Employing a dietitian to support your PCN

GP principal and PCN clinical director Dr Anil Shah shares advice and experience from employing a dietitian under the additional roles scheme

We are a group of five GP practices within the London borough of Newham and part of the newly formed North East London CCG.

Our Network serves nearly 40,000 patients. The population of Newham is relatively young and highly diverse, with more than 100 languages spoken. Our borough faces some significant health challenges: Newham is the third most deprived borough in London and there are many people facing health and social inequalities. Obesity, diabetes, asthma and hypertension are the predominant long-term conditions, along with very high mental health needs.

We are building our relationships with local services and working closely with our local trusts, mental health and diabetes services and district nursing team.

Our PCN team currently comprises a core team of 12 – a lead social prescriber, four social prescribing link workers, one dietitian, one pharmacy technician and five physician associates.

Why did we employ a dietitian?

Our aim was to offer a more bespoke and holistic service to our patients within primary care. We also saw this as a real opportunity to focus on addressing ‘root causes’ and patient education, to support prevention of some of the health conditions relating to diet and nutrition – in particular diabetes, hypertension, high cholesterol, coronary heart disease, stroke, gallbladder disease and osteoarthritis.

As a PCN team we identified this as an opportunity to be ‘proactive’ rather than ‘reactive’ to these health conditions and we worked with our dietitian to develop a comprehensive Dietetic Operating Model.

What do we hope to achieve through the new role?

We have identified a number of key proposed outcome measures where we hope to see a significant impact. These are:

• A reduction in GP clinical appointments and hospital admissions for long-term conditions linked to diet
• A reduction in HbA1c levels (over a 3–6-month period)
• An improvement in clinical risk factors – blood glucose control, blood cholesterol, blood pressure and weight
• An improvement in malnutrition risk, as measured by Malnutrition Universal Screening Tool (MUST) scores
• An improvement in eating patterns, habits and food choices
• Patients transitioning off supplements to food-first nutritional support
• Reduction in the number of ONS (oral nutritional supplement) prescriptions
• Improvement in patient behaviour change activation  
• Improvement and engagement with self-care and self-responsibility for health.

How we hired a dietician

Guidance with the Network Contract DES is clear on the qualification requirements needed for a primary care dietitian employed under the Additional Roles Reimbursement Scheme (ARRS). We chose to hire a dietitian at Band 7 on the NHS Agenda for Change scale. As the role in PCNs is so new, we only received applications from secondary care dieticians, but their skill set is completely transferable, and with some coaching on primary care pathways our dietician became embedded within the primary care team within a few weeks.

Key requirements for the role are:

• a BSc or pre-reg MSc under a training programme approved by the British Dietetic Association (BDA)
• must be a registered member of the Health and Care Professionals Council (HCPC)
• able to operate at an advanced level of practice
• must have access to appropriate clinical supervision and an appropriate named individual in the PCN to provide general advice and support on a day-to-day basis.

The candidate we recruited has now been in post for 12 months, having moved from a secondary care environment with the capability and enthusiasm to really want to make a difference in primary care.

What does the dietitian do for the PCN?

Over the past 12 months, the role has evolved, with a real emphasis on proactive care and running of a weekly dietetic clinic for following up on referrals from other members of our clinical team. Our dietitian has been able to support and consult with nearly 2,000 patients across our Network (around 5% of our population).

The working week includes:

• Support to diabetes patients with high HbA1c
• Support to housebound / care home patients
• Dedicated support to those patients on ONSs
• General dietetic clinic
• Attendance of administration and wellbeing team meetings, support for practice clinical meetings.

What support does the role require?

As the clinical director I work closely with our dietitian. I conduct monthly consultation audits on the dietitian’s documentation, provide clinical support as needed and have regular catch-up meetings to provide support and suggestions for improving consultations. The clinical leads and GP partners of all our PCN practices are available for support as and when required.

Supervision is crucial as the dietitian is largely working alone, and needs GP time to be able to check clinical information. Overall, the benefits we have seen outweigh the time taken.

How has the dietitian helped practices so far?

We have received fantastic patient feedback about having access to a dietitian. In addition, having an ‘in house’ referral service for our GPs has been well received – allowing our patients to be seen quicker and offering a more tailored service to meet their ongoing needs.

We have already seen a number of improvements towards our goals. For example, we have seen some significant reductions in HbA1c levels, with a number of patients achieving reductions of 20-30mmol/l after two or three interactions over a 6-month period.

We have also seen nutritional supplement prescribing streamlined and reduced by about 10% so far, due to better compliance and ordering. In addition, our dietician has brought a focus on reducing obesity and recently supported a project to assist patients with sickle cell disease.

Based on our experience so far, my advice would be that every PCN needs a dietitian – we are certainly looking to grow and develop the service for the future.

Dr Anil Shah is a GP principal in East London and clinical director at Newham North West 2 PCN