ANNOUNCEMENT OF COMMITTEE INQUIRY: HEALTH AND SOCIAL CARE WORKFORCE PLANNING.
The British Dietetic Association would like to thank you for the opportunity to provide written evidence for this inquiry.
The British Dietetic Association, founded in 1936, is the professional association for registered dietitians in Great Britain and Northern Ireland. It is the nation’s largest organization of food and nutrition professionals with over 6,000 members. About two-thirds of members are employed in the National Health Service. The remaining members work in education, industry, research, sport settings or freelance.
Dietetics is the interpretation and communication of the science of nutrition to enable people to make informed and practical choices about food and lifestyle, in both health and disease.
The title 'dietitian’ is protected by law, and only those who have passed a recognized course and are registered with the Health Professions Council can call themselves a dietitian.
Dietitians are concerned with the nutritional health of the general population and the nutritional care of individual patients within the NHS. To be successful in this individual dietitians and dietetic departments function at many levels within the system.
During pre-registration education a dietitian, in addition to passing a recognised degree, MSc or post-graduate diploma, will have passed a practical training programme which will have equipped the dietitian to work within a variety of settings. The practical component of the course is inherently linked with academic studies.
There has been the experience that because of financial strains, the number of undergraduate places has been cut. There needs to be consideration of demand across the profession, understanding that not all dietitians trained in Wales will work in Wales. Equally, there will be natural wastage, i.e not all those that train in dietetics will use their training in a health capacity.
Dietitians are also involved in a breadth of specialist practice. Expert practice takes 2-5 years to accumulate, through experiential learning; short courses; and inter-professional learning and working. There is an MSc in Advanced Dietetic Practice with a combination of inter-professional, uni-professionals and work-based learning modules.
There are currently 19 specialist groups within the BDA, indicating the breadth of specialist practice.
Community Nutrition
Cystic Fibrosis
Diabetes Management and Education
Dietitians in HIV and AIDS
Dietitians in Obesity Management
Dietitians in Sports and Exercise Nutrition
Food Allergy and Intolerance
Food Counts
Freelance Dietitians
Gastroenterology
Mental Health
Multicultural Nutrition
National Advisory Group for Older People
National Dietetic Managers
Oncology
Paediatrics
Parenteral and Enteral
Renal Nutrition
UK Heart Health and Thoracics
Within these specialities new specialties or sub-specialties are developed. These include stroke care within the speciality of older people, eating disorders and learning disabilities within the umbrella of mental health and renal disease and obesity with a focus on children.
After qualifying dietitians work in a wide range of specialities and settings, both within and outside the NHS.
There have been well publicised difficulties for health graduates trying to obtain their first post within the NHS. A survey of HEIs demonstrated that approximately 55.8% of 2006 graduates, whose destination was known, were employed in the NHS by February 2007. 9% were in other relevant posts and 12.7% went on to further study, including PhD.
A survey of new graduates showed that 47% of those with posts had to travel more than 50miles from their base and half had to take a temporary post as their first job. This indicates a change in employment where 90% of the previous years graduates had employment in the NHS.
Please find overleaf, specific information relating to the points within the terms of reference of the committee inquiry:
'The division of responsibility amongst organisations charged with workforce planning and the mechanisms the use’
'The availability and quality of intelligence to inform workforce planning’
'The involvement of all relevant stakeholders in the planning process’
The Workforce Development Unit (WDU) meeting, 25th October, with the Therapy professions, is a good example of involving key stakeholders in the process. Following this meeting the following actions are being taken forward:
A reference group is being established and it is key that there is dietetic involvement in this.
The development of a robust data collection system for meaningful workforce planning.
There is a need for consideration to be given to train and support people involved in workforce planning, to support their decision making.
'Changing patterns of demand(including an ageing population) and service provision in the health and social care sectors(including reconfiguration of services, use of new technology, new public service delivery arrangements)’
Changing patterns of demand
There is a well known risk of malnutrition in the elderly both in the community and in hospital.
With an ageing population there will also be increased demands associated with long term conditions.
Dietitians have a key role in the treatment of long term conditions and in some instances are the key profession involved.
Obesity
There is a key focus on obesity and partnerships have been established to develop and deliver obesity strategies. In many areas the nutrition and dietetic service and specialist dietitians have had a lead role in this.
