February 8, 2023 • 46 mins
Wednesday 8th February 2023
Dietetics Digest
The views discussed on the podcast are the views of the guest alone and not of another organisation.
What do First Contact Dietitians do in a PCN? w/ Rebecca Gasche RD
In 2020, dietitians started to join primary care and soon after the Roadmap to Practice was developed and we started to see the impact that dietitians could have in general practice. Rebecca has been one of these pioneering dietitians, breaking new ground. After completing her supplemental prescribing, she embarked on becoming a First Contact Dietitian. She has since become one of the first Health Education England-recognised First Contact Dietitians in the UK.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Aaron Boysen (00:00):
On this episode of the podcast, we have Rebecca
(00:02):
gash, and she talks about herjourney in becoming one of the
first first contact dieticiansin the UK.
Rebecca (00:09):
To me, though, I could see the potential that
dietitians could have in primarycare. And I was aware of what
we'd be working towards firstcontact practitioners. And I
think with my gastroenterologybackground, I could particularly
see how all the patients I wasseeing in the secondary care IBS
(00:29):
clinic, I could do that inprimary care and actually stop
them coming through the door andstop them even seeing the GP
when I become a first contactpractitioner so I could see the
potential there.
Aaron Boysen (00:43):
In 2020, dieticians start to join primary
care. And soon after the roadmapto practice was developed, and
we started seeing the impactthat dietitians could have in
general practice. Rebecca hasbeen one of these pioneering
dieticians breaking new ground.
After completing hersupplementary prescribing, she
embarked on becoming a firstcontact dietitian. She has since
(01:03):
become one of the first HealthEducation England recognized
first contact dietitians withinthe UK. If you're a dietitian,
who would be interested inadvancing their career in the
area of primary care, this is amust listen. So without further
ado, my name is Aaron Boysen.
This is the dietetics digestpodcast. So ensure that you chew
(01:25):
it thoroughly, as there's a lotto digest here. So thank you,
Rebecca, for coming on thispodcast. Today I'm talking about
your role as a first contactdietitian. Now Rebecca has
completed her training. And sheis a fully qualified, a first
contact practitioner and also afirst contact dietitian working
within primary care. And she'sbeen working in primary care for
quite a while and has quite awealth of experience. But maybe
(01:48):
we could go back a little bit intime to when you first started
out in dietetics. And what yourmain interests were and, and
things like that. So why did youactually want to become a
dietitian originally?
Rebecca (01:58):
Yeah. So Well, first of all, thank you very much for
having me on air on. It's agreat great to be here. So going
back and way back. I guess backwhen I was at school, I guess
that's when we first startedwanting you know, when you're
wondering what you want to do atuniversity, it can be really
tough. And I'd already I'dalways had an interest in health
and also food. sounds a bitcheesy, but helping people and I
(02:24):
hadn't actually heard ofdietetics before but it was my
mum that suggested it actually,you know, she was helping me
with my UCAS applications. Andshe thought, you know, health
care, food diet. Why didn't yougo for that? So yeah, I do have
to thank my mum for directing meto the dietetic world and yeah,
it wasn't really until had someday shadowing and then started
(02:46):
university and you start yourfirst placement where you really
kind of get to see what what itis like being a dietitian, and
luckily, I loved it.
Aaron Boysen (02:55):
Yeah. So what was your What was your first role in
practice coming out ofuniversity then what was like
the initial role you had as anewly qualified dietician?
Rebecca (03:03):
Yeah, so my first role like like a lot of newly
qualified dietitians, it was anacute role in a in a district
general hospital. So I was onthe wards a lot. I did a
community clinic, cardiac rehabsessions and things, things like
that. It was actually at thesame hospital where I had my C
placement and it was reallygood. You know, it gained a lot
(03:25):
of experience covering thedifferent wards, you know, the
medical wards, surgical wards,respiratory wards. So, yeah, it
was kind of a good basis for mydietetic knowledge, I would say.
Aaron Boysen (03:37):
And, and I'm always interested in this
question. So you are a bandPfeiffer? How long? How was
that? How long was that period?
Rebecca (03:45):
Yes. So I qualified and got my first job in 2013. And I
was a band five for three years.
So got got my band six job in2016. So that sounds in this day
and age, it sounds like a longtime to be training as a band
five. And I think it just showshow, you know, progression and
the profession itself havechanged so much over the years.
(04:08):
So yeah, two and a half, threeyears as happy band five
Aaron Boysen (04:14):
and what made you want to make that change? What
was the sort of triggeringpoint? Was it just, I need a bit
of extra cash in my bankaccount? Or was it was it? Was
it something obviously that'salways helpful? I'm not gonna
lie. It is always however, butwhat was the what was the point
that made that change happen?
Rebecca (04:31):
Well, I think when you get to that point of you know,
in, in your first role, I doneall the rotations kind of on in
that post, I suppose. And I wasjust really ready to specialize
my knowledge and focus onsomething more more specific. So
interestingly, the band six postI got was actually a it was a
(04:52):
community post and I wasthinking because I had a lot of
work on the wards to begin with.
I was thinking oh, communityI'll give it a go. But I'm not
sure. I'll see see where itgoes. A bit of a process. So
Aaron Boysen (05:06):
inspired by the job advert you didn't see it
out. You were more sitting thereas a band five, wait, itching
for a band six. And you werelike, I'm just gonna take this
opportunity see where it leadsme kind of thing?
Rebecca (05:16):
Yeah, well, partly for that, I guess. I mean,
obviously, the job did interestme it was a bit more of a
project development post, I'dsay and the focus on the service
development was ingastroenterology. And I thought,
you know, that mix of focusingon gastro, but also developing a
service would be a really goodnext step up in my career and
(05:40):
skill set. So it was kind of adifferent angle than what I've
been doing, which I suppose iswhat I was looking for. And so
that job involved me developingan IBS service. So a dietitian
led IBS service in the trustthat I worked for. And the
success of that, you know, we'vegot so many patients through as
(06:01):
you're aware, lots of Petepatients suffer with IBS, or
irritable bowel syndrome, itactually created a full time
post, just focusing ingastroenterology. So that was my
specialist area up until I movedinto primary care in 2021.
Aaron Boysen (06:18):
That sounds like a good sort of pathway, the
dietitian led clinic leading toa more primary care role. How
did you find that job? IBS allday, every day? How did you How
was how was that experience foryou?
Rebecca (06:30):
So I must admit, it wasn't IBS all day, every day.
That was the initial focus ofthe project work but like I
said, developed into a full timegastro post, and then on to
leave for gastroenterology,which took on a lot more kind of
the managerial and overseeingthe service side of things. But
yeah, it was a mix of IBS andother gastroenterology
(06:53):
conditions. Although it wasquite IBS, heavy, as you say,
lots of lots of patients comingthrough the door with that
condition. I mean, I think Ihave a soft spot for the IBS
cohort, I knew that might be alittle bit, a little bit of an
out there statement, because asyou say, it can be a bit heavy.
Seeing so many patients with thesame condition
Aaron Boysen (07:15):
heavy I mean, they're often quite complex,
multifactorial, the diagnosis isa little bit of a, we don't have
a clue what's going on. Sotherefore, it's IBS. And it just
gets thrown at patients. Andit's a massive umbrella
conditions. I do think that hasits challenges. Whereas another
one that's clearly defined,maybe like celiac disease
talking in the area,gastroenterology, you know what
(07:37):
the problem is? There's no, youhave to do? Let's do it. It's a
little bit more, a little bitmore clear in that sense.
Rebecca (07:44):
Yeah, and, and I do agree with you there, actually.
But I think that also bringsback to the point that
dieticians are such a goodprofession to be seeing the
cohort of IBS patients becauseas you say, it is a bit of a
process of diagnosing thatcondition. It's, you know,
ruling out other conditions,sometimes patients can feel a
(08:06):
little bit dismissed by youknow, other healthcare
professionals, and I feel likedieticians have the correct
skill sets, empathy and time toreally work with these patients.
I think the reason I enjoyworking with them so much is the
the job satisfaction. Obviously,we can't cure everyone. But I
(08:28):
felt like that cohort ofpatients had such a good
response with diet and lifestyleon the most part. And you know,
even the really complex one withcrossing over conditions that
you it was good to work with thegastroenterology team. And you
know, I felt overall, I couldreally help them, which was very
satisfying.
Aaron Boysen (08:48):
And obviously, you've moved from that role into
a clinical lead role. And wasthe clinical lead role part of
primary care? Or was thatafterwards?
Rebecca (08:57):
No. So this is still my secondary care role. This
actually CrossTie the, duringCOVID time, so bit of a
structure, team structurechange, and I took on some
additional responsibilities suchas the ICU and surgical pathways
as well. So quite quite achallenging time through COVID.
Obviously, as everyone workingthrough that period would most
(09:21):
likely agree with me. So yeah,that was all clinical leading of
those pathways, but in secondarycare, but that kind of next step
up to the clinical lead level,gave me more more skills to
transfer over to primary care.
Aaron Boysen (09:35):
Definitely, I think, obviously, within primary
care often dietitians areworking a lot more in isolation.
And they've got a sort of leaderservice because dietitians are
new no one knows what they do.
While they know sort oftheoretically what they do, but
they don't really didn't reallyexperience the amazing ness of a
dietitian before so it's againsort of leading that sort of
(09:55):
element of it compared to thegastroenterologist, which are
probably He already bought andpaid for members of the diet
Well, from my experience arealready bought and paid up paid
are members of the dietician fanclub. So that's that's quite
helpful in sort of building aservice getting buy in that kind
of thing. Yeah, definitely.
Whereas in primary care, theymight not necessarily have the
(10:16):
as conditioned for dietitian,should we say?
Rebecca (10:19):
Yes. And I think that's one. That's one of the main
things that I've noticed,actually. And I suppose one of
the challenges, which I'm sureI'll go on to talk about in more
detail, but just trying totrying to implement it and get
the dieticians, names and skillsets and actually an
understanding of what we do andwhat we can do, most
(10:39):
importantly, out there toclinicians and patients in
primary care. I moved intoprimary care in April 2021. But
I was actually working a splitrole. So I worked a few days a
week in primary care. And I wasstill doing my clinical lead
duties the other days of theweek. So yeah, I kind of have my
fingers in both pies, as, as youcould say.
