London Procurement Programme Clinical Oral Nutrition Support Project

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1 London Procurement Programme Clinical Oral Nutrition Support Project Project Leads: Project Managers: Catherine Forrest Louise Wilkie Peter Sharott Phil Aubrey Support Management: Ian Jones Joanne Jones

2 Contents Page Executive Summary 4 Introduction 6 Aim 6 Methodology 7 Results 7 Tables: Table : Community Trust Questionnaire Table 2: Acute Trust Questionnaire Table 3: Community Trust ONS Expenditure Annual Comparison Table 4: Community Trusts with an ONS Demand Management Dietitian Table 5: Summary of Verbal Responses form Interviews Table 6: Cost of ONS in Nursing Homes over a Six Month Period of Time (study) Table 7: Role of the Dietitian within a Care Home Setting Table 8: Discharge Notification from Acute Trusts Charts: Chart : Community Trust WTE Dietetic and Support Staff Chart 2: Community Trust Dietetic WTE per AfC Banding Chart 3: Acute Trust WTE Dietetic and Support Staff Chart 4: Acute Trust Dietetic WTE per AfC Banding Chart 5: London Community Trusts Total Dietetic WTE Staffs Chart 6: London Acute Trusts Total Dietetic WTE Staffs Chart 7: London Acute Trusts WTE Dietetic Staffs per 00 Beds Chart 8: London Community Trusts WTE Dietetic Staffs per 00,000 Unified Weighted Population Chart 9: 2005/06 Community Trust ONS FP0 Expenditure Chart 0: 2006/07 Community Trust ONS FP0 Expenditure Chart : 2007/08 Community Trust ONS FP0 Expenditure Chart 2: Community Trust ONS Expenditure Cumulative 3 years Comparison ( ) Chart 3: Community Trust ONS Expenditure per 00,000 Unified Weighted Population Chart 4: ONS Expenditure Comparison of Community Trusts with Prescribing Dietitian vs. without Prescribing Dietitian Lead Chart 5: WTE Community Trust Prescribing Remit Dietitians per 0,000 ONS Expenditure (2007/08) Chart 6: London Community Trusts Index of Multiple Depravation (IMD) vs. Dietetic WTE vs. ONS Expenditure (2007/07)/00,000 Population Chart 7: London Community Trust Dietetic WTE Staffs per GP Practice Chart 8: London Community Trust Dietetic WTE Staffs per Community Pharmacy Chart 9: Top Barriers to ONS Demand Management Initiatives Chart 20: Top Responses to Views on ONS Usage in Trust (Acute and Community) Chart 2: Main ONS User Groups Reported by Community Trusts Chart 22: Top Responses on What Would Improve ONS Demand Management Initiatives Discussion 29 Limitations 43 Conclusion 44 Recommendations 45 Acknowledgements 46 Appendices: Appendix : Background Appendix 2: Methodology Appendix 3: Full Questionnaire Findings Appendix 4: Full Interview Summary Appendix 5: ONS Audit/Project Report Summaries Greenwich PCT Hounslow PCT NHS Kensington and Chelsea Wandsworth PCT NHS Westminster Appendix 6: Community Trust ONS Case Studies Appendix 7: Letter of Introduction Appendix 8: List of Acute and Community Trusts Invited to Participate Appendix 9: Community Trusts ONS Expenditure Data 2 Page

3 Appendix 0: Examples of Discharge/Communication Letters 73 Glossary 78 References 8 NHS London Procurement Programme. Material from this document may be reproduced by other NHS Trusts free of charge in any format or medium provided it is reproduced accurately and not used in a misleading context. The source of the material must also be identified and the copyright status acknowledged. Permission should be sought before reproducing or distributing to others. Commercial copying and use is prohibited. Project Contact Details: Project Leads Catherine Forrest Specialist Community Dietitian Louise Wilkie Specialist Community Dietitian Project Management Peter Sharott Pharmaceutical Adviser, London Specialised Commissioning Group Strategic Pharmaceutical Lead, London Procurement Programme Philip Aubrey Deputy Medicines Procurement Specialist London and East of England London Procurement Programme P&MM Operational Lead Project Support Management Ian Jones Head of Nutrition and Dietetics Services, NHS Westminster Joanne Jones Nutrition and Dietetics Services Manager, NHS Kensington and Chelsea 3

4 Executive Summary The London Procurement Programme Clinical Oral Nutrition Support Project (LPPCONSP) assessed Oral Nutritional Supplement (ONS) demand management initiatives across London. Participation was sought from all London Acute, Community and Mental Health Trusts. Summary: ONS demand management is a multi factorial issue. There is clear evidence for potential cost savings on ONS prescribing by having specific Demand Management Dietitians within a Trust. The majority of London Community Trusts do not have a Demand Management Dietitian in place and subsequently fail to implement appropriate procedures resulting in a continual increase in expenditure. Financial cost savings from appropriate prescribing can be measured however additional cost savings associated with improved nutrition should also be taken into account (e.g. reduced frequency and length of hospital stay, reduced GP visits and improved wound healing). Great variation in dietetic resources over London in both the Acute and Community Trust settings is also highlighted in this project. As a result of this variation, many Trusts are failing to implement the NICE Guidelines (32) for Nutrition Support (2006). The findings of this project indicate the potential cost savings and improvements in patient care that are achievable with the implementation of ONS demand management initiatives. These initiatives will ensure cost and quality improvements are achieved together not only from appropriate ONS prescribing but also from the prevention and treatment of malnutrition. In order to use limited resources effectively and direct those resources appropriately, the management of malnutrition and ONS use should consist of a targeted approach which is proactive rather than reactive. To address these issues a strategic, multi-organisational, sustainable approach is required over London. Investment is required in order to ensure that continuous improvements are made and sustained in the identification and appropriate treatment of malnutrition resulting in improvements in health outcomes, both now and in the future. This should be adopted as an integral part of patient care in order to provide a high quality service as well as value for money. 4

