What do First Contact Dietitians do in a PCN? w/ Rebecca Gasche RD

Aaron Boysen: 0:00

On this episode of the podcast, we have Rebecca gash, and she talks about her journey in becoming one of the first first contact dieticians in the UK.

Rebecca: 0:09

To me, though, I could see the potential that dietitians could have in primary care. And I was aware of what we'd be working towards first contact practitioners. And I think with my gastroenterology background, I could particularly see how all the patients I was seeing in the secondary care IBS clinic, I could do that in primary care and actually stop them coming through the door and stop them even seeing the GP when I become a first contact practitioner so I could see the potential there.

Aaron Boysen: 0:43

In 2020, dieticians start to join primary care. And soon after the roadmap to practice was developed, and we started seeing the impact that dietitians could have in general practice. Rebecca has been one of these pioneering dieticians breaking new ground. After completing her supplementary prescribing, she embarked on becoming a first contact dietitian. She has since become one of the first Health Education England recognized first contact dietitians within the UK. If you're a dietitian, who would be interested in advancing their career in the area of primary care, this is a must listen. So without further ado, my name is Aaron Boysen. This is the dietetics digest podcast. So ensure that you chew it thoroughly, as there's a lot to digest here. So thank you, Rebecca, for coming on this podcast. Today I'm talking about your role as a first contact dietitian. Now Rebecca has completed her training. And she is a fully qualified, a first contact practitioner and also a first contact dietitian working within primary care. And she's been working in primary care for quite a while and has quite a wealth of experience. But maybe we could go back a little bit in time to when you first started out in dietetics. And what your main interests were and, and things like that. So why did you actually want to become a dietitian originally?

Rebecca: 1:58

Yeah. So Well, first of all, thank you very much for having me on air on. It's a great great to be here. So going back and way back. I guess back when I was at school, I guess that's when we first started wanting you know, when you're wondering what you want to do at university, it can be really tough. And I'd already I'd always had an interest in health and also food. sounds a bit cheesy, but helping people and I hadn't actually heard of dietetics before but it was my mum that suggested it actually, you know, she was helping me with my UCAS applications. And she thought, you know, health care, food diet. Why didn't you go for that? So yeah, I do have to thank my mum for directing me to the dietetic world and yeah, it wasn't really until had some day shadowing and then started university and you start your first placement where you really kind of get to see what what it is like being a dietitian, and luckily, I loved it.

Aaron Boysen: 2:55

Yeah. So what was your What was your first role in practice coming out of university then what was like the initial role you had as a newly qualified dietician?

Rebecca: 3:03

Yeah, so my first role like like a lot of newly qualified dietitians, it was an acute role in a in a district general hospital. So I was on the wards a lot. I did a community clinic, cardiac rehab sessions and things, things like that. It was actually at the same hospital where I had my C placement and it was really good. You know, it gained a lot of experience covering the different wards, you know, the medical wards, surgical wards, respiratory wards. So, yeah, it was kind of a good basis for my dietetic knowledge, I would say.

Aaron Boysen: 3:37

And, and I'm always interested in this question. So you are a band Pfeiffer? How long? How was that? How long was that period?

Rebecca: 3:45

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 in 2016. So that sounds in this day and age, it sounds like a long time to be training as a band five. And I think it just shows how, you know, progression and the profession itself have changed so much over the years. So yeah, two and a half, three years as happy band five

Aaron Boysen: 4:14

and what made you want to make that change? What was the sort of triggering point? Was it just, I need a bit of extra cash in my bank account? Or was it was it? Was it something obviously that's always helpful? I'm not gonna lie. It is always however, but what was the what was the point that made that change happen?

Rebecca: 4:31

Well, I think when you get to that point of you know, in, in your first role, I done all the rotations kind of on in that post, I suppose. And I was just really ready to specialize my knowledge and focus on something more more specific. So interestingly, the band six post I got was actually a it was a community post and I was thinking because I had a lot of work on the wards to begin with. I was thinking oh, community I'll give it a go. But I'm not sure. I'll see see where it goes. A bit of a process. So

Aaron Boysen: 5:06

inspired by the job advert you didn't see it out. You were more sitting there as a band five, wait, itching for a band six. And you were like, I'm just gonna take this opportunity see where it leads me kind of thing?