Aaron Boysen (11:02):
And how did you find sort of straddling the two
two days in primary care,
Rebecca (11:06):
it was a lot to it was a lot to do I work full time.
But yeah, juggling both of thosethings. And I think it was
trying to being there for mypathway and my team members,
whilst also being out in primarycare, I think was the biggest
thing to juggle, but that hassince changed. So in moving
(11:28):
forward to September, this year,2020. Or last year, I should
say, 2022, I have started theAdvanced Practice masters. So
instead of doing I've let go ofmy clinical lead duties and
secondary care and absorbed theAdvanced Practice masters. So
now I am studying and working inprimary care. Wow. So
Aaron Boysen (11:51):
just back to the primary care. Why did you want
to go into the primary careroles? There were new roles. No
one had a clue really what theywere do at the time? Probably.
There was just the guidance fromNHS England called the desert
requirements just said you needto be advanced level, what
possessed you to go into thisrole?
Rebecca (12:08):
That's a very good question. And you're right it,
the roles were very vague, Iguess no one really knew what
they what they were going to beor become because the full
guidance wasn't released byHealth Education England at that
point, I was in a bit of afortunate position, because
another one of my dieteticcolleagues was actually already
(12:29):
working in a primary care role.
So I had insight from her on howthe roles worked. And you know,
what's going on, so I wasn'tgoing in completely blind. For
me, though, I could see thepotential that dietitians could
have in primary care. And I wasaware of what we'd be working
towards first contactpractitioners. And I think with
(12:50):
my gastroenterology background,I could particularly see how all
the patients I was seeing in thesecondary care IBS clinic, I
could do that in primary careand actually stop them coming
through the door and stop them.
Even seeing the GP when I becomea first contact practitioner. So
I could see the potential there.
I'd also going from my band fiveacute role into my band, six
(13:13):
more community role. And thenthe clinical leads, again,
through COVID, taking on more ofthe acute stuff, the ICU and
surgical pathways, for me thatthat confirmed in my mind that I
do prefer community work ratherthan Ward work, obviously, it
was all great experience andlearning for me the work I did
(13:34):
three COVID. But for me, itshowed me that actually my
passion is seeing patients inmore of a clinical session
Aaron Boysen (13:42):
and imagined with patients who have IBS, you get a
lot of speaking done, whereas onICU, they get a lot I speak in
so it's a little bit probablyquite quite polar opposites to
be honest.
Rebecca (13:54):
Yeah, exactly. So you know, it's it's good. It's good
to try different thingsthroughout your career. But you
know, it's it's those things andtrying new things that cement
really what you want to do.
Aaron Boysen (14:06):
I think so you said you're excited. You had an
inside scoop. What did you knowthat everyone else didn't know?
What was what was your What wasyour colleague doing? Or what?
What did you know what made youexcited? How did she did she
pitch it to USA? Rebecca, comejoin me? Or how did that work?
Out? What What? What convincedyou to come across?
Rebecca (14:25):
So it wasn't anything in particular that my colleagues
said, but I think as you said,it's it, it was going into those
roles a bit blind at the time,you know, it's a bit clearer
now. But so just knowing someonewho was in the roles and the
types of patients that she wasgetting through the door, she
could kind of prep you give mean idea of what patients were
coming in, and then it wouldhelp me put the pieces of the
(14:48):
puzzle together in my head aboutokay, I could do that in this
way and help in this way. Soyeah, it wasn't anything
groundbreaking, I'm afraid butit just gave me an insight of
actually how the rules work,which is always useful.
Aaron Boysen (15:00):
And then how was your experience going into
primary care? So you'd obviouslydecided, your colleague or
friend told you about thisamazing role that you could do?
And he had said, Okay, I don'treally have much of an idea
about this role, but I sort ofimagined it in my own head
descriptions, probably not veryclear. Let's let's go for it.
And how was that firstexperience within primary care?
Rebecca (15:23):
Yeah, it was, you know, it was good, very different to
secondary care, even working incommunity clinics, but kind of
being under that secondary care.
Umbrella. It was reallyinteresting seeing actually the
difference in the way otherclinicians in the in the PCs,
their clinics run, even how theydo their consultations, what
(15:43):
patients expect from theappointments. So yeah, it was a
huge shift, actually more of ashift than I thought it would be
kind of transferring my previousknowledge over to it.
Aaron Boysen (15:58):
Can you give us any concrete examples of how the
consultations differed? Like,what's a different consultation?
How would it look compared to asecondary care consultation?
Rebecca (16:07):
So I think I think the biggest thing that I noticed in
primary care was the not bookingfollow ups, I think, for diet,
dietitians in their clinics, wesee patients, and we're like,
yes, we've seen you, we advisethis changes to your diet, I'm
gonna follow you up in sixweeks, eight weeks, whatever it
might be. Whereas in primarycare, it's a lot more focusing
(16:30):
on you see the patient, you giveyour advice or treatment there,
and then you safety net. Andthen you say any issues get back
in touch, and it's a lot moreownership on the patient to book
in with you as they would dobooking with the GP booking and
with the ANP. So I think thatwas that was something different
for me to learn. And it feels abit weird after, you know,
(16:52):
keeping a lot of patients on mycaseload for so long in
secondary care, seeing patientsonce and then being like, Okay,
you get back in touch with me,if you need and a lot more of
exploring patients ideas. It'scalled ideas, concerns and
expectations. So ice is thephrase that we use in primary
care. So it's often when youhave an appointment with the GP,
(17:15):
they'll say, you've booked theappointment, you've told the
reception staff what your issueis, and then you speak with the
GP and they say, How can I help?
And sometimes that can be a bitlike, oh, well, you know why I'm
why I've made an appointment.
But actually, that's a way ofexploring what the patient's
wants from the consultation andhow they think, or how they
(17:37):
would expect you to help andwhat concerns that you want them
that they want you to listen to.
So yes, a little things likethat.
Aaron Boysen (17:45):
Okay, so dietitians in primary care,
don't book follow ups.
Rebecca (17:50):
So you can book follow ups. Absolutely. And don't get
me wrong, I do book follow upsfor some of my patients. But I
just think that was a goodexample of the differences in
the primary care and secondarycare clinics. I mean, the idea
of primary care and, you know,working as first contact
dieticians is to have slotsavailable for patients to be
(18:12):
able to book in with you. So, inthe same way that GPS ANPS, and
other health professionalsworking in primary care, they
don't want really long waittimes for their clinics, because
you want patients to be able tobe booked in on the day, or a
few days in advance,
Aaron Boysen (18:30):
at least within that short time period. So it's
more, it's more, yeah, it's morelike primary care, you don't
have a waiting list of a month,because then it always becomes a
bit like a community service.
Rebecca (18:41):
Yeah, exactly. And don't get me wrong. I know, I
know that some of the PCs arethat dieticians are working in
absolutely huge. And sometimesthey don't have enough
dieticians to support the numberof patients that they're seeing.
So yeah, some people do havehave wait times. And yeah, but I
suppose that's the ultimate aimto try and be working more. So
(19:02):
like the other primary careclinician.
Aaron Boysen (19:05):
And I think it's always important to remember
that every, just because aperson does a certain thing in
different way or a differentarea. And I think this is such a
crucial point in primary care.
Every practice, not just everyPC, and every practice will be
slightly different. And it's hisown unique machine. And they'll
do it differently, because for amultitude of reasons, because
(19:25):
they've always done it that way.
Because the partners or thebusiness owners basically do it
want it done that way, orbecause it's the best way for
their community for the whatthey expect what they're
expecting out of theircommunity. Did you find that
difficult as a clinician toadapt to each individual
practice?
Rebecca (19:43):
Yes, yeah, definitely.
And that's a really good pointthat you've raised actually,
that all the GP practices workso differently. So in my PCN, I
cover for GP practices in theChester area, and that and
they're also different and thatcan be due to patient
demographics. And you know, youhave to work, work with what
works in that GP practice, ifthat makes sense. So yeah, that
(20:08):
was another thing that surprisedme. Actually, I thought I'm
working for this PCN. It will bethe same across the board, but
no, very different. And, youknow, some of my clinics have
different different slots forthat patient demographics. So
for example, if I have morepatients, prescribed orlistat to
help with weight loss, theirreviews tend to be quicker. So I
(20:30):
have 15 minute slots for those.
Whereas the other ones that havefull 30 minute slots, more focus
on IBS and in certain areas,more focus on weight loss and
diabetes in other in other GPpractices. So yeah, it's taken a
while to get the feel for eacharea. And definitely integrating
(20:51):
in multiple GP practices in theGP in a PCN is challenging.
Aaron Boysen (20:59):
Yeah, definitely, I think because you've got so
many different environments tofit into that the staff one
question, you said yourappointments, were 30 minutes in
length, is that correct? ForIBS, but all the stats fifth 15
minutes, I've never done an allstat. I'm not quite sure what's
covered in those. But what Iwant to focus on is the IBS one,
because that's the one that'smost interesting to me. Okay, I
see patients with IBS. And myappointments were from
(21:22):
recollection. 45 minutes. Okay.
And I would struggle, I wouldstruggle to fit everything in
the time wasn't long enough? Howdo you do it in 30? minutes,
like in? Like, how do you managethat,
Rebecca (21:32):
but 45 minutes, that is that that is very lucky.
Aaron Boysen (21:37):
Even a staff service, I'll tell you that. I
was I was.
Rebecca (21:41):
So I suppose I've been used to I've always had 30
minute appointments in myclinics in my previous roles.
And actually, and actually, thatwas looked at as a bit of a
luxury you know, some of thecommunity clinics had 30 minutes
for a new and 15 minutes for afollow up. So they've everyone's
thought, oh, Rebecca has gastroclinic, she gets 30 minutes for
(22:01):
every appointment. So I, I'vealways been used to working to
that timeframe. Again, workingin primary care, you do get used
to the templates that you havein your in your head or on the
on the IT system that you'reusing. So you do just get into a
rhythm, I find the work inprimary care easier to gather
(22:22):
all the information actuallythan I did in my secondary care
job, it seems to be easier tofind everything that might just
be me, and the systems that I'veused in the past. But yeah, I'd
Yeah, I don't know if that'sreally answered your question.
