London Procurement Programme Clinical Oral Nutrition Support Project

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

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 (2005-08) 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 8 9 8 20 25 33 34 4 0 2 2 3 4 4 5 6 6 7 7 7 9 2 22 23 24 24 25 26 27 27 47 5 52 57 6 68 70 7 72

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 Email: catherineforrest@nhs.net Louise Wilkie Specialist Community Dietitian Email: louise.wilkie@kc-pct.nhs.uk Project Management Peter Sharott Pharmaceutical Adviser, London Specialised Commissioning Group Strategic Pharmaceutical Lead, London Procurement Programme Email: peter.sharott@btinternet.com Philip Aubrey Deputy Medicines Procurement Specialist London and East of England London Procurement Programme P&MM Operational Lead Email: Philip.Aubrey@nwlh.nhs.uk Project Support Management Ian Jones Head of Nutrition and Dietetics Services, NHS Westminster Email: ian.jones@westminster-pct.nhs.uk Joanne Jones Nutrition and Dietetics Services Manager, NHS Kensington and Chelsea Email: joanne.jones@kc-pct.nhs.uk 3

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

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

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

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 2007. 3 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

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

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

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 300.00 250.00 200.00 WTEs 50.00 00.00 50.00 0.00 Dietitians Dietetic Assistants Admin & Clerical Others Totals WTEs 95.87 29.0 7.76 8.68 26.32 Chart provides data on the number of WTE equivalent dietitians and support staff for London Community Trusts. 95.87 WTE dietitians work across London Community Trusts with 29.0 dietetic assistants. Others include nutritionists and nutrition assistants. 0

Chart 2: Community Trust Dietetic WTE per AfC Banding 30.00 20.00 0.00 00.00 90.00 80.00 WTEs 70.00 60.00 50.00 40.00 30.00 20.00 0.00 0.00 8d 8c 8b 8a 7 6 5 5 4 3 7 6 5 4 3 2 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 50.72 band 6 posts and 0.88 band 5. There is one 8C banded management post with 2.6 banded 8b and 2 banded 8a.

Chart 3: Acute Trust WTE Dietetic and Support Staff 450.00 400.00 350.00 300.00 250.00 WTEs 200.00 50.00 00.00 50.00 0.00 Dietitians Dietetic Assistants Admin & Clerical Others Totals WTEs 290.89 67.75 27.43 5.50 39.57 Chart 3 provides data on the number of WTE equivalent dietitians and support staff for London Acute Trusts. 290.89 WTE dietitians work across London Acute Trusts with 67.75 dietetic assistants. Others include nutritionists and nutrition assistants. Chart 4: Acute Trust Dietetic WTE per AfC Banding 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 0.00 00.00 WTEs 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 0.00 0.00 8d 8c 8b 8a 7 6 5 5 4 3 7 6 5 4 3 2 Dietitians Dietetic Assistants Admin & Clerical 2

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 64.22 band 6 posts and 47.70 band 5. There are 7.58 8C banded management posts with 9.97 banded 8b and 27.34 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 0.00 5.00 0.00 5.00 20.00 25.00 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 8.43. 3

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 0.00 5.00 0.00 5.00 20.00 25.00 30.00 35.00 40.00 45.00 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 3.98. 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 0.00 0.50.00.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00 4

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 2.24. 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 0.00.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 0.00 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 3.28. 5

Chart 9: 2005/06 Community Trust ONS FP0 Expenditure 600,000 500,000 ONS FP0 Expenditure 400,000 300,000 200,000 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 700,000 600,000 500,000 ONS FP0 Expendtiure 400,000 300,000 200,000 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

Chart : 2007/08 Community Trust ONS FP0 Expenditure 700,000 600,000 ONS FP0 Expenditure 500,000 400,000 300,000 200,000 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 (2005 2008) 700,000 600,000 500,000 400,000 300,000 200,000 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 2005/06 2006/07 2007/08

Charts 9-2 tabulate PCT ONS expenditure from 2005-2008. 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 2006/2007 2007/2008 Barking and Dagenham 278,450 292,060 +3 60 Barnet 526,240 606,433 +80 93 Bexley 34,630 372,233 +30 603 Brent 539,860 573,75 +33 89 Bromley 486,382 567,244 +80 862 Camden 409,984 399,83-0 80 City and Hackney 348,787 385,85 +37 028 Croydon 383,707 436,994 +53 287 Ealing (off FP0) 434,695 376,384-58 3 Enfield 374,366 407,646 +33 280 Greenwich 407,348 456,842 +49 494 Hammersmith and 344,564 383,765 +39 20 Fulham Haringey 380,897 390,99 +9302 Harrow 279,689 34,97 +34 508 Havering 379,759 40,273 +30 54 Hillingdon 36,278 32,72 +4894 Hounslow 377,385 437,796 +60 4 Islington 372,222 356,793-5 429 Kensington and Chelsea 223,63 27,272 +48 09 Kingston 76,69 74,283-2336 Lambeth 578,69 594,335 +6 23 Lewisham 632,67 599,482-33 35 Newham 453,583 438,639-4 944 Redbridge 382,006 404,40 +22 404 Richmond and 249,004 26,47 +2 467 Twickenham Southwark 470,026 493,72 +23 695 Sutton and Merton 384,279 430,483 +46 204 Tower Hamlets 405,48 423,876 +8 728 Waltham Forrest 34,040 362,892 +2 852 Wandsworth 445,986 437,36-8670 Westminster 394,284 426,384 +32 00 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

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 250,000 200,000 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

Table 4: Community Trusts with an ONS Demand Management Dietitian PCT Post Start Details Ealing Full service redesign 2006 3 WTE Prescribing ONS (off FP0) Hillingdon April 2008 6 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 2007 0.4 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 2008 0.2 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

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 800 600 400 200 0 2005-2006 2006-2007 2007-2008 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

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 0.00 0.02 0.04 0.06 0.08 0.0 0.2 0.4 0.6 0.8 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

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 50.00 45.00 WTEs/00,000 Population 250,000 IMD Score 40.00 35.00 30.00 25.00 20.00 5.00 0.00 5.00 0.00 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

