Reforming healthcare education funding:
creating a sustainable
future workforce
Consultation Response from the British Dietetic Association (BDA)
The British Dietetic Association, as the professional association for registered dietitians in Great Britain and Northern Ireland, is pleased to have the opportunity to contribute to this consultation. Founded in 1936, the BDA is the nation’s largest organisation of food and nutrition professionals with over 7,000 members.
Registered dietitians are the only qualified health professionals that assess, diagnose
and treat diet and nutrition problems at an individual and wider public health level.
Dietitians use the most up to date public health and scientific research on food, health
and disease, which they translate into practical guidance to enable people to make
appropriate lifestyle and food choices.
Above all else, the BDA seeks to ensure that the future of the dietetic profession is
secure. With this in mind, we have a number of concerns with the proposals funding
reform proposals, which we have outlined within logical sections below.
Postgraduate Diploma Students
Under item 3.8 the document indicates that The Department will work with
stakeholders to consider solutions to those that fall outside of the standard
Postgraduate Masters loan criteria. The pre-registration dietetic postgraduate diploma
is a popular alternative route to UG study and attracts applications from those with an
existing undergraduate qualification in either nutrition or a related science discipline.
The British Dietetic Association General & Education Trust is a Registered Charity No. 282553
The British Dietetic Association is a Company Limited by Guarantee. Company’s Registration 435492
Registered Office: 5th Floor, Charles House, 148/9 Great Charles Street Queensway, Birmingham B3 3HT
T:0121 200 8080 E: [email protected] www.bda.uk.com
It is thus often an avenue to a career in dietetics for the more mature student, many of
whom bring valuable experience and an understanding of the values-based nature of
the caring professions. Indeed current BDA figures show that approximately 17.5% of
student membership is from those studying on postgraduate programmes.
By virtue of their age, and the disproportionately high numbers of female dietetic
students (approximately 92%), many have caring responsibilities and thus access to
funding support will be an integral element of their ability to engage with this area of
study.
At present many of those studying on dietetic degrees are mature students (63%) and
for postgraduate students significant numbers exit at the postgraduate diploma route.
It is therefore a real possibility that recruitment to these courses might be adversely
affected should financial support not be extended to cover the earlier exit option.
Whilst postgraduate students may aspire to achieve a Masters level qualification in the
longer term, this may not be a financially viable option at the time of pre-registration
training, both in terms of costs of living and also in terms of supplementary fees that
may be associated with the additional units of study. The ability of the postgraduate
student to return to the workforce as quickly as possible also brings benefits to the
NHS and associated sectors and allows a staggered supply of newly qualified
dietitians to be maintained, helping to prevent peaks and troughs in recruitment.
Deferring the submission of the Masters element of a postgraduate degree is a wellrecognised approach within some healthcare programmes and can also allow the
student time to develop a robust and practice based research proposal, thus helping
to develop the evidence base of the profession.
Postgraduate Masters Loan
The proposal for the Postgraduate Masters loan is unrealistically low. In all likelihood
this will be the main source of income for many students. It falls well below the national
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living wage which is deemed by the Living Wage Foundation1 to be adequate to cover
the costs of living in the UK.
Currently the Living Wage figures are £8.25 outside London and £9.40 inside London.
Basing the equivalent salary on the standard basic NHS weekly hours of 37.5 the
annual minimum salary outside of London would be £16, 087 and inside £18,330. The
BDA argues that it is unfair to suggest that a postgraduate student can live adequately
on less than this and refutes the healthcare students’ ability to maintain an adequate
standard of living on the proposed £10,000 loan, should they be eligible to access this.
The BDA believes that the Masters Loan Scheme is unsuitable for healthcare
programmes and indeed was not designed with this student in mind. Rather it reflects
the needs’ of the more generalist degree programme, which is significantly less
intensive (allowing the student to supplement income with paid work) than two year
full time intensive pre-registration dietetic Masters or Diploma. The Dietetic Masters
programmes cannot be completed in one year thus creating a risk that such study
options are only open to students who are in a position to self-fund. This is clearly
contrary to principle of widening participation.