But I've just been used to
Aaron Boysen (22:39):
never known the luxury of a 45 minute
consultation.
Rebecca (22:42):
But I do know what you mean, you know, IVs patients,
they can be complex, and youknow, lots of different areas to
cover. So I suppose you do justget used to trying to try and to
focus on what you need to focuson. And although I've said We
try not to put follow ups, butthat is an option to bring them
back to discuss things further.
If you need to,
Aaron Boysen (23:02):
I can imagine 30 minutes is a long time to go
through everything. Yes, that'dbe nice. Especially Yeah. And
then you went on to obviouslyyou worked in primary care for a
little bit. And then you went onto do the first contact
dietitian training and becomewhat's the first contact
practitioner or first contactdietitian. Tell us about that
experience? Because there's forthose who aren't aware, the
(23:23):
first contact roadmap came outfrom Health Education England,
back in 2021. I think based onhis timeline, I think you may
have started it slightly beforethen. So how did that? How did
that work? What were your Whatare your thoughts going into it?
Why did you even consider goingon the course?
Rebecca (23:40):
Yeah, so So, again, I was fortunate that I had
direction from my from the trustthat I worked in, you know, we
knew that the the roadmap wouldbe released by Health Education
England, and that that's thekind of the direction that the
that the roles would be taking.
So yeah, back to my timeline. Istarted the started in primary
care, April 2021. And then Istarted the first contact
(24:05):
practitioner in primary caretaught module, so a master's
module in September 2021. So I'dhad a few months, you know,
getting getting the feel ofprimary care and then started
that in September. The road map,which you explained is from
health education, England, whichdetails how dietitians can go
from working in primary care toa first contact practitioner or
(24:29):
first contact dietitian and thenon to advanced practice, if
that's where you want to takethe roles as well. So that was
released in November. So becauseI was on a taught module for the
first contact practitioner rolesI was on it was a mixed module
with other healthcareprofessionals that go into these
(24:49):
roles. So the physios paramedic,I think that was a yeah, it's
just physios paramedics anddieticians on our modules,
myself and my colleague so theuniverse St had already kind of
mapped that module to meet theother professions, roadmaps. So
the university delivering thismodule. It kind of knew what it
needed to deliver to meet thedietetic roadmap. Obviously,
(25:14):
when the roadmap came out, Ibelieve the university did have
to demonstrate to HealthEducation England that they can
make meet the capabilities inthe module. But yeah, it didn't
affect things as such. Butobviously, it was exciting to
exciting is that the right word,to read the roadmap when it came
out? And you know, match it towhat I was learning on the
(25:38):
course?
Aaron Boysen (25:41):
How was your experience learning all this
stuff? Like, often this thesefirst contact roles? So seeing
patients as they come in througha GP surgery, possibly acting as
a diagnostic clinician? That'snot normally what dietitians? Do
we normally get a referral. Whatwas your thoughts about this?
(26:02):
What were your What was yourexperience doing this?
Rebecca (26:05):
Yeah, and that's a really good description. And I
suppose I've not really goneinto what what a first contact
practitioner or dietitian woulddo so absolutely, that seeing
seeing patients, although itdoesn't always have to be this
way, at the first point ofcontact, but if a patient phones
up the GP practice and says, orI've had been suffering with
(26:28):
loose stools for the last week,instead of seeing being booked
in with a GP, they can be bookedin with the first contact
dietician. And as you say, it'shaving those diagnostic skills.
So being able to order thetests, order the stool samples,
do an Abdo examination, do thegeneral ops and really screening
for red flags and knowing whensomething isn't quite right. So
(26:52):
I find that that side of youknow, clinical work really
exciting because as you say, itis different to what dietitians
would normally do. You know,even in the IVs service I ran in
secondary care, the patientswould have had to have a
diagnosis of IBS before comingto see the dietitian, and I
could really see how dietitianscan could be that at that point
(27:16):
of giving the diagnosis. So Soyeah, I found it exciting. It
is, it is a lot to learn, don'tget me wrong. And there's a lot
a lot of responsibility that youtake on in these first contact
roles.
Aaron Boysen (27:30):
So obviously, we're going to skip ahead now
and you're obviously qualified,you're a fully fledged first
contact dietitian, one of thefirst in the UK, only a handful
of people are have passed theroadmap. Now, how is your job
change? How does it look now?
Rebecca (27:46):
So since I started in primary care, and it's detailed
on the BDA website, and all thehealth education, England's
information, there's tends to befocused on for for patient
groups, you've gotgastrointestinal, so functional
bowel disorder, mostly diabetes,nutrition support, and frailty
and weight management. Sothey've always been the general
(28:10):
types of patients that I've hadin my clinic, I've actually left
my referral criteria very opento my primary care colleagues,
because that's, that's kind ofwhat what they want. They didn't
want to be filling out forms oranything like that. I just said,
you know, any, anything that Iactually book in with me, I'll
let you know if it's notappropriate. But even with
leaving that quite open, I havereally been focusing on seeing
(28:33):
those four types of patientgroups in my clinics. So when I
completed the first contactpractitioner module, I think
that there was a bit of oh, howare things going to change it?
Will it change right away? WillI be seeing all different types
of patients? The short answer ofthat is no, nothing, nothing
(28:53):
changed right away. It took alittle while before I could
could register as a firstcontact practitioner, as well.
So that's something to bear inmind. But since then, since
being fully qualified, it'sreally been a lot of focus on
trying to get the patientsthrough through the door
immediately from reception. Andso seeing seeing patients in
(29:15):
that first point of contact,like I keep saying, and that's
actually proved a little bitchallenging. So ideally, like I
said, have patients phone upwith Abdu discomfort, I have
some slots held back in myclinics to be opened on the day
for any patients phoning up, notjust with Abdu l gastro queries
with anything dietary wise. Sothe abdomen is the kind of the,
(29:36):
the best example really. Soit's, it's been able to accept
those patients in my clinic fromthe day it's also just been able
to accept patients who don'thave a don't have some diagnosis
or haven't haven't necessarilyseen a clinician. Previously, I
can see them first of all,whereas previously they would
(29:58):
have had to seen the G To thenurse, and then they would book
into my clinic. So it's givingthe reception team the ability
to book them straight in,
Aaron Boysen (30:07):
and how, say for example, it all, obviously
logistics are always achallenge, I think within any
healthcare system. And I alwayssay it's easy to write a policy.
It's always, like 10 times ashard to implement the policy.
Yeah. How would it work in likea perfect world? If everything
worked? Well? How would thepatient what would the patient
journey be? So patient calls upthe GP practice and says, I've
(30:30):
had loose stools for the lastthree weeks? I need to see I
need to have an appointment.
Rebecca (30:35):
Yeah, yeah. So I do actually have a real life
example of how this has worked,thankfully, so patient founder
had loose stools for a couple ofweeks reception booked them in
with myself. So the initialconsultation, we didn't really
focus on diet, which perhaps thepatient was expecting, because
(30:57):
you hear the word, even if it'sfirst contact dietitian,
patients then immediately thinkall you're going to talk about
is diet. But I suppose that'sone of the barriers that I've
been wanting to break down inthese, you know, we're not
really obviously dietitians, butwe can do such extended roles.
And that's the exciting part.
But anyway, patient came to seeme in clinic I took a history
from them loose stools for thepast few weeks, nothing really
(31:19):
changed. Nothing changed in hisdiet, not being away anywhere
traveling or not had anysickness, bugs, anything like
that. Check the biochemistryprevious tests that they'd had
done, family history there. Theyhave a family member who had
celiac disease, actually, buthad never been tested
(31:39):
themselves, medication history,any allergies, social history,
so you know, a thorough,thorough consultation just to
gather all the information. Itis an abdominal exam, but didn't
find anything. You know, theyweren't in severe pain. You find
any lumps or bumps just clarifyfor
Aaron Boysen (31:56):
people what you're looking for in that abdominal
exam? Sure, sure. There was IBSor celiac disease, that abdomen
is going to look?
Rebecca (32:03):
Yeah, exactly. So the women abdomen exam, it's, you
know, we're not going to knowthe oil. We're not supposed to
know the absolute ins and outsof you know, an Abdo exam as a
gastroenterologist would do. Youknow, I'm not necessarily doing
the thing, the thing good tapsor you know, anything specific
(32:24):
on the abdomen, I'm reallyfeeling the four quadrants for
any severe pain, technicalguarding of the patient is quite
rigid, you know, that kind ofsuggests that there might be
something more serious orsinister than IBS going on. So
you're looking for a softabdomen. You listen to bowel
(32:46):
sounds as well, you want thereto be some some gurgling with
the stethoscope. So yeah, it'snot it's not looking for
anything specific. But it'swatching the patient's reaction.
A lot of the time, you're pokingand prodding, and the patient's
wincing a lot. Like you say, youdon't get that presentation in
IBS, celiac disease.
Aaron Boysen (33:06):
Okay. And, yeah, okay, so you're looking for the
pain. And that obviously,suggests something a bit more
sinister. When you look atthings like abdominal masses and
things like that as well.
Rebecca (33:18):
Yeah, so that's one of the things that you'd feel for,
but, you know, it would have tobe quite a big mass to be able
to palpate really, but yeah,then the rest of that patient.
So you ordered bloods stoolsample for them, and explained,
you know, the process, that weneeded to rule out other things
that could be causing thesesymptoms. That said, I'd call
(33:41):
the patient back, once I had allthe results. So actually, I did
book a follow up for thispatient, and saw them again,
everything was within normalrange, which meant that the
symptoms were suggestive ofirritable bowel syndrome, I was
a bit surprised that the celiactest didn't come back positive
because there was a familyhistory. But no, that was all
fine. And then so it was at thesecond appointment, once we'd
(34:05):
gone once we'd ruled outeverything, anything more
sinister, that's when I couldgive my first diagnosis.
Basically, as a first contactdietitian, say, This is what the
condition is, this is how it'streated or can be treated. So we
went through dietary advice, andthen you know, it, there was the
option to use pharmacologicalpoints as well. But actually,
(34:28):
the patient didn't need need togo down that route. So we just
helped her support his symptomsthrough diet. So that is a, I
think, a good example of seeinga patient patient from the first
point of call and being able todiagnose, treat and manage their
symptoms all within the oneperson so we made some changes
to their diet and yes, symptomsdid improve. So happy patients
Aaron Boysen (34:52):
are the next stage be afterwards if they say the
symptoms didn't improve, and youmaybe had to try something else,
they still wanted to follow adietary approach. proach that
read online about this thingcalled the low FODMAP? Diet?
