Written evidence submitted by The British Dietetic Association (WBR0063)
2.1. There are currently just under 10,000 registered dietitians in the UK. Dietitians are qualified and legally regulated health professionals that assess, diagnose and treat dietary and nutritional problems at an individual and wider public-health level. They use the most up-to-date public health and scientific research on food, health and disease which they translate into practical guidance to enable people to make appropriate lifestyle and food choices.
2.2. Dietitians work in the NHS and in private clinics. They work with healthy and sick people in a variety of settings. They can work in the food industry, workplace, catering, education, sport and the media. Other care pathways they work in include mental health, learning disabilities, community, acute settings and public health.
3.1. This submission draws together evidence from the BDA’s most recent surveys of our membership to highlight the scale and impact of burnout and stress placed upon dietitians both before and during the COVID-19 pandemic.
3.2. We then discuss the need to expand the dietetic workforce to address some of the challenges that have been highlighted.
3.3. We also comment briefly on the recently published NHS People Plan and how it could address these challenges.
4.1. Despite the scale of nutrition related conditions such as obesity, type 2 diabetes and malnutrition, and significant demand for dietetic support and services, there are fewer than 4,400 dietitians working within the NHS in England according to the most recent NHS Digital data. Although that workforce has grown in recent years, it cannot keep up with demand, placing additional pressures on staff and making it more difficult for patients to access the dietetic support that they need.
4.2. The most recent NHS benchmarking project highlights how thin on the ground dietitian are. In inpatient settings, there are only 0.05 WTE dietitians per 1,000 occupied bed days. The clinical vacancy rate is reported at 7.8% and dietetics has the longest waiting time of the AHPs included within the analysis at 43 days.
4.3. The BDA’s most recent report on members views in relation to safe staffing and workload from before the COVID-19 outbreak dates to 2016. Its findings expose a significantly overworked and under resourced profession.
4.3.1. 72% of respondents reported working over their contracted hours, and over half of that was as unpaid overtime. Of that overtime, more than half was focused on paperwork and other indirect patient or service-focussed activity.
4.3.2. Members reported that an average of just 4% of their time was spend on training or other activity necessary for their self-development.
4.3.3. Most concerning, 43% of members believed their current workload to be “unsafe”. Of those that felt it was unsafe, 40% believe this left them unable to undertake appropriate CPD, 21% felt this impacted negatively on health (e.g. stress or illness) and 20% believed this impacted negatively on staff morale.
4.3.4. A significant number of those who reported that their case load was only safe only did so because they worked overtime, or stated that it became unsafe when they were expected to cover leave or sickness.
5.1. Many of the issues highlighted in section four have been made worse by the COVID-19 outbreak, which has placed additional stresses and pressures on the dietetic profession. Some services were paused, while some dietitians had to retrain for urgent frontline roles. There was a rapid move to virtual clinics which required a significant change to practice.
5.2. In some places, workforce pressures were exacerbated by a lack of Personal Protective Equipment. Some procedures, such as the fitting of naso-gastric tubes have not been classified as Aerosol Generating Procedures despite evidence to the contrary, with staff feeling unsafe as a consequence. More information on this topic can be found on the BDA website.
5.3. The BDA Trade Union undertook a rapid survey in April and May of 2020 to gather member’s experience of the COVID-19 pandemic and its impact on their practice.
5.3.1. One in six respondents raised concerns around health & safety in their work environment. There were numerous reported instances of social distancing measures not being implemented or adhered to in the workplace. In certain environments members reported that usage of workspace was near or at capacity when the epidemic hit and there was no additional capacity (which was compounded by the lack of computer resources). The starkest response simply stated that “We feel like lambs to the slaughter”.
5.3.2. One in three of those surveyed identified shortages of PPE and Hand Sanitiser (or both). One response highlighted the desperation felt by many NHS workers as the lack of sanitiser stock and PPE began to materialise: “We are out of wipes, hand gel, we have no masks”.
5.3.3. One in three reported workplace concerns. Members reported significant changes to work patterns, with the expectation that they would work longer shifts, at weekends and bank holidays where previously they had not. Others reported challenges with childcare, with a lack of flexibility about home working compounded with closed schools. One member outlined the difficult situation they faced: ““I’m a single parent with two kids aged 7 &14. I don’t want to put myself and them at additional risk as I have no one to help me if I get sick. Also, I have been refused childcare at schools currently this may change but is out of my hands.”
6.1. As mentioned before, the are too few dietitians for the level of demand with health and care services. To ensure safe and effective patient care now and in the future, we feel it is imperative that we expand the number of dietetic roles, and the expertise of our dietetic support worker workforce. We would like to see a commitment to further funding in this area.
6.2. We welcome the expansion of our primary care workforce following the addition of dietitians to the GP contract this year. Dietitians are best placed to support the priority group patients for programmes such as obesity prevention, cardiovascular, hypertension, diabetes and respiratory disease prevention and long-term condition management. In order to achieve expansion into primary care and other areas, additional funding and innovative ways to attract a workforce that reflects the local community is required. Training healthcare professionals takes time and requires the resources of existing staff, including the expansion of placement capacity and access to preceptorship programmes; therefore, trusts will need to be supported to implement innovative ways to meet the needs of additional placements and preceptorship programmes. To acknowledge the supervisors time and expertise, we would welcome additional financial recompense for student training.
6.3. Expansion is not only needed in terms of overall numbers, but also in the number of more specialist dietitians. Health Education England (HEE) will be funding a further 400 entrants to advanced clinical practice (ACP) training, we welcome the developments of the Centre for Advancing Practice in order to support these members in new and innovative roles. We would like to see funding also available for AHPs to develop essential ACP roles within their current area of practice in the NHS.
7.1. Several elements of the NHS People plan are welcome, but we believe it will need to go further in a number of ways.
7.2. We are pleased to see more funding is being made for CPD and supportive supervision, given that this is highlighted as key concern of members. We feel it is important that this funding is directly accessible to staff. The current figure which is equivalent to £1,000 per person over three years would backfill a band six post for roughly 40 hours over three years (equivalent to around one day per month), without considering any additional training costs occurred. In order to support staff to develop their research skills and the evidence base, additional funding into NIHR fellowship schemes for all AHP’s is required. Staff also need to be encouraged and supported to take these positions. We believe that newly qualified members of staff require a commitment from the NHS to allow for imbedded preceptorship programmes.
7.3. The People Plan acknowledges that employers should ensure people have sufficient rests and breaks. To provide a consistent approach and enable the environment to implement this, we feel it would be helpful to stipulate what the minimum should include and how they will be supported to do this
7.4. Flexibility in primary care and for junior doctors is specifically highlighted with the People Plan. We believe this adds inequality within the NHS and want to see this rolled out to all newly qualified healthcare professionals. As set out in the plan, we believe all staff should have access to flexible working shift patterns as well as flexibility in workplace location. The current plan does not clearly identify what is meant by flexible work patterns. In order to ensure this is not open to interpretation locally, any work on improving flexibility must be done through the mechanism of the staff council.
7.5. As set out in the plan, we believe that staff wellbeing services that were established as a result of COVID-19 – including psychological support, Schwartz Rounds, workplace wobble rooms and free car parking for staff should extend beyond the pandemic. The response has highlighted staff physical and mental health concerns, but we know that staff experienced similar issues prior to COVID-19.
 A more recent dietetic workforce survey, scheduled for early 2020, was delayed due to COVID-19, and is currently being undertaken. We would be happy to share the findings of this survey once it is complete with the committee.