Advanced Dietetic Clinical Practice by Christian Shaw

Added: 2026-05-21

[00:00:00]okay can you hear me perfect thank you um so I'm Yvonne I'm chairing with Katie and Jenna here and our first talk for this session is Christian who has a degree in Nutrition a postgraduate diploma in dietetics an MSC in advanced clinical practice and is a supplementary prescriber he works here in Sheffield and has published studies in dietary management of IBS I'm sure we're all Keen to hear his presentation so I'll hand over to you Christian they've got the clicker sorry the um so good morning so I'd like to talk to you today about advanced dietetic practice it's an exciting time for dietitians with the emerging new roles of advanced practice such as the first Contact practitioners in Primary Care in various ACP roles across other Healthcare settings I'd also like to share some data with you today from myself and a colleague's owner ACP Journey over the last few years and some of the clinical work that we've been involved in so what is Advanced diet Advanced clinical practice well as defined by the multi-professional framework for acps published in 2017 it includes complex decision making with a high degree of autonomy so underpinned by level seven or Master's education and it includes the four pillars of advanced practice clinical practice leadership and management Education and Research so why are new ways in working needed well in Pro in healthcare services are under significant strain in Primary Care there's issues with the Recruitment and Retention of GPS at a time where patients are living longer with multiple comorbidities furthermore many services are being diluted back to Primary Care to keep treatments close to home as a result there's a lot more workload in this setting GPS are experiencing stress but many looking to leave practice or take career breaks if we look at gastroenterology Services there's been issues with the recruitment of gastroenterologists for many years in 2020 48 of advertised posts remain vacant 25 of University Hospitals trusts and District hospitals had had a vacancy open for a 12-month period as a result we don't always meet the Royal College of Physicians recommended full-time equivalent consultant population figures per population figures as a result Consultants wait longer hours and have heavy case loads this is increasing stress and burnout across the profession as Services begin to struggle patage and satisfaction starts to decline the most recent survey published earlier this year in March regarding satisfaction in the NHS showed that the number of patients who would report themselves to be satisfied or quite satisfied is only at 29 which is down by seven percent from the previous year if we look at dissatisfaction specifically this has increased by 10 to 51 percent if we look across Services primary care and outpatients we see that outpatient services generally do better than primary care which has been the case for many years but even in this setting we're now seeing satisfaction is beginning to change if we look at the reasons to why patients are dissatisfied with Services software induced to the time they're waiting to be seen Staffing levels and the amount of money that's been spent on the NHS so it appears important to try and improve access to services so how can dietitians help well in GI diet is often the therapy or one of the main therapies for many GI disorders if we think about the gluten-free diet in Celiac disease if we think about the low FODMAP diet in IBS and potentially other disorders have got brain interactions and then just dietary change across lots of other areas in GI I think GI dietitians are in such a good place to upskill to take onto ownership of these conditions to help with services so what's been done already to help well in Primary Care we've got first Contact practitioner posts these were set up to for additions to assess diagnose and provide treatment for patients historically seen by a GP this would include seeing IBS and celiac disease unfortunately in secondary care there isn't any roadmaps to practice or guidelines available at present if we look at referrals coming into secondary care a study by Alex Ford's group in 2014 showed that around a third of referrals to a luminal GI clinic with a disorders or gut brain interactions of which IBS made up 10 percent a large U.S study including over 1 500 gastrologists showed that around 10 to 50 of outpatient time is percent specifically on RBS so dietitians upskilling to take on some burden of these different areas but not only helped with services but it was also free up gastroenterologists to see a more complex cases but is there any evidence to support dietetic Advance practice well despite the first Contact petition approach being underway there's very little data to support this practice in the UK but there is some promising results from Australia study by Ryan ettal in 2016 showed that 78 of patients could be managed exclusively in a GI clinic where a dietitian worked as a as a first Contact practitioner these patients were low risk so these were patients that if treatment was delayed were less likely to deteriorate and this included suspected IBD celiac disease reflux and anemia The dietitian was trained to request Bloods Imaging and endoscopy and after giving dietary advice 78 were managed on the pathway patients were also asked about their satisfaction with the clinic and 100 of the responders agreed they were satisfied with the clinic another study a few years later also from Australia showed some promising results too they described The dietitian first gastro Clinic where a gastroenterologist triage patients into the clinic who again were low risk these were patients that weren't likely to deteriorate this included patients that were less than 50 years old symptoms compatible with IBS nausea bloating and peps here The dietitian was trained to request some stool tests and blood tests and after giving dietary advice and some medication adjustments suggestions and 70 were managed in this pathway and only 10 percent of patients needed escalating to a gastroenterologists because of the presence of red flags same office a few years later approached patients from this sort of gut brain and Ferrari from The dietitian face gastro clinic and who had met the room for criteria for IBS and after the dietary advice and the medication changes they noted that 88 of the cohort had achieved a 50-point reduction in IBS symptoms severity scores and this was not there was no statistical difference across IBS subtypes what this showed was with the other study that the dietetic ACP model from referral to discharge was an effective approach so this brings me on to what we've been doing here in Sheffield back in 2019 myself and a colleague underwent physician-led training in a GI clinic for patients with symptoms likely to be compatible with IBS we also enrolled in an MSC in advanced clinical practice in the IBS clinics we developed skills to undertake a clinical history screen for red flags requested interpret information and tests and form a diagnosis we also asked patients about their satisfaction with our clinic in comparison to the doctor's clinic we've received 91 questionnaires back using a scale of 