Would you refer them on tocommunity services? Or would you
tackle that yourself in primarycare?
Rebecca (35:09):
Yeah, so this comes down to a lot about your your
own skill set, I think because Ibecause I know the low FODMAP
diet, so I could go through thatwith them. As I said, I'm a
prescriber, so I could prescribethe medications with them. But
depending on your on your skillset, and also what the other
local community dieticianservices are, like, you can
(35:32):
refer on for that. So. So Iknow, dietitians working in
primary care who aren't trainedin the low FODMAP diet. So if
they were in that position, theywould just refer on to the local
community, dietitian service, orif there's an IBS service. So
yeah, it does depend on your onyour backgrounds. I think that's
just another example of as theseroles, progress, you know,
(35:54):
hopefully all dieticians inprimary care will be able to
deliver that, you know, thatthat service, that dietary
advice, so that it's all held inone one place rather than
referring on because I thinkthat's, that's the ideal
scenario, that the patient justsees the right clinician at the
right time, and is just keptkept under that clinician until
(36:16):
they're better.
Aaron Boysen (36:17):
Definitely, I think, I think that's obviously
a really good example of how itcan work. And then its
implementation and working withthe practices and building that
relationship. And I thinkthat's, that's often crucial.
Even though you've got thequalification, you've ticked all
the boxes, often people don'tcare about how much you know,
until they you build arelationship with them, and
you're able to sort of establishthat protocol and are able to
(36:38):
see it happen. You can share asuccess story, something like
that saved quite a bit of GPtime, and the patient journey
might have also been a littlebit smoother as well.
Rebecca (36:47):
Yeah, I hope so.
Anyway, so yeah, in the samebreath, there have been barriers
to rolling out the firstcontacts work, you know, that
was a really good example of howit can work and how dieticians
can diagnose and manage apatient with a condition. But I
think there's going to be a lotof work needed in changing
perceptions on what a dietitiancan do. And this isn't just for
(37:09):
what our peers in primary careour colleagues view of what
dietitians can do, but also whatpatients think dietitians can
do. Because, you know, sometimesthose first contact slots aren't
being filled. And they speak tothe reception staff. And I say,
you know, I've noticed that thepatients with abdominal
(37:30):
discomfort being booked in witha GP, why have they not been
booked in with me? And it'sbecause they don't want to see a
dietitian, you know, at the endof the day patients, if they're
in discomfort, or they'reworried about something, if you
say, I'll put you in with a evenif you say first contact
dietician, they hear the worddietician and think, well, a
dietician, I don't need to speakabout diet, I need to have
(37:51):
tests, I need to be referred tothe hospital, I need a
colonoscopy, you know, that'sthe patient's ideas, and they
don't necessarily understandthat actually a dietitian can
action these things, then thenyeah, it's just educating,
educating them and educating thereception staff to be able to
explain that not that they havetime to go into detail, but I
(38:12):
think that's just an example ofwhy things will take a little
bit of time.
Aaron Boysen (38:19):
Yeah, definitely.
Yeah, I think that's often oftena struggle, struggle, just sort
of changing perceptions andthings like that. But I think as
hopefully as time goes on, as Ithink we get our team members
bought in and we see the successstories, they start sort of
understanding the importance ofthem. Yeah. And I think even
well established roles, like thephysiotherapist. I see a lot of
(38:40):
these online doing videos aboutwhy the receptionist asked you
about what you need, and they'reexplaining the physio service,
which actually has beenestablished for many, multiple
years. So again, it's justagain, it's not just about
educating the workforce. It'salso about educating the public
as well. Yeah. But actually, adietitian is very suited to be
(39:00):
able to do this, because I thinkwe default Lee like when I did
when I did the IBS clinics with45 minute appointments. I had we
actually screened for red flagsevery single time. And there was
many multiple times where we hadto refer back to the GP for
multiple tests, because therehad not been done. Exactly. I
think maybe the overcautiousness and perfection,
fractious nature of dietitiansmight serve as well in that in
(39:24):
that regard, I
Rebecca (39:26):
think yes, yeah, yeah.
And yeah, I definitely agree. Iagree with that.
Aaron Boysen (39:31):
So I think obviously, these roles are new
and they're quite exciting fordieticians. But we also know at
the same time there is what canbe described as like a workforce
crisis among healthcareprofessionals. Overall,
dietitians are a lot ofdepartments struggle to recruit
would you say these roles andthese roles are often band seven
roles that are paid at sort ofthe band seven level, or these
(39:54):
roles stealing all the moreexperienced dieticians away from
the NHS Trusts and causing moreproblems later on.
Rebecca (40:00):
So I wouldn't say well, I don't know, I wouldn't say
that they're stealing theexperience dieticians because
they are very different roles,you know, they're not going to
be suited for everyone, as yousay that they band seven roles,
the FC FC D roles. Whereas somepeople want to stay up sorry,
(40:22):
there been seven roles and thatthey're more kind of moving into
expert generalist roles. Soknowing a bit about each of
those conditions, whereas a lotof people with a lot of clinical
experience in a specific area,want to stay in that area, you
know, highly specialized, whichis, which is obviously great.
And I think the overall idea ofthese roles is not to not to
(40:46):
replicate what's already beingdone with dietetic services. So
we don't want to be just settingup another community, dietitian
clinic, in a GP practice, whatwe're doing is extending these
roles and advancing our skillsto be able to diagnose treat,
(41:07):
manage conditions, which, whichI suppose is the difference in
them. Definitely,
Aaron Boysen (41:12):
I think we can all I think one of the biggest
benefits is even if say, whenthat patient with IBS, you
didn't manage them withinprimary care. You refer them on
to community service. And evenif you've got competency in that
area, it might be the communityservice is really good. You want
to preserve your time in primarycare. Yeah, because you're quite
busy. So actually, what you'vebeen able to do, right there is
(41:34):
you've been able to obviouslyfree up time, but also you've
been able to give that patient abit of a head start. Yeah. So
they're ready to ready toprogress on further, further
strategies or things to considergoing forward.
Rebecca (41:45):
Yeah, exactly. And I think that's a good point to
raise as well, that as well asnot replicating what's already
being done by fantasticdietician services out there,
it's really important to workwith the other dietetic
services. So I still have veryclose links with the different
services that we have runningavailable, you know, the
(42:05):
diabetes education services, IVsservices, home visits, and you
know, that and the whole metaltubing, tube feeding service as
well. So actually having havinga know of what's going on with
the other things available topatients is really important
again, so you're not replicatingthings, and so that you can have
joint working as well, you know,I don't do home visits in my PCM
(42:30):
role that may be different forother people, but but for me,
it's I don't I would refer tothe community dieticians team
who have the home visit service.
So yeah, I suppose that's justanother example of how Joint
Working is important.
Aaron Boysen (42:45):
Definitely working together as a wider system.
Yeah, they don't say, oh,Rebecca saw in that patient.
She's a dietician, she canhandle it, she'll, she'll do a
great job. And I imagine youwould do a great job. Again,
it's thinking about how thesystems and how we can support
the patients the best we can, aninsurer all working together. So
we're not just trying tosometimes there is a temptation
(43:05):
of particularly with the highworkloads that people have to
sort of move between sort ofpush off certain things or, or
even sometimes feel like thedietician within primary care is
coming in and stealing your roleas taking patients off you.
Yeah. And again, I think talkingto the dietician and talk about
how you can work together, is itcrucial as well. And that goes
(43:26):
that goes both ways. For thedietitians in primary care, I'd
say, but also for the communityservice as well to have that
joint relationship and worktogether more collaboratively.
How can we work together andimprove patient journeys across
multiple different clinicians?
So what's next for you, Rebecca?
what's your what's your nextsteps? You're a fully trained
first contact dietitian, whatare you going to do next? What's
(43:48):
the next challenge for yourself?
So I was gonna make a littlejoke. If supplementary
prescribing wasn't enough, anddoing that to first contact
modules wasn't enough. Are youtaking a rest now then?
Rebecca (43:58):
Unfortunately, not. So in in September last year, I
started on the Advanced Practicemasters. So I kind of I knew
that's where I want to take mycareer. I love working in
primary care and working withthese types of patients. So
being able to advance my skillseven further. I feel lucky, very
(44:20):
lucky to have been been able toget a place on the Advanced
Practice masters. So yeah, I'mstill studying. But yeah, just
alongside my primary care work,
Aaron Boysen (44:29):
and how will your role change within primary care
once you become an ACP?
Rebecca (44:35):
Yeah, so I don't know the full answer to that I can I
can envision so you know, thethings I'm learning on the
Advanced Practice Masters is thesame, the same things that they
teach ANPS or, you know,Advanced Practice physio. So
again, the people on my cohort,our nurses, physios, paramedics,
pharmacists, all going intothese advanced practice work
(44:58):
roles, which I think is reallyexciting. In the fact that AHPS
can all share the same kind ofthe skills and knowledge to
create similar roles. So thebest way I describe it is I'm
learning the same skills as ana&p in the GP practice. So
technically, I would be able tosee any patient at that and na
(45:19):
NP would have so even peoplephoning up with a sore throat.
They can be booked into myclinic, and I'd be able to
diagnose tonsillitis andprescribe antibiotics, for
example. And so yeah, that's howthe role could look. Obviously,
things are changing so much withthe dietician, profession. So in
the two years that it will takeme to complete the Masters, who
(45:40):
knows where we'll be at?
Aaron Boysen (45:43):
Obviously, it's an evolving field. And I think,
yeah, you can definitely seethroughout your career, you seem
to be at the forefront of it. Soagain, you're going to be
developing this ACP role withinprimary care, Gandy, there isn't
many of them either. So again,you're developing this role,
you're establishing yourself asan ACP in primary care, and
(46:03):
helping to support the widerhealthcare system and bring that
dietetic knowledge closer to thepatients or at the moving closer
to the frontline of the doorwhere patients come in. Yeah,
definitely. Yeah, I think, whoknows the impact of that just
yet.
