Shared learning database

Walsall Healthcare NHS Trust
Published date:
July 2011

Growth in expenditure of oral nutritional supplements (ONS), which are commonly used to treat malnutrition, has risen substantially in recent years. A high proportion of supplements (57-75%) are prescribed inappropriately, resulting in significant waste and unnecessary healthcare costs. Despite this significant cost, evidence suggests that recognition of malnutrition and monitoring of patients in the community is poor and ONS are often used inappropriately. Assessing the appropriateness of ONS expenditure in the community falls into the NHS QIPP (Quality, Innovation, Productivity and Prevention) agenda. 1) London Procurement Programme Clinical Oral Nutrition Support Project (January 2009) 2) Loane D, Flanagan G, Siun A, McNamara E, Kenny S (2004) J Hum Nutr Diet 17 257-266 3) Kennelly S, Kennedy NP, Flanagan Rughoobur G, Glennon Slattery C, Sugrue S (2009) J Hum Nutr Diet 22(6) 511-520

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 ensure the appropriate prescribing of oral nutritional supplements (ONS) and to reduce the cost associated with inappropriate prescribing of ONS 1)To ensure that patients who were prescribed nutritional supplements had a nutritional assessment 2)To identify patients who no longer required prescribable oral supplements 3)To ensure patients who do require nutritional supplements are prescribed the appropriate type and volume 4)To share the findings with all GP practices, GP consortia and PCT MM Committee

Reasons for implementing your project

The cost of precribing ONS has risen in Walsall, and one of the general practitioners (GP's) was happy for a pilot to be done at her surgery to identify whether patients were being prescribed ONS appropriately.Many patients were being prescribed ONS inappropriately by GP's and nurses. GP's and nurses usually did not receive training on apprpriate prescription of ONS and malnutrition. 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.

How did you implement the project

The GP identified patients at the surgery who had been prescribed ONS in the past 12 months by GP's or other health care professionals involved in the patients care. The exceptions were patients from the surgery who were tube fed, patients already known to the dietitians, and palliative patients. Once the patients were identified, the GP surgery sent out appointment letters and patient questionnaires. For the patients who could not attend the clinic, a home visit was done. A baseline audit was completed before the clinics and home visits commenced. The clinical community dietitian and the practice pharmacist looked through patients records on EMIS to locate the original assessments and recommendations/prescriptions for ONS. The dietetic assessment looked at the medical history, anthropometry, biochemistry (if available), social factors such as lifestyle and social support. Factors also taken into consideration at assessment were diagnosis and prognosis (short and long term), treatment goals (GP to follow up on dietitian recommendations), mobility and activity levels, oral intake and current medication and weight or alternate measurements. 1,2 & 3 was achieved in clinic or home visit, whilst 4 was achieved at PCT Medicines Management Meeting, GP meeting and dietetic staff meeting. The costs not accounted for were dietitian's time, practice based pharmacist's time, discontinuing treatments (saving both GP time assessing and issuing prescriptions, as well as receptionist and admin time), prescription fee item cost.

Key findings

Of the 25 patients prescribed ONS, 4 patients were palliative and 1 had cancer - none of these patients had been asked to stop their supplements (some of these patients have been referred to specialist dietitian); 3 patients DNA'd of which one has a BMI of > 30;4 patients were referred to specialist dietitians; 4 continued on current regimen; 1 had left the surgery; 8 patients had BMI>20 and after nutritional assessment, ONS was discontinued. From the data, there was an annual cost saving of £20 454.60. Without dietetic intervention this cost saving would not have been available. The pilot shows that without dietitian intervention the 25 patients would have continued on their current ONS without review to assess them clinically and to either make recommendations, alter treatment options, alter quantities of the current ONS or discontinue treatment. An ongoing specialist dietetic service is important to maintain improvements in practice. Dietitians are more effective than GP's and nurses at offering support to patients with regards to ONS and helping to reduce inappropriate prescription.

Key learning points

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. Involvement of key stakeholders is fundamental to raise the profile and awareness of the need to identify and treat malnutrition in the community.

Contact details

Reka Ragubeer
Clinical Community Dietitian
Walsall Healthcare NHS Trust

Primary care
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