Shared learning database

GWH NHS Foundation Trust & NHS Swindon
Published date:
February 2011

The NHS QIPP agenda states that all NHS staff have a personal, professional and moral responsibility to address financial inefficiencies in order to treat more patients, more effectively (DOH 2010). Swindon PCT and GWH NHS Foundation Trust identified a need to improve prescribing practices of oral nutritional supplements (ONS) in the community in order to meet NICE guidelines and produce cost savings. The project included an initial audit to assess current prescribing practice in 4 GP practices identified as the highest prescribers of ONS. Nutritional education sessions were then devised to highlight the identification and treatment of malnutrition and provide guidelines to improve prescribing practices. So far a re-audit has been conducted on 2 of the GP practices 6 months post education to assess improvements in meeting NICE guidelines incorporating clinical and cost effective prescribing of ONS.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To increase knowledge about nutrition and improve prescribing practices of oral nutritional supplements (ONS) in the community focusing on effective nutritional screening and cost effective prescribing of ONS without impairing the quality of services offered to patients. 1. To identify current practices for adults prescribed ONS in GP surgeries. 2. To understand how patients are managed once prescribed ONS. 3. To provide recommendations based on NICE guidance to improve nutritional screening and prescribing of ONS, leading to improved adherence to evidence based practice and the reduction of malnutrition in the community. 4. To monitor nutritional interventions and the effectiveness of recommendations via re-audit and analysis of prescribing data.

Reasons for implementing your project

Malnutrition is both a cause and consequence of disease in adults. It is estimated to affect at least 3 million adults in the UK (Elia 2009) and costs the UK £13 billion annually in public expenditure (BDA 2009). Oral nutritional supplements (ONS) are commonly used to treat patients with malnutrition (Stratton 2000). General practitioners (GPs) and nurses are largely responsible for the management of patients in the community who are prescribed ONS, however it has been found that these professionals receive little training in nutrition, and practice relating to ONS is not always evidence based (Kennelly et al 2008). Nutritional Screening provides an opportunity to identify patients who are malnourished or at high risk of malnutrition and also helps to determine when or if ONS are required. By ensuring patients are assessed using a validated nutritional screening tool and ONS are only prescribed for those who are malnourished or at high risk of malnutrition it is possible to ensure ONS are used both clinically and cost effectively. Data showed that within a 12 month period (2009), £250,490 was spent on ONS in Swindon PCT, which included 28 GP practices (population registered to GPs = 216,357). NICE cost savings guidance suggest estimated cost savings by meeting NICE guidance could be £28,472 per 100,000 (NHS 2010) giving an estimated potential saving of £61,600 in Swindon.

How did you implement the project

1 & 2. An initial retrospective criterion based audit was carried out at 4 GP practices to assess current prescribing patterns of ONS in the Community. 11 standards based on NICE guidance were used. Patients were not included if they were under 18 or were taking ONS in addition to enteral feeds e.g. percutaneous endoscopic gastrostomy. The 4 GP practices selected were the highest prescribers of ONS during 2009. A single auditor was responsible for collecting the data with each GP practice; the data was collected from computer based record systems. The compliance target for each standard was 100% in order to meet NICE guidance. Percentages were calculated based on those that met the standard and those that did not. Those that met the exception or were non-applicable were not included within the percentage calculations. 3. Nutrition education was provided to GP practice staff which involved the use of a nutritional screening tool, 'MUST' - Malnutrition Universal Screening Tool (BAPEN) and implementing appropriate management guidelines based on the risk of malnutrition. The education also included appropriate ONS prescribing guidance. 4. To date 2 out of the 4 GP practices have been re-audited 6 months after providing nutrition education. As a result both GP practices decreased their prescribing costs of ONS by 39% and 38%, if this project saving was achieved throughout Swindon it would show a potential annual cost saving of over £95,186 (please note potential for savings vary between GP practices due to differing populations and demographics).

Key findings

Key findings from the initial audit found that standards were not being met across the majority of practices. There was no use of a nutritional risk screening tool being used in any of the 4 GP practices and there were no aims documented for any of the patients prescribed ONS during the audit period. There was also very little 'food first' nutritional advice being given to patients, and few patients were prescribed the recommended ONS or were given a 2 week trial of ONS to assess their preference to flavour and texture. Very few patients were reviewed prior to the next supply of ONS and even fewer were reviewed after 3 months to assess their ongoing need for ONS. Following the initial audit, nutritional education sessions were offered to every GP practice in Swindon PCT. To date the 4 GP practices involved in the initial audit have participated in education sessions as well as another 8 GP practices in the local PCT area (total 12 out of 28 practices). A re-audit was completed on 2 out of the 4 practices during 6 months post nutritional education. Both practices resulted in increasing their compliance with the standards. Practice 2, improved 6 out of the 11 standards, and practice 4, improved 9 out of the 11 standards. The implementation of the education led to: - increased use of 'MUST', increased documentation 'food first' advice, improved indications and aims of treatment when prescribing ONS, and increased use of a 2 week trial period to assess patients ONS preference. The initial audit was awarded the Mike Hellier Bronze Prize award at the GWH NHS Foundation Trust (2009). The audit project has also been selected for presentation at the Clinical Audit and Improvement Conference in London (February 2011) and an abstract is being written for publication.

Key learning points

- Direct comparisons cannot be made between GP practices due to differing practice populations and demographics. - The Audit was not able to assess patients that may be at risk of malnutrition but not prescribed ONS however considerations are being made for future audits in this area. - Considerations have been made for other teaching and documentation methods for nutritional screening and education (electronic education sessions & electronic 'MUST' risk calculations to be added to patient records). - To ensure nutritional screening and appropriate prescribing practices are implemented into commissioning pathways. - More dietetic support is needed to aid review and management of patients at risk of malnutrition - Ensuring that practices are re-audited regularly would provide the ongoing opportunity to monitor adherence to NICE guidelines. - To encourage GP practices who have not yet participated in the nutritional education sessions to engage with the process. - Involvement of key stakeholders is fundamental to raise the profile and awareness of the need to identify and treat malnutrition in the community. - Although the majority of standards continue to be below the required compliance target, improvements have been made. It takes time, continued promotion and education for policies and recommendations to be embedded into best practice.

Contact details

Kate Ashman/Natalie Kominek
Community Dietitian
GWH NHS Foundation Trust & NHS Swindon

Primary care
Is the example industry-sponsored in any way?