Rebecca (46:19):
Yeah. Yeah. And I suppose that's why I could have
been a bit vague with my answerthere because because we don't
know but I do think it's, it'svery exciting times for, for
dietitians that we are able toadvance our skills and our
learning in this way, and whoknows what the future will look
like for us in primary care.
On this episode of the podcast, we have Rebecca
(00:02):
gash, and she talks about herjourney in becoming one of the
first first contact dieticiansin the UK.
Rebecca (00:09):
To me, though, I could see the potential that
dietitians could have in primarycare. And I was aware of what
we'd be working towards firstcontact practitioners. And I
think with my gastroenterologybackground, I could particularly
see how all the patients I wasseeing in the secondary care IBS
(00:29):
clinic, I could do that inprimary care and actually stop
them coming through the door andstop them even seeing the GP
when I become a first contactpractitioner so I could see the
potential there.
Aaron Boysen (00:43):
In 2020, dieticians start to join primary
care. And soon after the roadmapto practice was developed, and
we started seeing the impactthat dietitians could have in
general practice. Rebecca hasbeen one of these pioneering
dieticians breaking new ground.
After completing hersupplementary prescribing, she
embarked on becoming a firstcontact dietitian. She has since
(01:03):
become one of the first HealthEducation England recognized
first contact dietitians withinthe UK. If you're a dietitian,
who would be interested inadvancing their career in the
area of primary care, this is amust listen. So without further
ado, my name is Aaron Boysen.
This is the dietetics digestpodcast. So ensure that you chew
(01:25):
it thoroughly, as there's a lotto digest here. So thank you,
Rebecca, for coming on thispodcast. Today I'm talking about
your role as a first contactdietitian. Now Rebecca has
completed her training. And sheis a fully qualified, a first
contact practitioner and also afirst contact dietitian working
within primary care. And she'sbeen working in primary care for
quite a while and has quite awealth of experience. But maybe
(01:48):
we could go back a little bit intime to when you first started
out in dietetics. And what yourmain interests were and, and
things like that. So why did youactually want to become a
dietitian originally?
Rebecca (01:58):
Yeah. So Well, first of all, thank you very much for
having me on air on. It's agreat great to be here. So going
back and way back. I guess backwhen I was at school, I guess
that's when we first startedwanting you know, when you're
wondering what you want to do atuniversity, it can be really
tough. And I'd already I'dalways had an interest in health
and also food. sounds a bitcheesy, but helping people and I
(02:24):
hadn't actually heard ofdietetics before but it was my
mum that suggested it actually,you know, she was helping me
with my UCAS applications. Andshe thought, you know, health
care, food diet. Why didn't yougo for that? So yeah, I do have
to thank my mum for directing meto the dietetic world and yeah,
it wasn't really until had someday shadowing and then started
(02:46):
university and you start yourfirst placement where you really
kind of get to see what what itis like being a dietitian, and
luckily, I loved it.
Aaron Boysen (02:55):
Yeah. So what was your What was your first role in
practice coming out ofuniversity then what was like
the initial role you had as anewly qualified dietician?
Rebecca (03:03):
Yeah, so my first role like like a lot of newly
qualified dietitians, it was anacute role in a in a district
general hospital. So I was onthe wards a lot. I did a
community clinic, cardiac rehabsessions and things, things like
that. It was actually at thesame hospital where I had my C
placement and it was reallygood. You know, it gained a lot
(03:25):
of experience covering thedifferent wards, you know, the
medical wards, surgical wards,respiratory wards. So, yeah, it
was kind of a good basis for mydietetic knowledge, I would say.
Aaron Boysen (03:37):
And, and I'm always interested in this
question. So you are a bandPfeiffer? How long? How was
that? How long was that period?
Rebecca (03:45):
Yes. So I qualified and got my first job in 2013. And I
was a band five for three years.
So got got my band six job in2016. So that sounds in this day
and age, it sounds like a longtime to be training as a band
five. And I think it just showshow, you know, progression and
the profession itself havechanged so much over the years.
(04:08):
So yeah, two and a half, threeyears as happy band five
Aaron Boysen (04:14):
and what made you want to make that change? What
was the sort of triggeringpoint? Was it just, I need a bit
of extra cash in my bankaccount? Or was it was it? Was
it something obviously that'salways helpful? I'm not gonna
lie. It is always however, butwhat was the what was the point
that made that change happen?
Rebecca (04:31):
Well, I think when you get to that point of you know,
in, in your first role, I doneall the rotations kind of on in
that post, I suppose. And I wasjust really ready to specialize
my knowledge and focus onsomething more more specific. So
interestingly, the band six postI got was actually a it was a
(04:52):
community post and I wasthinking because I had a lot of
work on the wards to begin with.
I was thinking oh, communityI'll give it a go. But I'm not
sure. I'll see see where itgoes. A bit of a process. So
Aaron Boysen (05:06):
inspired by the job advert you didn't see it
out. You were more sitting thereas a band five, wait, itching
for a band six. And you werelike, I'm just gonna take this
opportunity see where it leadsme kind of thing?
Rebecca (05:16):
Yeah, well, partly for that, I guess. I mean,
obviously, the job did interestme it was a bit more of a
project development post, I'dsay and the focus on the service
development was ingastroenterology. And I thought,
you know, that mix of focusingon gastro, but also developing a
service would be a really goodnext step up in my career and
(05:40):
skill set. So it was kind of adifferent angle than what I've
been doing, which I suppose iswhat I was looking for. And so
that job involved me developingan IBS service. So a dietitian
led IBS service in the trustthat I worked for. And the
success of that, you know, we'vegot so many patients through as
(06:01):
you're aware, lots of Petepatients suffer with IBS, or
irritable bowel syndrome, itactually created a full time
post, just focusing ingastroenterology. So that was my
specialist area up until I movedinto primary care in 2021.
Aaron Boysen (06:18):
That sounds like a good sort of pathway, the
dietitian led clinic leading toa more primary care role. How
did you find that job? IBS allday, every day? How did you How
was how was that experience foryou?
Rebecca (06:30):
So I must admit, it wasn't IBS all day, every day.
That was the initial focus ofthe project work but like I
said, developed into a full timegastro post, and then on to
leave for gastroenterology,which took on a lot more kind of
the managerial and overseeingthe service side of things. But
yeah, it was a mix of IBS andother gastroenterology
(06:53):
conditions. Although it wasquite IBS, heavy, as you say,
lots of lots of patients comingthrough the door with that
condition. I mean, I think Ihave a soft spot for the IBS
cohort, I knew that might be alittle bit, a little bit of an
out there statement, because asyou say, it can be a bit heavy.
Seeing so many patients with thesame condition
Aaron Boysen (07:15):
heavy I mean, they're often quite complex,
multifactorial, the diagnosis isa little bit of a, we don't have
a clue what's going on. Sotherefore, it's IBS. And it just
gets thrown at patients. Andit's a massive umbrella
conditions. I do think that hasits challenges. Whereas another
one that's clearly defined,maybe like celiac disease
talking in the area,gastroenterology, you know what
(07:37):
the problem is? There's no, youhave to do? Let's do it. It's a
little bit more, a little bitmore clear in that sense.
Rebecca (07:44):
Yeah, and, and I do agree with you there, actually.
But I think that also bringsback to the point that
dieticians are such a goodprofession to be seeing the
cohort of IBS patients becauseas you say, it is a bit of a
process of diagnosing thatcondition. It's, you know,
ruling out other conditions,sometimes patients can feel a
(08:06):
little bit dismissed by youknow, other healthcare
professionals, and I feel likedieticians have the correct
skill sets, empathy and time toreally work with these patients.
I think the reason I enjoyworking with them so much is the
the job satisfaction. Obviously,we can't cure everyone. But I
(08:28):
felt like that cohort ofpatients had such a good
response with diet and lifestyleon the most part. And you know,
even the really complex one withcrossing over conditions that
you it was good to work with thegastroenterology team. And you
know, I felt overall, I couldreally help them, which was very
satisfying.
Aaron Boysen (08:48):
And obviously, you've moved from that role into
a clinical lead role. And wasthe clinical lead role part of
primary care? Or was thatafterwards?
Rebecca (08:57):
No. So this is still my secondary care role. This
actually CrossTie the, duringCOVID time, so bit of a
structure, team structurechange, and I took on some
additional responsibilities suchas the ICU and surgical pathways
as well. So quite quite achallenging time through COVID.
Obviously, as everyone workingthrough that period would most
(09:21):
likely agree with me. So yeah,that was all clinical leading of
those pathways, but in secondarycare, but that kind of next step
up to the clinical lead level,gave me more more skills to
transfer over to primary care.
Aaron Boysen (09:35):
Definitely, I think, obviously, within primary
care often dietitians areworking a lot more in isolation.
And they've got a sort of leaderservice because dietitians are
new no one knows what they do.
While they know sort oftheoretically what they do, but
they don't really didn't reallyexperience the amazing ness of a
dietitian before so it's againsort of leading that sort of
(09:55):
element of it compared to thegastroenterologist, which are
probably He already bought andpaid for members of the diet
Well, from my experience arealready bought and paid up paid
are members of the dietician fanclub. So that's that's quite
helpful in sort of building aservice getting buy in that kind
of thing. Yeah, definitely.
Whereas in primary care, theymight not necessarily have the
(10:16):
as conditioned for dietitian,should we say?
Rebecca (10:19):
Yes. And I think that's one. That's one of the main
things that I've noticed,actually. And I suppose one of
the challenges, which I'm sureI'll go on to talk about in more
detail, but just trying totrying to implement it and get
the dieticians, names and skillsets and actually an
understanding of what we do andwhat we can do, most
(10:39):
importantly, out there toclinicians and patients in
primary care. I moved intoprimary care in April 2021. But
I was actually working a splitrole. So I worked a few days a
week in primary care. And I wasstill doing my clinical lead
duties the other days of theweek. So yeah, I kind of have my
fingers in both pies, as, as youcould say.
Aaron Boysen (11:02):
And how did you find sort of straddling the two
two days in primary care,
Rebecca (11:06):
it was a lot to it was a lot to do I work full time.