Rebecca: 5:16

Yeah, well, partly for that, I guess. I mean, obviously, the job did interest me it was a bit more of a project development post, I'd say and the focus on the service development was in gastroenterology. And I thought, you know, that mix of focusing on gastro, but also developing a service would be a really good next step up in my career and skill set. So it was kind of a different angle than what I've been doing, which I suppose is what I was looking for. And so that job involved me developing an IBS service. So a dietitian led IBS service in the trust that I worked for. And the success of that, you know, we've got so many patients through as you're aware, lots of Pete patients suffer with IBS, or irritable bowel syndrome, it actually created a full time post, just focusing in gastroenterology. So that was my specialist area up until I moved into primary care in 2021.

Aaron Boysen: 6:18

That sounds like a good sort of pathway, the dietitian led clinic leading to a more primary care role. How did you find that job? IBS all day, every day? How did you How was how was that experience for you?

Rebecca: 6:30

So I must admit, it wasn't IBS all day, every day. That was the initial focus of the project work but like I said, developed into a full time gastro post, and then on to leave for gastroenterology, which took on a lot more kind of the managerial and overseeing the service side of things. But yeah, it was a mix of IBS and other gastroenterology conditions. Although it was quite IBS, heavy, as you say, lots of lots of patients coming through the door with that condition. I mean, I think I have a soft spot for the IBS cohort, I knew that might be a little bit, a little bit of an out there statement, because as you say, it can be a bit heavy. Seeing so many patients with the same condition

Aaron Boysen: 7:15

heavy I mean, they're often quite complex, multifactorial, the diagnosis is a little bit of a, we don't have a clue what's going on. So therefore, it's IBS. And it just gets thrown at patients. And it's a massive umbrella conditions. I do think that has its challenges. Whereas another one that's clearly defined, maybe like celiac disease talking in the area, gastroenterology, you know what the problem is? There's no, you have to do? Let's do it. It's a little bit more, a little bit more clear in that sense.

Rebecca: 7:44

Yeah, and, and I do agree with you there, actually. But I think that also brings back to the point that dieticians are such a good profession to be seeing the cohort of IBS patients because as you say, it is a bit of a process of diagnosing that condition. It's, you know, ruling out other conditions, sometimes patients can feel a little bit dismissed by you know, other healthcare professionals, and I feel like dieticians have the correct skill sets, empathy and time to really work with these patients. I think the reason I enjoy working with them so much is the the job satisfaction. Obviously, we can't cure everyone. But I felt like that cohort of patients had such a good response with diet and lifestyle on the most part. And you know, even the really complex one with crossing over conditions that you it was good to work with the gastroenterology team. And you know, I felt overall, I could really help them, which was very satisfying.

Aaron Boysen: 8:48

And obviously, you've moved from that role into a clinical lead role. And was the clinical lead role part of primary care? Or was that afterwards?

Rebecca: 8:57

No. So this is still my secondary care role. This actually CrossTie the, during COVID time, so bit of a structure, team structure change, and I took on some additional responsibilities such as the ICU and surgical pathways as well. So quite quite a challenging time through COVID. Obviously, as everyone working through that period would most likely agree with me. So yeah, that was all clinical leading of those pathways, but in secondary care, 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: 9:35