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 0.00 0.05 0.0 0.5 0.20 0.25 0.30 0.35 0.40 0.45 0.50 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 0.00 0.0 0.20 0.30 0.40 0.50 0.60 24

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? 30 6 2 All ONS patients referred? 5 3 2 Can doctors prescribe without dietitian s knowledge? 33 2 Chart 9: Top Barriers to ONS Demand Management Initiatives (Acute and Community Trusts) 2 0 8 Response Number 6 4 2 0 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

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 0 9 8 7 Response Number 6 5 4 3 2 0 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

Chart 2: Main ONS User Groups Reported by Community Trusts 6 5 4 Response Numbers 3 2 0 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) 9 8 7 6 Response Numbers 5 4 3 2 0 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

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

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 00 000 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 00 000 of weighted population and Hounslow PCT have just 0.65 dietitians per 00 000 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

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 (2005 2008). 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 00 000 unified weighted population and ONS expenditure per 00 000 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

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 268 000 (weighted population of 328 848). 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

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

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

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 www.fareshare.org.uk,) and support projects, with 34

the aim of working towards establishing regular eating patterns of normal foods so as to reduce ONS dependency and to prevent further inappropriate prescribing of ONS. The use of ONS in the area of mental health is reported (anecdotally) to be high over London. Similarly to care homes and substance misuse, mental health has relatively low dietetic service provision. There are dedicated teams of dietitians working in the area of mental health over London however the results within this project are limited as only one MHT participated in the project. As with many Acute Trusts, the number of dietitians per 00 beds is below average. South London and Maudsley MHT have the lowest number of WTE dietitians per 00 beds (0.43) falling well below the London average of 2.24 WTE dietitians per 00 beds. ONS Management The initiation and ongoing management of patients on ONS can be complex with similar challenges for both Acute and Community Trusts. Acute Trusts face the challenges of lack of dietetic resources (no community dietitians in post to refer patients on to), poor prescribing practices by doctors and lack of communication between community health professionals. Whilst Community Trusts face the challenge of Acute Trusts over prescribing ONS with poor discharge practices, poor prescribing practices from GPs and lack of dietetic capacity to see ONS patients. A common theme to emerge from the qualitative data with both the Acute and Community Trusts was a blame culture and lack of ownership of ONS prescribing management. It has been highlighted from this project that there is great variations in practice over London for initiating, reviewing and monitoring patients receiving ONS. Awareness over London of the issues around ONS prescribing is increasing with over half of the PCTs (62%) having either a policy or care pathway in place to manage ONS prescribing. However when interviewed many departments state that the training and implementation for the policies vary greatly and audits around their use and effectiveness are seldom carried out. This is reportedly due to the lack of resources (dietitian s time) to provide ongoing training and audit. There is a distinct lack of Community Trusts over London with a Nutrition Steering Group. Such steering groups tend to exist within the acute setting however just seven Community Trusts (24%) stated the existence of a group. NICE recommends that having a Community Nutrition Team taking a multidisciplinary approach to nutrition within the 35

community is valuable, and that such a team would consist of dietitians, district nurses, care home staff, speech and language therapists (SALTs), physiotherapists and occupational therapists (OTs). The team should then work with GPs, caterers, patients, relatives and carers to prevent and treat malnutrition as necessary. Furthermore NICE states that such a team would ideally develop protocols and care pathways for nutrition support, along with educational initiatives to ensure that all health professionals understand the importance of nutrition in patient care (2006). These may be the necessary steps required in Community Trusts to improve the highlighted problem of lack of ownership of ONS prescribing and improve the co-ordinated care of patients requiring oral nutrition support. Again, additional resources are required in many of the London Community Trusts to allow such developments to take place to improve quality of care, improve appropriate prescribing and realise cost benefits. When interviewed, both acute and community dietitians expressed the perceived benefit of ONS being taken off FP0 with the management of ONS sitting solely with dietitians, so allowing tighter dietetic control. This is not possible in the current situation without greater numbers of dietitians and administration systems in place to manage the increased caseload effectively. Currently, 97% of Community Trusts have ONS on FP0; therefore, 97% of ONS in the community are generated/written by a GP/Doctor. However as stated only 7% of Community Trusts provide GPs with training on appropriate ONS prescribing thus highlighting the possible shortfall of prescriber education and awareness. The only Community Trust in London that does not have ONS on FP0 is Ealing PCT. In response to the escalating ONS prescribing costs Ealing PCT have taken a different approach to ONS management. The dietetic department have taken over the provision and monitoring of feeds for Ealing PCT patients by taking the feeds off FP0 prescription (as the dietitians are not yet prescribers). This current demand management model of care is tied in with the current enteral feed contract and allows patients to receive intervention from dietitians who are the best placed to deliver it as well as allowing the dietitian to have more control over the management of ONS prescribing. Apart from the benefits to ONS demand management it also enables implementation of the recommendations set out by NICE (2006) Other London Community Trusts have taken a different approach to ONS demand management. NHS Kensington and Chelsea and NHS Westminster for example worked in 36

