British Dietetic Association Response to Health Education England s (HEE) Commissioning and Investment Plan 2016/17 Summary The BDA is very disappointed and concerned that short term financial constraints risk the health of the population and a reduction in the quality of healthcare by a short-sighted reduction in preregistration commissions. Furthermore we are concerned that HEE has not referred to the NHS Five Year Forward View which pledges to take prevention seriously. Given that diet is now considered to be the most important modifiable lifestyle factor, dietitians should play a key role in making prevention happen i.e. preventing obesity and associated long term conditions the cost of which is escalating. This means that in a reduction in the number of dietitians being trained will hinder the achievement of the NHS prevention ambition. Consequently the BDA are asking HEE to reconsider the reduction in commissions published on 23 December 2015 and to return to the original commissioning intentions as presented to the AHP HEEAG in the autumn. Introduction On 23 rd December 2015, following the Government s Comprehensive Spending Review of 25 th November 2015, Health Education England published its financial plans for the forthcoming financial year. This document acknowledges the announcement of changes to the current bursary and fee arrangements for nursing, midwifery and allied health professions (AHP) training from the 2017/18 academic year onwards, however states that the potential risks and opportunities have not be considered as part of HEE s published 2016/17 financial plans. In terms of dietetic education, the BDA is extremely concerned about HEE s decision to cut dietetic commissions by 8.5% (equating to a loss of 29 training places across England). Not only is this proportionally the largest but one cut amongst the AHPs (podiatry is reduced by 9.7%) but also proportionally the fourth largest reduction across all health and care training commissions. In addition, the judgement fails to take into account the information presented by the BDA in its 2015/16 Call for Evidence submission. The BDA challenges a number of the assumptions underpinning HEE s decision making process in this regard. Such challenges aim to clarify factors impacting upon HEE s data in two distinct respects: 1. HEE s workforce supply data does not adequately consider external factors impacting upon the availability of dietetic resource; 2. In identifying priority areas of investment, HEE has not considered the demand for dietetics and the role that nutrition support plays in delivering improved patient outcomes and NHS cost savings; nor the value in training of a dietetic workforce that can span the NHS, social care and public health and the role of dietetics in a preventative approach.
Dietetics is a small profession and the imposed cuts risk destabilising the viability of education provision across a number of England based Universities. In light of future challenges to education provision for AHPs, this appears to be imprudent and hasty decision, with limited consideration for the long term implications and the sustainability of such a vital health profession. This report revisits data presented in the Call for Evidence submission 2015/16 and in doing so, contests some of HEE s hypotheses. Workforce Supply Data In its report, HEE states that forecasts of future supply show that we are training more people to enter the system than those leaving the system in every profession. The BDA would argue that assumptions concerning FTE dietetic NHS staff are unlikely to be accurate. Based on the data outlined in the table Forecast Increases in available supply to the NHS workforce 2015 to 2020 (pg 3) HEE appears to envisage a greater supply of dietetic expertise than is accurate. Whilst the majority of graduates enter the NHS in the first instance, this is nearer 80% than 100%. This means that at the outset there is a 20% discrepancy between HEE estimated supply and actual resource. Indeed, this pattern is further borne out by BDA membership data which also reflects the 80:20% split. It is also worthwhile noting that the average hours worked by the 94% female workforce is 0.85 FTE; contributing to further discrepancy. For comparison the numbers of dietitians becoming available to work in the whole of the UK through HCPC registration increased by 1692 between 2010 and 2015, so it is highly improbable that in NHS England alone, that the FTE will rise by 1514 in a similar time. In addition, HEE is invited to note the discrepancies between the data presented within its own report. The table on page 3 indicates that the supply of dietitians within the NHS workforce in 2015 is 4,042. However, data presented on page 9 indicates a demand of 4,264, thus presenting a shortfall of 222 dietetic staff. It is therefore not unreasonable of the BDA to query HEE s assertion that there is to be an over-supply in future years. Indeed this shortfall is confirmed by anecdotal information received from dietetic managers who report difficulties recruiting to dietetic posts, particularly in the areas of mental health and paediatrics. In 2012 the Centre for Workforce Intelligence (CfWI) published a report based around education commissioning risks (dietitians). 