5 Recommendations: Clinical Recommendations Ensure NICE Guidelines 32 for Nutrition Support (2006) implemented Nutrition Support Care Pathway across primary and secondary care is in place Nutrition Policy in place within care and residential homes Organisational wide screening programme as per NICE guidance (2006) in place in Acute, Community and Mental Health Trusts Structured training for health professionals and appropriate voluntary sector staff on malnutrition screening Regular auditing of prescribing practices of healthcare professionals Implement LPPCONSP Guidelines (2009) Monitoring and review processes in place to measure clinical effectiveness Strategic Recommendations Community Trusts to commission dietitian lead ONS Demand Management services to ensure clinical recommendations are implemented Commissioning Specifications for secondary care to focus on meeting NICE guidelines Future Developments To explore the possibility of incorporating ONS prescribing in Local Enhanced Schemes (LES) - Locally To explore the possibility of incorporating malnutrition into QOF Points - Nationally 5

6 Introduction The London Procurement Programme Clinical Oral Nutrition Support Project (LPPCONSP) assessed Oral Nutritional Supplement (ONS) demand management initiatives across London; the following report is a compilation of the findings and recommendations. The use of ONS has increased over the last decade causing concerns of their efficacy and cost to be raised (Todorovic, 2005). ONS, while playing a vital role in the nutritional status of many patients, also have a significant cost incurred to the National Health Service (NHS). The cost of adult ONS in London alone (2007/8) is just under 3 million (London Procurement Programme). Nationally it is estimated at 80 million (prescribing data). Throughout the UK, various health communities have undertaken audits to review the use of ONS (Gall et al 200, Jones and Jones 2006, Forrest 2007) (see Appendix 5 Greenwich PCT, NHS Westminster, NHS Kensington and Chelsea, Hounslow PCT, Wandsworth PCT). Audit has highlighted that a high proportion of ONS prescriptions are initiated without clear prescribing indications and are inappropriately used. Furthermore the absence of systematic processes to assess and monitor individuals at nutritional risk was evident. With increasing resources being spent on prescriptions there is an acknowledged need to optimise prescribing habits (Royal College of General Practitioners 2006). Emphasis is on cost-effective prescribing, which does not impair the quality of service offered to patients. Aim The aim of this project was to assess demand management initiatives for ONS across all London Acute, Community and Mental Health Trusts. Primary project objectives: Assessing current demand management initiatives for ONS Assessing compliance with NICE Guidance (32) for Nutrition Support (2006) Developing recommendations for implementing demand management strategies 6

7 Methodology The London Procurement Programme seconded two full-time registered dietitians due to relevant experience and expertise to undertake the project. The project was initially funded for six months and at the time of writing was extended for a further four months. Participation was sought from all London Acute, Community and Mental Health Trusts. See Appendix 2 for detailed methodology Results Please note all data collated in this section is based on information gathered between May-September Community Trusts and 3 Acute Trusts were contacted to participate in the project with the following results. Community Trusts: 29/3 Community Trusts (94%) responded to the questionnaire 3/3 Community Trusts (00%) responded to the workforce database 25/3 Community Trusts (8%) took part in an interview Acute Trusts: 27/3 Acute Trusts (87%) responded to the questionnaire 27/3 Acute Trusts (87%) responded to the workforce database 26/3 Acute Trusts (84%) took part in an interview Mental Health Trusts (MHTs): One MHT responded to the questionnaire, workforce database and took part in an interview. 7

8 Questionnaire Responses Main Findings: See Appendix 3 for full questionnaire results. Table : Community Trust Questionnaire (n=29) Department Information Question Yes No Do you currently have a Prescribing Dietitian (Lead)? 28% (n = 8) 72% Does your organisation/trust a have a Specialist Nutrition Support Nurse? 7% 83% Does your organisation/trust have a multidisciplinary Nutrition Steering Group/Committee? Current Practice Does your trust have a malnutrition screening tool in place? Is it MUST? 24% 76% 86% 4% 96% 4% Do you provide Community staff with malnutrition screening training? 66% 34% Do you provide training for catering staff within your Community Trust? 3% 87% Does your trust currently have policies/procedures or care pathways in place for 62% 38% the management of ONS? Are your current ONS prescriptions on FP0? 97% 3% Do you accept referrals for ONS assessment? 86% 4% Do you provide Community staff with training on ONS usage? 59% 4% Budget Do you receive any industry rebates on the prescriptions for ONS? 7% 93% Table highlights the main findings from the Community Trust questionnaires. 29 Community Trusts completed questionnaires. Currently 28% have a dietitian with an ONS demand management remit. 86% have a malnutrition screening tool in place of which 96% use MUST as the tool of choice. 66% provide training to staff on malnutrition screening. 8

