Remote and rural working in the Highlands: Challenging training models

Evelyn Newmanby Evelyn Newman (@EvelynNewman17)

When I was a student dietitian, all those years ago, the prospect of delivering a dietetic service was limited to a model of clinical care set mainly in a hospital. Student dietetic placements rarely involved much time outside an acute unit, tho there was a 4 week opportunity within the 30 week block, to have a “complementary” experience somewhere (mine was in a health promotion setting in central Bristol) However, for many of my peers it simply involved working in a community rather than acute hospital.

Consultations were always face to face in clinics, wards or occasionally domicillary settings. Communication was limited to landlines, although not all patients had one…. Mobile phones, Apps and the internet were certainly not an option (I really am showing my age!) and you had to be patient and wait for ages for journals, reports, consultations etc to reach you to try and keep up to date.

Today, I am fortunate to have a very unique role covering the North Highland area, which means that I support 73 care homes and a couple of dozen care at home services. The geography is vast, stretching from John O Groats in the North, to Lochaber in the South, Skye in the West and Nairn in the East. The North Coast 500 (@northcoast500 for any tweeters) forms part of my mobile workplace and  is quite often my panoramic “office” with views so spectacular at times, I have to stop and tweet photos of my journey. Telephone reception and Internet access can often be quite challenging so I listen out for the familiar sound of emails “pinging” to know when I can pull over and  get some work done en route.

North West Coast-minI’ll park up at a vantage point, overlooking a loch or beautiful mountain-scape and take a break to catch up on new correspondence and voicemails, make phone calls, have a drink and stretch my legs (weather permitting) Breathing in fresh sea or mountain air is a mile away from my many and varied former jobs: working in prisons (the smell of hundreds of men in cell blocks is unique!); commuting 2 hours each way in and out of London, using the underground etc (dark, oppressive, unfriendly, shrouded with the fragrance of  hundreds of hot commuters) or driving up and down busy motorways round the urban landscape of Greater Manchester, focused largely on avoiding the numerous speed cameras (not always successfully!)

My various roles bear little resemblance to my expectations of  what my future as a dietitian might hold when I left University, but the basic skill set I started with, coupled with my interest in trying out new things and making the most of the many opportunities that came my way, should give confidence to others that anything is possible. You just need to adapt your approach, build on your unique skill set as a dietitian and be prepared to learn (vertically sometimes) so you continue to develop.

I’ve done a full circle to the North of Scotland, in terms of where I started living and learning but the way we deliver health and social care now is vastly different and I’m delighted to still be growing professionally in such a fast moving, person-centred working environment. I am a member of NHS Highland’s senior social care team; an outsider in a world of social workers’ but am accepted for the contributions I can bring to the work of the wider team. I equally value the different model of care which social workers promote, within a culture of co-production, supporting an assets-based approach and a steely determination to make sure that service users are listened to. The professional language and working culture may be different from clinical care settings but we complement each other well with our shared values and appreciation of each others’ roles.

NHS Highland has been responsible for adult social care for less than 5 years and wherever I go to deliver training or meet care staff and residents, the atmosphere is always warm and welcoming, appreciating the personal touch and the opportunity to make a difference to care locally. Integration has opened the eyes of care staff to a whole range of experts and links they might never have known about. Most importantly care (as per inspection reports) for residents and service users has improved as a result of this mutual support and access to approachable, evidence-based skills and care. For my part, I see and hear about great examples of services users’ mealtimes, food, fluid and nutritional care and innovative ways of supporting people to eat and drink what they want. My role in quality development allows me the benefit of spending more than just 30 minutes’ consultation time in any setting. I can take time to look around, to sit and chat with people, to really get under the skin of the care setting, if you like. There’s a danger of practitioners delivering a clinical service to care home residents in the same way that you might in a hospital setting: it can be hard to understand that their advice and input may not be accepted by service users and many healthcare staff will benefit from greater exposure to this care setting to appreciate that it is the residents who are actually in charge of how they live their lives.

Starting to expose future clinicians to this early in university placements is one way that we, in NHS Highland, have tried to engage student dieticians in understanding the differences. A,B,C and Masters students have now experienced and evaluated placements in Highland social care settings (care home and care at home) The feedback from them, the service users and care staff has been so positive that I could have many more students than I’m allocated.

A few dietetic colleagues have expressed some concerns that this may not preparing dietitians for the future hospital workforce but what if new dietitians don’t want to work in hospitals or if more jobs are created in community/integrated care settings.

Within our profession, planning future workforce needs we have to consider, how to  support the delivery of effective care in future within a culture where our aging service users are frailer, living longer- often lacking capacity, taking numerous medicines but whose views have to be facilitated and must come first.

Many people being cared for at home rely on visits (maybe 3 or 4  a day) from carers who (because of time constraints and other tasks to carry out) can do little more nutritionally than heat up food in a microwave and leave a drink on the side. How much do you think it’s possible for them to actually eat or drink each day: especially if they need assistance?

These are a very nutritionally vulnerable group of individuals, often lonely and socially isolated. Our student placements have highlighted some of these issues and I would encourage HEIs and other areas to explore this through the eyes of those studying at pre-registration or masters levels. More research and exposure is needed to help commissioners and others prevent falls, dehydration, malnutrition and expensive, preventable hospital and care home admissions.

My job allows me to advocate for good quality nutritional care in such settings, based on worked experiences, service users’ stories and the unique set of  expert skills I have as a dietitian, which I have continued to develop and adapt over these last 3 decades (maybe a bit more…!)

I would encourage all of my dietetic, HEI and AHP colleagues to continue to develop a dietetic workforce fit for the future and look at new ways of working in social care settings.

Please get in touch if you’d like to discuss further; contact me on evelyn.newman@nhs.net or tweet @evelynnewman17

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