-based approaches tailored to young people’s personal and developmental needs and their early illness stage.
Having said that, whilst FREED is based on a deceptively simple idea, how early intervention is done really matters. There are examples of ambitious early intervention initiatives for eating disorders that have been ineffective and have not been able to show either a shortened duration of illness or improved outcomes.
Early intervention creates a win-win situation
FREED is designed as a "service within a wider eating disorders service". The reason for this is to avoid the fragmentation, communication issues, potential for duplication of effort, and access hurdles/bureaucratisation that come with multiple separate services. It also means that any cost savings achieved by the introduction of FREED into a team (through reduction of inpatient admissions) can readily be reinvested into the same service, thereby benefitting all service users, including those with long-standing illnesses.
“We have no nay-sayers, just operational challenges”
On the strength of the evidence supporting it, FREED was adopted in 2020 by the Academic Health Sciences Networks (AHSNs; now the Health Innovation Networks) into their national programme for scaling. With AHSN support and some additional funds from NHS England, we successfully rolled out FREED to all eligible Trusts in England during the pandemic, training hundreds of clinicians. Towards the end of the programme in Autumn 2022/Spring 2023, we interviewed clinicians and AHSN leads from most regions in England about their views on FREED, its implementation and its sustainability.
The views of these different stakeholders closely mirrored each other and were uniformly enthusiastic: People fully endorsed the concept of early intervention and FREED, noted the improved patient outcomes and also how empowering FREED is in bringing out the best in clinical teams. Stakeholders also acknowledged that there are operational challenges, for example, in terms of how to deliver early intervention when managing staffing shortages and increased referral numbers. However, stakeholders agreed that these challenges could be and should be overcome. In the words of one AHSN representative: "early intervention is not optional; it is a necessity".
Where to next?
We are operating in an NHS that has been described by Health Secretary, Wes Streeting, as "broken". In this context, and given a rise in eating disorders incidence since the pandemic, FREED, whilst embedded into teams across England, remains at risk of being delivered as ‘FREED in name only (FRINO)’. Therefore, appropriate and continued secure funding is needed to support its delivery with fidelity.
FREED on its own is an important cornerstone for early intervention in eating disorders, but there is much more that needs doing. The next frontier for early intervention in eating disorders must be brainier and better and to tear down systemic, institutional, and administrative barriers to early intervention. To make intervention even earlier, awareness raising and early detection are important, as there are still far too many people who do not access the help they deserve, especially those from minoritised ethnic groups, those from lower SES backgrounds, those with resource insecurities, and those from minoritised gender and sexual identity groups. There are further inequalities in that the under 18s can self-refer to services whilst young people aged 18+ seen in adult services often have gate-keeping hurdles thrown in their path. These inequalities urgently need to be rectified.
But how can we make early intervention 'brainier and better'? This involves developing a much better understanding of the interplay between biological and psychosocial risk factors for eating disorders and how these intersect with risk factors for other mental health disorders. Such knowledge could lead to much more personalised prevention and early intervention of eating disorders that will further improve outcomes. Our large UKRI-funded EDIFY research programme focuses on many of these questions - you can visit our website to learn more EDIFYresearch.co.uk.
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