9 Table 2: Acute Trust Questionnaire (n=27) Department Information Question Yes No Do you currently have a Prescribing Dietitian (Lead)? 4% (n=) 96% (n=26) Does your organisation/trust a have a Specialist Nutrition Support Nurse? 4% (n=) 59% (n=6) Does your organisation/trust have a multidisciplinary Nutrition Steering Group/Committee? Current Practice Does your trust have a malnutrition screening tool in place? Is it MUST? 85% (n=23) 5% (n=4) 00% (n=27) 0% 48% (n=3) 52% (n=4) Do you provide hospital staff with malnutrition screening training? 00% (n=27) 0% Do you provide training for catering staff within your hospital? 48% (n=3) 52% (n=4)* Do you provide Community staff with malnutrition screening training? 4% (n=) 96% (n=26) Does your trust currently have policies/procedures or care pathways in place for 52% (n=4) 48% (n=3) the management of ONS? Do you accept referrals for ONS assessment? 93% (n=25) 7% Are all patients receiving ONS referred and assessed by a dietitian? 30% (n=8) 70% Who prescribes ONS within your hospital? Dietitians 93% Doctors 89% Nursing Staff % Nutrition Team 5% Do you provide hospital staff with training on ONS usage? 70% 30% Is there a standard daily prescription of ONS in any department in your 7% 93% hospital/specific wards? When a patient is being discharged on ONS who organises the TTOs? Doctor 33% Dietitian 59% Nurses 37% Catering 4% Pharmacy 5% What is the standard quantity of ONS supplied on discharge (TTOs)? 3 Days 5% 7 days 56% 4 days 22% month 4% Other 9% Do you have a discharge policy for TTOs? 4% (n=) 59% Is this discharge policy agreed with your local Community Dietitians? 26% (n=7) 73% Is the need for a continued ONS prescription assessed prior to a patients discharge home? 78% (n=2) 22% Who receives notification of patients discharged into the community on ONS? GP 00% Practice Nurse 4% Community Dietitians 63% District Nurse 7% Who follows up patients discharged on ONS? Hospital Dietitian 56% Community Dietitian 67% GP 59% District Nurse 4% Not followed up 9% Budget 3.5 Do you receive any industry rebates on the prescriptions for ONS? 5% 85% Table 2 highlights the main findings from the Acute Trust questionnaires. 27 Acute Trusts completed questionnaires. 9

10 It should be noted that the one Acute Trust with a prescribing lead is in fact employed in the community and has no direct influence on acute prescribing, however secondary influence is through good relationships with acute dietetic colleagues (i.e. community trusts provide acute service). Chart : Community Trust WTE Dietetic and Support Staff WTEs Dietitians Dietetic Assistants Admin & Clerical Others Totals WTEs Chart provides data on the number of WTE equivalent dietitians and support staff for London Community Trusts WTE dietitians work across London Community Trusts with 29.0 dietetic assistants. Others include nutritionists and nutrition assistants. 0

11 Chart 2: Community Trust Dietetic WTE per AfC Banding WTEs d 8c 8b 8a Dietitians Dietetic Assistants Admin & Clerical Chart 2 provides a breakdown of community dietetic establishment staff (all staff) per Agenda for Change (AfC) pay banding. The majority of dietitians are band 7 (9.56) with a further band 6 posts and 0.88 band 5. There is one 8C banded management post with 2.6 banded 8b and 2 banded 8a.

12 Chart 3: Acute Trust WTE Dietetic and Support Staff WTEs Dietitians Dietetic Assistants Admin & Clerical Others Totals WTEs Chart 3 provides data on the number of WTE equivalent dietitians and support staff for London Acute Trusts WTE dietitians work across London Acute Trusts with dietetic assistants. Others include nutritionists and nutrition assistants. Chart 4: Acute Trust Dietetic WTE per AfC Banding WTEs d 8c 8b 8a Dietitians Dietetic Assistants Admin & Clerical 2

13 Chart 4 provides a breakdown of Acute Trust dietetic establishment staff (all staff) per Agenda for Change (AfC) pay banding. The majority of dietitians are band 7 (7.78) with a further band 6 posts and band 5. There are C banded management posts with 9.97 banded 8b and banded 8a posts. Chart 5: London Community Trusts Total Dietetic WTE Staff Westminster Wandsworth Waltham Forest Tower Hamlets Sutton & Merton Southwark Richmond & Twickenham Redbridge Newham Lewisham Lambeth Kingston Kensington & Chelsea Islington Hounslow Hillingdon Havering Harrow Haringey Hammersmith & Fulham Greenwich Enfield Ealing Croydon City & Hackney Camden Bromley Brent Bexley Barnet Barking & Dagenham London Community Trusts WTEs Chart 5 provides workforce data on whole time equivalent (WTE) dietetic staff posts for all London Community Trusts and include both clinical and public health dietitians (where applicable), dietetic/nutrition assistants and administration/clerical. Brent PCT has the highest WTE posts (20.5) with Hounslow PCT and Richmond and Twickenham PCT having the lowest (.45 and.4 respectively). The London average is

14 Chart 6: London Acute Trusts Total Dietetic WTE Staff Whipps Cross - Wal For Bromley Hospital Whittington West Middlesex Hospital UCL St Marys Hospital St Helier Hospital Royal National Ortho Hosp SLAM - Maudsley Royal Free Redbridge Acute Queen Elizabeth Woolwich North Middlesex Hospital NWLH Trust Newham Hospital Mayday Hospital Lewisham Uni hospital Kingston Hospital Kings College Hospital Homerton Hospital Hillingdon and Mt Vernon Havering Hospital Hammersmith/CX H Guys Hospital Ealing Hospital Chelsea and Westminster Chase Farm and Barnet Barts and The London Acute Trusts WTEs Chart 6 provides workforce data on whole time equivalent (WTE) dietetic staff posts for all London Acute Trusts (responders) and includes dietitians, dietetic/nutrition assistants and administration/clerical. Barts and the London Trust have the greatest number of staff (38.64) with The Royal National Orthopaedic Hospital having the lowest (.0). Hospital size (bed numbers) must be considered; see Chart 7 below. The London average is Chart 7: London Acute Trusts WTE Dietetic Staffs per 00 Beds Whipps Cross - Wal For Bromley Hospital Whittington West Middlesex Hospital UCL St Marys Hospital St Helier Hospital Royal National Ortho Hosp SLAM - Maudsley Royal Free Queen Elizabeth Woolwich North Middlesex Hospital NWLH Trust Newham Hospital Mayday Hospital Lewisham Uni hospital Kingston Hospital Kings College Hospital Homerton Hospital Hillingdon and Mt Vernon Barking, Havering & Redbridge Hospital Trust Hammersmith/CX H Guys Hospital Ealing Hospital Chelsea and Westminster Chase Farm and Barnet Barts and The London Acute Trusts