partnership with industry to each secure a fixed term post for one year to manage ONS. The remit of these posts was to target the highest spending GP practices within the individual Trusts to highlight and assess all patients receiving a prescription for ONS. Training programmes around malnutrition screening have been initiated, an ONS care pathway implemented and improved links with local Acute Trust dietitians have occurred. Appropriate resources to support ONS demand management initiatives promoting a food first approach have also been produced. To date all patients highlighted to be receiving a prescription for ONS in 8 out of the 43 GP practices within NHS Kensington and Chelsea have been reviewed. 70% of the patient s prescriptions for ONS have been discontinued after being deemed inappropriate or unnecessary following dietetic assessment. The project, although now at the end of the fixed term funding, continues and additional dietetic resources (2 permanent WTE dietitians) are in place to continue to take the work forward. Please see Appendix 5 for further details on NHS Kensington and Chelsea, NHS Westminster and other Community Trust s experiences. Acute Trusts BAPEN (2008) reports that approximately one in three adults (of all ages) is at risk of malnutrition on admission to hospital, care homes and mental health units. 28% of all subjects screened on admission to hospital and care during BAPENs Nutrition Screening Survey 2007 were shown to be at risk (of malnutrition) the vast majority (22%) at high risk (Elia 2008). With such a high incidence of malnutrition or risk of malnutrition on admission it is not surprising that the area of oral nutrition support features heavily on the majority of acute dietitian s caseloads and similarly to the community dietitian, it is not just dedicated nutrition support dietitians who see such patients. Malnutrition Screening and Clinical Practice NICE 2006 states that all hospital patients on admission and all outpatients at their first clinical appointment should be screened (for malnutrition) and this repeated weekly for inpatients and where there is clinical concern for outpatients. Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with the appropriate skills and training. 00% of the Acute Trusts who responded have a malnutrition screening tool in place with 00% providing malnutrition screening training for nursing staff and 33% providing training for consultants/doctors. Of the Acute Trusts 48% are currently using the Malnutrition Universal Screening Tool (MUST). Others use the Birmingham Heartlands Nutrition Screening Tool, an adaptation of the MUST screening tool or a locally developed hospital specific screening tool. In the acute setting the 37

malnutrition screening tool is the basis for the majority of referrals for assessment and subsequent intervention for nutrition support with 93% of Acute Trusts accepting referrals for ONS assessment if the patient is highlighted to be at risk of malnutrition or malnourished. However out of this 93% only 30% state that all patients requiring ONS are seen by a dietitian. The hospitals that do not see all patients on ONS indicate that, due to the high volumes of referrals and the relatively small numbers of dietitians within the hospital, they simply do not have the capacity within current resources to see all patients. Chart 6 shows the total numbers of WTE dietitians in each Acute Trust and Chart 7 displays the number of WTE dietitians in each Acute Trust per 00 hospital beds. Similarly to the Community Trust results, this indicates great variation between the Acute Trust staffing levels and again highlights inequalities of service provision in different geographical areas of London. With the relatively low numbers (just 30%) of Acute Trust dietitians seeing all patients on ONS it highlights the issue of the high number of patients receiving ONS from nursing staff without receiving assessment and advice from a dietitian. Qualitative data indicates that the majority of Acute Trust wards hold their own bulk supply of ONS with little control over the distribution to patients by ward staff. In such instances anecdotal evidence suggests that ONS are used as a first line treatment of malnutrition instead of food first/food fortification in the acute situation which is contrary to NICE 2006 guidelines which state dietary modification should be the first-line treatment of malnutrition. In such circumstances ONS initiated in the Acute Trusts may then be continued unnecessarily in the community setting further adding to the issue of inappropriate and unnecessary prescribing. Although the infrastructure is often in place in Acute Trusts to screen and monitor for malnutrition, many state that when audited the actual screening tool completion is very poor. One Acute Trust who audited screening tool completion found that just 7% of the hospital population had a screening tool completed with no evidence of repeated screening thereafter; therefore patients in need of intervention may be missed. One contributing factor may be that although malnutrition screening training has been implemented, many Acute Trusts are unable to provide regular training sessions with responses indicating that training sessions ranged from monthly (5%), annually (27%) or on an ad hoc basis when requested by staff. Trusts highlighted improvement and a marked increase of screening tool completion following training and felt that ongoing regular training sessions improved the situation further. Another factor that could contribute to the poor completion of malnutrition screening tools is that screening has not yet been imbedded as a core part of an initial assessment. 38

NICE states that due to the relatively small numbers of dietitians in most hospitals, some of their roles must be delegated to other ward staff. The dietitians therefore need to develop hospital protocols and care pathways on nutrition support, and to participate in the education of the entire workforce. Just over half (52%) of Acute Trusts have taken steps towards this and have a policy or care pathway in place to manage ONS prescribing within the hospital. However few are carrying out any audits around compliance or the effectiveness of such policies. 93% of Acute Trusts state that ONS is initiated by dietitians, 89% by doctors and % by nursing staff. However, when it comes to training healthcare professionals on the appropriate prescribing of ONS, 59% train ward staff (nursing staff) and only % provide training for doctors although, as indicated the second highest initiators of ONS is doctors (89%). Qualitative data indicates many Acute Trusts feel that doctors are inappropriately prescribing ONS without dietetic assessment or the dietitian s knowledge. As a consequence, patients are often discharged on ONS having had no dietetic assessment, dietary advice or means of follow up. This therefore highlights the need for initiatives within Acute Trusts around the prescribing of ONS, ideally with a multidisciplinary team approach including dietitians, medical staff, nursing staff, ward staff and pharmacy and should include robust training programmes for reinforcement. Such initiatives may be best placed within the already established Nutrition Support/Steering Groups. NICE recommends that all Acute Trusts should have a multidisciplinary nutrition support team working within the clinical governance framework and employ at least one specialist nutrition support nurse. Of the Acute Trusts who responded less than half (4%) stated they have a specialist nutrition support nurse. 85% stated that they have a Multidisciplinary Nutrition Steering Group in place, with 00% of them having dietetic representation, 74% having consultant representation, 83% having pharmacist representation, 74% having nursing staff representation and 74% having hospital catering representation. Catering Qualitative data indicates many of the Acute Trusts feel that the high usage of ONS within hospitals comes as a direct result of issues with catering budgets and practices. The general opinion was that due to the relatively low costs of prescribing ONS within the acute setting (many Acute Trusts have a contract price of p per ONS unit) the issues around inappropriate usage and prescribing of ONS are not regarded as a priority. However many 39

