Definitions

Definitions

Please note: for consistency, throughout this document, we will use the term “patient” to refer to patient, service user or client. We recognise that service user is often the preferred term, however the NHS AHP Job Planning best planning guide (2019) ¹ only uses the term “patients” and therefore we will also, to reduce any confusion. This document also uses the term FTE (full time equivalent) rather than WTE (whole time equivalent).

Workload and caseload need to be defined before addressing the issue of safe workload. The elements of an individual’s workload are defined on the next page as dietetic activities. It is not correct to describe the work of a dietitian only in terms of clinical work. Depending on the pay band and job role of a dietitian, non-clinical work elements can often be equal to or even greater than the clinical caseload.

Caseload

A caseload is the number of patients for which 1.0 FTE dietitian is carrying responsibility at any one point in time. This will include all cases which have been assessed and are under treatment/review and have not been discharged and for which the dietitian has a duty of care. In some situations, there will also be a potential caseload which includes the population of patients for whom the dietitian carries some degree of reviewing responsibility in terms of identification of problems and providing input if required (for example, patients in a Care Home setting) but who are not being treated at the current time. Caseload can be expressed as a number of patients or care episodes, or hours of dietetic time to manage the patient population.

Workload

A professional workload is that work which can be carried out by 1.0 FTE dietitian. In total it comprises a variety of dietetic activities which together constitute the professional dietetic role. In most cases it will include work inherent in a defined clinical situation or caseload.

Dietetic activities and job plans

These have been re-categorised to match the Job Planning Activity Classification for AHPs (2019) ¹

• ‘Direct Clinical Care’ (DCC) which is divided into two main areas
• individual patients’ attributable (IPA) DCC (all the time spent with individuals and all the associated activities required for that patient (including typing up notes, writing GP letters etc.) Individual patient contacts may be face to face or remotely via telephone or video consultation
• non-individual patient attributable (non-IPA) DCC such as MDT meetings, communication with other health care professionals, developing resource materials for patients 
• Supporting Professional Activities (SPA) such as clinical service management, staff training, student training, CPD, practice supervision, clinical governance activities, department meetings and appraisals
• additional responsibilities (ANR) which are usually Trust wide appointed roles
• external Duties (ED) are externally funded e.g. education, teaching, research
• travel; for example, between sites or home visits is included as a separate section within each of the areas given above

see appendix 1.1 for activity and plan flow chart

Patient contacts

Defined simply as a direct patient contact is a contact between a healthcare professional and a patient including proxy contact which is between a healthcare professional and another person on behalf of a patient e.g., parent, carer.

In practice, a patient contact may be defined as the package of dietetic care for that individual per session or appointment which would include all relevant aspects of time associated for that individual per session - either in a one to one or in a group setting. The setting may be face to face or via remote delivery. The length of time expected for a patient contact needs to be sufficient to allow for data collection, dietetic assessment and intervention, liaison with relevant health care professionals and subsequent writing up in notes including electronic documentation. A contact may be categorised as an initial /new contact (the first contact between the patient and the dietetic service) or a review /follow-up contact (all subsequent contacts for that same referral or episode of care).

Workload safety

Assessing when practice moves from safe to unsafe is a complex and subjective process with multiple factors to consider. Under the HCPC Standards of Proficiency, dietitians are required by law to manage their own workload and resources and practice safely and effectively. They have a duty as HCPC registrants under the Standards of Conduct Performance and Ethics ¹⁷ to manage risk and report concerns about safety.

The following are key components of such an assessment and are explained in more detail in the BDA document ‘Workload Management’ (2017) ¹⁸ which will be updated in 2024/25.

1. benchmarking
2. practice supervision
3. good practice
4. job description/contract of employment
5. risk assessment
6. complexity

New to the assessment of workload safety is patient complexity. A patient complexity tool has been developed and has been used in the 2023 Safe Staffing, Safe Workload survey for the first time.

Reference to workload safety in the remainder of this document is based on the perceptions of individual clinicians rather than verified entities that have been assessed based on the components above. Nonetheless, there is a significant value in clinician concerns that can be indicative of system failure with potential impact on patient safety.

Whilst this document reports on workload activities and perceptions of safety, the sister document ‘Workload Management’ ¹⁸ provides direction on how to address the problem of a workload that has been assessed as unsafe and provides guidance on protecting the staff member from having to manage an unsafe caseload. To this end the workload management guidance provides advice from a professional, ethical and employment relations standpoint.

A further BDA endorsed document providing guidance on estimating patient complexity which should help with placing dietetic staff with the correct skill set and clinical time allocation to undertake their caseload safely, is expected to be published in 2024 following validation throughout the UK in a variety of different clinical settings.       

Patient Complexity

There are several definitions of patient complexity; though a “complex patient” is commonly defined as patients with complex care needs requiring more time and effort than the average patient. Patient complexity is important in delivering safe caseload management. Complexity is based on patient’s' needs and intervention types, rather than how difficult the dietitian personally found the task. For example, differing bands of dietitians and assistants working in specialist areas are likely to feel more competent to assess more complex patients in that specific area compared with other colleagues.