Diabetes
A Workforce and Training Framework for the Delivery of Diet and Lifestyle Care Pathways, for Long Term Conditions; A Diabetes Perspective
was commissioned by the Diabetes Workforce Executive Group at the DoH and was developed by a task group consisting of members of the Diabetes Management and Education Specialist Group of the BDA, and supported by the BDA Professional Development Committee. Although the report focuses on the NSF for England, the document hopes that the principles of workforce re-design and the solutions will be relevant to the other nations.
The key service, workforce gaps and pressures on dietetic diabetes services were identified by the Workforce Task Group as follows:
Inequality of access to dietetic services in all settings of diabetes care across the health economy in all geographical areas.
Local initiatives are unsupported by inadequate infrastructures and resources
New workforce models are not underpinned by appropriate, quality assured, accredited and validated training programmes which are dietetic led.
The group was tasked to consider solutions to the workforce dilemma.
The key solution is a shift of the dietetic skills and care delivery to focus on the more specialist and highly complex cases at all points of the diabetes care pathway. This will require the funded development of validated Dietary Screening and Education Tools to enable trained personnel to deliver the education and information components of the dietary package. It is vital that tailored and individualised one-to- one dietetic care is not lost.
There are also changing roles and responsibilities in mental health services.
Dietitians have many roles within mental health services including a well established role within the treatment of eating disorders. In general mental health services there is a growing recognition that service users suffer more physical ill health relating to lifestyle, and that these needs are often not met in primary care. Dietitians are active in action to improve the physical health of service users by reducing the risk of CHD, diabetes, obesity, cancer, gastrointestinal side effects of medication, malnutrition and disordered eating by working with the multi-disciplinary team to identify the nutritional needs of those at risk.
Dietitians work with inpatient and community teams implementing appropriate care plans to address these needs, implementing lifestyle changes such as
health promotion and working with weight loss groups; and working with hotel service providers ensuring that all nutritional requirements are met within the
inpatient and community locations and helping Trusts meet Healthcare Commission standards on food provision.
Caswell Regional Medium Secure Forensic Unit Nutrition Focus Group
This is a multi-professional group facilitated by the dietitian that is examining the evidence for the development of a Nutrition Charter for patients with serious mental illness. To date, resources have been developed for use in the clinic and have intergrated nutrition risk screening and weight management advice into the CPA documentation used at the clinic.
Health Care Professionals need to be skilled to support the change from a 'medical’ model of care to a model which involves encouraging and supporting self care.
There are also increasing demands, relating to managing the rising expectations of the public.
Reconfiguration and loss of dietetic posts
80% of departments are subject to recurrent budget reduction with 21.7% of dietetic managers identifying that they would have to disestablish dietetic posts to meet financial targets. This is being achieved by losing posts from establishments as they become vacant, rather than through redundancy of individuals.
Many nutrition and dietetic departments are currently restructuring, to meet financial and organisational imperatives. It is likely that this restructuring will result in the loss of the further loss of dietetic posts.
It is those in positions of dietetic management and leadership who are being placed at risk. Within both primary and secondary care organisations’ AHPs are being reorganised into multi-professional teams to provide services to a locality or care group. Uni-professional leadership is then replaced with shared or therapy managers.
Although there are arguments to support this approach, there are risks to both the professionals involved and the Trusts. Risks identified by NHS organisation who have decided to retain dietetic managers include possible loss of income, risk to meeting Standards for Better Health targets and NICE guidance such as Adult Nutritional Support; risk to recruitment and retention within the service and loss of practice placements for student dietitians.
Many Trusts have identified that dietetics is a profession with little overlap with other professions in that there is a separate curriculum, purpose, remit and job role. Some general management activities can be carried out by generic mangers, but clinical operational management requires a professional with understanding of the basis of the profession
'Cross border arrangements with the NHS in England’
UWIC and the University of Chester have an agreement to exchange placements for mutual benefit. Welsh Trusts provide a small number of placements at times when they are not required by UWIC students and these along with a small number of placements from North Wales Trusts are exchanged with the University of Chester for placements in the North West of England at times that are required by UWIC students. This provides the University of Chester with placements that are accessible for local students, including those resident in Wales and enables UWIC to match placement supply with demand.
Professional bodies have a key role in supporting/providing a network of communication across the UK and sharing of good practice.