of the acute dietitians who responded are very aware of the costs incurred and the increasing financial issues that Community Trusts are facing. Several Acute Trusts have taken steps to work with the catering department and improve patient meal times including implementing Protected Mealtimes and Red Tray Systems. 48% provide some form of training for the catering department within their trust however just 30% provide training on food fortification which would be the preferred first line approach in the treatment of malnutrition. NICE 2006 states that in most cases additional foods, snacks and nourishing fluids along with fortification using additional high protein and energy foods can prevent and correct malnutrition. The reason for the food first approach not being advocated in Acute Trusts is often related to financial constraints. It was reported that the meals, snacks and drinks available within the hospitals were of poor quality and that supplementing a patient s intake with additional kcals/protein using a food first approach was simply not an option. This is often due to the limited availability (if available at all) of additional snacks or food stuff for fortification. It was reported that a small number of Acute Trusts had difficulty ordering basics such as full cream milk on some wards. Such issues with hospital catering paired with the nursing staff having less time to feed patients due to the increasing demands on their time can further contribute to increasing ONS usage within the hospital setting. Approximately 50% of patients are commenced on sip feeds whilst in hospital (McCombie 999) this can therefore have a knock-on effect in the community. Discharging The follow up of patients on ONS post discharge is crucial. Patients should be followed up and monitored by healthcare professionals who are suitably trained and patients should be followed up every 3-6 months or more frequently depending on clinical condition (NICE 2006). Many prescriptions for ONS are initiated in the acute setting where patients may be acutely ill, recovering from illness or not familiar with the food available. However, on discharge home such factors may no longer apply and the medical condition of such patients and the availability of a wider range of foods within familiar surroundings may improve the individual s appetite, often decreasing or ceasing the need for a continued ONS prescription. Without the structures in place for appropriate monitoring and regular follow up, improvements in oral intake and nutritional status are unlikely to be highlighted therefore, allowing unnecessary and subsequently inappropriate prescriptions for ONS continue. 40

As can be seen in Table 8, 00% of acute dietitians would notify the GP of a patient being discharged on ONS. Whilst a letter of discharge is sent to 00% of GPs, other health professionals may be notified depending on patient need with actual monitoring assumed and is not guaranteed. The discharging department refers to the health professionals but patients are not always followed up as per NICE guidance. For example, responses indicate 56% of hospital dietitians follow up ONS patients when questioned further this percentage can decrease due to high DNA rate. Should a patient DNA they may be discharged back to the GP or not at all (depending on department policy and dietitian discretion) they would therefore receive no follow up. Table 8: - Notification Given for Patients Discharged on ONS Community Health Professional % of Acute Units Who Notify GP 00% Community Dietitian 63% District Nurse 7% Practice Nurse 4% 78% Acute Trusts assess the need for the ONS prescription to be continued prior to discharge but this is only for those patients who are known to the dietitian. Qualitative data indicates that the majority of dietetic departments are not aware of all ONS patients on discharge. ONS items are automatically listed on the patient discharge To Take Out/Away (TTO/As) drug list therefore, the prescription often continues in the community without the GP having full knowledge of the treatment goals. 4% of NHS Trusts have an ONS discharge policy with 26% having agreed this policy with their local community dietitians. One issue that was raised on several occasions was the lack of communication between acute and community dietetic departments. However, it should be noted that while some hospitals discharge patients locally others discharge patients both nationally and internationally, therefore, the practicalities of agreeing a discharge policy with the local community dietitians may be limited. Very few audits have however been carried out to measure the effectiveness of such discharge policies. 63% of patients are referred to community dietitians. Consideration should also be given to the limited access to community dietetic services. As stated, several Community Trusts lack a dietetic service and in areas where there is a service they may not accept ONS 4

referrals due to a lack of resources. Follow up is via the Acute Trust or, more often, the GP is solely responsible. The discharging letter sent to health professionals varies greatly between dietetic departments. The information regarding the ONS prescriptions is typically brief with no treatment goals, monitoring plan, or ACBS indication given (see Appendix 0). To improve monitoring of patients and encourage appropriate use of ONS this information is recommended; it provides a base for further assessment and gives non-dietetic health professionals guidance on ONS initiation and use. There is no standard discharge form for ONS in London although recently several PCT departments have been piloting this (NWL). Individual dietetic departments may have a letter template used at the dietitian s discretion. Evidence indicates that GPs do not monitor ONS patients as recommended by NICE (Gall et al 200, Loane et al 2004, Forrest 2007) and therefore patients receiving an ONS prescription are not reviewed to ensure that nutritional objectives and goals have been reached. Such patients then remain on supplements long term and often inappropriately. For example an obese patient with Diabetes (highlighted through ONS demand management work in a West London PCT) was receiving a prescription for ONS (four times daily) over a seven year period. This prescription was deemed to be inappropriate and was ceased following dietetic intervention. This patient was unaware of the appropriate use of ONS and the possible effects it was having on weight and diabetes control and was receiving continued repeat prescription for ONS from the GP with no monitoring. This particular case of poor monitoring practices resulted in poor quality of care and unnecessary costs to the NHS in the region of 6,62 (over the seven years) further strengthens the case for the need for improved prescribing and monitoring practices in London. See Appendix 6 for further ONS case studies. Some Acute Trusts have taken positive steps to try to prevent patients being discharged on ONS without dietetic assessment and advice in order to try and prevent inappropriate prescribing. Steps taken have included the development of a discharge policy whereby patients must see the dietitian prior to discharge otherwise the ONS are taken off the drug list with the aim of avoiding patients being discharged and getting lost in the system with a repeat prescription for ONS. Another Trust has made the training around malnutrition and appropriate prescribing mandatory for all junior doctors and new staff within the trust and another is working jointly with the pharmacy department to monitor all patients written 42

up for ONS on the ward drug charts, then regularly notifies the dietitian of all patients listed to receive ONS. Although there have been some initiatives put in place there is still considerable work to be done to ensure issues of ONS prescribing are tackled. Each individual Trust will have specific local issues therefore one size does not fit all with demand management initiatives. Limitations of the Report Several limitations may affect the interpretation of the data collected. Firstly the data used in regards to the population size and dietetic staffing levels includes children. The costing information included in the study is for adult ONS only. It was decided that paediatric ONS would not be included in this study due to the time constraints of a six month project. With regards to the staffing levels as previously highlighted many Acute and Community Trusts have service level agreements and to distinguish exact allocation of dietetic time in some areas (acute or community) is difficult. Although response rates were very good they were not 00% therefore this is not a complete representation of London. A large component of the data collected for this study was via questionnaire the results are therefore dependent on individual interpretation and subsequent answering of these questions. The qualitative data generated from the interviews was predominantly the individuals opinion. 43

