Dieticians in mental health trusts can help make the shift to preventive wellbeing services, says Stuart Shepherd

While the impact on dietary health of many drug treatments used in mental health has long been recognised - with side-effects that can include obesity, hyperlipidaemia, hyperglycaemia and diabetes - it is only more recently that the poor physical health of service users and the broader relationship between diet, mood and behaviour have received proper attention.

150 - Approximate number of dieticians working in mental health

80 - Number of those working only in eating disorder units

Dieticians are well placed to provide mental health trusts with a range of clinical and management services that match the requirements of a shift from sickness to proactive and preventive wellbeing services.

Some mental health trusts have a well established practice of directly employing dieticians. And, with more trusts acquiring foundation status and seeking to manage a greater number of services in-house, these substantive posts have increased.

“There are trusts that provide a very good nutrition and dietetics service,” says Ursula Philpot, senior lecturer at Leeds Metropolitan University and advanced practitioner at the Yorkshire Centre for Eating Disorders. “For 500 beds they will have five or six dieticians. But equally there are trusts with the same number of beds where services are poorly commissioned. They might only have one dietician in for just two days a week. How they are meant to manage I have no idea.”

What they almost certainly won’t be doing under such circumstances is fulfilling CQC mental health and learning disability core standard 15b - to provide a nutritional assessment for each patient so that their dietary requirements can be met at all stages of treatment.

The numbers of dietetic specialists and support staff in mental health are growing, and these are helping to tackle issues such as elevated body mass index (BMI) and increased waist circumference that are a problem for many service users.

Dietary interventions

“There are trusts employing HCA grade nutrition practitioners to deliver dietary interventions and advice,” says Ms Philpot. “They work alongside and are managed by the professionally trained and qualified dieticians who don’t need to be seeing every patient and can lead on things like health and wellbeing initiatives and obesity strategies.”

“Patients are very keen to get the basics of self-management right,” she continues, “and they appreciate advice about food because they understand it can improve both their physical and mental health.”

The British Dietetic Association mental health group, which Ms Philpot chairs, is engaged in work to examine national standards for dietetic services in mental health. A report, looking at issues including practice, caseload parity with other allied health professionals and staff structure, will be published later in the year.

Jo Smith is the Band 8a dietetic adviser and clinical lead at Tees, Esk and Wear Valleys Foundation Trust, which employs eight dieticians and an assistant, with two additional posts created since services were gradually transferred from primary care, beginning back in 2008.

“Provision was always historically based but as referrals have grown we have been able to support requests for further funding,” says Ms Smith. “Learning disability had no dietician of its own but a caseload of 60. Since we raised that with management internal money has been found.”

The trust’s dietetic team is developing a nutrition care pathway, working with partners to deliver a Shape-Up pilot with inpatients and commissioning arrangements to allow for mental health dietician input into community specialist weight management programmes.

A commissioner’s perspective

Wayne Goddard, NHS Doncaster assistant director, commissioning and strategic development, says: “We recognised from the quality and outcomes framework that a healthy diet and good physical health are good indicators for mental health. So our mental health providers are being incentivised with an extra payment for doing a nutritional screening on admission to their units. They record the patient’s body mass index and weight as well as a diary of their normal food and fluid intake.

“Depending upon the severity of any deficiencies that might be indicated, the patient will be signposted to either a dietician or wellbeing nurse. They can give educational advice and support to help the individual adapt their diet which in turn will improve their mental health. The intention is that this approach will form part of the specifications in the new contract.”

He adds: “The trust has a mental health dietician in a substantive post who reports to Malcolm Peet, the lead clinician for nutrition in mental health. Professor Peet is a consultant psychiatrist involved in providing a service for nutritional assessment and treatment within an early intervention in psychosis team.”

Professor Peet’s studies of the role of nutrition in mental health are widely published.

Dieticians and Mental Health trust strategy

In addition to face-to-face patient work senior dieticians can offer:

  • audit and research support on all aspects of nutrition in mental health and the effectiveness of dietetic interventions
  • consultation on protocols and approaches to the therapeutic management of complex dietary problems
  • development and training programmes for the mental health multidisciplinary team to deliver first line nutritional interventions
  • advice on implementing relevant NICE guidelines
  • recommendations for inpatient menu planning

Dietician numbers increasing slowly: head count of dietetic staff since 2000

Source: The NHS Information Centre for Health and Social Care: NHS Hospital and Community Health Services, Non-Medical Staff, England, 1998-2008