Definitely, I think, obviously, within primary care often dietitians are working a lot more in isolation. And they've got a sort of leader service because dietitians are new no one knows what they do. While they know sort of theoretically what they do, but they don't really didn't really experience the amazing ness of a dietitian before so it's again sort of leading that sort of element of it compared to the gastroenterologist, which are probably He already bought and paid for members of the diet Well, from my experience are already bought and paid up paid are members of the dietician fan club. So that's that's quite helpful in sort of building a service getting buy in that kind of thing. Yeah, definitely. Whereas in primary care, they might not necessarily have the 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 sure I'll go on to talk about in more detail, but just trying to trying to implement it and get the dieticians, names and skill sets and actually an understanding of what we do and what we can do, most importantly, out there to clinicians and patients in primary care. I moved into primary care in April 2021. But I was actually working a split role. So I worked a few days a week in primary care. And I was still doing my clinical lead duties the other days of the week. So yeah, I kind of have my fingers in both pies, as, as you could 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 those things. And I think it was trying to being there for my pathway and my team members, whilst also being out in primary care, I think was the biggest thing to juggle, but that has since changed. So in moving forward to September, this year, 2020. Or last year, I should say, 2022, I have started the Advanced Practice masters. So instead of doing I've let go of my clinical lead duties and secondary care and absorbed the Advanced Practice masters. So now I am studying and working in primary care. Wow. So

Aaron Boysen: 11:51

just back to the primary care. Why did you want to go into the primary care roles? There were new roles. No one had a clue really what they were do at the time? Probably. There was just the guidance from NHS England called the desert requirements just said you need to be advanced level, what possessed you to go into this role?

Rebecca: 12:08

That's a very good question. And you're right it, the roles were very vague, I guess no one really knew what they what they were going to be or become because the full guidance wasn't released by Health Education England at that point, I was in a bit of a fortunate position, because another one of my dietetic colleagues was actually already working in a primary care role. So I had insight from her on how the roles worked. And you know, what's going on, so I wasn't going in completely blind. For me, though, I could see the potential that dietitians could have in primary care. And I was aware of what we'd be working towards first contact practitioners. And I think with my gastroenterology background, I could particularly see how all the patients I was seeing in the secondary care IBS clinic, I could do that in primary care and actually stop them coming through the door and stop them. Even seeing the GP when I become a first contact practitioner. So I could see the potential there. I'd also going from my band five acute role into my band, six more community role. And then the clinical leads, again, through COVID, taking on more of the acute stuff, the ICU and surgical pathways, for me that that confirmed in my mind that I do prefer community work rather than Ward work, obviously, it was all great experience and learning for me the work I did three COVID. But for me, it showed me that actually my passion is seeing patients in more of a clinical session

Aaron Boysen: 13:42

and imagined with patients who have IBS, you get a lot of speaking done, whereas on ICU, they get a lot I speak in so it's a little bit probably quite 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 things throughout your career. But you know, it's it's those things and trying 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 know that everyone else didn't know? What was what was your What was your colleague doing? Or what? What did you know what made you excited? How did she did she pitch it to USA? Rebecca, come join me? Or how did that work? Out? What What? What convinced you 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 someone who was in the roles and the types of patients that she was getting through the door, she could kind of prep you give me an idea of what patients were coming in, and then it would help me put the pieces of the puzzle together in my head about okay, I could do that in this way and help in this way. So yeah, it wasn't anything groundbreaking, I'm afraid but it 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 obviously decided, your colleague or friend told you about this amazing role that you could do? And he had said, Okay, I don't really have much of an idea about this role, but I sort of imagined it in my own head descriptions, probably not very clear. Let's let's go for it. And how was that first experience within primary care?

Rebecca: 15:23

Yeah, it was, you know, it was good, very different to secondary care, even working in community clinics, but kind of being under that secondary care. Umbrella. It was really interesting seeing actually the difference in the way other clinicians in the in the PCs, their clinics run, even how they do their consultations, what patients expect from the appointments. So yeah, it was a huge shift, actually more of a shift than I thought it would be kind of transferring my previous knowledge 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 a secondary care consultation?