Given the current high demand for pre-registration dietetics programmes as a second
career / degree option, it is a distinct possibility that mature students will select to study
for a second undergraduate degree as the financial terms associated with this are
more favourable. This would appear to be a retrograde step, both for the student and
for the profession and limits the potential research opportunities (either during the
degree or at a later date) thus stunting scientific advancements in this field.
The BDA urges the funders to consider applying similar rules to Postgraduate preregistration healthcare Masters programmes and Diplomas as exist for Postgraduate
Certificate of Education (PGCE) students. This would enable the future workforce to
access the same loan amounts and terms as their undergraduate counterparts. This
would enable this cohort of students to pay back their loans sequentially, rather than
1
http://www.livingwage.org.uk/calculation
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concurrently (as per the current proposal).
Fear of debt is a very real phenomenon and should not be under-estimated. As
reiterated throughout this consultation response, the high proportion of second career
and mature students entering the dietetic profession brings valuable skills to the NHS
and it is important that such high quality applicants are not prevented from entering
the profession through as a result of concerns over debt repayment.
Further undergraduate level study
Much of the consultation paper appears based upon the premise that the choices and
behaviours of healthcare students will be similar to those of other students within the
University system. However, the BDA is not convinced this stands up to scrutiny.
Firstly, it is important to acknowledge that the BDA is delighted Department for
Business will forthwith recognise nursing, midwifery and allied health courses as
STEM subjects, taking into account the significant value and resource intensive nature
of the training. However, within the consultation document the comparator data in item
2.9 relates to current STEM students, where the majority of courses lead to careers
with high earning potential.
Future healthcare students are likely to be concerned about return on educational
investment and their ability to clear their student debt in a timely fashion, without
accruing significant interest charges. Such concerns can only be exacerbated when
students are required to increase their financial burden by entering into further debt
for a second degree.
Whilst the terms associated with the second undergraduate degree are confusingly
more favourable than the Masters loan, a significant repayment on income above
payment threshold salary is likely to be an important consideration in terms of
affordability calculations for the graduate, the majority of whom will have limited
capacity to achieve higher grade posts without embarking upon yet more study (at
Masters level) later in their careers.
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Effectively, it is possible that the effect of the proposed second undergraduate degree
route is that those who choose to change career (again many of whom bring extensive
experience and a real desire to serve the public) will only do so if they are already in
a financially robust position. This risks creating a two tier approach entirely at odds
with the widening participation agenda.
Reflections on the proposals – standard student support system
The BDA first wishes to acknowledge the mandatory inclusion of healthcare
programmes under the access agreement arrangements. This is a welcome addition
and the profession has a desire to see the career pathway promoted within
disadvantaged communities.
However, there is a need to ensure that dietetic
programmes remain a viable financial option for universities to run.
The smaller healthcare programmes are expensive to run due to the high level of
teaching, supervision and assessment required, in addition to the capital investment
in simulation suites and other equipment necessary for the training of practitioners.
Without sufficient investment from HEFCE teaching grants / student opportunities
funds, it is possible that universities will be seeking lucrative income from overseas
students. In turn this may impact on availability of practice education placements and
the numbers of domestic student places available. This is in a climate of uncertainty
where the profession is keen to preserve the high demand and high quality
applications for dietetics pre-registration programmes that it currently enjoys.
It is
important that the quality of applications is monitored and that universities continue to
recruit excellent widening participation candidates choosing alternative career
pathways.
The Government should be wary of a creating a system which is unattractive to both
university providers and potential healthcare students. Equally, there is a risk that an
increased proportion of the newly qualified workforce would choose to work outside of
the public sector (industry, freelance etc) in order to achieve more rewarding re-
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numeration packages, which may create an under-supply within the public sector
healthcare workforce.
Potential repercussions of this eventuality may include NHS staff dissatisfaction and
stress, costly recruitment campaigns and reliance on agency staff (as seen in the
teaching profession) and a disproportionately high overseas workforce (which in turn
would be restricted due to laws affecting earning potential and associated working
visas).
The BDA values the non-refundable carers allowance outlined in Table 2. This will be
an essential component in helping to attract applicants from the mature and low
income cohorts. However, a contribution to childcare costs even when combined with
student loan and the Government’s Child Support contributions may not be a
financially viable option for low income or sole earner families.