But yeah, juggling both of thosethings. And I think it was
trying to being there for mypathway and my team members,
whilst also being out in primarycare, I think was the biggest
thing to juggle, but that hassince changed. So in moving
(11:28):
forward to September, this year,2020. Or last year, I should
say, 2022, I have started theAdvanced Practice masters. So
instead of doing I've let go ofmy clinical lead duties and
secondary care and absorbed theAdvanced Practice masters. So
now I am studying and working inprimary care. Wow. So
Aaron Boysen (11:51):
just back to the primary care. Why did you want
to go into the primary careroles? There were new roles. No
one had a clue really what theywere do at the time? Probably.
There was just the guidance fromNHS England called the desert
requirements just said you needto be advanced level, what
possessed you to go into thisrole?
Rebecca (12:08):
That's a very good question. And you're right it,
the roles were very vague, Iguess no one really knew what
they what they were going to beor become because the full
guidance wasn't released byHealth Education England at that
point, I was in a bit of afortunate position, because
another one of my dieteticcolleagues was actually already
(12:29):
working in a primary care role.
So I had insight from her on howthe roles worked. And you know,
what's going on, so I wasn'tgoing in completely blind. For
me, though, I could see thepotential that dietitians could
have in primary care. And I wasaware of what we'd be working
towards first contactpractitioners. And I think with
(12:50):
my gastroenterology background,I could particularly see how all
the patients I was seeing in thesecondary care IBS clinic, I
could do that in primary careand actually stop them coming
through the door and stop them.
Even seeing the GP when I becomea first contact practitioner. So
I could see the potential there.
I'd also going from my band fiveacute role into my band, six
(13:13):
more community role. And thenthe clinical leads, again,
through COVID, taking on more ofthe acute stuff, the ICU and
surgical pathways, for me thatthat confirmed in my mind that I
do prefer community work ratherthan Ward work, obviously, it
was all great experience andlearning for me the work I did
(13:34):
three COVID. But for me, itshowed me that actually my
passion is seeing patients inmore of a clinical session
Aaron Boysen (13:42):
and imagined with patients who have IBS, you get a
lot of speaking done, whereas onICU, they get a lot I speak in
so it's a little bit probablyquite quite polar opposites to
be honest.
Rebecca (13:54):
Yeah, exactly. So you know, it's it's good. It's good
to try different thingsthroughout your career. But you
know, it's it's those things andtrying new things that cement
really what you want to do.
Aaron Boysen (14:06):
I think so you said you're excited. You had an
inside scoop. What did you knowthat everyone else didn't know?
What was what was your What wasyour colleague doing? Or what?
What did you know what made youexcited? How did she did she
pitch it to USA? Rebecca, comejoin me? Or how did that work?
Out? What What? What convincedyou to come across?
Rebecca (14:25):
So it wasn't anything in particular that my colleagues
said, but I think as you said,it's it, it was going into those
roles a bit blind at the time,you know, it's a bit clearer
now. But so just knowing someonewho was in the roles and the
types of patients that she wasgetting through the door, she
could kind of prep you give mean idea of what patients were
coming in, and then it wouldhelp me put the pieces of the
(14:48):
puzzle together in my head aboutokay, I could do that in this
way and help in this way. Soyeah, it wasn't anything
groundbreaking, I'm afraid butit just gave me an insight of
actually how the rules work,which is always useful.
Aaron Boysen (15:00):
And then how was your experience going into
primary care? So you'd obviouslydecided, your colleague or
friend told you about thisamazing role that you could do?
And he had said, Okay, I don'treally have much of an idea
about this role, but I sort ofimagined it in my own head
descriptions, probably not veryclear. Let's let's go for it.
And how was that firstexperience within primary care?
Rebecca (15:23):
Yeah, it was, you know, it was good, very different to
secondary care, even working incommunity clinics, but kind of
being under that secondary care.
Umbrella. It was reallyinteresting seeing actually the
difference in the way otherclinicians in the in the PCs,
their clinics run, even how theydo their consultations, what
(15:43):
patients expect from theappointments. So yeah, it was a
huge shift, actually more of ashift than I thought it would be
kind of transferring my previousknowledge over to it.
Aaron Boysen (15:58):
Can you give us any concrete examples of how the
consultations differed? Like,what's a different consultation?
How would it look compared to asecondary care consultation?
Rebecca (16:07):
So I think I think the biggest thing that I noticed in
primary care was the not bookingfollow ups, I think, for diet,
dietitians in their clinics, wesee patients, and we're like,
yes, we've seen you, we advisethis changes to your diet, I'm
gonna follow you up in sixweeks, eight weeks, whatever it
might be. Whereas in primarycare, it's a lot more focusing
(16:30):
on you see the patient, you giveyour advice or treatment there,
and then you safety net. Andthen you say any issues get back
in touch, and it's a lot moreownership on the patient to book
in with you as they would dobooking with the GP booking and
with the ANP. So I think thatwas that was something different
for me to learn. And it feels abit weird after, you know,
(16:52):
keeping a lot of patients on mycaseload for so long in
secondary care, seeing patientsonce and then being like, Okay,
you get back in touch with me,if you need and a lot more of
exploring patients ideas. It'scalled ideas, concerns and
expectations. So ice is thephrase that we use in primary
care. So it's often when youhave an appointment with the GP,
(17:15):
they'll say, you've booked theappointment, you've told the
reception staff what your issueis, and then you speak with the
GP and they say, How can I help?
And sometimes that can be a bitlike, oh, well, you know why I'm
why I've made an appointment.
But actually, that's a way ofexploring what the patient's
wants from the consultation andhow they think, or how they
(17:37):
would expect you to help andwhat concerns that you want them
that they want you to listen to.
So yes, a little things likethat.
Aaron Boysen (17:45):
Okay, so dietitians in primary care,
don't book follow ups.
Rebecca (17:50):
So you can book follow ups. Absolutely. And don't get
me wrong, I do book follow upsfor some of my patients. But I
just think that was a goodexample of the differences in
the primary care and secondarycare clinics. I mean, the idea
of primary care and, you know,working as first contact
dieticians is to have slotsavailable for patients to be
(18:12):
able to book in with you. So, inthe same way that GPS ANPS, and
other health professionalsworking in primary care, they
don't want really long waittimes for their clinics, because
you want patients to be able tobe booked in on the day, or a
few days in advance,
Aaron Boysen (18:30):
at least within that short time period. So it's
more, it's more, yeah, it's morelike primary care, you don't
have a waiting list of a month,because then it always becomes a
bit like a community service.
Rebecca (18:41):
Yeah, exactly. And don't get me wrong. I know, I
know that some of the PCs arethat dieticians are working in
absolutely huge. And sometimesthey don't have enough
dieticians to support the numberof patients that they're seeing.
So yeah, some people do havehave wait times. And yeah, but I
suppose that's the ultimate aimto try and be working more. So
(19:02):
like the other primary careclinician.
Aaron Boysen (19:05):
And I think it's always important to remember
that every, just because aperson does a certain thing in
different way or a differentarea. And I think this is such a
crucial point in primary care.
Every practice, not just everyPC, and every practice will be
slightly different. And it's hisown unique machine. And they'll
do it differently, because for amultitude of reasons, because
(19:25):
they've always done it that way.
Because the partners or thebusiness owners basically do it
want it done that way, orbecause it's the best way for
their community for the whatthey expect what they're
expecting out of theircommunity. Did you find that
difficult as a clinician toadapt to each individual
practice?
Rebecca (19:43):
Yes, yeah, definitely.
And that's a really good pointthat you've raised actually,
that all the GP practices workso differently. So in my PCN, I
cover for GP practices in theChester area, and that and
they're also different and thatcan be due to patient
demographics. And you know, youhave to work, work with what
works in that GP practice, ifthat makes sense. So yeah, that
(20:08):
was another thing that surprisedme. Actually, I thought I'm
working for this PCN. It will bethe same across the board, but
no, very different. And, youknow, some of my clinics have
different different slots forthat patient demographics. So
for example, if I have morepatients, prescribed orlistat to
help with weight loss, theirreviews tend to be quicker. So I
(20:30):
have 15 minute slots for those.
Whereas the other ones that havefull 30 minute slots, more focus
on IBS and in certain areas,more focus on weight loss and
diabetes in other in other GPpractices. So yeah, it's taken a
while to get the feel for eacharea. And definitely integrating
(20:51):
in multiple GP practices in theGP in a PCN is challenging.
Aaron Boysen (20:59):
Yeah, definitely, I think because you've got so
many different environments tofit into that the staff one
question, you said yourappointments, were 30 minutes in
length, is that correct? ForIBS, but all the stats fifth 15
minutes, I've never done an allstat. I'm not quite sure what's
covered in those. But what Iwant to focus on is the IBS one,
because that's the one that'smost interesting to me. Okay, I
see patients with IBS. And myappointments were from
(21:22):
recollection. 45 minutes. Okay.
And I would struggle, I wouldstruggle to fit everything in
the time wasn't long enough? Howdo you do it in 30? minutes,
like in? Like, how do you managethat,
Rebecca (21:32):
but 45 minutes, that is that that is very lucky.
Aaron Boysen (21:37):
Even a staff service, I'll tell you that. I
was I was.
Rebecca (21:41):
So I suppose I've been used to I've always had 30
minute appointments in myclinics in my previous roles.
And actually, and actually, thatwas looked at as a bit of a
luxury you know, some of thecommunity clinics had 30 minutes
for a new and 15 minutes for afollow up. So they've everyone's
thought, oh, Rebecca has gastroclinic, she gets 30 minutes for
(22:01):
every appointment. So I, I'vealways been used to working to
that timeframe. Again, workingin primary care, you do get used
to the templates that you havein your in your head or on the
on the IT system that you'reusing. So you do just get into a
rhythm, I find the work inprimary care easier to gather
(22:22):
all the information actuallythan I did in my secondary care
job, it seems to be easier tofind everything that might just
be me, and the systems that I'veused in the past. But yeah, I'd
Yeah, I don't know if that'sreally answered your question.
But I've just been used to
Aaron Boysen (22:39):
never known the luxury of a 45 minute
consultation.
Rebecca (22:42):
But I do know what you mean, you know, IVs patients,
they can be complex, and youknow, lots of different areas to
cover. So I suppose you do justget used to trying to try and to
focus on what you need to focuson. And although I've said We
try not to put follow ups, butthat is an option to bring them
back to discuss things further.