Rebecca: 16:07

So I think I think the biggest thing that I noticed in primary care was the not booking follow ups, I think, for diet, dietitians in their clinics, we see patients, and we're like, yes, we've seen you, we advise this changes to your diet, I'm gonna follow you up in six weeks, eight weeks, whatever it might be. Whereas in primary care, it's a lot more focusing on you see the patient, you give your advice or treatment there, and then you safety net. And then you say any issues get back in touch, and it's a lot more ownership on the patient to book in with you as they would do booking with the GP booking and with the ANP. So I think that was that was something different for me to learn. And it feels a bit weird after, you know, keeping a lot of patients on my caseload for so long in secondary care, seeing patients once and then being like, Okay, you get back in touch with me, if you need and a lot more of exploring patients ideas. It's called ideas, concerns and expectations. So ice is the phrase that we use in primary care. So it's often when you have an appointment with the GP, they'll say, you've booked the appointment, you've told the reception staff what your issue is, and then you speak with the GP and they say, How can I help? And sometimes that can be a bit like, oh, well, you know why I'm why I've made an appointment. But actually, that's a way of exploring what the patient's wants from the consultation and how they think, or how they would expect you to help and what concerns that you want them that they want you to listen to. So yes, a little things like that.

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 ups for some of my patients. But I just think that was a good example of the differences in the primary care and secondary care clinics. I mean, the idea of primary care and, you know, working as first contact dieticians is to have slots available for patients to be able to book in with you. So, in the same way that GPS ANPS, and other health professionals working in primary care, they don't want really long wait times for their clinics, because you want patients to be able to be 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 more like 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 are that dieticians are working in absolutely huge. And sometimes they don't have enough dieticians to support the number of patients that they're seeing. So yeah, some people do have have wait times. And yeah, but I suppose that's the ultimate aim to try and be working more. So like the other primary care clinician.

Aaron Boysen: 19:05

And I think it's always important to remember that every, just because a person does a certain thing in different way or a different area. And I think this is such a crucial point in primary care. Every practice, not just every PC, and every practice will be slightly different. And it's his own unique machine. And they'll do it differently, because for a multitude of reasons, because they've always done it that way. Because the partners or the business owners basically do it want it done that way, or because it's the best way for their community for the what they expect what they're expecting out of their community. Did you find that difficult as a clinician to adapt to each individual practice?

Rebecca: 19:43

Yes, yeah, definitely. And that's a really good point that you've raised actually, that all the GP practices work so differently. So in my PCN, I cover for GP practices in the Chester area, and that and they're also different and that can be due to patient demographics. And you know, you have to work, work with what works in that GP practice, if that makes sense. So yeah, that was another thing that surprised me. Actually, I thought I'm working for this PCN. It will be the same across the board, but no, very different. And, you know, some of my clinics have different different slots for that patient demographics. So for example, if I have more patients, prescribed orlistat to help with weight loss, their reviews tend to be quicker. So I have 15 minute slots for those. Whereas the other ones that have full 30 minute slots, more focus on IBS and in certain areas, more focus on weight loss and diabetes in other in other GP practices. So yeah, it's taken a while to get the feel for each area. And definitely integrating in multiple GP practices in the GP in a PCN is challenging.

Aaron Boysen: 20:59

Yeah, definitely, I think because you've got so many different environments to fit into that the staff one question, you said your appointments, were 30 minutes in length, is that correct? For IBS, but all the stats fifth 15 minutes, I've never done an all stat. I'm not quite sure what's covered in those. But what I want to focus on is the IBS one, because that's the one that's most interesting to me. Okay, I see patients with IBS. And my appointments were from recollection. 45 minutes. Okay. And I would struggle, I would struggle to fit everything in the time wasn't long enough? How do you do it in 30? minutes, like in? Like, how do you manage that,

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 my clinics in my previous roles. And actually, and actually, that was looked at as a bit of a luxury you know, some of the community clinics had 30 minutes for a new and 15 minutes for a follow up. So they've everyone's thought, oh, Rebecca has gastro clinic, she gets 30 minutes for every appointment. So I, I've always been used to working to that timeframe. Again, working in primary care, you do get used to the templates that you have in your in your head or on the on the IT system that you're using. So you do just get into a rhythm, I find the work in primary care easier to gather all the information actually than I did in my secondary care job, it seems to be easier to find everything that might just be me, and the systems that I've used in the past. But yeah, I'd Yeah, I don't know if that's really 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 you know, lots of different areas to cover. So I suppose you do just get used to trying to try and to focus on what you need to focus on. And although I've said We try not to put follow ups, but that 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'd be nice. Especially Yeah. And then you went on to obviously you worked in primary care for a little bit. And then you went on to do the first contact dietitian training and become what's the first contact practitioner or first contact dietitian. Tell us about that experience? Because there's for those who aren't aware, the first contact roadmap came out from Health Education England, back in 2021. I think based on his timeline, I think you may have started it slightly before then. So how did that? How did that work? What were your What are your thoughts going into it? Why did you even consider going on the course?