1 It was noted the high proportion of part time dietitians suggests that supply must be judged upon real time work within the NHS. It also notes the high numbers of staff who choose to leave NHS employment in their 40s and 50s, which impacts upon higher level expertise available. In addition, the gender demographics of the profession cannot be overlooked. As 95% of UK dietitians are female, backfill required for maternity leave is a very real consideration and in England, the NHS is already reliant upon those trained in other clusters within the UK, in order to meet demand. Within its report, HEE indicates that it has taken into account people leaving NHS employment to work in the independent and care sectors, although referencing of such data is absent and suggests 1 March 2012, CWfi, Workforce risks and opportunities (dietitians)
an oversupply of NHS dietetic resource. However, the BDA would dispute that such modelling to 2020 fully takes into account the changing health and social care landscape plus the public health agenda and the unique position that dietetics plays within these. It is likely that in supporting an ageing population with co-morbidities and long term conditions, there will be increased need for dietitians to work outside of (but in support of) the NHS. This workforce will be a vital component in reducing the burden on acute services and ensuring the nutritional well-being of the population. It would erroneous to simply note the increases in respect of NHS workforce only and fail to consider the likely sector demand changes required of a future dietetic workforce, tasked with preventative, primary and tertiary care responsibilities (alongside secondary care deliverables). The role of dietitians in health promotion and public health Diet is the second most important modifiable risk factor for ill health in the UK after smoking. As a population the UK is living longer but not healthier with many people have one or more long term conditions. Obesity and its associated health problems such as diabetes, hypertension and cancer are an ever increasing problem in the UK. It does not make sense that, at a time when the NHS has pledged a radical upgrade in prevention and public health (in its Five Year Forward View published over a year ago in October 2014), the number of training places for dietitians is reduced significantly. Registered dietitians are unique in that they work with individuals with a vast range of conditions including obesity and associated long term conditions to assess, diagnose and treat nutrition and diet related problems. Of relevance to the promised upgrade in prevention in the NHS, dietitians work with populations to translate the most recent scientific evidence into practical guidance to enable people to make appropriate lifestyle and food choices. If not working directly with the public, dietitians are often working as system leaders in public health and also as trainers of others who can work directly on public health interventions. By preventing ill health the need for people to visit their GP or accident and emergency will be reduced, but to do this investment needs to be made in the training of the professionals best equipped to achieve a measurable improvement in public health i.e. dietitians. There is clearly an increasing need for dietitians to meet the pledge to upgrade prevention by the NHS and a cut in the number of training places being commissioned would jeopardise the ability of the NHS to achieve this. HEE Priority Investment Opportunities Within its 2016/17 Commissioning and Investment Plan, HEE has identified areas of high demand where significant proportions of investment are to be targeted. Although outlined within its 2015/16 Call for Evidence submission, the BDA would argue that the vital role of dietitians and the potential for this staffing group to generate NHS cost savings within these areas has been largely overlooked. Dietitians provide a cost effective and highly skilled alternative resource to traditional models of NHS delivery, having the qualifications to and skills to address complex conditions from a holistic perspective.