If you need to,
Aaron Boysen (23:02):
I can imagine 30 minutes is a long time to go
through everything. Yes, that'dbe nice. Especially Yeah. And
then you went on to obviouslyyou worked in primary care for a
little bit. And then you went onto do the first contact
dietitian training and becomewhat's the first contact
practitioner or first contactdietitian. Tell us about that
experience? Because there's forthose who aren't aware, the
(23:23):
first contact roadmap came outfrom Health Education England,
back in 2021. I think based onhis timeline, I think you may
have started it slightly beforethen. So how did that? How did
that work? What were your Whatare your thoughts going into it?
Why did you even consider goingon the course?
Rebecca (23:40):
Yeah, so So, again, I was fortunate that I had
direction from my from the trustthat I worked in, you know, we
knew that the the roadmap wouldbe released by Health Education
England, and that that's thekind of the direction that the
that the roles would be taking.
So yeah, back to my timeline. Istarted the started in primary
care, April 2021. And then Istarted the first contact
(24:05):
practitioner in primary caretaught module, so a master's
module in September 2021. So I'dhad a few months, you know,
getting getting the feel ofprimary care and then started
that in September. The road map,which you explained is from
health education, England, whichdetails how dietitians can go
from working in primary care toa first contact practitioner or
(24:29):
first contact dietitian and thenon to advanced practice, if
that's where you want to takethe roles as well. So that was
released in November. So becauseI was on a taught module for the
first contact practitioner rolesI was on it was a mixed module
with other healthcareprofessionals that go into these
(24:49):
roles. So the physios paramedic,I think that was a yeah, it's
just physios paramedics anddieticians on our modules,
myself and my colleague so theuniverse St had already kind of
mapped that module to meet theother professions, roadmaps. So
the university delivering thismodule. It kind of knew what it
needed to deliver to meet thedietetic roadmap. Obviously,
(25:14):
when the roadmap came out, Ibelieve the university did have
to demonstrate to HealthEducation England that they can
make meet the capabilities inthe module. But yeah, it didn't
affect things as such. Butobviously, it was exciting to
exciting is that the right word,to read the roadmap when it came
out? And you know, match it towhat I was learning on the
(25:38):
course?
Aaron Boysen (25:41):
How was your experience learning all this
stuff? Like, often this thesefirst contact roles? So seeing
patients as they come in througha GP surgery, possibly acting as
a diagnostic clinician? That'snot normally what dietitians? Do
we normally get a referral. Whatwas your thoughts about this?
(26:02):
What were your What was yourexperience doing this?
Rebecca (26:05):
Yeah, and that's a really good description. And I
suppose I've not really goneinto what what a first contact
practitioner or dietitian woulddo so absolutely, that seeing
seeing patients, although itdoesn't always have to be this
way, at the first point ofcontact, but if a patient phones
up the GP practice and says, orI've had been suffering with
(26:28):
loose stools for the last week,instead of seeing being booked
in with a GP, they can be bookedin with the first contact
dietician. And as you say, it'shaving those diagnostic skills.
So being able to order thetests, order the stool samples,
do an Abdo examination, do thegeneral ops and really screening
for red flags and knowing whensomething isn't quite right. So
(26:52):
I find that that side of youknow, clinical work really
exciting because as you say, itis different to what dietitians
would normally do. You know,even in the IVs service I ran in
secondary care, the patientswould have had to have a
diagnosis of IBS before comingto see the dietitian, and I
could really see how dietitianscan could be that at that point
(27:16):
of giving the diagnosis. So Soyeah, I found it exciting. It
is, it is a lot to learn, don'tget me wrong. And there's a lot
a lot of responsibility that youtake on in these first contact
roles.
Aaron Boysen (27:30):
So obviously, we're going to skip ahead now
and you're obviously qualified,you're a fully fledged first
contact dietitian, one of thefirst in the UK, only a handful
of people are have passed theroadmap. Now, how is your job
change? How does it look now?
Rebecca (27:46):
So since I started in primary care, and it's detailed
on the BDA website, and all thehealth education, England's
information, there's tends to befocused on for for patient
groups, you've gotgastrointestinal, so functional
bowel disorder, mostly diabetes,nutrition support, and frailty
and weight management. Sothey've always been the general
(28:10):
types of patients that I've hadin my clinic, I've actually left
my referral criteria very opento my primary care colleagues,
because that's, that's kind ofwhat what they want. They didn't
want to be filling out forms oranything like that. I just said,
you know, any, anything that Iactually book in with me, I'll
let you know if it's notappropriate. But even with
leaving that quite open, I havereally been focusing on seeing
(28:33):
those four types of patientgroups in my clinics. So when I
completed the first contactpractitioner module, I think
that there was a bit of oh, howare things going to change it?
Will it change right away? WillI be seeing all different types
of patients? The short answer ofthat is no, nothing, nothing
(28:53):
changed right away. It took alittle while before I could
could register as a firstcontact practitioner, as well.
So that's something to bear inmind. But since then, since
being fully qualified, it'sreally been a lot of focus on
trying to get the patientsthrough through the door
immediately from reception. Andso seeing seeing patients in
(29:15):
that first point of contact,like I keep saying, and that's
actually proved a little bitchallenging. So ideally, like I
said, have patients phone upwith Abdu discomfort, I have
some slots held back in myclinics to be opened on the day
for any patients phoning up, notjust with Abdu l gastro queries
with anything dietary wise. Sothe abdomen is the kind of the,
(29:36):
the best example really. Soit's, it's been able to accept
those patients in my clinic fromthe day it's also just been able
to accept patients who don'thave a don't have some diagnosis
or haven't haven't necessarilyseen a clinician. Previously, I
can see them first of all,whereas previously they would
(29:58):
have had to seen the G To thenurse, and then they would book
into my clinic. So it's givingthe reception team the ability
to book them straight in,
Aaron Boysen (30:07):
and how, say for example, it all, obviously
logistics are always achallenge, I think within any
healthcare system. And I alwayssay it's easy to write a policy.
It's always, like 10 times ashard to implement the policy.
Yeah. How would it work in likea perfect world? If everything
worked? Well? How would thepatient what would the patient
journey be? So patient calls upthe GP practice and says, I've
(30:30):
had loose stools for the lastthree weeks? I need to see I
need to have an appointment.
Rebecca (30:35):
Yeah, yeah. So I do actually have a real life
example of how this has worked,thankfully, so patient founder
had loose stools for a couple ofweeks reception booked them in
with myself. So the initialconsultation, we didn't really
focus on diet, which perhaps thepatient was expecting, because
(30:57):
you hear the word, even if it'sfirst contact dietitian,
patients then immediately thinkall you're going to talk about
is diet. But I suppose that'sone of the barriers that I've
been wanting to break down inthese, you know, we're not
really obviously dietitians, butwe can do such extended roles.
And that's the exciting part.
But anyway, patient came to seeme in clinic I took a history
from them loose stools for thepast few weeks, nothing really
(31:19):
changed. Nothing changed in hisdiet, not being away anywhere
traveling or not had anysickness, bugs, anything like
that. Check the biochemistryprevious tests that they'd had
done, family history there. Theyhave a family member who had
celiac disease, actually, buthad never been tested
(31:39):
themselves, medication history,any allergies, social history,
so you know, a thorough,thorough consultation just to
gather all the information. Itis an abdominal exam, but didn't
find anything. You know, theyweren't in severe pain. You find
any lumps or bumps just clarifyfor
Aaron Boysen (31:56):
people what you're looking for in that abdominal
exam? Sure, sure. There was IBSor celiac disease, that abdomen
is going to look?
Rebecca (32:03):
Yeah, exactly. So the women abdomen exam, it's, you
know, we're not going to knowthe oil. We're not supposed to
know the absolute ins and outsof you know, an Abdo exam as a
gastroenterologist would do. Youknow, I'm not necessarily doing
the thing, the thing good tapsor you know, anything specific
(32:24):
on the abdomen, I'm reallyfeeling the four quadrants for
any severe pain, technicalguarding of the patient is quite
rigid, you know, that kind ofsuggests that there might be
something more serious orsinister than IBS going on. So
you're looking for a softabdomen. You listen to bowel
(32:46):
sounds as well, you want thereto be some some gurgling with
the stethoscope. So yeah, it'snot it's not looking for
anything specific. But it'swatching the patient's reaction.
A lot of the time, you're pokingand prodding, and the patient's
wincing a lot. Like you say, youdon't get that presentation in
IBS, celiac disease.
Aaron Boysen (33:06):
Okay. And, yeah, okay, so you're looking for the
pain. And that obviously,suggests something a bit more
sinister. When you look atthings like abdominal masses and
things like that as well.
Rebecca (33:18):
Yeah, so that's one of the things that you'd feel for,
but, you know, it would have tobe quite a big mass to be able
to palpate really, but yeah,then the rest of that patient.
So you ordered bloods stoolsample for them, and explained,
you know, the process, that weneeded to rule out other things
that could be causing thesesymptoms. That said, I'd call
(33:41):
the patient back, once I had allthe results. So actually, I did
book a follow up for thispatient, and saw them again,
everything was within normalrange, which meant that the
symptoms were suggestive ofirritable bowel syndrome, I was
a bit surprised that the celiactest didn't come back positive
because there was a familyhistory. But no, that was all
fine. And then so it was at thesecond appointment, once we'd
(34:05):
gone once we'd ruled outeverything, anything more
sinister, that's when I couldgive my first diagnosis.
Basically, as a first contactdietitian, say, This is what the
condition is, this is how it'streated or can be treated. So we
went through dietary advice, andthen you know, it, there was the
option to use pharmacologicalpoints as well. But actually,
(34:28):
the patient didn't need need togo down that route. So we just
helped her support his symptomsthrough diet. So that is a, I
think, a good example of seeinga patient patient from the first
point of call and being able todiagnose, treat and manage their
symptoms all within the oneperson so we made some changes
to their diet and yes, symptomsdid improve. So happy patients
Aaron Boysen (34:52):
are the next stage be afterwards if they say the
symptoms didn't improve, and youmaybe had to try something else,
they still wanted to follow adietary approach. proach that
read online about this thingcalled the low FODMAP? Diet?
