Elevator interview
Emma Harewood
What is your role? How did you move into this role and what is your background?
I am currently Director of Integration at Surrey Heath CCG responsible for leading the integration of health, social care and the voluntary sector and establishing integrated care teams in the community.
From a background in paediatric dietetics I moved into dietetic management and professional leadership roles, and then into executive lead roles in Quality and Improvement. 18 months ago I left my substantive post and set up my own consultancy business, providing support in transformation, quality and cost improvement to a variety of providers and commissioners in the NHS. It is surprising how you can weave dietetics into most integration models and quality reviews!
With the still relatively 'new' NHS Clinical Commissioning Groups (CCGs) how do you think that the commissioning of services, such as dietetic services, will change nationally?
Good nutrition and the importance of diet in health and wellbeing are frequently the conversation of commissioners, public health and GPs. And yet, dietetics as a profession, remains largely unknown in the commissioning world. Many dietetic services are acute based and therefore in danger of being lost in large acute contracts which focus on admissions avoidance, HCAIs and A&E targets.
There are opportunities right now as CCGs work with social care to design integrated teams in the community. If local dietetic departments can provide commissioners with the right information at the right time, detailing how dietitians can enable people to stay at home longer, then there is the opportunity to influence commissioning decisions. CCGs will be looking to see how dietetics can support the integrated care team professionals with training and the patient/carers with improved nutrition and wellbeing. With the financial pressures faced by the NHS, suddenly the importance of good nutrition in enabling people to stay well enough to self-care is paramount.
For specialist services (such as diabetes, cancer, paediatrics) there are clinical leads (usually local GPs) in each CCG that are highly influential in commissioning plans and local decisions. Specialist dietitians can build relationships and influence these GPs, in terms of ensuring dietetics is on the broader commissioning agenda as well as providing business cases to be shared at the CCG clinical decision making forums.
How big is the population in one of the areas with whom you work with? How many different care settings does this cover?
The CCG I am working with is one of the smaller CCGs in the country, with just a 90,000 population and 10 GP practices. Most CCGs are 200-300,000 population and around 30-40 GP practices. CCGs currently commission acute hospital care, community services (nursing and therapy), mental health and learning disability services, continuing healthcare. Some of the smaller CCGs work together with one CCG as the lead commissioner to enable county-wide commissioning.
Specialist services, tertiary acute hospitals, health visiting, GP practices are commissioned by NHS England and the Area teams. The County Councils commission school nursing and social care, including funded care home beds and reablement.
Which key documents do you find most useful in supporting your case for dietetic services?
The task when preparing a compelling case for your local CCG is to ensure that you understand their priorities. These will be based on national drivers such as ‘Everyone Counts planning guidance 2014-18’ and the ‘Better Care Fund’ guidelines, as well as local public health demographics that highlight the local health need such as the ‘Joint Strategic Needs Assessment’ or JSNA. Your CCG will have a 5 year strategic plan and a Plan on a Page that clearly outlines the health needs they are looking to address and their investment plans. For example: readmissions, avoidable admissions, obesity and alcohol consumption in working age men, suicide rates.
Once you are clear of the CCGs priorities and how to can align your case then I would suggest moving on to national clinical guidelines such as NICE quality standards and speciality specific guidance. These will be familiar to the Clinical Lead at the CCG that you are there to convince and will provide robust evidence to support your case. Think about would happen to your local population or flow of patients if the guidelines were not implemented locally. For example, more children with complex needs attending A&E or being admitted for PEG replacement as no dietetic service.
Where there is no national guidance related to dietetics consider:
- Local benchmarking with other dietetic services
- An audit, for example, malnutrition/dehydration related hospital admissions
- Bid from national funds for a pilot of dietetic intervention and work with the CCG/acute trust/community pharmacy team to monitor impact on outcomes.
In your experience of working with different CCGs who decides/develops any guidelines around prescribing of enteral tube feeds and or oral nutritional supplements?
Prescribing guidelines are usually written by the CCG clinical lead for Medicines Management and the Prescribing Team for the CCG. Often they liaise with the acute dietetic department but not always, usually dependant on relationships from Primary Care Trust days. If you don’t yet know your Prescribing Team lead then start to build that relationship.
Currently CCGs are looking at sip feeds and specialist feeds – there is a consensus that some of these feeds are continued on too long without review. Another area that is frequently on the list is specialist baby milks, especially after 6 months. This would be a good area to offer a CCG a one off invest to save service of dietetic review with the potential to evidence the need for an ongoing increase to community dietetic service.
What should dietitians do to make sure they are continued to be seen as the experts in good nutrition whether it be advising other healthcare professionals or budget holders? How can dietitians increase their profile?
Ensure you know your CCGs 5 year plan and commissioning intentions. Understand the local priorities raised in the JSNA, and by the Transformation Board and Health & Wellbeing Board.
Get to know your local CCG clinical leads in the specialities relevant to your role. Offer to meet quarterly. Some potential clinical leads include:
- Unplanned care – integrated care teams, frail elderly pathways, admissions avoidance especially readmissions, supporting nursing homes
- Long term conditions – cardiac, stroke, diabetes, respiratory
- End of life care or cancer.
Follow your CCG on Twitter and ensure you make your presence known. For example, Tweet them 3 months in advance of national health promotion weeks and offer to support the local population with events or articles.
Attend CCG stakeholder events for the local population. You will often find reps here from the local acute trust, mental health trust and voluntary sector, as well as the general public. These are great opportunities to shape the commissioning intentions and funding plans.
Offer up business cases that will support the CCG priorities and QIPP change. Provide simple, fact-based information linked to local outcomes and priorities.
What would you say dietitians bring in your experience and, as a profession, what behaviour should we 'dial up' when talking to those who commission services?
Dietitians have a breadth of knowledge in health conditions from health promotion and prevention, to disease management and specific treatments. Dietitians work with the acutely unwell, frail elderly, paediatric and mental health/learning disabilities. This means for a commissioner, dietitians can offer insight and holistic solutions to a multitude of issues and priorities.
When talking to commissioners dietitians are well placed to ask: “How can we support you to meet your priorities?” And it always helps to do your homework and to be able to play back the local health concerns and priorities: “I have noticed that you have an increasing number of people readmitted after falls. Have you considered how improving nutrition and hydration can reduce the risk of repeat falls by xx%?”
Commissioners cannot be the experts in everything so remember the 3 steps:
- Identify the local health issues/priority and play it back to the CCG
- Describe succinctly how dietitians can help with evidence/national guidance where available
- What would the dietetic service do and what would be the impact on patients and staff.
Finally remember the timescales – Commissioning intentions for 15/16 are developed and signed by September 2014, so now is the time to go to your local CCG stakeholder events.
Where do you live?
Near Guildford, Surrey
What three places or things should people go or do if visiting the area in which you live?
- Picnic tea and dog walk at the top of Pitch Hill – one of the Surrey Hills
- A show at G-live
- A meal at the Thai Terrace.
What is the book you are reading at the moment or would like to read?
Whichever one I can buy on my way to relax in the Scottish Highlands.
What is your favourite meal?
Coronation chicken, new potatoes and a big salad.