15 Chart 7 provides workforce data on whole time equivalent (WTE) dietetic staff posts (including assistants and administration/clerical) per 00 beds for all London Acute Trusts. St Mary s Hospital (Imperial NHS Trust) has the highest number of staff per 00 beds (4.75) with South London and Maudsley having the lowest (0.43). The London average is Chart 8: London Community Trusts WTE Dietetic Staffs per 00,000 Unified Weighted Population Westminster Wandsworth Waltham Forest Tower Hamlets Sutton & Merton Southwark Richmond & Twickenham Redbridge Newham Lewisham Lambeth Kingston Kensington & Chelsea Islington Hounslow Hillingdon Havering Harrow Haringey Hammersmith & Fulham Greenwich Enfield Ealing Croydon City & Hackney Camden Bromley Brent Bexley Barnet Barking & Dagenham London Community Trusts Chart 8 provides workforce data on whole time equivalent (WTE) dietetic staff posts (including assistants and administration/clerical) per 00,000 unified weighted populations for all London Community Trusts. NHS Kensington and Chelsea have the highest (9.48) with Newham PCT and Hounslow PCT having the lowest (0.65 and 0.69 respectively). The London average is

16 Chart 9: 2005/06 Community Trust ONS FP0 Expenditure 600, ,000 ONS FP0 Expenditure 400, , ,000 00,000 0 Lewisham Ealing Lambeth Brent Bromley Barnet Southwark Wandsworth Camden Newham Greenwich Islington Hounslow Tower Hamlets Haringey Sutton & Merton City & Hackney Community Trust Chart 0: 2006/07 Community Trust ONS FP0 Expenditure Redbridge Westminster Croydon Havering Hillingdon Hammersmith & Fulham Enfield Bexley Barking & Dagenham Waltham Forest Harrow Richmond & Twickenham Kensington & Chelsea Kingston 700, , ,000 ONS FP0 Expendtiure 400, , ,000 00,000 0 Lewisham Lambeth Brent Barnet Bromley Southwark Newham Wandsworth Ealing Camden Greenwich Tower Hamlets Westminster Sutton & Merton Croydon Redbridge Haringey Community Trust Havering Hounslow Enfield Islington City & Hackney Hammersmith & Fulham Bexley Waltham Forest Hillingdon Harrow Barking & Dagenham Richmond & Twickenham Kensington & Chelsea Kingston 6

17 Chart : 2007/08 Community Trust ONS FP0 Expenditure 700, ,000 ONS FP0 Expenditure 500, , , ,000 00,000 0 Barnet Lewisham Lambeth Brent Bromley Southwark Greenwich Newham Hounslow Wandsworth Croydon Sutton & Merton Westminster Tower Hamlets Havering Enfield Redbridge Camden Community Trust Haringey City & Hackney Hammersmith & Fulham Ealing Bexley Waltham Forest Islington Hillingdon Harrow Barking & Dagenham Kensington & Chelsea Richmond & Twickenham Kingston Chart 2: Community Trust ONS Expenditure Cumulative 3 years Comparison ( ) 700, , , , , ,000 00,000 0 Barking & Dagenham Barnet Bexley Brent Bromley Camden City & Hackney Croydon Ealing Enfield Greenwich Hammersmith & Fulham Haringey Harrow Havering Hillingdon Hounslow Islington Kensington & Chelsea 7 Kingston Lambeth Lewisham Newham Redbridge Richmond & Twickenham Southwark Sutton & Merton Tower Hamlets Waltham Forest Wandsworth Westminster 2005/ / /08

18 Charts 9-2 tabulate PCT ONS expenditure from Lewisham PCT had the highest ONS expenditure for 2005/06 and 2006/07. Barnet PCT has the highest expenditure for 2007/08 ( 606,433). Kingston PCT has consistently had the lowest expenditure. Population size must be taken into account (see Chart 3). Expenditure has risen annually by varying degrees in all but seven Community Trusts. Five of these Community Trusts have dietitians with an ONS demand management remit in post. Table 3: Community Trust ONS Expenditure Annual Comparison PCT Sip Spend Sip Spend Change in Spend 2006/ /2008 Barking and Dagenham 278, , Barnet 526, , Bexley 34, , Brent 539, , Bromley 486, , Camden 409, , City and Hackney 348, , Croydon 383, , Ealing (off FP0) 434, , Enfield 374, , Greenwich 407, , Hammersmith and 344, , Fulham Haringey 380, , Harrow 279,689 34, Havering 379,759 40, Hillingdon 36,278 32, Hounslow 377, , Islington 372, , Kensington and Chelsea 223,63 27, Kingston 76,69 74, Lambeth 578,69 594, Lewisham 632,67 599, Newham 453, , Redbridge 382, , Richmond and 249,004 26, Twickenham Southwark 470, , Sutton and Merton 384, , Tower Hamlets 405,48 423, Waltham Forrest 34, , Wandsworth 445, , Westminster 394, , Table 3 compares annual ONS expenditure for 2006/07 vs. 2007/08. The greatest reduction in expenditure was in Ealing PCT who has redesigned the service to cease FP0 prescribing and therefore this reduction is expected. Lewisham PCT has reduced the annual spend by 33,35 in the past year. The largest increase in annual expenditure for 2007/08 was 80,862 in Bromley PCT, followed closely by Barnet PCT with 80,93. Seven Community Trusts have reduced ONS expenditure from 2006/07 to 2007/08; five of 8