Conclusion This project has identified that ONS demand management is a multi factorial initiative. There is clear evidence for potential cost savings on ONS prescribing by having specific Demand Management Dietitians in post leading on ONS demand management initiatives within a Trust. The majority of London Community Trusts do not have a Demand Management Dietitian in place and therefore fail to implement appropriate ONS demand management procedures resulting in a continual increase in expenditure. The actual financial cost savings from appropriate prescribing can be measured however the additional cost savings for the NHS associated with improved nutrition, for example, reduced frequency and length of hospital stay, reduced GP visits and improved wound healing should also be taken into account. Great variation in dietetic resources over London in both the Acute and Community Trust setting has also been highlighted from this project. As a result of the variation in dietetic resources, many London Trusts (both acute and community) are failing to implement the NICE Guidelines (32) for Nutrition Support (2006). The findings of this project highlight possible cost savings and improvements in care not only from appropriate ONS prescribing but also from the prevention and treatment of malnutrition and in many cases cost and quality improvements can be achieved together. In order to use limited resources effectively and direct 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 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. 44

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 45

Acknowledgements We would like to give special thanks to the LPPCONSP members (Peter Sharott, Philip Aubrey, Ian Jones and Joanne Jones) for their contribution to the project. Additional thanks to those NHS Trusts that contributed with data provision and Ruth Eager, Prescribing Information Analyst for all her assistance with the data analysis. 46

Appendix : Background Malnutrition in the UK is an important public health problem; both physiologically and financially (Stratton, 2005). Malnutrition is associated with increased morbidity, mortality and increased length of hospital admission (Cochrane, 2007). The cost of treating these consequences of malnutrition is estimated at 7.3billion, 50% of which is spent in the community setting (NICE 2006, Cochrane 2007). Malnutrition may occur as a result of illness or from a variety of physiological and social co-factors (Cochrane, 2007). It has a diversity of effects, influencing every system of the body (Stratton et al, 2003). Some adverse effects of malnutrition include: Impaired immune responses - increasing risks of infection Reduced muscle strength and fatigue Reduced respiratory muscle function - resulting in increased difficulties in breathing and expectoration, in turn increasing the risk of chest infection and respiratory failure Impaired thermoregulation - predisposition to hypothermia Impaired wound healing and delayed recovery from illness Apathy, depression and self neglect Increased risk of admission to hospital and length of stay Poor libido, fertility, pregnancy outcome and mother child interactions (MAG, 2000) It is estimated that at least two million adults in the UK are affected by malnutrition at any one time (MAG, 2000). Data from the Nutrition Screening Survey in the UK in 2007 shows 28% of patients admitted to hospitals and 30% of patients admitted to care homes were at risk of malnutrition (Russell & Elia, 2008). The majority of these patients were found to be at a high risk of malnutrition. More than 95% of malnutrition identified on admission originates in the community, demanding strategies to identify and treat malnutrition in this setting (NICE, 2006). The groups most vulnerable to being at a high risk of malnutrition are people with chronic disease, elderly, those who have recently been discharged from hospital and those with low socio-economic status and/or socially isolated (MAG, 2000). Malnutrition remains a costly problem as the poor nutritional status of many patients is not identified in routine clinical practice (Cochrane, 2007); consequently malnutrition can often 47

remain untreated (Stratton et al, 2003). It can lead to increased infection rate, delays in recovery, increases in visit to General Practitioners (GP s) and increases in the frequency and length of hospital stays (King et al, 2003). Individuals with a BMI of <20kg/m² have been shown to have 9% more prescriptions, 6% more GP visits and 24% more hospital admissions than individuals with a BMI of 20-25kg/m² (Martyn et al, 998). Oral nutrition support can be described as the modification of an individual s food and drink to increase the overall nutritional content (i.e. the carbohydrate, fat and/or protein) (NICE, 2006). This can involve the use of extra snacks or nourishing drinks, food fortification and in some cases, includes the use ONS. ONS are increasingly being used to treat malnutrition within the community setting by providing additional nutritional support (Todorovic, 2005). An ONS is a commercially available product. There is a wide choice of ONS products from various manufacturers and provide the basic nutritional requirements including vitamins and minerals. There are a range of different styles and flavours available; milkshake, fruit juice or yoghurt and the calorie and protein content varies in each ONS, generally ranging from 25-330kcal and 2-20g respectively (British National Formulary, 2008). ONS is classified a borderline substance by the Advisory Committee of Borderline Substances (ACBS) which states it should only be considered in the following patient groups: Short bowel syndrome Intractable malabsorption Pre-operative preparation of patients who are undernourished Proven inflammatory bowel Following total gastrectomy Dysphagia Bowel fistulas Disease-related malnutrition Continuous ambulatory peritoneal dialysis (CAPD) Haemodialysis The British National Formulary (2008) states: ACBS recommends products on the basis that they may be regarded as drugs for the management of specified conditions. Doctors should satisfy themselves that the products 48

