The North Derbyshire Nutrition Support Project: Increasing appropriate Oral Nutrition Supplement prescriptions

The overall aim of this project was to improve the quality of provision of nutrition support services to patients across North Derbyshire, whilst ensuring the appropriate prescription of ONS.

• Raise awareness of the importance of nutrition risk screening, using the Malnutrition Universal Screening Tool (MUST).
• Improve the quality of the nutritional care provided to patients at nutritional risk, in line with NICE Quality Standard QS24.
• Raise awareness of the local nutrition support pathway, emphasising a food first approach.
• Review and assess the current ONS provision to ensure appropriate evidence based ONS provision, in line with NICE Clinical Guideline CG32.

Malnutrition remains a significant public health concern, affecting more than 3 million people in the UK (Elia and Russell, 2009), with an enormous cost to the UK health economy. The use of oral nutrition supplements has been identified to be clinically effective at reducing malnutrition; however as these items can be costly to prescribe, their use should be monitored on a regular basis.

Despite an abundance of national and local guidance, anecdotal evidence suggests that these products are still being prescribed inappropriately within primary care. Nationally, it has been estimated that more appropriate prescribing could generate a 20% reduction in ONS prescriptions, resulting in annual cost savings of almost £27 million, equating to approximately £44,000 per 100,000 patients (PrescQIPP, 2017).

Across the North Derbyshire Clinical Commissioning Group (CCG) and Hardwick CCG, the expenditure on ONS was approximately £1.1 million during 2014-2015 across the 51 general practices. This cost has increased substantially year-on-year, with an annual increase of 20-24% from the 2012/2013 financial year.

In light of this continued growth, the appropriateness and cost-effectiveness of current ONS prescribing practices was considered. Following discussions between local General Practitioners, North Derbyshire medicines management team and the nutrition and dietetic department at Chesterfield Royal Hospital NHS Foundation Trust (CRHFT), it was agreed that prescribing support dietitians (PSDs) were best placed to assess the appropriateness of current prescriptions, due to their skills and knowledge in the provision of nutrition support.

References Elia, M., and Russel, C. A. (2009) Combating malnutrition; Recommendations for Action. Available at: http://www.bapen.org.uk/pdfs/reports/advisory_group_report (PDF)  PrescQIPP (2017)

Guidelines for the appropriate prescribing of oral nutritional supplements (ONS) for adults in primary care (PDF). 

In 2012, the initial concept for the Nutritional Support Project was developed. To prove its worth, a limited number of general practices were audited to look at the potential cost savings which could be made. This data allowed us to estimate potential cost saving figures across the wider area.

After the initial data was collected in 2012, numerous meetings were held between the Dietitians, CCG stakeholders and finance departments. Agreement was reached in 2014 that CRHFT would provide funding for 1 full-time band 6 dietitian and that the funding for a further full-time band 6 dietitian would be split between North Derbyshire CCG and Hardwick CCG. As a result of the joint funding, it was agreed that that savings generated from these posts would be split between CRHFT and the CCGs. Funding was initially granted for a fixed period of 2 years. After the 2 year review, this funding was made permanent. It was agreed that 2 full times dietitians were required in order to meet the project aim and objectives.

The medicines management technicians generated searches for all patients receiving ONS on repeat prescription or who had an acute issue of ONS within the past six months. The PSD’s then attended general practices to review the medical journal entries and correspondence of these patients on SystmOne or EMIS. The following patients were excluded from the audits: patients under the age of 18, patients with gastrostomy feeds, patients who had passed away, patients who had their ONS discontinued by the General Practitioner (GP) or who had transferred general practices.

Decisions were then made as to whether ONS prescriptions should be continued, discontinued or reviewed if further information was required. Where further information was required, we conducted a telephone or home assessment. We rectified inappropriate ONS prescriptions by changing to a more clinically and/or cost effective alternative, increasing or reducing the dose, or discontinuing ONS where indicated.

All of our decisions were based on national guidance from NICE and BAPEN, local prescribing guidelines, clinical judgement and patient preferences. Where we found appropriate ONS prescriptions, we continued these and documented a recommended plan for their ongoing management.

We calculated annualised cost savings per practice following the audit, and disseminated these to each general practice via a written report. We also offered verbal feedback (including training) to all practices. This innovative project differs from similar initiatives across the country, because it includes all of the 51 general practices across both CCGs in the audit and review process, rather than focusing solely on the highest spending practices. This approach was taken to provide an equitable service to all general practices across the county.

We conducted the audit in all 51 general practices in North Derbyshire over an 18 month period. After we applied the exclusion criteria, 1430 patients were included in the audit process. Of these, 57% (n=812) continued with their repeat prescription for ONS, 18% of (n=256) ONS prescriptions were stopped as they were no longer clinically indicated, and 12% (n=169) of ONS prescriptions were changed to a more appropriate alternative. 15% (n=209) of ONS prescriptions were acute issues only, therefore these remained unchanged due to their acute nature. Some patients with multiple ONS prescriptions fitted into more than one category, hence the total percentage equating to 102%.

The results indicated that approximately 30% of ONS prescriptions were inappropriate for the patient’s existing nutritional needs. This highlighted that the NICE CG32 and QS24 standards have not consistently been adhered to across North Derbyshire.

From the project we generated substantial cost savings of £182,203.36, which were split equally between the two CCGs and CRHFT. This equates to £46,000 per 100,000 patients, exceeding the benchmark set by PrescQIPP of £44,000 per 100,000 patients.

Following the evaluation of the initial project cycle, it is now being repeated to identify whether the substantial cost savings generated have been sustained. Preliminary findings have identified similar savings per practice from the re-audit cycle, suggesting that further support is needed to generate sustained improvements in ONS prescribing practices in primary care.

This worthwhile project has provided a better understanding of the prevalence of malnutrition and current prescribing practices across North Derbyshire. We gave tailored, general practice specific feedback to all practices and offered training, in order to promote adherence to NICE CG32, QS24 and the local nutrition pathway.

The uptake of training has been lower during the second audit cycle; therefore we need to provide additional encouragement to general practices to continue to accept training. We will be attending prescribing lead meetings to provide feedback to key GP’s in the area to ensure prescribing lead GP’s are aware of the current issues and guidelines. The project has been disseminated to other dietitians through publication in complete nutrition (September 2017). To generate sustained improvements in prescribing practices, SystemOne and EMIS prescribing tools are being developed for primary care staff in conjunction with the North Derbyshire medicines management team.