19 which have conducted audits into ONS use in the community and/or employ ONS demand management dietitians. Chart 3: Community Trust ONS Expenditure per 00,000 Unified Weighted Population 250, ,000 50,000 00,000 50,000 0 Hammersmith & Fulham London Community Trusts Lewisham Bromley Hounslow Barnet Brent Bexley Lambeth Redbridge Greenwich Havering Harrow Richmond & Twickenham Westminster Southwark Wandsworth Barking & Dagenham Waltham Forest Enfield Islington Camden Tower Hamlets Haringey Hillingdon Croydon Kensington & Chelsea Newham City & Hackney Sutton & Merton Kingston Ealing Chart 3 compares ONS expenditure for London Community Trusts against the unified weighted population. Lewisham PCT has the greatest expenditure per unified weighted population ( 26,656) and Ealing PCT the lowest ( 5,670). The London average is 59,67. 9

20 Table 4: Community Trusts with an ONS Demand Management Dietitian PCT Post Start Details Ealing Full service redesign WTE Prescribing ONS (off FP0) Hillingdon April month contract Medicines Management funded Islington August 2007 WTE Medicines Management funded Kensington and Chelsea December 2007 WTE Industry funded fixed term contract Kingston Vacant at present 0.6 WTE Medicines Management Funded Sutton and Merton 2003 WTE Wandsworth 2004 WTE Medicines Management funded Westminster November WTE Industry funded fixed term contract Additional ONS Prescribing Posts Hammersmith and New position commencing July 0.2 WTE Fulham 2008 Haringey Newly advertised Sept 08 WTE Newham Freelance contract March 2008 August WTE Table 4 provides details on those Community Trusts with a dietitian with an ONS demand management remit. Several posts are fixed-term contracts with one Community Trust employing a freelance dietitian to lead on ONS prescribing reviews. Posts are funded from a number of sources; dietetic budget, industry grant and medicines management budgets. One post monitors not only ONS use but also gluten free and anti-obesity medication prescribing. Ealing PCT has the highest number of prescribing dietitians due to the service redesign of discontinuing FP0 prescribing and therefore the caseload has increased dramatically. Since this data was gathered, additional funding has been secured for further posts. 20

21 Chart 4: ONS Expenditure Comparison of Community Trusts with Prescribing Dietitian vs. Community Trusts without Prescribing Dietitian London StHA Chart to Show Sip Feed Net Ingredient Cost per 000 Standard Pus,400,200,000 NIC per 000 SPUs Community Trusts with dietitian lead Community Trusts with no dietitian lead Chart 4 indicates that ONS expenditure in Community Trusts without a dietitian leading on ONS demand management (n=23) has increased over a three year period; currently 22.3% (2007/08 data) higher than those Community Trusts with a dietitian with an ONS focus. The expenditure of Community Trusts with a prescribing dietitian has increased slightly but substantial cost avoidance has been achieved. This cost difference across London would be equivalent to.77million. 2

22 Chart 5: WTE Community Trust Prescribing Remit Dietitians per 0,000 ONS Expenditure (2007/08) London Community Trusts Westminster Wandsworth Community Trusts Sutton & Merton Kingston Kensington & Chelsea Islington Hillingdon Ealing WTE Chart 5 compares WTE dietitians with an ONS demand management remit to 0,000 ONS expenditure for the year 2007/08. Eight Community Trusts have dietitians involved in ONS management with Ealing PCT having the greatest number due to the service redesign. Seven posts fall below 0.04 of the ONS expenditure in the respective Community Trusts. 22

23 Chart 6: London Community Trusts Index of Multiple Depravation (IMD) vs. Dietetic WTE vs. ONS Prescribing Expenditure (2007/2008)/00,000 Population IMD Score WTEs/00,000 Population Expenditure/00,000 Population WTEs/00,000 Population 250,000 IMD Score London PCTs Tower Hamlets City & Hackney Islington Newham Haringey Southwark Camden Lambeth Waltham Forest Westminster Greenwich Barking & Dagenham Lewisham Hammersmith & Fulham Brent Ealing Hounslow Enfield Kensington & Chelsea London PCTs Wandsworth Croydon Redbridge Hillingdon Barnet Bexley Havering Sutton & Merton Harrow Bromley Kingston Richmond & Twickenham Chart 6 compares the index of multiple deprivation (IMD) score for each Community Trust against the number of WTE dietetic staffs per 00,000 population and the annual ONS expenditure per 00,000 population. expenditure and high IMD scores. 200,000 50,000 00,000 50,000 There is no direct correlation between ONS 0 Expenditure/00,000 Population 23

