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01 May 2016

The British Dietetic Association (BDA) considers that professional leadership is essential within any health and social care organisation to generate an environment within the professional grouping where the delivery of high quality services, centred around the patient is paramount. Professional leadership also drives service improvement and development and generate new business opportunities. The leadership for the nutrition and dietetic services should be provided by a registered dietitian in a designated professional lead role. 

There are many models of service management which do not rely on uni‐professional management and these can be very effective. However, individual allied health professions have a unique knowledge and skill base (as demonstrated by separate core pre‐registration training and statutory registration) and the need for uni‐professional advice and support to these clinicians within organisations is absolutely essential at a strategic and organisational management level. 

Where there is no dietetic service manager the professional lead provides advice and support to the organisation about the delivery and risks associated with the nutrition and dietetic services and the organisation of broader nutrition services. With these dual responsibilities the professional lead provides vital governance support to the organisation to manage risk.  

There are other responsibilities of the role which, while not of primary importance are necessary, if not critical, to the professional and workforce development of the staff group. These include practice placements for student professionals, continuing professional development and career and workforce development for the whole professional group. A lack of focus for these activities within an organisation caused by the loss of a professional lead role leads to a decline in morale, loss of career development opportunities and subsequent difficulties in maintaining high quality, safe and responsive services.

The BDA recommends that

  • All health and social care organisations which employ dietitians to carry out roles that require the application of professional capabilities should ensure the provision of professional leadership to those dietitians.

  • All health and social care organisations should also have AHP Directors to ensure the organisations are able to maximise the contribution of dietitians and other allied health professions to improving health outcomes. 

Dietetic services are most often complex services which comprise patient care individually and in groups along with education and training for others to undertake nutritional care. Many services also have a public health dietetic or health promotion role. As almost any patient within any pathway can have nutritional needs, dietetic services are provided across most, if not all, of an organisation. In organisations which provide service across acute, community and primary care sectors dietetics can be especially complex and provide the full range of nutrition and dietetics services from individual care through organisational policy to public health nutrition.  

Dietetic services are often comparatively small compared to other AHP services and generally provide services across most care pathways. In a multi‐professional team model, this can lead to no more than one dietitian within each team and often a dietitian working within more than one team. The same applies to dietetic support workers. This can lead to risk to the organisation of staff at all grades being left with inadequate professional support.  

However, within most organisations it is also important to have a strong voice for the nutritional care of the whole patient population and a lead dietitian working alongside a nutrition committee and operational colleagues in catering, nursing, medicine and pharmacy is vital to ensure safe and effective nutrition services which meet the relevant national standards. This needs to be a dietitian with broad experience and a good understanding of food, nutrition, food services, clinical nutrition and the organisations’ priorities. 

The BDA is dismayed that 10%of healthcare organisations consider that they can provide safe and effective services without designated professional leadership. (Source NHS Benchmarking 2015).

Strong professional leadership is necessary to generate an environment within the professional grouping where the patient is at the centre and where delivery of high quality services is paramount. The most important areas of this function are governance, service development, commissioning and tendering, education and training and workforce development. 

Shared leadership

The Healthcare Leadership Model (2012) applies to all health care roles; where everyone shares responsibility for success of the team and organisation and leadership capabilities are demonstrated by everyone in the team. The BDA expects all dietitians to develop and demonstrate leadership capabilities within their professional practice and to contribute to the success of the teams they work within. The application of leadership capabilities within multi‐professional teams is fundamental to the team function and the improvement of outcomes for patients. The delivery of nutritional care within health organisations is complex and many issues require coordinated action across the organisation. The development of professional practice consistently across an organisation again requires coordinated action. These situations both require shared and situational leadership where all take responsibility for recognising the need for action and taking steps to make this happen, and the situational leader facilitates the action.

The BDA recognises and endorses the value of all members of the dietetic workforce demonstrating leadership and fully supports and encourages the development of a culture of shared leadership within organisations and teams. 

Governance

Professional leadership regarding specific professional issues, mentoring and post graduate training can only be provided from within the profession (similar to that provided by the Head of Midwifery to midwives). It may be argued that any Health and Care Professions Council (HCPC) regulated professional lead can provide statutory advice regarding regulation. However, the interpretation of the generic Code of Conduct, Performance and Ethics (HCPC 2016) in particular clinical situations requires specific knowledge and understanding of the scope of practice of the specific profession and the professional involved. 

Ensuring safe practice and, where necessary, raising a concern about the safety of services or individual practice are a key responsibility of the professional leadership role. The Francis Enquiry into Mid Staffordshire Trust (Francis Enquiry, 2009) has emphasised the importance of professional leadership in providing this environment. All health professional codes include a duty of candour and the requirements to raise concerns. Professional leads support individuals to identify and raise concerns and are the route to escalate concerns appropriately through the organisation.

Professional leads key roles are in ensuring the quality of professional dietetic practice by striving to ensure safe effective and efficient services are delivered. They have the key roles in promoting the culture of quality within the services. Within a service with effective leadership there will be a culture of attention to safety and risk management; of striving for excellent professional practice through evidence based practice and ensuring the efficient use of resources. 

It is likely that the professional lead role will help the organisation reduce waste, especially in circumstances where there are issues that impact on all the dietetic staff within an organisation. These could be as simple as responding to patient safety alerts or ensuring all professional staff are registered to the complexity of the implementation of electronic patient records. 

