Chapter 5: Advancing roles & Comparison

Advancing Roles in Dietetics

These include Advanced Clinical Practitioners (ACP), First Contact Practitioners (FCP) and Consultant Dietitians

ACPs

Findings from the survey relating to advanced care practitioners are as follows:

• 92% stated their workloads were excessive
• 4% were supplementary prescribers
• 10% of the time was spent on clinical service management tasks (including appraisals)
• 56% of the time was spent on DCC
• workplace settings included Primary Care, Mental Health, Community settings and the largest number (63%) employed in Acute settings.
• bandings: these ranged from 8c to Band 6. The majority were Band 8a (35%) and band 7 (37%)

Advanced Practitioner roles support dietitians in developing their clinical career pathways undertaking roles central to meeting the changing demands by on the NHS. These roles enable practitioners to expand their contribution to healthcare and gain personal job satisfaction. This level of practice supports the retention of experienced clinical staff.  

ACPs are experienced practitioners working with a high degree of autonomy and complex decision-making skills, which can include prescribing.

Benefits of Dietetic Advanced Practice roles include developing services where the RD is the first point of contact, leading to fewer appointments, quicker referral times, better patient outcomes and reducing the workload on medical colleagues.

ACPs must work across the Four Pillars of Advanced Practice (practice, evidence-based practice research, facilitated learning and leadership). These professionals work at Masters level or equivalent achieving PG certificates, Diplomas or full Masters degrees i.e., Level 7 in all four Pillars. There is an expected time frame of 18 – 24 months to achieve all these competencies. There are different entry points of entry for this level of practice; entry level with Preceptorship, Enhanced level (Dietitian with an in-depth knowledge), Advanced level (authoritative knowledge, operating at Masters Level) and Consultant (national and/or international leader in their field). Most work at Band 8a and above.  trainee ACP/APs may be practising at Band 7 level until all competencies are met. For some ACP/APs this role may be an opportunity to further develop their clinical career to consultant level.

Some RDs have the term ‘Advanced’ in their job titles but may not be working at this level for various reasons. For these cases the job title may need rewording or further training completed to meet the requirements of ACP.

Each of the four nations in the UK has its own National Framework for Advanced Practice which can be accessed on line. The BDA produced guidance documents in 2023, ‘Advanced Practice’ and ‘Manager considering Advanced Practice posts’ which are available on the BDA website.

Of the 23 ACPs who responded to this question in the survey, 30% had completed the relevant training to achieve the required levels of competency in all Four Pillars, and 70% had not.

FCPs

Findings from the survey relating to first contact practitioners are as follows:

• 71% stated their workloads were excessive
• 69% of the time was spent on DCC
• workplace settings included freelance appointments, primary care (50%), Community (25%) and acute settings.
• bandings: these were Band 7 with one ‘outlier’ at band 5.

FCPs work as diagnostic clinicians in Primary Care, and practice at Masters level i.e. band 7 and above. Practitioners are required to have at least 5 years post graduate experience including 3 years in a specialist area before training to become a FCP. When starting training for this role they should be level 7 in clinical practice and some experience within the other 3 Pillars. Qualifications are gained either by completing e learning modules and a portfolio or via an HEI FCP level 7 module.

Of the 9 FCP who responded to this question in the survey, 5 (55%) had completed their training and 4 (45%) had not.

Consultant Dietitians

This is a relatively small group of professionals, in the Band 8 range, who are national and international leaders in their field. They possess higher qualifications including doctoral level in their scope of practice. They make complex judgements as well innovate and lead to advance practice.

• Findings from the survey relating to consultant dietitians are as follows:50% stated their workloads were excessive
• 10% of the time was spent on externally funded education and training
• 10% of the time was spent on additional trust wide appointment roles
• 12% of the time was spent on service management tasks (including appraisals)
• 41% of the time was spent on DCC
• workplace settings were primary care, community and acute (50%) settings.
• bandings: these were equally spread between band 7, 8a, 8b and 8c.

Comparisons with previous survey (2015)

Mean percentage DCC in different workplace settings

The percentage of the DCC or patient related activity were very similar for most workplace settings except for the acute sector, where the %DCC increased markedly. 

There were no significant differences between those who said workload was safe (or not excessive) and those who said it was not safe (or excessive) in both the 2015 and 2023 data.

Mean percentage DCC per band

All percentage DCC figures in 2023 were higher than the 2015 data and higher than BDA guidance from 2017.

There was little change for bands 6 and 7, though the increase was greater for both bands 5 and 8a in 2023. For the band 8a respondents, this is likely to be due to the fact that a considerable number who responded were in very specialist clinical roles, rather than managerial ones, compared with the 2015 survey respondents.

The BDA would recommend that the mean percentage DCC for band 5 should be updated to 80%. This would facilitate sufficient time for preceptorship and skill and knowledge development. We would also recommend an initial lower level of DCC for those Dietitians moving into a new specialist area, who would also benefit from preceptorship. We also recommend that the percentage DCC will need to be reviewed for higher bands (e.g. ACP, consultant) as some may have a higher DCC worktime than when this guidance was originally created.

Mean length of time per patient contact

In 2015, the estimated mean time spent per patient contact new and review) was approximately 40 minutes. No further details were available regarding length of time per contact in this baseline survey.

In contrast, when asked how much time was spent for a dietetic consultation in 2023, new patient consultations were around 60 minutes and reviews 45 minutes, and often longer.

Safe number of patient contacts

Comparison between mean annual number of contacts per year and perception of workload safety

There were significantly fewer patients seen in the 2023 survey.

This is likely to be due to the increased length of time spent per patient, reflecting the increasing complexity of patients seen, with less complex patients remaining on “prioritisation or waiting lists” and the increasing requirement for post dietetic intervention paperwork.

Perception of workload safety

In 2015, 43% felt their workload was unsafe. This figure increased to 55% in 2023 with a further 20% being “undecided” if it was safe or unsafe; this choice was not an option in the 2015 survey.

In 2023, 77% felt their current workload was excessive and 23% felt it was not excessive (actual number: 429). It is interesting to note that most those who said that their workload was safe also said it was “not excessive”. However, most of those who stated that their workload was “unsafe” or “undecided” also stated that their workload was excessive. Hence, the term “excessive” is probably a more sensitive marker than the term “unsafe”.

Workload Concerns

In the baseline survey, dietitians were asked to choose up to three workload concerns, though they able to choose more. In the 2023 survey, they were able to choose up to six concerns, but this was the maximum they could choose, see appendix 16.1 for more details

Despite an increase in the number that could be chosen, it is very clear to see that the percentage of respondents with workload concerns has increased markedly, and that there are similar concerns chosen most often; namely lack of opportunity to develop self in work time, and patients not seen in a timely manner.