Rebecca: 23:40

Yeah, so So, again, I was fortunate that I had direction from my from the trust that I worked in, you know, we knew that the the roadmap would be released by Health Education England, and that that's the kind of the direction that the that the roles would be taking. So yeah, back to my timeline. I started the started in primary care, April 2021. And then I started the first contact practitioner in primary care taught module, so a master's module in September 2021. So I'd had a few months, you know, getting getting the feel of primary care and then started that in September. The road map, which you explained is from health education, England, which details how dietitians can go from working in primary care to a first contact practitioner or first contact dietitian and then on to advanced practice, if that's where you want to take the roles as well. So that was released in November. So because I was on a taught module for the first contact practitioner roles I was on it was a mixed module with other healthcare professionals that go into these roles. So the physios paramedic, I think that was a yeah, it's just physios paramedics and dieticians on our modules, myself and my colleague so the universe St had already kind of mapped that module to meet the other professions, roadmaps. So the university delivering this module. It kind of knew what it needed to deliver to meet the dietetic roadmap. Obviously, when the roadmap came out, I believe the university did have to demonstrate to Health Education England that they can make meet the capabilities in the module. But yeah, it didn't affect things as such. But obviously, it was exciting to exciting is that the right word, to read the roadmap when it came out? And you know, match it to what I was learning on the course?

Aaron Boysen: 25:41

How was your experience learning all this stuff? Like, often this these first contact roles? So seeing patients as they come in through a GP surgery, possibly acting as a diagnostic clinician? That's not normally what dietitians? Do we normally get a referral. What was your thoughts about this? What were your What was your experience doing this?

Rebecca: 26:05

Yeah, and that's a really good description. And I suppose I've not really gone into what what a first contact practitioner or dietitian would do so absolutely, that seeing seeing patients, although it doesn't always have to be this way, at the first point of contact, but if a patient phones up the GP practice and says, or I've had been suffering with loose stools for the last week, instead of seeing being booked in with a GP, they can be booked in with the first contact dietician. And as you say, it's having those diagnostic skills. So being able to order the tests, order the stool samples, do an Abdo examination, do the general ops and really screening for red flags and knowing when something isn't quite right. So I find that that side of you know, clinical work really exciting because as you say, it is different to what dietitians would normally do. You know, even in the IVs service I ran in secondary care, the patients would have had to have a diagnosis of IBS before coming to see the dietitian, and I could really see how dietitians can could be that at that point of giving the diagnosis. So So yeah, I found it exciting. It is, it is a lot to learn, don't get me wrong. And there's a lot a lot of responsibility that you take 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 the first in the UK, only a handful of people are have passed the roadmap. 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 the health education, England's information, there's tends to be focused on for for patient groups, you've got gastrointestinal, so functional bowel disorder, mostly diabetes, nutrition support, and frailty and weight management. So they've always been the general types of patients that I've had in my clinic, I've actually left my referral criteria very open to my primary care colleagues, because that's, that's kind of what what they want. They didn't want to be filling out forms or anything like that. I just said, you know, any, anything that I actually book in with me, I'll let you know if it's not appropriate. But even with leaving that quite open, I have really been focusing on seeing those four types of patient groups in my clinics. So when I completed the first contact practitioner module, I think that there was a bit of oh, how are things going to change it? Will it change right away? Will I be seeing all different types of patients? The short answer of that is no, nothing, nothing changed right away. It took a little while before I could could register as a first contact practitioner, as well. So that's something to bear in mind. But since then, since being fully qualified, it's really been a lot of focus on trying to get the patients through through the door immediately from reception. And so seeing seeing patients in that first point of contact, like I keep saying, and that's actually proved a little bit challenging. So ideally, like I said, have patients phone up with Abdu discomfort, I have some slots held back in my clinics to be opened on the day for any patients phoning up, not just with Abdu l gastro queries with anything dietary wise. So the abdomen is the kind of the, the best example really. So it's, it's been able to accept those patients in my clinic from the day it's also just been able to accept patients who don't have a don't have some diagnosis or haven't haven't necessarily seen a clinician. Previously, I can see them first of all, whereas previously they would have had to seen the G To the nurse, and then they would book into my clinic. So it's giving the reception team the ability to book them straight in,