24 Chart 7: London Community Trust Dietetic WTE per GP Practice Westminster Wandsworth Waltham Forest Tower Hamlets Sutton & Merton Southwark Richmond & Twickenham Redbridge Newham Lewisham Lambeth Kingston Kensington & Chelsea Islington Hounslow Hillingdon Havering Harrow Haringey Hammersmith & Fulham Greenwich Enfield Ealing Croydon City & Hackney Camden Bromley Brent Bexley Barnet Barking & Dagenham London Community Trusts Chart 7 provides data on the number of WTE dietitians per GP practice according to Community Trust (the number of GP practices vary between boroughs). NHS Kensington and Chelsea have the highest volume of dietitians per GP practice (0.44) with Hounslow PCT having the lowest (0.02). The average for London is 0.6. Chart 8: London Community Trust Dietetic WTE per Community Pharmacy Westminster Wandsworth Waltham Forest Tower Hamlets Sutton & Merton Southwark Richmond & Twickenham Redbridge Newham Lewisham Lambeth Kingston Kensington & Chelsea Islington Hounslow Hillingdon Havering Harrow Haringey Hammersmith & Fulham Greenwich Enfield Ealing Croydon City & Hackney Camden Bromley Brent Bexley Barnet Barking & Dagenham London Community Trusts

25 Chart 8 compares the number of WTE dietitians per Community Pharmacies for each Community Trust. NHS Kensington and Chelsea have the highest volume of WTE dietitians (0.5) with Hounslow PCT and Richmond and Twickenham PCT having the lowest amount (0.03). The average for London is 0.5. Interview Responses: Qualitative Data collated from interviews with Trust managers/team for Acute, Community and Mental Health Trusts. This is a summary of verbal responses (not all trusts responded to each question as they did in the questionnaire). See Appendix 4 for a detailed summary of the interview responses Table 5: Summary of Verbal Responses from Interviews Question Yes No Unsure Looked ay ONS prescribing within own Trust? 7 9 Audited own practice? 6 29 Feel ONS prescribing requires input? All ONS patients referred? Can doctors prescribe without dietitian s knowledge? 33 2 Chart 9: Top Barriers to ONS Demand Management Initiatives (Acute and Community Trusts) Response Number GPs: difficult to engage Acute: poor discharges/over prescribe Sustainability Workforce Issues & Capacity Reasons stated No Community Dietitians Resistance to change One size won't fit all Chart 9 highlights the main reasons Acute and Community Trust dietitians feel would be barriers to improving ONS prescribing practices. These barriers include GPs and the 25

26 difficulty of engaging them, poor discharge practices of Acute Trusts, sustainability and workforce capacity; simply not enough dietitians to do this work and ensure quality practice. Funding for increased dietetic staff was high on the list of requirements if an impact is to be made and sustained. Chart 20: Acute and Community Trust Top Responses to Views on ONS Usage in Trust Response Number Cheap: ethical vs cost dilemma in Acute Don't consider use in PCTs - assume all patients seen Overused Not thought about - PCT problem only Not used appropriately Response Considering going off FP0 Lack of community dietitians to follow up patients Encourage use: some wards have policy of two ONS/day for patients High usage in substance misuse & nursing homes Chart 20 highlights dietitian s views on ONS usage in their own trusts. Many trusts responded with similar themes. The most notable and highest comment on general ONS use was the pricing within the acute setting. As ONS is generally 0.0 per single unit in the majority of NHS Trusts, there is an acknowledgment that these products are often overused and not considered an acute responsibility as the main cost falls to the Community Trusts. An area of concern is the notion that ONS is being used instead of snacks/alternative foods as it is cheaper and easier to do therefore creating an ethical versus cost dilemma. 26

27 Chart 2: Main ONS User Groups Reported by Community Trusts Response Numbers Nursing Homes Substance Misuse Elderly Mental Health Low income/high deprevation Main ONS Groups Reported Chart 2 indicates the main ONS users groups as stated by Community Trust dietitians. Nursing homes and the elderly population are considered the largest users with substance misuse also a high user. These user groups vary across boroughs and therefore prescribing priorities differ. Chart 22: Top Responses on What Would Improve ONS Demand Management Initiatives (Acute and Community Trusts) Response Numbers Funding - further dietitians Standard forms, templates, guidelines to adopt Facts & figures reported to highlight problem Responses Extensive GP/HCP mandatory training & participation in audit Dietitians & Pharmacists working together Dietitians to have prescribing rights - increased control 27

28 Chart 22 provides details on what dietitians feel would help to improve and sustain ONS demand management initiatives. The top response was more staff resources; more dietitians to ensure the quality of work is sustainable. Further responses included standard forms and guidelines, highlighting the problem with accurate expenditure figures, mandatory training for staff involved in prescribing ONS, close working between dietitians and pharmacy and dietetic prescribing rights to ensure more control. 28