Under 3.31, the document suggests that the UK is likely to see an increase in full time
mature students entering onto healthcare programmes, in-line with the general
population. The BDA disputes this assumption as unproven. It is possible that a
significant proportion of those wishing to enter the profession via this route may not
have come from lucrative first careers, rather will have come through the NHS Support
Worker route. It is unlikely that this cohort will have accrued sufficient savings to
enable them to invest in their future studies and support their dependents throughout
this period unless they have financial support from elsewhere. This is again at odds
with the widening participation agenda and should be considered and addressed.
Point 3.36 identifies an excess of £300 which all students will need to be able to
contribute towards the costs of travel for practice education in order to attend practice
education placements (a compulsory part of pre-registration dietetic education).
Due to the size of the profession dietetic students are often placed at locations many
miles from their university as local education opportunities are not necessarily
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available in every county or city, as they are for some larger professions. Whilst the
BDA and the profession is innovating to develop increased capacity and local
placements, dietetic education cannot be sustained if students are unable to travel to
placement sites. Travel is essential and has a cost which it will be difficult for some
students to afford and thus the BDA would call for the proposed means tested travel
bursary and excess charges to be abolished.
Further thoughts on student demand
The additional 10,000 nursing, midwifery and allied health profession student demand
figure (as identified by Department of Health) is, in the BDA’s view, yet to be
substantiated and is potentially arbitrary. As a professional body the BDA is keen to
understand the calculations behind the statement.
The BDA wishes to stress the importance of ensuring that the new funding system
does not operate under the premise that healthcare students will behave in a similar
manner to the wider student population. For the healthcare professions, earning
potential is likely to be lower than for many other graduates. Moreover, the dietetic
profession provides a valuable and much needed resource which significantly impacts
on population wellbeing, managing long term conditions and reducing the financial
burden on the NHS.
The long term financial burden that study will place upon
healthcare graduates and their limited capacity to repay (thus accruing ongoing
interest and affecting borrowing potential) is a cause for concern for both Government
and the student alike.
Notwithstanding the above, the BDA will be delighted if the new system does increase
the number of students with the assumption that there will be more dietitians to meet
demand. Nevertheless, it is crucial that the calibre of the profession and the students
accepted is maintained and that entry requirements to courses remain high. Dietetics
produces graduates with a singularly unique mix of clinical scientific skills, combined
with a values based, service user focused approach, alongside psychological and
behavioural change techniques. Under the current system, dietetics is a high demand
programme of study, ensuring that those selected embody the values and skills
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required to succeed through the intensive pre-registration training. This is reflected in
the low attrition rates. It will be important to monitor the situation post funding reform
to ensure that standards are maintained and that the universities do not see a
decrease in the numbers of mature, second career applicants who offer so much to
the profession and to service delivery.
The BDA urges the Government to ensure that recruitment is sustainable and that
there is sufficient domestic resource to meet demand. In order for this to happen, preregistration healthcare programmes must be appealing to the potential student and
must be financially viable for the university to run.
Issues of Fair Access
With an approximately 92% female dietetic student cohort, the issue of student
maternity leave is an important one. It should be recognised that many students
(particularly mature students) may resign from jobs in order to study dietetics and thus
will relinquish their rights to a workplace maternity scheme. The BDA believes that it
is vitally important that a) the discretionary bursary becomes a statutory obligation and
b) that the full 12 months maternity support is provided (as per the current bursary).
As outlined above, the premise that healthcare students should be judged in line with
the general student population is flawed and does not take into account the absolute
necessity of this workforce for the future of English healthcare provision. It must
remain an accessible study option for all.
The issue of access to funding for part time students does not apply to dietetic
programmes at the current time as all are delivered on a full time basis. This is due to
the fact that whilst there is demand nationally, as a smaller healthcare profession, this
has not as yet translated at local level. However, the profession acknowledges that
part time options (combining study with employment) may become increasingly
appealing to healthcare students under the proposed funding changes.