Aaron Boysen: 30:07

and how, say for example, it all, obviously logistics are always a challenge, I think within any healthcare system. And I always say it's easy to write a policy. It's always, like 10 times as hard to implement the policy. Yeah. How would it work in like a perfect world? If everything worked? Well? How would the patient what would the patient journey be? So patient calls up the GP practice and says, I've had loose stools for the last three 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 of weeks reception booked them in with myself. So the initial consultation, we didn't really focus on diet, which perhaps the patient was expecting, because you hear the word, even if it's first contact dietitian, patients then immediately think all you're going to talk about is diet. But I suppose that's one of the barriers that I've been wanting to break down in these, you know, we're not really obviously dietitians, but we can do such extended roles. And that's the exciting part. But anyway, patient came to see me in clinic I took a history from them loose stools for the past few weeks, nothing really changed. Nothing changed in his diet, not being away anywhere traveling or not had any sickness, bugs, anything like that. Check the biochemistry previous tests that they'd had done, family history there. They have a family member who had celiac disease, actually, but had never been tested themselves, medication history, any allergies, social history, so you know, a thorough, thorough consultation just to gather all the information. It is an abdominal exam, but didn't find anything. You know, they weren't in severe pain. You find any lumps or bumps just clarify for

Aaron Boysen: 31:56

people what you're looking for in that abdominal exam? Sure, sure. There was IBS or 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 know the oil. We're not supposed to know the absolute ins and outs of you know, an Abdo exam as a gastroenterologist would do. You know, I'm not necessarily doing the thing, the thing good taps or you know, anything specific on the abdomen, I'm really feeling the four quadrants for any severe pain, technical guarding of the patient is quite rigid, you know, that kind of suggests that there might be something more serious or sinister than IBS going on. So you're looking for a soft abdomen. You listen to bowel sounds as well, you want there to be some some gurgling with the stethoscope. So yeah, it's not it's not looking for anything specific. But it's watching the patient's reaction. A lot of the time, you're poking and prodding, and the patient's wincing a lot. Like you say, you don'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 at things 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 to be quite a big mass to be able to palpate really, but yeah, then the rest of that patient. So you ordered bloods stool sample for them, and explained, you know, the process, that we needed to rule out other things that could be causing these symptoms. That said, I'd call the patient back, once I had all the results. So actually, I did book a follow up for this patient, and saw them again, everything was within normal range, which meant that the symptoms were suggestive of irritable bowel syndrome, I was a bit surprised that the celiac test didn't come back positive because there was a family history. But no, that was all fine. And then so it was at the second appointment, once we'd gone once we'd ruled out everything, anything more sinister, that's when I could give my first diagnosis. Basically, as a first contact dietitian, say, This is what the condition is, this is how it's treated or can be treated. So we went through dietary advice, and then you know, it, there was the option to use pharmacological points as well. But actually, the patient didn't need need to go down that route. So we just helped her support his symptoms through diet. So that is a, I think, a good example of seeing a patient patient from the first point of call and being able to diagnose, treat and manage their symptoms all within the one person so we made some changes to their diet and yes, symptoms did improve. So happy patients

Aaron Boysen: 34:52

are the next stage be afterwards if they say the symptoms didn't improve, and you maybe had to try something else, they still wanted to follow a dietary approach. proach that read online about this thing called the low FODMAP? Diet? Would you refer them on to community services? Or would you tackle that yourself in primary care?