29 Discussion The main objectives of this project were to assess the current ONS demand management initiatives across London and to assess compliance with NICE Guidance (32) for Nutrition Support (2006) in the Acute, Community and Mental Health Trust settings. The levels of dietetic staffing were clarified separately. Community Trust Dietetic Staffing There is clear evidence of considerable variation in the allocation of dietetic services over London Community Trusts. Chart 5 compares dietetic WTE for each individual Community Trust over London and Chart 8 compares dietetic WTE per weighted population for each Community Trust in London. These figures give an indication of the overall level of staffing for the population; for example NHS Kensington and Chelsea have 9.48 WTE dietitians per of weighted population and Hounslow PCT have just 0.65 dietitians per of weighted population. This highlights the vast differences in dietetic staffing between Community Trusts resulting in inequitable access to services in London. There is even greater variation in the allocation of dietitians working as an ONS prescribing dietitian (eight Community Trusts, 28%). Of these eight Trusts, five are employed full time, four are employed on a fixed term contract, one post is vacant, four are employed via medicines management departments and three departments receive funding from Industry, two of which are temporary. Throughout the UK, various health communities have undertaken audits to review the use of ONS (Gall et al 200). Research has highlighted that a high proportion of ONS prescriptions are initiated without clear criteria and are inappropriately used. Recent studies carried out in NHS Westminster (Forrest 2007) and a similar study in NHS Kensington and Chelsea (unpublished) found that 75% of patients receiving a prescription for ONS were in fact deemed to be inappropriate. Furthermore the absence of systematic processes to assess and monitor individuals at nutritional risk was evident. In London, these audits have primarily been managed by dietitians through fixed term contracts. However funding for such posts has rarely been sustained and therefore, the work has not continued. The most common basis for discontinuing posts was the lack of initial cost saving results. Immediate cost savings were projected in all projects due to the high level of inappropriate prescribing however for many reasons were not seen initially in the expenditure reports. Reasons for the lack of an actual cost saving have been attributed to 29

30 the increased detection and subsequent treatment of malnutrition, improved prescribing practices (e.g. twice daily rather than once daily doses) and the failure of GPs to discontinue ONS prescriptions when advised to do so. It should also be noted that such projects take time to become established and form the necessary infrastructure and as such when the funding is fixed term the cost saving may not become evident over such a short period of time. This further emphasises the need for long-term and sustainable demand management initiatives. While a cost saving is not evident in all trusts with a prescribing post a cost avoidance is clearly indicated. Chart 4 compares those trusts with prescribing posts with those without a post over a three year period ( ). Close analysis indicates a positive correlation between the level of dietetic resource to manage ONS prescribing and the halt/reduction in ONS spend. A difference of 0.8% in 2005/06, 8% in 2006/07 and 22.3% in 2007/08 demonstrates the benefit of having such a post. In other words those Community Trusts without prescribing posts in 2007/2008 have a 22.3% higher expenditure of ONS over the time period and this year on year rise is projected to continue. It would therefore appear that the halt/reduction in ONS expenditure correlates with having an ONS Management Dietitian in post. Chart 6 compares London Community Trust s Index of Multiple Deprivation (IMD) score, WTE dietitians per unified weighted population and ONS expenditure per weighted population. It is widely accepted that deprivation increases the risk of early death and is associated with higher rates of illness from certain diseases. Deprivation is also associated with a higher incidence of substance and alcohol misuse and mental health issues. It could be assumed that areas of London with a higher IMD score would have greater health needs and subsequently have increased prescribing costs and need for more resources (in this case dietitians). This is however not the case and the IMD scores over London do not correlate with the prescribing costs per population size or the number of WTE dietitians. Therefore there is no correlation between deprivation, the dietetic staffing levels and the ONS spend within the community. This could be attributed to the fact that there are differences in the focus of the dietitians within a department which may not necessarily be nutrition support or ONS demand management. Additionally due to limited capacity in dietetic departments, without a dedicated dietitian to lead on ONS management, such work may be overlooked. Anecdotal evidence suggests that there is a greater positive impact on ONS prescribing practices when there is a dedicated dietitian/s assigned to oversee and drive ONS management initiatives. 30

31 Caseloads typically vary throughout dietetic departments and more often than not, it is not just dietitians with an ONS prescribing remit or indeed a nutritional support remit that see patients for ONS. 86% of Community Trusts state that they accept referrals for ONS assessment; however the capacity for the community dietetic departments to deal with such referrals varies greatly across London Community Trusts. For example, one department has only 0.8 WTE dietitian to cover the whole PCT with a total population of (weighted population of ). Furthermore this 0.8 WTE is not dedicated to any one speciality of dietetics and, therefore, this time is divided over a number of conditions. In addition, several Community Trusts only have the capacity to see patients in either a GP practice or care home setting; therefore no other dietetic input is available. Of concern is the lack of domiciliary services for house bound patients (which is often the case for patients requiring assessment for ONS). The Community Trusts (4%) who do not accept any referrals for ONS assessment do not have any community dietitians with an oral nutrition support remit and therefore there is no one to refer such patients to. In these circumstances patients on ONS discharged from the acute setting will not receive the continued monitoring and assessment that is required. NICE (2006) state that in order to implement the NICE Guidelines 32 for Nutrition Support, based on the population sizes of the 3 London Community Trusts alone, an estimated additional 26.7 WTE dietitians are required. This is the basic workforce estimate however when recent local data is factored into this equation (for example the incidence of malnutrition and ONS usage) this figure is likely to be much higher. This further highlights the shortfall in resources in the area of nutrition support over London. Malnutrition Screening NICE (2006) states that in the community, screening to identify malnutrition and risk of malnutrition should be carried out on admission to care homes, on initial registration at GP surgeries and when there is clinical concern and that screening should be carried out by appropriately trained health professionals. A high number of Community Trusts (86%) have a malnutrition screening tool in place. Of these Community Trusts, 96% use the Malnutrition Universal Screening Tool (MUST) which is validated nationally. Less than half (48%) of Community Trusts offer malnutrition screening training to GPs, 45% offer training to Practice Nurses and 55% offer the training to District Nurses. No Community Trusts currently offer training to Community Pharmacists although qualitative data has highlighted the perceived benefits of their involvement in ONS management. Anecdotal evidence suggests that the completion rates of malnutrition screening tools in the community setting 3