It is important to realise that, along with input to recognised pathways by specialist staff, there are general dietetic services which provide vital nutritional care to patients and service users in any setting. Nutritional issues can arise in any patient in any setting and the general service needs to be able to manage this variety of needs. A particular issue may be patients diagnosed with a long term condition such as diabetes while an inpatient for another condition. At this stage they are unlikely to be treated in the diabetes pathway but will need some early intervention and education by the general service to ensure a safe discharge. An effective professional lead will ensure that patient focussed issues such as this are identified and the appropriate service is available and provided by a suitably trained and supported professional; and that the resources are available to meet those patient needs.

Policy Statements

Service Development

Many services work across organisational boundaries and are therefore well placed to ensure continuity of nutritional care wherever the service user is. Advanced and consultant dietitians have in depth knowledge and understanding at operational and strategic level in a discrete area of practice. A Professional Dietetic Lead works across the whole service and therefore integrates developments across the whole service. 

The professional lead will support the development of partnerships and interagency working including with 3rd sector organisations, other statutory organisations or agencies. Nutrition and dietetic services generate income for organisations through new commissioned services; services to statutory and voluntary organisations either contracted or ad hoc; development of resources or services which are then sold such as training packs, training and information sheets. The Professional Lead will take the initiative in identifying opportunities and leading on the development of service proposals and tenders, either on behalf of the service or supporting others. 

Implementing service developments such as 7 day services in a fragmented dietetic service is difficult and poses a risk to the organisation.  The professional lead supports the safe implementation of the service; ensuring the necessary capabilities and supervision across the services.

The NHS recognises the value of professional leadership in leading service change. Professional Leads provide high level input to strategic planning across the organisation and lead strategic planning for their profession.  

Professional leads provide advice to commissioners on proposed new services or on how services can be developed to improve quality, efficiency and outcomes.  This level of engagement and business development is almost impossible within patient facing roles. Without professional leadership roles dietetic services and therefore their employers risk losing business and income and fragmenting services.

Education and Training

The loss of professional leadership impacts on education and training of the future professionals and, therefore, the future workforce. This may not be of immediate concern to the organisation but will impact on recruitment and retention of staff and on the quality of nutritional services across the community, ultimately impacting on quality of care, morbidity and mortality. A lack of co‐ordinated education and training provision on nutrition within a health and social care community will also impact on health outcomes, referral rates and discharge planning contributing to bottle necks in the system and deteriorating demand management. This has wide reaching implications for NHS organisations.

The Professional Lead ensures the organisation of student training, ensuring a coherent programme and the quality of the experience. This promotes the department and the organisation to all students in the Higher Education Institute (HEI), not only to those who are placed. It also ensures that the profession are adhering to the HCPC Standards of Proficiency and Standards of Conduct, Performance and Ethics (HCPC 2016). These activities are crucial to recruitment and retention strategies within Dietetic Services.

Workforce Development

It is widely acknowledges that the health and care service delivery and organisation has to change profoundly. These changes are complex and to implement them requires the existing workforce to question their practice, develop new roles and often, access education and development to ensure fitness to practice. While any member of the dietetic team can do this, it is most often a dietitian in a leadership role that truly leads the change, appropriately challenging entrenched views and making the change possible.

The profession in now in the circumstances where in many specialities and settings it is more difficult to recruit staff with the necessary capabilities. A key role of the Professional Lead within a dietetic service is to identify these key posts and consider succession planning and to provide the range of development opportunities which allow new staff to develop their clinical and other work related skills. This is managed through preceptorship programmes and ensuring that new entrants to the workforce are given the opportunity to practice within a range of environments and specialties, while providing the general nutrition and dietetic services. When services are fragmented this becomes very difficult and the opportunities to develop this wide ranging expertise are limited.  

Other professionals and related staff support the implementation of nutrition and dietetic care plans and consistent public health messages around nutrition. Within this multi professional and multi-agency environment Professional Leads have a key role to play in advising on scope of practice for their professional group and others including competency development and education and training.  

The Professional Lead develops and supports new roles becoming firmly embedded while maintaining quality assurance around service delivery, e.g.: Band 4 Assistant Practitioner posts, generic support workers, etc.

Provision

In theory, all the above roles could be carried out by a number of individuals who each have responsibility for the roles within their respective specialties or teams. However, the skills and knowledge required to undertake these roles successfully require concerted effort and resources to develop and if undertaken by those whose primary role is service delivery will lead to duplication and will detract from the service delivery role. There may also be a loss of connection with professional bodies at a strategic level through loss of access to regional.

Further Information and References

1. The NHS Leadership Academy (2013) http://www.leadershipacademy.nhs.uk/wp-content/uploads/dlm_uploads/2014/10/NHSLeadership-LeadershipModel-colour.pdf (last accessed 03/05/16)

2. Health Professions Council. (2016) Code of Conduct, Performance and Ethics. HPC: London http://www.hcpc-uk.org.uk/aboutregistration/standards/standardsofconductperformanceandethics/ (last accessed 203/05/16)

3. Department of Health. (2010) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009. Chaired by Robert Francis QC. The Stationary Office: London http://www.midstaffspublicinquiry.com/sites/default/files/First_Inquiry_report_volume_ 1_0.pdf (last accessed 20/3/12)

4. NHS Scotland. (2009) Delivering Quality through Leadership: NHS Scotland Leadership Development Strategy. NHS Scotland: Edinburgh http://www.scotland.gov.uk/Publications/2009/10/29131424/0  (last accessed 20/3/12)

5. Department of Health, Social Services and Public Safety (2012) Improving Health and Wellbeing through Positive Partnerships. A Strategy for the Allied Health Professions in Northern Ireland 2012‐2017. DHSSPSNI: Belfast http://www.dhsspsni.gov.uk/ahp‐strategy‐feb‐2012.pdf (last accessed 20/3/12)