can safely be prescribed, that patients are adequately monitored and that, where necessary, expert hospital supervision is available. Many audits of ONS prescribing practices have highlighted that ACBS indications are not recorded when prescribing these products (Jones et al, Forrest 2007) Inappropriate prescribing of ONS has significant cost implications. The cost of a month s supply of a standard ONS product taken once daily is on average 5 (approximately.70 per unit) (British National Formulary, 2008). This will have approximately a kg weight gain. To achieve the same weight gain, with the approximate cost of 5 a month, a patient could have a daily glass of full fat milk and a chocolate biscuit. For example a recent Community Trust patient was found to have an ongoing script of 3 x ONS per day for nine years despite these drinks not being clinically indicated and the patient having a BMI of 32kg/m 2 (obese). The total cost of this script equates to 6 09.64. This re-enforces the need for regular monitoring of patients on ONS to ensure usage remains appropriate. Appendix 6 provides further examples of inappropriately prescribed ONS and cost incurred. It is important to note however, that the appropriate prescription of these products in addition to dietary advice together with clear goals and regular monitoring can result in improved nutritional status (Cochrane, 2007). The audit of local practice by Jones and Jones (2006), Forrest (2007) Gall et all (200) and McCombie (999) highlighted concerns in terms of screening and monitoring of patients on ONS. Decision making to commence ONS appears to be based on inadequate nutrition knowledge (Loane et al 2004). In addition, a high percentage of patients are not screened using a validated screening tool (e.g. MUST) and monitoring was poor once ONS was commenced (Loane et al 2004, Gall et al 200). NICE guidance recommends patients receiving nutritional support be monitored every three months or sooner if clinically necessary (2006). Furthermore, NICE guidelines (2006) state that people having oral nutrition support (including ONS) in the community should be monitored by healthcare professionals with the relevant skills and training in nutritional monitoring. Dietitians are in the best position to be delivering this service, having skills in dietary counselling and an up to date knowledge of the clinical guidelines (Cochrane 2007). The current situation across London at present appears that 49

the majority of patients on ONS (both in the Acute and Community Trust setting) are not seen by the dietitian due to limited capacity. Nursing staff, doctors and GP s are relied upon to give dietary advice and monitor patients receiving ONS if the patient is not under the care of a dietitian. 50

Appendix 2: Methodology Two full-time registered community dietitians seconded for six months (at the time of writing this has been extended until 3/3/09) Meetings with key stakeholders Presentations to Medicines Management Leads (Acute and Community Trusts) and the London Dietetic Managers (LDM) to inform of project Letter of project introduction emailed to all LDM and Medicines Management Leads (see Appendix 7). List of LDM obtained through the LDM Group; consent sort to provide this list. Questionnaire piloted with three dietitians, alterations made as necessary Questionnaires emailed to all dietetic managers in Acute, Community and Mental Health Trusts in London. Questionnaires were split into separate categories to meet the project objectives. Follow up emails and telephone calls to ensure maximum participation. Option of opting out of project offered. Cut off for inclusion 29/9/08. Private Hospitals or non-nhs Hospitals were not included. Due to the size of the project and initial time period, only adult ONS was assessed. Request for supporting documentation: ONS policies/guidelines, standard letters for correspondence, referral criteria, previous ONS audit reports, job descriptions, diet sheets etc Workforce data collation epact ONS expenditure data collation Interviews/meetings with all participating Trust dietetic departments (phone consultations or one-to-one interviews offered) Request for ONS case studies from all prescribing dietitians Notification to the British Dietetic Association, Royal College of Nursing and Royal College of GPs of project work Collation and analysis of data; meeting with data analysis Report on findings to key stakeholders Recommendations and guidelines on demand management initiatives proposed Development of London ONS templates for implementation 5

Appendix 3: Full Questionnaire Findings Community Trust Questionnaire (n=29): Department Information Question Response. Do you currently have a Prescribing Dietitian (Lead)? Yes 28% (n = 8) No 72%.3 Do you provide a Dietetic Service in the following areas: Nursing Homes Yes 76% Residential Homes Yes 72% Sheltered Homes Yes 45% Mental health Units Yes 34% Bedded Services Yes 38% Learning Disability Units Yes 38% Rehab Units Yes 62%.5 Does your organisation/trust a have a Specialist Nutrition Support Nurse?.6 How many WTE nurses are in post?.7/8 Does your organisation/trust have a multidisciplinary Nutrition Steering Group/Committee? Who is a member:.9 How often does the group/committee meet? Current Practice 2. Does your trust have a malnutrition screening tool in place? 2.2 Is it MUST? Yes 7% No 83% WTE 0% 2 WTE 3% 3 WTE 0% Other 2% Yes 24% No 76% Consultant 0% Pharmacist 7% GP 0% Nutrition Nurse 3% Practice Nurse 3% Community Matron 7% District Nurse 7% Ward Staff 0% Dietitian 24% Service User 0% Other 4% Weekly 0% Monthly 3% Bi-Monthly 0% Quarterly 7% Six Monthly 0% Annually 0% Other 3% - ad-hoc meetings as deemed necessary Yes 86% No 4% Yes 96% No: 4% 2.6 Do you provide PCT staff with malnutrition screening training? 2.7 If yes please indicate the frequency of the training sessions? Yes 66% No 34% Monthly 7% Bi-Monthly 7% Quarterly 7% Six Monthly 7% Annually 0% Other 2% 2.8 Who is the training open to? 52 GP 48% (n=4) Practice Nurse 45% Dietitian 34%

Ward Staff 45% District Nurse 55% Community Matron 52% Pharmacist 3% Other 28% 2.9 Do you provide training for catering staff within your Community Trust? Yes 3% No 87% 2.0 If Yes - what is included in the training? Food fortification 34% Texture modification 34% Menu planning 3% Other 0% 2.4 Does your trust currently have policies/procedures or care pathways in place Yes 62% for the management of ONS? No 38% 2.5 Are your current ONS prescriptions on FP0? Yes 97% No 3% 2.6 Do you accept referrals for ONS assessment? Yes 86% 2.7 If No - why not? No 4% 2.7 Do you provide community staff with training on ONS usage? Yes 59% No 4% 2.8 If Yes please tick to indicate who receives the training. GP 7% Nutrition Nurse 4% Dietitian 34% Nursing Staff 55% Pharmacist 4% Ward Staff 34% Catering 2% Other 3% Budget 3.5 Do you receive any industry rebates on the prescriptions for ONS? Yes 7% No 93% 3.7 What does the rebate get used for? - Training & Education - General Trust Use Any other comments? Departmental Information: The input for Nursing Homes and Learning Disability Units is ONLY for HETF patients so no ONS. Used to have a prescribing dietitian in post that did lots of good work and training with GP etc however the funding for the post did not continue. Prescribing post funded by Medicine Management is currently vacant - 0.6WTE Previous prescribing dietitian funded by Medicine Management but post frozen - no plans known to recruit. One Dietitian in the rehab team only. Community Dietetic service provides one to one sessions in GP clinics only. Almost no input into Nutrition Support. Nutrition Steering group meet only to review policies Current Practice Use to have a post therefore care pathways etc are in place however no longer in post as funding did not continue however pathways etc still used but not as well as the training did not continue. Ad hoc training if requested No Community Dietitians at present, MUST implemented but now post vacant so no training etc offered, no ONS referrals as no Community Dietitians, some GP dietitians however little nutrition support work with clinics Nutritional assessment and malnutrition training for nursing staff in the community includes info on the use of ONS. Training also accessed by some care homes The community team (HEN) in Lewisham is only for patients with an enteral feeding tube. A leaflet has been developed on NS in the community to help with food fortification and the appropriate use of ONS and is given out at training 53

