Publication
HEBS obesity campaign: training needs assessment
5. The role of the community dietitian : findings from interviews
Interviews were conducted with 9 Chief and /or Community Dietitians across the five health board areas. The purpose of the interviews was to identify the structures and levels of provision of dietetics services in the sample locations, the roles of the dietitians interviewed in terms of primary care inputs and referral criteria, and activities related to the SIGN guidelines.
5.1 Service structure
5.1.1 Service Conditions
All of the community dietitians interviewed were Trust employed and their provision focused on primary care. Two main service structures were in operation: hospital based with outreach and health centre/primary care based. Hospital based dietitians tended to have a geographical remit with responsibility for specific primary care teams, running clinics in practice premises, local hospitals and patient’s homes. The health centre/primary care based dietitians were not ‘attached’ to the primary care teams that housed them. Rather they were based in practice premises with available accommodation, but still had a geographical remit running clinics in other practice premises at perhaps monthly intervals in a similar way to their hospital based colleagues. Opportunities for development of strong links with any one primary care team were limited due to time constraints.
One group of acute Trust hospital based dietitians saw particular advantages in their location in that there could be considerable continuity of patient care from hospital to community. One obvious disadvantage for all geographically based services is the time spent travelling to different clinic bases. Others emphasised the desirability of developing closer links with primary care teams in particular to promote a more holistic, multidisciplinary approach to obesity management.
5.1.2 Level of Cover
The Trusts in which the community dietitians were based directly employed between 0.5 and 5.0 WTE community dietitians to respond to all primary care team referrals. All of the interviewees indicated that the level of resource did not meet the demand from primary care, particularly if traditional service delivery models were maintained. One interviewee indicated that compared to the level of physiotherapy and speech therapy provision within the Trust, community dietitian cover was approximately 2.2 WTE’s short. GPs in some localities had directly influenced the provision of dietetic cover by bringing pressure to bear on Trusts. In other areas, fundholding practices were purchasing dietitian cover for monthly clinics.
5.1.3 Roles
Dietitians described three main roles; a clinical role, a training role and a health promotion role with associated resource and policy development. The traditional division of time between these roles was described as 70% clinical and 30% training and health promotion. Due to clinical demand, health promotion and training activities were being perpetually squeezed for most dietitians. Some dietitians had been expressly employed by their Trusts to adopt only a clinical role, but they were trying to maintain and develop their involvement in health promotion and training as it was seen as an integral part of their professional role. This was difficult, however, as their output was assessed purely on the basis of patient contacts.
5.1.4 Clinical Activity
Clinical activity is predominantly clinic based but also includes some home visits. Clinics are normally arranged on a 1:1 appointment system with 30 minute slots per patient. Following assessment, patients are offered advice and follow up appointments to monitor their progress. Dietitians indicated that counselling is a fundamental element of dietetic activity. Counselling, monitoring and support of patients on a dietitians caseload can sometimes last for months or years. The system can therefore become congested very quickly and waiting lists develop.
The management of simple obesity is a low priority for dietitians. Current priorities lie with obese patients with additional risk factors or existing chronic disease, and paediatric cases. This was perceived to reflect a limited use of the wide range of skills dietitians had to offer. Due to the pressures they are under, however, dietitians do not feel obliged to market their skills. Although currently simple obesity patients are not a priority and tend to go to the bottom of the waiting list unless a paediatric case, the need to raise activity levels in the management of simple obesity in response to the SIGN guidelines was identified.
5.1.5 Referral Criteria
Dietitians’ code of practice requires a medical referral to be made. GPs are therefore the main users/gatekeepers of community dietetic services. GPs use of community dietitians varies. Some use the service judiciously and appropriately, some over-refer simple obesity cases and some do not refer at all.
The over-referral of simple obesity cases places dietetic services under considerable additional pressure. Despite the pressures, not all dietitians had issued referral criteria to the GPs they covered. In three locations GPs were left to prioritise what they referred. In other areas, attempts had been made to define protocols and referral criteria. In particular, criteria had been outlined that patients with a BMI less than 30 should not be referred to the dietitian in the first instance. They should either be referred to the PN or HV or encouraged to attend a commercial weight reduction organisation. If after three months no progress had been made and the patient remained motivated to tackle the weight problem, they could then be referred to the dietitian for assessment and advice, but they may still be returned to the care of the PN for ongoing monitoring and support. Despite these efforts, GPs continue to refer simple obesity cases outwith the criteria.