Rebecca: 35:09

Yeah, so this comes down to a lot about your your own skill set, I think because I because I know the low FODMAP diet, so I could go through that with them. As I said, I'm a prescriber, so I could prescribe the medications with them. But depending on your on your skill set, and also what the other local community dietician services are, like, you can refer on for that. So. So I know, dietitians working in primary care who aren't trained in the low FODMAP diet. So if they were in that position, they would just refer on to the local community, dietitian service, or if there's an IBS service. So yeah, it does depend on your on your backgrounds. I think that's just another example of as these roles, progress, you know, hopefully all dieticians in primary care will be able to deliver that, you know, that that service, that dietary advice, so that it's all held in one one place rather than referring on because I think that's, that's the ideal scenario, that the patient just sees the right clinician at the right time, and is just kept kept under that clinician until they're better.

Aaron Boysen: 36:17

Definitely, I think, I think that's obviously a really good example of how it can work. And then its implementation and working with the practices and building that relationship. And I think that's, that's often crucial. Even though you've got the qualification, you've ticked all the boxes, often people don't care about how much you know, until they you build a relationship with them, and you're able to sort of establish that protocol and are able to see it happen. You can share a success story, something like that saved quite a bit of GP time, and the patient journey might have also been a little bit smoother as well.

Rebecca: 36:47

Yeah, I hope so. Anyway, so yeah, in the same breath, there have been barriers to rolling out the first contacts work, you know, that was a really good example of how it can work and how dieticians can diagnose and manage a patient with a condition. But I think there's going to be a lot of work needed in changing perceptions on what a dietitian can do. And this isn't just for what our peers in primary care our colleagues view of what dietitians can do, but also what patients think dietitians can do. Because, you know, sometimes those first contact slots aren't being filled. And they speak to the reception staff. And I say, you know, I've noticed that the patients with abdominal discomfort being booked in with a GP, why have they not been booked in with me? And it's because they don't want to see a dietitian, you know, at the end of the day patients, if they're in discomfort, or they're worried about something, if you say, I'll put you in with a even if you say first contact dietician, they hear the word dietician and think, well, a dietician, I don't need to speak about diet, I need to have tests, I need to be referred to the hospital, I need a colonoscopy, you know, that's the patient's ideas, and they don't necessarily understand that actually a dietitian can action these things, then then yeah, it's just educating, educating them and educating the reception staff to be able to explain that not that they have time to go into detail, but I think that's just an example of why things will take a little bit of time.

Aaron Boysen: 38:19

Yeah, definitely. Yeah, I think that's often often a struggle, struggle, just sort of changing perceptions and things like that. But I think as hopefully as time goes on, as I think we get our team members bought in and we see the success stories, they start sort of understanding the importance of them. Yeah. And I think even well established roles, like the physiotherapist. I see a lot of these online doing videos about why the receptionist asked you about what you need, and they're explaining the physio service, which actually has been established for many, multiple years. So again, it's just again, it's not just about educating the workforce. It's also about educating the public as well. Yeah. But actually, a dietitian is very suited to be able to do this, because I think we default Lee like when I did when I did the IBS clinics with 45 minute appointments. I had we actually screened for red flags every single time. And there was many multiple times where we had to refer back to the GP for multiple tests, because there had not been done. Exactly. I think maybe the over cautiousness and perfection, fractious nature of dietitians might serve as well in that in that regard, I

Rebecca: 39:26

think yes, yeah, yeah. And yeah, I definitely agree. I agree with that.

Aaron Boysen: 39:31

So I think obviously, these roles are new and they're quite exciting for dieticians. But we also know at the same time there is what can be described as like a workforce crisis among healthcare professionals. Overall, dietitians are a lot of departments struggle to recruit would you say these roles and these roles are often band seven roles that are paid at sort of the band seven level, or these roles stealing all the more experienced dieticians away from the NHS Trusts and causing more problems later on.

