How to… employ a dietitian

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

We are a network of five GP practices in the London borough of Newham, part of the recently formed North East London CCG. Our network serves nearly 40,000 patients. The population is relatively young and highly diverse, with more than 100 languages spoken, and is the third most deprived borough in London. Obesity, diabetes, asthma and hypertension are the predominant long-term conditions, along with very high mental health needs. 

Why did we employ a dietitian?
Our aim was to offer a bespoke and holistic service to our patients in primary care. We also saw this as a real opportunity to focus on addressing root causes and patient education, and to prevent some health conditions relating to diet and nutrition – in particular diabetes, hypertension, high cholesterol, coronary heart disease, stroke, gallbladder disease and osteoarthritis.

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. 
• A reduction in HbA1c levels (over a three-to-six-month period).
• An improvement in clinical risk factors – blood glucose, 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.
• To transition patients off supplements and onto food-first nutritional support.
• A reduction in the number of oral nutritional supplement (ONS) prescriptions.
• An improvement in patient behaviour change.  
• An improvement in self-care and self-responsibility for health.

How we hired a dietitian
Guidance in the network contract DES is clear on the qualification requirements for employing a primary care dietitian under the additional roles reimbursement scheme (ARRS).¹ 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 dietitians, but their skill set is completely transferable. With some coaching on primary care pathways our dietitian was embedded in the primary care team within a few weeks.

What does the dietitian do for the PCN?
During the past 12 months, the role has evolved, with an emphasis on proactive care. Our dietitian runs a weekly clinic, following up on referrals from other members of our clinical team. The dietitian has consulted with nearly 2,000 patients across our network, which is around 5% of our population.

The working week includes:

• Supporting diabetes patients with high HbA1c.
• Supporting housebound and care home patients.
• Supporting patients on an ONS.
• General dietetic clinic.
• Attending administration and wellbeing team meetings, and practice clinical meetings.

What support does the role require?
As the CD 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 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. Also, our GPs have welcomed the access to an in-house referral service – so patients can be seen quicker and offered a more tailored service to meet their needs.

We have already seen a number of improvements. 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 six-month period. 

We have also seen nutritional supplement prescribing streamlined and reduced by about 10%, due to better compliance and ordering. In addition, our dietitian has brought a focus on reducing obesity in the local population and recently supported a project to help 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 develop the service for the future.

Dr Anil Shah is a GP principal in east London and CD at Newham North West 2 PCN

Reference 

• NHS England. Network Contract DES. Contract specification 2021/22 – PCN Requirements and Entitlements. October 2021

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