Would you refer them on tocommunity services? Or would you
tackle that yourself in primarycare?
Rebecca (35:09):
Yeah, so this comes down to a lot about your your
own skill set, I think because Ibecause I know the low FODMAP
diet, so I could go through thatwith them. As I said, I'm a
prescriber, so I could prescribethe medications with them. But
depending on your on your skillset, and also what the other
local community dieticianservices are, like, you can
(35:32):
refer on for that. So. So Iknow, dietitians working in
primary care who aren't trainedin the low FODMAP diet. So if
they were in that position, theywould just refer on to the local
community, dietitian service, orif there's an IBS service. So
yeah, it does depend on your onyour backgrounds. I think that's
just another example of as theseroles, progress, you know,
(35:54):
hopefully all dieticians inprimary care will be able to
deliver that, you know, thatthat service, that dietary
advice, so that it's all held inone one place rather than
referring on because I thinkthat's, that's the ideal
scenario, that the patient justsees the right clinician at the
right time, and is just keptkept under that clinician until
(36:16):
they're better.
Aaron Boysen (36:17):
Definitely, I think, I think that's obviously
a really good example of how itcan work. And then its
implementation and working withthe practices and building that
relationship. And I thinkthat's, that's often crucial.
Even though you've got thequalification, you've ticked all
the boxes, often people don'tcare about how much you know,
until they you build arelationship with them, and
you're able to sort of establishthat protocol and are able to
(36:38):
see it happen. You can share asuccess story, something like
that saved quite a bit of GPtime, and the patient journey
might have also been a littlebit smoother as well.
Rebecca (36:47):
Yeah, I hope so.
Anyway, so yeah, in the samebreath, there have been barriers
to rolling out the firstcontacts work, you know, that
was a really good example of howit can work and how dieticians
can diagnose and manage apatient with a condition. But I
think there's going to be a lotof work needed in changing
perceptions on what a dietitiancan do. And this isn't just for
(37:09):
what our peers in primary careour colleagues view of what
dietitians can do, but also whatpatients think dietitians can
do. Because, you know, sometimesthose first contact slots aren't
being filled. And they speak tothe reception staff. And I say,
you know, I've noticed that thepatients with abdominal
(37:30):
discomfort being booked in witha GP, why have they not been
booked in with me? And it'sbecause they don't want to see a
dietitian, you know, at the endof the day patients, if they're
in discomfort, or they'reworried about something, if you
say, I'll put you in with a evenif you say first contact
dietician, they hear the worddietician and think, well, a
dietician, I don't need to speakabout diet, I need to have
(37:51):
tests, I need to be referred tothe hospital, I need a
colonoscopy, you know, that'sthe patient's ideas, and they
don't necessarily understandthat actually a dietitian can
action these things, then thenyeah, it's just educating,
educating them and educating thereception staff to be able to
explain that not that they havetime to go into detail, but I
(38:12):
think that's just an example ofwhy things will take a little
bit of time.
Aaron Boysen (38:19):
Yeah, definitely.
Yeah, I think that's often oftena struggle, struggle, just sort
of changing perceptions andthings like that. But I think as
hopefully as time goes on, as Ithink we get our team members
bought in and we see the successstories, they start sort of
understanding the importance ofthem. Yeah. And I think even
well established roles, like thephysiotherapist. I see a lot of
(38:40):
these online doing videos aboutwhy the receptionist asked you
about what you need, and they'reexplaining the physio service,
which actually has beenestablished for many, multiple
years. So again, it's justagain, it's not just about
educating the workforce. It'salso about educating the public
as well. Yeah. But actually, adietitian is very suited to be
(39:00):
able to do this, because I thinkwe default Lee like when I did
when I did the IBS clinics with45 minute appointments. I had we
actually screened for red flagsevery single time. And there was
many multiple times where we hadto refer back to the GP for
multiple tests, because therehad not been done. Exactly. I
think maybe the overcautiousness and perfection,
fractious nature of dietitiansmight serve as well in that in
(39:24):
that regard, I
Rebecca (39:26):
think yes, yeah, yeah.
And yeah, I definitely agree. Iagree with that.
Aaron Boysen (39:31):
So I think obviously, these roles are new
and they're quite exciting fordieticians. But we also know at
the same time there is what canbe described as like a workforce
crisis among healthcareprofessionals. Overall,
dietitians are a lot ofdepartments struggle to recruit
would you say these roles andthese roles are often band seven
roles that are paid at sort ofthe band seven level, or these
(39:54):
roles stealing all the moreexperienced dieticians away from
the NHS Trusts and causing moreproblems later on.
Rebecca (40:00):
So I wouldn't say well, I don't know, I wouldn't say
that they're stealing theexperience dieticians because
they are very different roles,you know, they're not going to
be suited for everyone, as yousay that they band seven roles,
the FC FC D roles. Whereas somepeople want to stay up sorry,
(40:22):
there been seven roles and thatthey're more kind of moving into
expert generalist roles. Soknowing a bit about each of
those conditions, whereas a lotof people with a lot of clinical
experience in a specific area,want to stay in that area, you
know, highly specialized, whichis, which is obviously great.
And I think the overall idea ofthese roles is not to not to
(40:46):
replicate what's already beingdone with dietetic services. So
we don't want to be just settingup another community, dietitian
clinic, in a GP practice, whatwe're doing is extending these
roles and advancing our skillsto be able to diagnose treat,
(41:07):
manage conditions, which, whichI suppose is the difference in
them. Definitely,
Aaron Boysen (41:12):
I think we can all I think one of the biggest
benefits is even if say, whenthat patient with IBS, you
didn't manage them withinprimary care. You refer them on
to community service. And evenif you've got competency in that
area, it might be the communityservice is really good. You want
to preserve your time in primarycare. Yeah, because you're quite
busy. So actually, what you'vebeen able to do, right there is
(41:34):
you've been able to obviouslyfree up time, but also you've
been able to give that patient abit of a head start. Yeah. So
they're ready to ready toprogress on further, further
strategies or things to considergoing forward.
Rebecca (41:45):
Yeah, exactly. And I think that's a good point to
raise as well, that as well asnot replicating what's already
being done by fantasticdietician services out there,
it's really important to workwith the other dietetic
services. So I still have veryclose links with the different
services that we have runningavailable, you know, the
(42:05):
diabetes education services, IVsservices, home visits, and you
know, that and the whole metaltubing, tube feeding service as
well. So actually having havinga know of what's going on with
the other things available topatients is really important
again, so you're not replicatingthings, and so that you can have
joint working as well, you know,I don't do home visits in my PCM
(42:30):
role that may be different forother people, but but for me,
it's I don't I would refer tothe community dieticians team
who have the home visit service.
So yeah, I suppose that's justanother example of how Joint
Working is important.
Aaron Boysen (42:45):
Definitely working together as a wider system.
Yeah, they don't say, oh,Rebecca saw in that patient.
She's a dietician, she canhandle it, she'll, she'll do a
great job. And I imagine youwould do a great job. Again,
it's thinking about how thesystems and how we can support
the patients the best we can, aninsurer all working together. So
we're not just trying tosometimes there is a temptation
(43:05):
of particularly with the highworkloads that people have to
sort of move between sort ofpush off certain things or, or
even sometimes feel like thedietician within primary care is
coming in and stealing your roleas taking patients off you.
Yeah. And again, I think talkingto the dietician and talk about
how you can work together, is itcrucial as well. And that goes
(43:26):
that goes both ways. For thedietitians in primary care, I'd
say, but also for the communityservice as well to have that
joint relationship and worktogether more collaboratively.
How can we work together andimprove patient journeys across
multiple different clinicians?
So what's next for you, Rebecca?
what's your what's your nextsteps? You're a fully trained
first contact dietitian, whatare you going to do next? What's
(43:48):
the next challenge for yourself?
So I was gonna make a littlejoke. If supplementary
prescribing wasn't enough, anddoing that to first contact
modules wasn't enough. Are youtaking a rest now then?
Rebecca (43:58):
Unfortunately, not. So in in September last year, I
started on the Advanced Practicemasters. So I kind of I knew
that's where I want to take mycareer. I love working in
primary care and working withthese types of patients. So
being able to advance my skillseven further. I feel lucky, very
(44:20):
lucky to have been been able toget a place on the Advanced
Practice masters. So yeah, I'mstill studying. But yeah, just
alongside my primary care work,
Aaron Boysen (44:29):
and how will your role change within primary care
once you become an ACP?
Rebecca (44:35):
Yeah, so I don't know the full answer to that I can I
can envision so you know, thethings I'm learning on the
Advanced Practice Masters is thesame, the same things that they
teach ANPS or, you know,Advanced Practice physio. So
again, the people on my cohort,our nurses, physios, paramedics,
pharmacists, all going intothese advanced practice work
(44:58):
roles, which I think is reallyexciting. In the fact that AHPS
can all share the same kind ofthe skills and knowledge to
create similar roles. So thebest way I describe it is I'm
learning the same skills as ana&p in the GP practice. So
technically, I would be able tosee any patient at that and na
(45:19):
NP would have so even peoplephoning up with a sore throat.
They can be booked into myclinic, and I'd be able to
diagnose tonsillitis andprescribe antibiotics, for
example. And so yeah, that's howthe role could look. Obviously,
things are changing so much withthe dietician, profession. So in
the two years that it will takeme to complete the Masters, who
(45:40):
knows where we'll be at?
Aaron Boysen (45:43):
Obviously, it's an evolving field. And I think,
yeah, you can definitely seethroughout your career, you seem
to be at the forefront of it. Soagain, you're going to be
developing this ACP role withinprimary care, Gandy, there isn't
many of them either. So again,you're developing this role,
you're establishing yourself asan ACP in primary care, and
(46:03):
helping to support the widerhealthcare system and bring that
dietetic knowledge closer to thepatients or at the moving closer
to the frontline of the doorwhere patients come in. Yeah,
definitely. Yeah, I think, whoknows the impact of that just
yet.
Rebecca (46:19):
Yeah. Yeah. And I suppose that's why I could have
been a bit vague with my answerthere because because we don't
know but I do think it's, it'svery exciting times for, for
dietitians that we are able toadvance our skills and our
learning in this way, and whoknows what the future will look
like for us in primary care.
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