5.2 The need for a shift in emphasis
In response to the need to rise to ever increasing demand from primary care teams and also, in some cases, as a response to the perceived demands of the implementation of the SIGN guidelines, several dietetics departments are actively shifting their emphasis from predominantly 1:1 clinical work to other models of service provision. The scale of the obesity problem is perceived to be too great for any one profession to manage alone, therefore most initiatives aim to enhance or utilise the skills of other professional groups, particularly the primary care team, in collaboration with community dietitians. Service development initiatives are therefore placing particular emphasis on health promotion and training activities in primary care or on multidisciplinary groupwork. Other service development initiatives include open access clinics in primary care and increased inputs to community education and community development programmes.
Various initiatives are described below.
5.2.1 Training Activities and Resource Development
Some departments are shifting/have shifted their emphasis to greater training and resource development activities. Some departments were in the early stages of shifting their emphasis but one reported having totally reversed its time allocation to 70% training and health promotion activity and 30% clinical activity. With this change of emphasis the department is offering training to primary care team staff. Some resistance was experienced to this kind of shift in emphasis in some areas. Some GPs preferred the idea of clinical provision from the dietetic department rather than having yet another role placed in the domain of the primary care team. Nevertheless, community dietitians saw a clear need to enhance, co-ordinate and upgrade current weight management activities in primary care.
Weight management activities in primary care, predominantly run by PN’s, were described as of variable quality with inconsistencies in the information given to patients. With appropriate training, however, primary care team staff, and particularly PN’s, are perceived to be perfectly capable of taking some of the monitoring and support roles currently undertaken by community dietitians. Some dietetic departments are therefore targeting practice nurses, and other nursing specialities (HVs, DNs, School Nurses and hospital nurses) for training inputs. It was noted that it is sometimes difficult to get PN’s released to attend training, however, given the perceived low priority of obesity management within primary care. Generally, training is not offered to GPs due to a perceived lack of interest, but it was suggested that to raise the profile of obesity management in primary care, it may be more appropriate to deliver training to primary care team units rather than to professions in isolation. This might lead to a more co-ordinated, multidisciplinary approach to the management of obesity within practices.
In addition to training activities, community dietitians also act as a resource to primary care teams giving advice over the phone and providing weight reduction sheets and other resources. This too was seen as an area of input that could be further developed to provide more consistent and accurate dietary advice for patients through the primary care team.
5.2.2 Community Education and Community Development Inputs
The value of dietetic inputs to community education and community development initiatives including the provision of cookery classes and talks on health eating were identified as another area of activity worthy of expansion. The desirability of closer links with community education departments and health promotion units was highlighted.
5.2.3 GP Referral to Exercise Schemes
Some dietetics departments are involved in GP Referral to Exercise schemes providing dietary advice to participants. These schemes are seen to work extremely well and to be popular with patients. This is perceived to be an area of activity which could be usefully expanded.
5.2.4 Groupwork and Multidisciplinary Collaboration
Other departments maintain an emphasis on clinical activity but are placing greater emphasis on multidisciplinary groupwork with patients. Pilots of such activities are ongoing.
One example is the GP practice attachment of a community dietitian for the development of groupwork programmes. The aim is to develop a model for dietetic group treatment for weight and non-insulin dependent diabetes management (see exemplar practice 1, section 4.3.4). A second example is a multidisciplinary initiative for the management of non-insulin dependent diabetes involving the primary care team, a dietitian and a chiropodist.
In a Health Promotion Resource Centre in Greater Glasgow, a healthy eating and exercise group runs twice week. The group is run by HVs from a local health centre, a community dietitian and an aerobic tutor funded by health promotion. The groups have been running for two years and a number of structures have been explored. Initially, only GP referrals were taken. It was found, however, that patients preferred the idea of being able to attend with a friend and so the groups now consist of entirely self referred individuals. The ‘bring a friend’ approach is perceived to have reduced default rates. The groups are advertised in the local health centre and in the resource centre itself. Some GPs mention the groups to patients and the HVs actively promote it. Initially, group attendance could be indefinite. A different health topic was covered each week combined with exercise and weigh-ins. After a while it became apparent that the same people were coming week after week with mixed results in terms of weight loss. This raised concerns regarding dependency and it was decided that attendees should be encouraged to move on and implement what they had learned. The groups therefore now run on 8 week cycles. After eight weeks members are still able to come and get weighed and access advice and support but no longer take part in the group programme. The programme is currently being evaluated.