'Changing professional roles and training programmes’
AHPs, including dietitians possess a broad range of skills in assessment, diagnosis and care planning etc and are capable of providing care across the full range of agencies/sectors/levels. Jobs traditionally earmarked for one professional group should be offered more equally based on competence than professional background.
Dietitians are working as part of multiprofessional/multi-agency teams across traditional boundaries and continue to work to enhance this with each other, other organisations and also users. Opportunities are also being taken to share knowledge across teams/professions.
Dietitians are and continue to develop new ways of working. They are taking the lead in the redesign of services and new roles have been and continue to be created to make more effective use of the workforce and skill mix.
South Wales, Neath Port Talbot Prescribing Support Dietitian
Bro Morgannwg NHS Trust working in partnership with Neath Port Talbot Local Health Board has funded a fixed term post for the first Prescribing Support Dietitian in Wales. The role has 3 main strands: education of care home staff and health professionals in the identification and treatment of malnutrition, thus improving the prescribing and use of sip feeds; audit work with GP practices to improve the quality of care for patients receiving oral nutritional products; and the development of policy in areas of nutritional support in the community, the review of patients receiving weight management drugs and gluten-free products on prescription.
In the first 6 months of the project, over 650 people have received training and substantial savings have been achieved through partnership working with local GPs. The role has been shown to be a useful resource for healthcare professionals in the community with the development of care pathways for oral nutritional support and a range of patient information leaflets. This has increased confidence in the community in the knowledge that nutritional products are being used appropriately and more effectively.
The Community Project Dietitian has worked in partnership with Prof Kevin Morgan and colleagues of Cardiff University to explore the young peoples’ perceptions of the project and it’s outcomes to provide additional evaluation of the project.
Bro Morgannwg, Specialist Community Dietitian, Grant Programme Funded.
The Welsh Assembly Government has funded a community dietetic post within Bro Morgannwg NHS Trust. A grant programme was established by the Assembly to increase the capacity of dietitians in Wales to inform and support communities in healthy eating through, facilitating with appropriate training, the incorporation of nutrition into the work of other people working with groups of children, young people and or families in the community e.g. youth workers, sure start workers, care workers.
This is being achieved through training of key community workers using an accredited Open college Network (OCN) course and other bespoke training sessions.
The Community Food and Nutrition Skills Training Course was written by Community Dietitians in Wales and accredited by the Open College Network. The course aims to provide standardized, quality assured nutrition training for local food project workers to enable then to give accurate healthy eating messages to the wider population. Participants having successfully attained accreditation will then go on to establish nutrition projects in their own area.
Bro Morgannwg NHS Trust Nutrition and Dietetics Service have close links with both Neath Port Talbot and Bridgend National Public Health Service
and many community partners e.g. and Age Concern, Young Peoples Partnerships, Communities First Partnerships and has been working alongside these partners in the development of strategic health improvement action plans. It is hoped that the planned programme of nutrition training will be a key part in achieving many of the recommendations in the action plans.
Nutrition training for NPT Physical Activity & Sports Service (Education, Leisure& Lifelong Learning), Bridgend Community First Development Workers and Leisure Centre Staff is being delivered and the first OCN Community Food and Nutrition skills course is being run with key workers from Community First areas, Oral health Service and National Public health service staff being the first participants. Other nutrition training for health professionals is being delivered across the trust e.g. up to date training on topical issues such as Childhood Obesity for Health Visitors.
The planned programme of nutrition training and education will ensure that standardised, and up to date nutrition education is available to community workers and health professionals alike thereby enabling them to give accurate healthy eating messages to the wider public.
The professional body, who owns the curriculum is regularly reviewing and updating this to ensure that graduates, in particular, are fit for purpose.
There does need to be adequate provision for postgraduate development in both a uni and multi professional setting.
'Joint working between health and social care agencies’
Bro-Morgannwg NHS Trust - Screening for malnutrition in the community - a learning disability services perspective.
This aim of this audit was to assess compliance with NICE Clinical Guideline 32, 1.2.4 : People in care homes should be screened on admission and when there is a clinical need. Though only 3 out of the 12 participating organisations (providing a range of services for clients who have a learning disability) had a structured nutrition risk assessment in place, all undertook some aspects of nutritional surveillance either as a matter of organisational process or as a result of direct dietetic intervention. All expressed interest in using a structured nutrition risk assessment.