Rebecca: 40:00

So I wouldn't say well, I don't know, I wouldn't say that they're stealing the experience dieticians because they are very different roles, you know, they're not going to be suited for everyone, as you say that they band seven roles, the FC FC D roles. Whereas some people want to stay up sorry, there been seven roles and that they're more kind of moving into expert generalist roles. So knowing a bit about each of those conditions, whereas a lot of people with a lot of clinical experience in a specific area, want to stay in that area, you know, highly specialized, which is, which is obviously great. And I think the overall idea of these roles is not to not to replicate what's already being done with dietetic services. So we don't want to be just setting up another community, dietitian clinic, in a GP practice, what we're doing is extending these roles and advancing our skills to be able to diagnose treat, manage conditions, which, which I 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, when that patient with IBS, you didn't manage them within primary care. You refer them on to community service. And even if you've got competency in that area, it might be the community service is really good. You want to preserve your time in primary care. Yeah, because you're quite busy. So actually, what you've been able to do, right there is you've been able to obviously free up time, but also you've been able to give that patient a bit of a head start. Yeah. So they're ready to ready to progress on further, further strategies or things to consider going forward.

Rebecca: 41:45

Yeah, exactly. And I think that's a good point to raise as well, that as well as not replicating what's already being done by fantastic dietician services out there, it's really important to work with the other dietetic services. So I still have very close links with the different services that we have running available, you know, the diabetes education services, IVs services, home visits, and you know, that and the whole metal tubing, tube feeding service as well. So actually having having a know of what's going on with the other things available to patients is really important again, so you're not replicating things, and so that you can have joint working as well, you know, I don't do home visits in my PCM role that may be different for other people, but but for me, it's I don't I would refer to the community dieticians team who have the home visit service. So yeah, I suppose that's just another 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 can handle it, she'll, she'll do a great job. And I imagine you would do a great job. Again, it's thinking about how the systems and how we can support the patients the best we can, an insurer all working together. So we're not just trying to sometimes there is a temptation of particularly with the high workloads that people have to sort of move between sort of push off certain things or, or even sometimes feel like the dietician within primary care is coming in and stealing your role as taking patients off you. Yeah. And again, I think talking to the dietician and talk about how you can work together, is it crucial as well. And that goes that goes both ways. For the dietitians in primary care, I'd say, but also for the community service as well to have that joint relationship and work together more collaboratively. How can we work together and improve patient journeys across multiple different clinicians? So what's next for you, Rebecca? what's your what's your next steps? You're a fully trained first contact dietitian, what are you going to do next? What's the next challenge for yourself? So I was gonna make a little joke. If supplementary prescribing wasn't enough, and doing that to first contact modules wasn't enough. Are you taking a rest now then?

Rebecca: 43:58

Unfortunately, not. So in in September last year, I started on the Advanced Practice masters. So I kind of I knew that's where I want to take my career. I love working in primary care and working with these types of patients. So being able to advance my skills even further. I feel lucky, very lucky to have been been able to get a place on the Advanced Practice masters. So yeah, I'm still 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, the things I'm learning on the Advanced Practice Masters is the same, 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 into these advanced practice work roles, which I think is really exciting. In the fact that AHPS can all share the same kind of the skills and knowledge to create similar roles. So the best way I describe it is I'm learning the same skills as an a&p in the GP practice. So technically, I would be able to see any patient at that and na NP would have so even people phoning up with a sore throat. They can be booked into my clinic, and I'd be able to diagnose tonsillitis and prescribe antibiotics, for example. And so yeah, that's how the role could look. Obviously, things are changing so much with the dietician, profession. So in the two years that it will take me to complete the Masters, who knows where we'll be at?

Aaron Boysen: 45:43

Obviously, it's an evolving field. And I think, yeah, you can definitely see throughout your career, you seem to be at the forefront of it. So again, you're going to be developing this ACP role within primary care, Gandy, there isn't many of them either. So again, you're developing this role, you're establishing yourself as an ACP in primary care, and helping to support the wider healthcare system and bring that dietetic knowledge closer to the patients or at the moving closer to the frontline of the door where patients come in. Yeah, definitely. Yeah, I think, who knows 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 answer there because because we don't know but I do think it's, it's very exciting times for, for dietitians that we are able to advance our skills and our learning in this way, and who knows what the future will look like for us in primary care.