Acute Trust Questionnaire (n=27): Department Information Question Response. Do you currently have a Prescribing Dietitian (Lead)? Yes 4% (n=) No 96% (n=26).3 Do you provide an out reach Dietetic Service in the following areas: Nursing Homes Yes 5% Residential Homes Yes 5% Sheltered Homes Yes 4% Mental health Units Yes 7% Bedded Services Yes 0% Learning Disability Units Yes % Rehab Units Yes 30% Other.5 Does your organisation/trust a have a Specialist Nutrition Support Nurse?.6 How many WTE nurses are in post?.7/8 Does your organisation/trust have a multidisciplinary Nutrition Steering Group/Committee? Who is a member: Yes 4% (n=) No 59% (n=6) WTE 5% 2 WTE 8% 3 WTE 4% Other 4% Yes No 85% (n=23) 5% (n=4) Consultant 63% Pharmacist 70% Nutrition Nurse 33% Nursing Staff 63% Ward Staff 33% Catering 63% Service User 30% Dietitian 85%.9 How often does the group/committee meet? Current Practice 2. Does your trust have a malnutrition screening tool in place? 2.2 Is it MUST? 2.6 Do you provide hospital staff with malnutrition screening training? 2.7 If yes please indicate the frequency of the training sessions? 2.8 Who is the training open to? 54 Other 48% SALT, Infection Control, Biochemist Weekly 4% Monthly % Bi-Monthly 5% Quarterly 48% Six Monthly 0% Annually 4% Other 4% Yes 00% (n=27) No 0% Yes 48% (n=3) No 52% (n=4) - Birmingham Heartlands Tool - Hospital Specific Screening Tool - Modified versions of MUST & Birmingham Heartlands Tool - Combination of MUST & Waterlow Score Yes 00% (n=27) No 0% Monthly 5% (n=4) Bi-Monthly 5% (n=4) Annually 27% (n=7) Other 37% (n=0) Ad-hoc training when requested or following audit. Consultant 33% Dietitian 33% Nutrition Nurse 33%

2.9 Do you provide training for catering staff within your hospital? 2.0 If Yes - what is included in the training? 2. Do you provide community staff with malnutrition screening training? 2.2 Frequency: 2.3 Who is the training open to? Nursing Staff 00% Ward Staff 85% Pharmacist 33% Other 22% (Not specified) Yes 48% (n=3) No 52% (n=4)* Food fortification 30% Texture modification 22% Menu Planning 5% Other 26% Yes 4% (n=) No 96% (n=26) 6 monthly 4% Nursing Staff 00% Ward Staff 00% Yes 52% (n=4) No 48% (n=3) 2.4 Does your trust currently have policies/procedures or care pathways in place for the management of ONS? 2.5 Are your current ONS prescriptions on FP0 Yes 22% No 78% 2.6 Do you accept referrals for ONS assessment? Yes 93% (n=25) 2.7 If No - why not? No 7% 2.20 Are all patients receiving ONS referred and assessed by a dietitian? Yes 30% (n=8) 2.2 If No - why not? No 70% No Dietetic Service Ward Doctors do not inform Dt Workforce/Staff numbers Referral does not meet criteria No reason given 2.22 Who prescribes ONS within your hospital? Dietitians 93% Doctors 89% Nursing Staff % Pharmacy 0% Nutrition Assistants 0% Nutrition Team 5% 2.7 Do you provide hospital staff with training on ONS usage? 2.8 If Yes please tick to indicate who receives the training. Yes 70% No 30% Consultant 0% Junior Doctors % Nutrition Nurse 5% Dietitian 9% Nursing Staff 67% Pharmacist % Ward Staff 59% Catering 5% 2.25 Is there a standard daily prescription of ONS in any department in your hospital/specific wards? Yes 7% No 93% 2.26 When a patient is being discharged on ONS who organises the TTOs? Doctor 33% Dietitian 59% Nurses 37% Catering 4% Pharmacy 5% 2.27 What is the standard quantity of ONS supplied on discharge (TTOs)? 3 Days 5% 7 days 56% 4 days 22% month 4% Other 9% 2.28 Do you have a discharge policy for TTOs? Yes 4% (n=) No 59% 2.30 Is this discharge policy agreed with your local Community Dietitians? Yes 26% (n=7) No 73% 2.3 Is the need for a continued ONS prescription assessed prior to a patients Yes 78% (n=2) discharge home? No 22% 2.32 Who receives notification of patients discharged into the community on ONS? GP 00% Practice Nurse 4% Community Dietitians 63% District Nurse 7% 2.33 Who follows up patients discharged on ONS? Hospital Dietitian 56% Community Dietitian 67% GP 59% 55

Practice Nurse 0% District Nurse 4% Not followed up 9% Budget 3.5 Do you receive any industry rebates on the prescriptions for ONS? Yes 5% No 85% 3.7 What does the rebate get used for? - General Trust Use - Not sure Any other comments: Follow up of patients on ONS is based on whether or not the Community Trust dietitians see pts for ONS nutrition support Follow up varies depending on pt needs. There are no ONS or discharge policies but 'standard practice agreed' Not all patients are seen by the Community Dietitians as it is not always felt necessary. Patients are only referred and subsequently seen if the acute Dietitian feels there is a need for input. Patients seen in community if community dietitians in post/typically 2 ONS per day given when prescribed on ward level FUP generally by hospital dietitian, rarely referred to the community. The ONS policy only relates to hospital therefore no need to consult community dietitians If patients are referred to the community, then as far as we know, they will follow up patients. If patients are due for a follow-up appointment (i.e. attending an out patient clinic) in the acute trust then we may follow them up. Patients can however be missed. If the patient is within the area then they will be followed up by the hospital dietitian (as the community dietitian does not follow up hospital ONS) If the patient is out of area then we liaise with the local community dietitians re follow up. Patient FUP dependant on individual - can be in the hospital, community or none. Request /2 supply from GP. 56