The BDA is keen to see part time study options developed for dietetic students. It
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encourages universities to consider the possibility under their corporate social
responsibility agenda in order to help support the widening participation agenda and
future population healthcare requirements. Indeed, the organisation will be working
closely with its partner universities to consider such options if demand is proven. In
particular, the BDA is keen to explore the option of HEFCE Catalyst Funding provision
to develop dietetic degree apprenticeships, in line with current Government initiatives.
Practice Education Placements
When considering funding of future placements, Health Education England (HEE)
must take into account the diverse breadth of working environments for dietetics,
within the NHS and beyond.
It should be noted that under item 2.4 that Department of Health has identified the
artificial cap that has historically been placed on training numbers. Through previous
Call for Evidence submissions the BDA has invited HEE to consider the wider
workforce requirements for dietetics. Indeed, in item 2.11 the consultation document
openly recognises that there is currently instability in ‘home-grown workforce supply’
in the social care environment, an argument that the BDA has made previously with
regard to the need for staffing within this crucial sector. Thus the BDA is extremely
keen to work with HEE to ensure that future workforce planning data is robust and
adequately maps to the requirement to the public health workforce in terms of dietetic
intervention. However there are some concerns that whether the move towards a loan
model has reduced HEE’s own levers to influence workforce planning going forward,
potentially leaving smaller professions vulnerable to the vagaries of the market
approach.
The work of dietitians in non NHS roles is crucial to the wellbeing of the population
and can have significant impact on reducing the cost burden to the NHS. For example,
dietitians play a critical role in the public health agenda and in supporting healthy life
changes for the population (thus reducing the NHS burden). Similarly, the role of the
dietitian in the social care setting ensures that service users are adequately nourished
and the impact is a reduction in the number of acute admissions required.
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The General Practice Forward View (April 2016)2 identifies 5,000 ‘other healthcare
professionals’ needed to deliver the increasing healthcare outputs within the Primary
Care sector. The dietetic profession is exceedingly well placed to contribute to this
initiative, fulfilling a vital function managing nutritional care requirements for those with
multiple long term conditions including IBS, obesity and diabetes. In addition, the
dietetic workforce has the capability to undertake the more strategic roles, training
others to manage conditions such as malnutrition. In the emerging models of care
dietitians are assuming a consultancy style role. This does not detract from the other
areas of practice where they remain in a highly clinical role (particularly within MDTs).
The dietitians’ integral role in supporting a multi-disciplinary approach to care could
valuably be demonstrated through the innovative and emerging new models of care
(such as the vanguard sites). Indeed the profession both qualified and students in
training, should be sought out in order to fulfil a cohesive role in providing the crucial
nutritional advice and guidance that is clearly part of the dietetic remit.
In addition, regardless of sector (whether this be private, third or the more traditional
acute or community care) dietetic interventions have the power to beneficially impact
the public purse, reducing the number of NHS contacts (with GPs, hospital medics
and other healthcare professionals) required.
In order to add cost benefit and capacity to the system, as outlined above, the BDA
calls upon HEE to ensure that funding is made available to cover the cost of training
dietetic students to work across the range of environments required. The profession
has concerns that the artificial caps currently placed upon the numbers of dietetic
student placements may remain, due to incomplete workforce planning data (failing to
take into account the dietetic workforce required beyond the NHS). The impact would
be limited funding for practice education placements which in turn may limit the
number of student pre-registration training places available.
2
https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf
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Historically, funding for placement education has often been difficult for the placement
provider to identify and ring-fence, as it is subsumed within broader departmental and
Trust budgets. Going forward, funding for placements must transparently follow the
student journey to ensure that adequate staff resource is made available, protecting
the quality of work based training provision whilst maintaining adequate staff levels to
safeguard patient safety.
In partnership with appropriate usage of HEFCE training grants, the BDA would
welcome a commitment from HEE to fund all practice placement activity for every
domestic student. Healthcare programmes are costly to run and universities must be
incentivised to continue to recruit domestic students and train the future domestic
healthcare workforce, rather than flooding the higher education system with students
from the lucrative overseas market. Thus a balance must be found. Equally the cost
of funding any shortfall in practice education placements should not fall to the student
as this may further deter applications and impact on the viability of the courses and as
a consequence, the staffing resource available to the NHS, public sector and beyond.
HEE has a mandate to ensure sufficient healthcare workforce for the future and a
crucial element of this is securing the practice based training required.