0 to 10 on satisfaction we saw high level satisfaction across both clinics with no statistical differences between the delivery after the training period we begin to live it to deliver to a weight gastroenterology clinics and we've just recently completed our mscs earlier this year in the 208 gastroenterology service for those that are not familiar this is an urgent referral pathway for Primary Care or GPS to refer to secondary care because they have a patient they suspects May have a GI malignancy who requires an urgent assessment so unlike the Australian studies these patients are considered to be high risk they will deteriorate if they don't have an agent assessment so as this was a new service after a six-month period of delivering these clinics we set up a service evaluation to explore patient satisfaction during that period 273 patients attended the clinic and we received 133 questionnaires back with a response rate of just under 55 percent in the clinics we undertook full clinical histories looked for red flags took into consideration the symptoms the signs the referral Bloods and past investigations to decide on what would be the best test to investigate the individual but also take it into consideration The Who performance statuses or their Fitness for investigation so are they fit enough to undergo bowel preparation and colonoscopy for example and as we can see from the table those on an upper GI pathway were most likely to have abdominal pain and weight loss and also vomiting and dysphagia where those on a lower GI pathway are most likely to have a positive fit test change in bowel habit abdominal pain and iron deficiency anemia in regard to investigations almost 90 percent of patients had investigations we requested over 400 different tests and as you can see from the table here that the most commonly requested tests with gastroscopy colonoscopy CT scan those are an upper GI pathway as we would expect we're most likely to have a gastroscopy those on a lower GI pathway colonoscopy and we had similar amounts of CTS requested between both of the pathways in regard to after investigations we were able to effectively discharge 87 of patients from the pathway we did find GI or malignancy in four percent in just over one percent we're undergoing further tests at the time the study and to because they were suspected these Figi means see and 13 needed follow-up in a GI subspeciality so this is because we found something from the tests that would indicate something like IBD for example and 12 needed follow-up in another medical or Surgical Specialty again usually because from CT scans you found all sorts of different things and often we needed a refill to Gynecology or Urology moving on to Patient satisfaction we used a satisfaction questionnaire which was given to all patients who attended the clinic or sent out to them and this included questions of zero to five was a 0 to 10 scale about satisfaction and a final sixth question about what went well or things we could improve in the service we received 133 questionnaires as mentioned a response rate just under 55. as you can see from demographics most patients 61 to 79 which we would expect from two or eight Pathways with female and retired in regards to satisfaction across the five questions using the zero to ten scale we saw high levels of satisfaction across all five domains including confidence in the clinician if they have more more than 95 of patients would all score a seven or more across all of those domains as well in regard to question six the free text box 76 of patients left a comment and through analysis you can see some of the key themes of satisfaction so overall satisfaction information provision clinician knowledge symptom exploring creating a welcome environment professionalism and I think all of these are important in any bonds practice but I think a few stood out to me in dietetic advanced clinical practice and information provision patients were really satisfied with the level of detail we gave them in regarding what tests they needed and why symptom exploring taking a full clinical history patients felt they were confident they'd been fully assessed using a symptom proforma was a really useful thing that we've used in our practice and then lastly creating an environment where the patient felt they could share information didn't feel rushed and I think that's really important because a lot of the patients are very apprehensive because they're on a pathway for suspected cancer so they do come quite worried lastly I wanted to talk a little bit about dietetic prescribing almost 20 percent of patients seen in our Clinic during that time needed a medication prescribing or adjusting this most commonly included a PPI such as lansoprazolomeprazole or iron replacement due to iron deficiency anemia because patients are new to service they've not seen a doctor in secondary care or a consultant in secondary care we could not use supplementary prescribing this highlights a major hindrance with current legislation because ACP roles a lot of the time are set for us to see patients new to service and you're just not able to use supplementary prescribing in that way as a result we have to ask GPS to prescribe or doctors to prescribe this puts additional strain onto services that are already struggling so until dietitians gain independent prescribing rights and we're going to our ACP practice is going to be is going to be limited so in summary NHS services are struggling dietitians are well placed in GI given the role of diet the dietetic 208 Clinic was well accepted by patients this is important because there isn't much UK data out there and giving these new roles coming out we need some data to suggest they are effective and the results will suggest that you know dietetic ACP roles should be considered workforce planning to help with Services however as always we always need more research to evidence dietetic advanced practice so thank you for listening any questions [Applause] thank you Christian for a fantastic talk really insightful and interesting um we have time for one quick question has anyone got a burning question thank you um I'd just be interested to see what are the barriers for dietitians getting prescribing rights at the minute I think it's a matter of time I think we have to earn our Stripes it's supplementary prescribers before we'll then be able to become independent prescribers that's the pathway that all the other professions are now independent prescribers have had to go down the issue we have is because we're limited and we can't use supplementary prescribing we can't gather that data in real world that it is being effective so I think there's a barrier there so I do if anyone here is a supplementary prescriber and you can undertake an audit or some kind of service evaluation where you collect that data I think that is where what we need to be doing we need to be showing that we can prescribe as supplementary prescribers and I think then with time we'll the legislation will come in but who knows thanks thank you Christian and in the interest of time Christians kindly offered that if you've got any other questions he'll be available throughout the day and the breaks and the lunchtime so we'll move on thank you thanks