A move to groupwork was seen to have certain obstacles to overcome, primarily ones of space, time and staffing. The lack of suitable venues is the first practical obstacle. Most health centres do not have adequate space to hold groups, especially ones which incorporate exercise. The second obstacle is finding time for preparation. The initial preparation involved for groupwork is extensive and programmes have to be carefully planned. Once established, however, they can be run in time-efficient cycles. The third obstacle is one of staffing. Informed, motivated staff who can make a regular commitment to a group programme have to be identified. If these obstacles can be overcome, groupwork was seen to offer an important way forward.
5.2.5 Open Access/Self Referral
In some areas, GP fundholding created an environment where dietetic departments had to become more receptive to the demands of primary care. One result of this was the establishment of open access clinics within primary care settings. This required a change to the dietitians code of practice to allow non-medical (i.e. self) referrals, but once this obstacle was overcome, clinics were successfully established. The practices organised appointments and strict ratios were established to contain the demand. Although the open access system was found to be more taxing for the dietitian because they had no referral information to go on, a review of the reasons for self referral found them to be similar to other clinics. It was thought that self referred individuals would be more motivated to succeed with weight reduction than GP referred patients, but this programme had not been audited.
5.3 Response to the sign guidelines
In general, community dietitians saw a lead role for themselves in implementation of the SIGN guidelines as they have the skill base necessary. They emphasised the resource implications, however, and noted that a holistic multidisciplinary response to obesity management was required.
Most responses to the SIGN guidelines were in their early stages. One dietitian had developed a weight management training programme based on SIGN and was to offer the training to nursing staff for the first time this year. One dietetic department was developing a training pack based on SIGN and was working with their local university department of general practice to establish a method of auditing for SIGN. The plan is to offer training, possibly to primary care team units rather than to individual professions, to allow time for implementation of training and then to audit.
The main response to SIGN identified during interviews was the DAGOS (Dietitians Action Group on Obesity - Scotland) initiative. DAGOS is a group of self-appointed dietitians with a firm commitment to develop dietetic practice in obesity management and was established following a one day conference on the ‘Management of the Overweight’ hosted by Tayside Dietitians in December 1996. Participants reflect the range of dietetic practice including clinical activity (hospital, community, primary care), health promotion, research, undergraduate and post -graduate education, service management and dietetic specialist areas (diabetes and paediatrics).
The overriding aim of DAGOS is to establish ways to facilitate the implementation of the SIGN guidelines, Obesity in Scotland and to assist dietitians to develop best practice for obesity prevention and management..
Strategic aims of the group are to:
- maximise the use of available resources
- work with others to raise awareness and encourage collaboration
- utilise non-dietetic expertise and
- systematically evaluate and report on current and future activities
The group is currently attempting to:
- review current practice in obesity management
- evaluate the effect of implementing SIGN recommendations on the dietetic management of obesity
- establish best practice in obesity management
- explore opportunities for prevention and management of obesity using the SIGN guidelines in paediatric practice
5.4 Implications of 'Designed to Care'
It was considered likely that GP Co-operatives would place demands on dietetics for new service structures - probably attached dietitians. It was anticipated that this would lead to the creation of more dietetics posts and closer, more collaborative links with primary care professionals. Developing closer links with primary care teams for the management of overweight and obesity and utilising the skills and resource of other professionals would require priorities and targets to be agreed and for the role of all primary care team professionals to be maximised through training and protocol development.
5.5 Summary and conclusions
Community dietitians perceive themselves as having a lead role to play in the implementation of the SIGN guidelines. Even prior to the SIGN guidelines, however, community dietitians were under resourced. Expanding their activities in simple obesity management in response to the SIGN guidelines can only exacerbate the resource problem.
Two main responses to this dilemma have been identified; increased emphasis on training and health promotion activities and increased multidisciplinary collaboration, both with emphasis on primary care involvement. The lack of motivation of many primary care teams, and particularly GPs, to get involved in such activities has been highlighted as a significant barrier to progress, however.
Although dietitians are collaboratively reviewing methods of taking forward the SIGN guidelines into practice through DAGOS, it would appear that this process will be impeded by the lack of formal evaluation or audit of past and present multidisciplinary service initiatives. Infrastructures need to be put in place to enhance the identification of evidence-based practice.
The latter may ultimately increase GP motivation to become involved in weight management initiatives as the lack of demonstrably clinically effective methods for obesity management has proved to be a barrier to the development of collaborative initiatives in the past.
Overall, it would appear that this is a time of great challenge and potential for dietetic services, and for community dietetics in particular.