Lucy Hyam & Ulrike Schmidt

Eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder, typically emerge between ages 16 and 25, a period marked by rapid physical, social, and emotional development. These illnesses can have serious long‑term effects on physical health, mental wellbeing, relationships, and education or work. Early intervention is vital to improve outcomes and reduce the need for longer and more intensive treatments. Despite this, many young people still face long delays before receiving help, partly due to increasing demand on NHS eating disorder services.

FREED (First Episode Rapid Early Intervention for Eating Disorders) is the first evidence-based programme designed specifically for young people who have recently developed an eating disorder. FREED has been nationally scaled across England, and when delivered as intended, has been shown to reduce wait times, improve recovery outcomes, and generate substantial savings for the NHS. However, eating disorder services remain under pressure, and the consistency and quality of FREED delivery vary across the country, putting FREED’s long-term effectiveness at risk.

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This project focuses on strengthening implementation fidelity research in FREED. Implementation fidelity asks the question - is FREED being delivered as it is intended to be? My PhD research developed the first implementation fidelity tool for early intervention eating disorders, developed primarily for FREED services. This tool is a structured way to measure how closely services follow the model’s core elements, such as rapid access to assessment and treatment, high-quality data monitoring, use of psycho-education, and attention to community engagement and outreach.

Initial testing of this tool across six NHS services showed that it is both feasible and useful in determining areas of high or low fidelity. For example, early findings demonstrated wide variation in services’ ability to meet FREED’s rapid access targets, illustrating why routine monitoring is essential: without it, services may drift away from the model over time, reducing its impact. However, fidelity reports can also empower services to celebrate areas of high fidelity and examples of best practice.

This study will refine the tool and test it on a larger scale. First, we will work closely with clinicians and advisory groups to ensure the tool is practical, user-friendly, and helpful for service planning. Next, we will conduct a long-term multisite assessment of fidelity in FREED services. We will explore whether fidelity improves over time and whether higher‑fidelity services achieve better patient outcomes, such as reduced eating disorder symptoms after treatment. We will also run a focus group with young people who have been on the FREED pathway, ensuring their perspectives guide how the fidelity tool is used and how results are communicated. Finally, findings will be brought together in a policy report designed to support NHS service improvement and inform future commissioning. This project fills an important evidence gap in eating disorder research. By strengthening FREED, the project supports NHS priorities to expand access to evidence-based care, reduce inequality, and improve the experiences of young people affected by eating disorders in the UK and internationally.