32 are poor. This may be as a direct result from lack of training provided to community staff. Of the Community Trusts that do offer malnutrition screening training the frequency of training sessions varies between trusts and ranges from monthly organised sessions (7%) to ad-hoc annual sessions (0%). This clearly shows that although a relatively high number of Community Trusts have a malnutrition screening tool in place (86%) very few have a consistent systematic approach to malnutrition screening training or the necessary infrastructure in place to comply with NICE (2006) recommendations. To ensure that malnutrition is being detected and subsequently treated in the community, where the problem is highlighted to start (BAPEN 2008), the need for widespread education, training and monitoring initiatives is clear. In order to implement such education, training and monitoring initiatives a multi-organisational, strategic approach is required to succeed. Chart 7 and Chart 8 show the WTE dietetic staffing levels per GP practice and per Community Pharmacist within London Community Trusts. These tables give some indication of the scale of the task of education, training and monitoring initiatives within the community setting and highlight the need for increased resources to allow such programmes to be initiated and sustained. The lack of training for staff may contribute to lack of awareness, resulting in poor completion rates and failure to detect malnutrition. To meet the recommendations set out in the NICE guidelines, additional resources are required to both detect and subsequently treat malnutrition. ONS User Groups Qualitative data (see Chart 2) indicates many dietetic departments identified that the highest use of ONS within their Community Trust falls within the areas of mental health, substance misuse and nursing homes. Although 76% of the Community Trusts state that they provide input into nursing homes, the services vary greatly between Trusts, ranging from an allocation of one day per week, one day per month to occasional telephone input on an ad-hoc basis. This population is particularly at risk as the prevalence of malnutrition increases with escalating frailty and physical dependence (Stratton et al 2003). The effects of malnutrition on an individual s quality of life and the additional costs of increased morbidity and mortality that accompanies inadequate nutrition should also be taken into consideration in this patient group. The Department of Health s National Minimum Standards for Care Homes for Older People (2003) and NICE (2006) state that patients should be screened on admission and that their dietary needs and preferences should be assessed. NICE also highlights that care homes should provide adequate quantities of good quality food so as to avoid the unnecessary and inappropriate use of nutrition support. However without the resources in 32

33 place to raise awareness of malnutrition and provide education, care home staff are unlikely to receive the necessary training. Increased dietetic support with the objective of improving nutritional care in care homes is required in order to improve the current situation. Ideally all patients should have initial and ongoing nutrition risk assessment and nutrition care pathways should then be followed depending on the outcome with dietetic referral, intervention and monitoring available if required. An increase in dietetic resources within care homes could provide guidance, training and support for malnutrition screening, dietary intervention, catering issues, food fortification and menu planning therefore reducing ONS use as a first line treatment option for malnutrition. Increased dietetic input into care homes can also allow tighter control of ONS prescribing with a reduction in inappropriate usage. Shakouri gives one example of dietetic intervention in two West London Nursing Homes with ONS usage over a six month period following the introduction of robust food first initiatives which can be seen in Table 6 (unpublished 2008). The cost of ONS reduced by 579 over the six month period of time. By adopting a food first approach and implementing care home staff education and training initiatives, the inappropriate use of ONS as a first line option for treating malnutrition has ceased. Not only has the usage and subsequent cost of ONS reduced but the appropriateness and quality of the food, snacks and drinks has also improved significantly, resulting in better clinical outcomes, quality of care and a reduction in referrals to the dietitian for nutrition support intervention. (Unpublished Shakouri NHS Westminster 2008) Table 6: - The Cost of ONS in 2 Nursing Homes Over a 6 Month Period of Time Month Cost February 76 March 780 April 496 May 230 June 309 July 82 Table 7 provides information on the possible scope of dietetic involvement within care homes. However at present there is a significant lack of community dietetic support and infrastructure throughout London for this to happen. 33

34 Table 7: - Possible Roles of a Dietitian within the Care Home Setting To assess and provide ongoing management of individual residents in need of dietetic intervention To develop and implement a nutrition risk screening tool and subsequent intervention To develop and review policies, procedures and standards in relation to meeting the nutrition and hydration needs of residents To implement ONS management initiatives Food service assessment including menu planning and advising on special diets/religious or cultural needs Staff training and support Health promotion and preventive programmes Development of resources Involvement in continuous quality improvement Substance misuse is another high ONS user group and has been highlighted as an area of increasing concern due to both cost and appropriateness. This area rarely receives dietetic input; no Community Trusts reported that they have a dedicated dietitian in this field. Many of the hospitals report to see substance misuse inpatients who are often commenced on ONS during the hospital admission (if not already on ONS prior to this). Malnutrition is common among drug users and can lead to further complications including a reduction in immune function (Jones 997). In addition to substance misuse, socioeconomic factors and lifestyle can further contribute to nutritional deficiencies and malnutrition. Staff working within this area (including GPs) have indicated that ONS is often prescribed as there is little other information/resources around to support alternatives (e.g. food) and that there is the feeling they need to do something to help. Once commenced on ONS the review of substance misuse patients is reportedly difficult due to the extremely high DNA rate (McCombie 999). ONS is reportedly traded on the street and used as street currency. ONS drinks are recommended in addition to normal food and should not replace it, otherwise the cost of the ONS is effectively equivalent to purchasing food (Stratton et al 2003). Under such circumstances it would be more appropriate to deal with the underlying causes by referring to the appropriate support services within the area, i.e. Social Services. Information, resources and further training needs to be made available to GPs and other Health Care Professionals (HCPs) working within the area of substance misuse to allow them to direct clients to alternative sources of nutrition, (i.e. FareShare Community Food Network and support projects, with 34

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