As a training need was identified a registered dietitian has been appointed short term to facilitate the implementation of nutritional screening within the identified organisations. An abstract submission of the audit was panel reviewed and approved for poster presentation at the first Welsh Clinical Audit and Effectiveness Conference 2007.
Bro-Morgannwg NHS Trust - Accessible Information for people who have a learning disability.
The Directorate of Learning Disabilities is the largest provider of specialist health services to people with a learning disability in Wales. This specialist regional service covers a population base of 1.4 million of which approximately 6,000 people have a learning disability.
People with learning disabilities have the same baseline nutritional requirements as the general population in health and in illness. However variations in the levels of cognitive and communication abilities necessitate different modalities of providing information in order to meet people’s needs (Department of Health, 2004B).
The use of other communication techniques such as audio/visual tapes, pictures/photographs, symbols, practical demonstrations, nutritional games, e-learning and other IT support should be developed and used appropriately (Bell, 2005).
The Directorate’s Specialist Nutrition and Dietetic team in partnership with Speech and Language Therapy and the Welsh Assembly Government (WAG) produced a bilingual booklet on healthy living in an accessible format. This booklet which was launched in the Senedd May 2006 by Jane Hutt AM. Copies are available from the Public Health Strategy Division of WAG - Tel 02920 825935,also available for download from the Internet at: www.wales.gov.uk/healthchallenge
The Specialist Nutrition & Dietetic Team has also produced a range of booklets on Diabetes and Healthy Eating for their clients which are used by a variety of healthcare professionals throughout the Directorate. Positive feedback has been received from staff, carers and clients. Work is in progress to produce 'talking’ information sheets in both CD and DVD formats and photographic menus to support client choice.
'The workforce needs of the public, voluntary and private sectors’
The workforce needs of all of these sectors needs to be considered.
Dietititians work in the public, voluntary and private sectors and work alongside/in partnership with individuals/groups within all three of these sectors.
In addition, other agencies may contract with the NHS to provide services. For example, Enteral tube feeding contracts.
'The recruitment of a workforce that reflects the diversity of the welsh communities, including Welsh speaking staff and those from the BME group, general equality issues with particular reference to the retention of staff’
Trusts have developed welsh language schemes, in accordance with the Welsh Language Act(1993).
Local Trusts are making available welsh speaking courses for their staff in order to promote the welsh language.
Bwrdd Cymru, Welsh Board of The British Dietetic Association, since its conception in November 2006, has produced all of its key documents in Welsh and English.
Bwrdd Cymru, the Welsh Board of The British Dietetic Association, which is officially launching at The Senedd on 7th November, has representation from the dietetic managers group in Wales known as the All Wales Dietetic Managers Committee(AWDMC), CDiW (Community Dietitians in Wales) as well as the BDA representative on WTAC(Welsh Therapies Advisory Committee); regional dietetic representation; student representation and representatives for education, research, clinical governance and professional development. As such, Bwrdd Cymru provides good mechanisms for communicating with the profession in Wales, provides a focus for all BDA activity in Wales, establishes a forum for discussion of pertinent issues and provides a stronger voice for dietitians in Wales. For example, Nicola Morris, BDA Policy Officer together with 3 BDA members recently met with Jenny Randerson, Welsh Liberal Democrat Assembly Member for Cardiff Central to discuss a ballot she had recently won for a private member’s measure in the Welsh Assembly on Healthier School Meals. This was an opportunity to discuss the Measure, how this fits in with the soon to be launched 'Appetite for Life’ document on school meals and to highlight the key role that dietitians have to play in this area. The meeting also provided a chance to illustrate some of the fantastic work dietitian’s are already involved in within schools in Wales and to raise the profile of community dietetics in Wales.
A key priority for Bwrdd Cymru is, 'Developing the Dietetic Workforce’, as evidence from the BDA Bwrdd Cymru manifesto:
"Dietetic professional leads continuously review their own workforce to support strategic change and demand.
Working in partnership with key stakeholders in Wales and the wider Professional Body to develop a workforce that is flexible, has a defined career pathway and makes best use of all skills e.g. Dietetic Support Workers, Expert Practitioner roles.
Addressing the availability of dietetic posts in Wales for new dietetic graduates.”
I would be grateful if you could provide me with any feedback to this evidence and inform me of any further work.
Nicola Morris
Policy Officer for Northern Ireland, Scotland and Wales
On behalf of the Welsh Board of The British Dietetic Association