Finally it is important that HEE fully considers its quality monitoring processes to
ensure that a standardised approach across the UK is adopted and that the new HEE
Quality Framework3 is applied consistently at cluster level.
This will produce
comparable datasets and will reduce the administrative burden on university staff. In
addition, it must be recognised that students investing in their future are likely to have
higher expectations of the programme. Staff must thus not be hindered by excessive
quality monitoring (although it is an important aspect of the higher education provision)
and instead be free to provide the teaching, support and feedback that the student
demands. It is hoped that QAA’s HEDIIP4 project and implementation of the may go
some way to addressing these concerns and that HEE and other stakeholders will be
3
4
https://hee.nhs.uk/sites/default/files/documents/HEE_J000584_QualityFramework_FINAL_WEB.pdf
https://www.hediip.ac.uk/
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able to elicit quality monitoring data from one central resource, although this is likely
to be some way off.
Smaller and specialist health subjects
The BDA is pleased that HEE recognises the issue of viability for small and specialist
courses and the impact on the healthcare profession should such courses cease to be
viable.
At present, though a relatively small profession, dietetic programmes do not struggle
to recruit applicants. However, it is important that this trend be maintained and
applicants to programmes are diverse in background and representative of the
population served. The quality and quantity of applications to pre-registration dietetic
programmes must be closely monitored with interventions commenced as and when
required.
Dietetic training programmes produce a workforce that, as outlined above, can impact
on NHS and public budgets, improve patient satisfaction and provide valuable
consultancy and support to the wider healthcare team. Good nutrition is a crucial
factor at the heart of positive outcomes from the majority (if not all) conditions.
The quality of the training programme and the premise of patient safety consequently
determines the cost of the provision, which can be costly in line with other healthcare
programmes.
The BDA welcomes the forthcoming HEFCE technical consultation on teaching grants
and urges the organisation to engage in a full costing exercise to identify the
mechanisms through which vital small and specialist courses can be sustained.
Conclusions
As outlined in the response above, the BDA foresees potential risks and benefits to
the implementation of the new student funding regime. There is potential for the
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profession to increase in size, with universities extending the number of student offers
per cohort, thus protecting or increasing the viability of the programmes of study.
However, in order for this to be achieved, the following must be taken into account:
1. The profile of the dietetic student body is disproportionately female with mature
students over-represented. Many students enter the profession with nutrition
related first degrees. Thus it is crucial that the loan system be equitable and
offer fair access to postgraduate study, students with caring responsibilities and
those from low income families – in line with the widening participation agenda.
2. Workforce planning, as carried out by HEE, should take into account the
increased demand for dietitians, both within the NHS and in support of NHS
initiatives to improve the health of the nation. Practice education commissions
must increase to reflect this demand and to ensure continued viability of dietetic
pre-registration education.
3. Within the forthcoming HEFCE technical consultation, the BDA will emphasise
the need for dietetic education to be granted increased financial support
(through the teaching grant and associated banding). The costs associated
with delivering dietetic education are significant, with courses requiring a high
staff to student ratio plus technical equipment and resource to safeguard
standards of teaching.
Finally, whilst the Government outlines the significant cost savings to the public purse
which it believes the changes to healthcare student funding will bring, the BDA remains
skeptical that these savings will truly be realised. Concerns such as those outlined in
the recent report published by London Economics5 indicate that a significant
proportion of nursing and AHP students will not repay their loans.
5
http://londoneconomics.co.uk/wp-content/uploads/2016/05/UNISON-NUS-Report-Nurse-fees-and-funding24-05-2016-FINAL-VERSION-LONDON-ECONOMICS.pdf
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The sustainability of the dietetic workforce will rest on the ability of universities to
recruit high calibre domestic students onto pre-registration courses; ones which can
offer quality practice education experience. If this is not achieved, the impact will be
an inability to recruit dietitians to the NHS and a costly reliance on agency and
overseas staff.
The ability to maintain recruitment and deliver excellent work based training is
attainable and within the Government’s gift to secure. The BDA is therefore eager to
continue to work with all relevant bodies to ensure a dynamic and sustainable supply
of dietitians for the future.
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