Dietitians in Local and National Transformational Roles – what do we do?

As the Scottish Government’s Modernising Patient Pathways Programme’s Professional Dietetic Advisor and Lead for Coeliac Disease and as NHS Tayside’s Nutrition MCN Programme Manager, I was asked to share some of what I do and how I lead the transformation of pathways and services both locally and nationally.

I have been working as a dietitian for nearly 30 years; almost 20 of these in Tayside and 7 of them with the Scottish Government. I lead on whole system transformational change within clinical pathways where nutrition plays a key role in treatment. Leading pathway and service change requires the same skill set and over the years we have developed within the Tayside Nutrition MCN an approach which is a blend of healthcare public health, the Scottish Approach to Service Design (SAtSD), quality improvement and research. Healthcare public health is concerned with maximising the population benefits of healthcare and reducing inequalities while meeting the needs of individuals and groups. This is achieved by prioritising available resources, by preventing diseases and by maximising health related outcomes through design, access, utilisation and evaluation of effective and efficient healthcare and social care interventions and pathways of care (Faculty of Public Health, 2015).  

My approach both locally and nationally involves:

  1. Identifying the key issues and population need (including health inequalities)
  2. Working with stakeholders (including people living with the condition and third sector organisations) to co-produce change – based on the Scottish Co-production Network principles and the published evidence base
  3. Using SAtSD to co-designing novel approaches to pathways and services
  4. Co-creating pathways with the person at the centre with a focus on supported self-management
  5. Ensuring digital first approaches wherever possible within pathways
  6. Testing pathways/services using quality improvement approaches (PDSA, 30 day rapid cycle tests)
  7. Co-assessing and tracking improvement with data to deliver positive change and best experience, outcomes, spend and practice.
  8. Research and publication thereby sharing and spreading knowledge and learning.

My national and local role requires an adaptive leadership style as many of the issues are complex with no straightforward answers or solutions. Therefore I have had to be a good facilitator of change, bringing key people together to enable a better understanding of the issues, collaborating on solutions and synergising and energising the thinking of others. Good communication is needed to help people visualise the issues and possible new futures. I have had to become a better capability builder, helping others transfer their knowledge and skills to the co-design process and a strategist by designing and planning action to ensure programmes meet overall aims and targets. I have had to review the published evidence base and stakeholder views and how effective are the new ways of working. It has required the development of entrepreneurial skills that ensure the end to end development of new digital ways of working, then testing and rolling out at scale as a co-creator of change and a supporter of others in new roles.

The challenge I was given by Scottish Government in 2016 was to deliver an improved, clinically appropriate, cost effective, safe and sustainable coeliac disease service on a ‘once for Scotland’ basis.  The transformation of the service was particularly relevant to help meet the 2020 Vision, in terms of services being provided to the highest standards of quality and safety. The following Modernising Patient Pathways Programme core principles have been incorporated into the new coeliac disease pathway and now all pathways I help transform:

  • strengthening self-management
  • accessing decision support and care in the community
  • using the consultant resource only for the most complex cases
  • enhancing the role of the wider multi-disciplinary team in the community
  • optimising e-health and digital technology
  • reducing variation in practice

The approach I take has brought many successes and new improved pathways of care for coeliac disease, nutritional support, weight management, IBS and type 2 diabetes. The new pathways have led to novel services and ways of working being created such as the Gluten-free Food Service, care home ONS support and dietetic-led pathways of care. New digital platforms have also been co-designed and implemented as a result, meeting pathway need and assisting people to self-manage whilst reducing demand on the clinician, thereby freeing-up time to deliver care to those who need it the most. Platforms such as was co-designed and is the first and only platform in the UK which assists people to order gluten-free food using their NHS gluten-free unit allocation. Inhealthcare services for IBS and nutritional support have also been co-created to help people self-manage. Oviva support for people living with or at risk of type 2 diabetes has been delivered at pace in Tayside and will help transform how we deliver services in the future within the NHS in Scotland. These are all truly transformational pathways, services and digital platforms which will allow the population of Scotland to have a different experience of care provision, focusing on what supports them and encouraging active participation in co-delivery of care. Covid-19 has brought the digital agenda into sharp focus with digital now not optional but essential. The 4 Nations AHP Rehabilitation Statement of 2020 makes this clear and gives us a great springboard to change. We need to maximise this going forward, grab the opportunities and the learning, and truly transform dietetic care and our workforce.

It has been a pleasure to work in my transformative dietetic role over the years in Tayside and Scotland. One of the highlights has been working with many talented dietitians who go above and beyond to deliver and test new ways of working, collectively developing new pathways and digital support tools. I see a very bright future for the profession and I know that one positive Covid-19 legacy will be the ongoing embedding and development of digital dietetics.

Jacqueline Walker MSc BSc RD



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