Primary Care With changing demographics and service delivery models, increased numbers of dietitians will be required as cost efficient and evidence based members of the primary care team. Dietitians fulfil a vital function managing nutritional care requirements for those with multiple long term conditions including IBS, obesity and diabetes (to name but a few). The BDA is thus disappointed to note the lack of investment in dietetic training in recognition of the integral role that dietitians play within the primary care giving team. The number of people aged over 85 is expected to more than double over the next 25 years from 1.4 million in 2010 to 3.5 million by 2035 2, with over a quarter of the population having a long-term condition and an increasing number of these having multiple conditions such as diabetes, renal disease, stroke and cancer. Much of the world s disease burden results from a few largely preventable risk factors, most of which are related to diet and lifestyle. What people eat affects not only their current health but also their risk of future disease. The consequences of diet in terms of obesity and hypertension for example, have a major influence on the development of cardiovascular disease. Obesity also increases the risk of type 2 diabetes and exacerbates other health problems such as arthritis and respiratory disease. It is also estimated that as many as one-third of cancers may be associated with diet 3. Dietitians assess, diagnose and treat diet and nutrition problems at an individual and wider public health level. They play a crucial role in long term conditions where dietary modification is fundamental to management of the conditions, or to reducing their progression, e.g. diabetes, cystic fibrosis, intestinal failure, renal disease and cancer. With regards to the acknowledged current and significant pressures on primary care services (and in particular those of the GP), dietitians are helping to ease the situation and have the potential to ease it further. Innovative dietitian-led services are being created across the country to support people with conditions such as coeliac disease and Irritable Bowel Syndrome both of which are time intensive conditions for the GP to manage. These new services have helped to reduce the pressure on GP time and services. Dietetic services and expertise in primary care and the community are wide ranging and span from preconception, pregnancy, birth, childhood and adulthood (including most physical and mental health conditions) and ultimately contribute to dignified death. Dietitians are already helping to reduce the workload of GPs by working directly with patients, helping them to self- manage their health conditions, or through training of primary care staff. Dietitians are also making sure that prescriptions for nutritional products (oral nutritional supplements, tube feeds, specialist formula milks and gluten free products) are appropriate and in so doing saving GP services significant amounts of money. The Five Year Forward View envisaged that GP services would be remodelled to meet the changing needs of the UK population. The new models of care include Multispecialty Community Providers and Primary and Acute Care Systems both of which should include dietetic services. Dietitians are experts in motivational interviewing, behaviour modification techniques, working with group and individuals and leading small and large scale community interventions. This means that they are capable of helping to deliver new models of primary care in a different, cost effective way that eases the workload of stretched GPs. It seems a retrograde step to cut the number of commissioned dietetic training 2 The Office for National Statistics (ONS) (2012) Population Ageing in the United Kingdom, its Constituent Countries and the European Union. 2 Parkin, M., Boyd, L., Darby, S. et al. (2011) The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer, 105(S2): pp Si-S81 3
places at a time when dietitians are helping to reduce the pressures in primary care and have the potential to do much more. Mental Health Workforce People with mental health problems are at higher risk of physical health problems than the general population and often have coexisting co-morbidities. Having depression can double the risk of developing Coronary Heart Disease. People with mental illnesses such as schizophrenia are more likely to develop cardiovascular disease, obesity, abnormal lipid levels or diabetes. Dietetic interventions lead to reduced malnutrition, weight management, reduction in nutrition related side-effects of psychiatric medications, improve self-care and management of co-morbid conditions, and improved health and nutritional status. Cancer Whilst the independent cancer services review commissioned by NHS England focusses one early diagnosis to improve outcomes; outcomes improve when the clinical treatment services are of an equally high standard. Dietitians improve the nutritional status of patients before, during and after treatment to maximise wellbeing, minimise co-morbidities and admissions and maximise recovery and long term wellbeing. Dementia Dementia is one of the greatest health crisis of this age- with an ageing population the incidence of dementia will only increase along with the demand for health and care services. Nutrition and dietetic interventions to encourage a Mediterranean style diet reduce the risk of developing dementias (along with cardiovascular diseases). If dementia develops, maintaining a good nutritional status and preventing malnutrition as part of a multimodal intervention may help keep people in their homes longer and delay premature admission to residential care. Summary The case against the cuts to the commissioning numbers for student dietetic places has been described in detail. The BDA is very disappointed and concerned that short term financial constraints risk the health of the population and a reduction in the quality of healthcare by this short-sighted reduction in pre-registration commissions. Furthermore we are concerned that HEE has not referred to the NHS Five Year Forward View which pledges to take prevention seriously. Given that diet is now considered to be the most important modifiable lifestyle factor, dietitians should play a key role in making prevention happen i.e. preventing obesity and associated long term conditions the cost of which is escalating. This means that in a reduction in the number of dietitians being trained will hinder the achievement of the NHS prevention ambition. Consequently the BDA are asking HEE to reconsider the reduction in commissions published on 23 December 2015 and to return to the original commissioning intentions as presented to the AHP HEEAG in the autumn.