Appendix 4: Interview Qualitative Data Full Summary Discussion Point Response Number of similar responses Main ONS user groups Nursing Homes 5 Substance Misuse 4 Elderly 5 Mental Health 3 Efforts to tackle doctors prescribing without dietetic referral Low income/high deprivation Staff training sessions GP training (including QOF workshops) GP incentive scheme via Pharmacy Audit of GP prescribing practices (including dietetic, pharmacy and in-house audits) Directives sent to lead clinicians on appropriate use of ONS Staff open days taste testing & education Script switch encouraging GPs to prescribe cheaper options of ONS Auditing hospital staffs ONS prescribing Nutrition Steering Group in place that reports to Clinical Governance Encourage only to give ONS on the advice of a dietitian ONS waste audits to highlight food first and appropriate prescribing Policy produced re ONS Launched training sessions at medical staff induction Dietitians highlight doctors who prescribing inappropriately 3 4 4 5 2 3 Perceived benefits from London Wide ONS Policy Universal use Possibly good in separate London clusters as too many opinions across London All work differently so question if it will work Do we need one? Very useful for those trusts without anything at present Will only be of benefit if sufficient staff are in place to implement extra resources and support is required Must be adaptable: have different fits for different areas of practice Clinical judgement still important Great to raise awareness of the issue Will standardise work across trusts improve practice Some trusts already have own policy unsure would alter Good to have LPP backing and interest Positive but needs to be short and to the point Consistency over London however does not want the acute pricing structure to change GPs would respond better to policy/guidance if backed by LPP and SHA/DH Patient choice must be considered Concerned with ONS stock levels if stated in policy 3 2 2 4 3 4 3 3 2 ONS dispensing methods: Dietitian delivers stock to ward, not labelled for specific pts & nursing staff known to give out to other patients Dietitian/doctors writes on the drug chart, ONS not 57 3

labelled, pharmacy hold stock and deliver and ward staff distribute Stock with dietitian aware of all patients receiving it Stock on ward level, not ordered per pt, staff give out Pharmacy dispense Ordered, stored and distributed to wards by catering, wards hold own stock and give to patients. Catering order, budget sits with pharmacy, dietitians write on drug charts and ward staff give on drug rounds also carry out Build Up rounds distributed by ward hostess Pharmacy order, catering store, wards receive own stock and dietetics re-charge wards for usage. TTOs collected via pharmacy. Paid for by dietetics who re-charge wards 2 4 2 3 Comments on ONS use in Trust: Not used appropriately, more benefit if was done so Overused Cheap: dilemma cheap in acute setting, cheaper/easier than ordering snacks for pts so overused. Is cost vs. ethical dilemma. Don t consider use in Community Trusts assume all pts followed up as recommended Prescribing from dietitians not always appropriate also Never thought about it more community problem No ownership of ONS management Considering going off FP0 Not used appropriately by a lot of health care professionals (especially doctors) Patients are often lost in the system following discharge Lack of community dietitians to follow up ONS patients following discharge therefore left to the GP Encourage use of other ONS on wards (Build Up) Some wards as standard prescribe 2 x ONS per day to every patient who has #NoF in Care of the Elderly The problem lies with the GP not an acute issue Community Trust management of ONS is very disorganised Lack of follow up of patients prior to discharge from acute unit High usage in substance misuse, nursing homes Rarely advise over the counter supplements i.e. Build Up GPs need to monitor no standards in place 2 9 3 2 2 2 2 2 2 2 Comments on what would help: Standard forms, templates and guidelines to standardise/streamline practice Acute & Community Trusts working together Dietitians having prescribing rights increased control Funding for further dietitians/staff resources (can be postcode lottery ) Advice on auditing own practice Case studies to highlight inappropriate use Incentives for GPs to monitor more (QOF) Better quality of food in hospital and greater flexibility to fortify food and better access to additional snacks Dietitians & Pharmacy working together Development of a Risk Register for patients on ONS so that all involved i.e. District Nursing, Social Services, Meals on Wheels etc are all aware and can monitor More emphasis on food first and food fortification in the acute setting Facts and figures to be published to highlight the 58 6 2 4 8 2 3 2 4 2 5

problems Extensive GP/HCP mandatory training & participation in audits There should be financial penalties for GPs for poor prescribing practices BDA accreditation would add more weight (commissioners like this) Benchmarking across sectors Awareness of where to refer (community dietitians etc) Improved patient education and awareness of ONS Needs to be a strategy in place with support from senior management, directors and finance Patients are discharged on ONS only if they have been assessed by a dietitian and the dietitian recommends ONS with monitoring and follow up in place Increased input support for low income groups around extra s specifically for food and nutrition Involvement of senior level nursing staff and management is required Increased MDT working Need the Strategic Health Authority to back strategy 5 2 2 Barriers to ONS demand management initiatives: No baseline data therefore difficult to monitor impact Sustainability GPs: difficult to engage/not cooperating with ONS audits/not referring ONS pts/don t stop ONS as recommended Acute: poor discharges pts fall through cracks / not our problem /blame culture/over prescribing Quality of dietitians doing monitoring pts Pharmacy priorities vs. dietitians (cost saving vs. quality of care) Workforce issues limited resources to train staff/audit practice and usage/monitor pts No community dietitians to refer too Funding NH/RH reluctant to engage with dietitians in ONS work Resistance to change One size won t fit all different population groups Difficult to monitor and follow up some groups i.e. substance misuse Trusts off FP0 and those considering it, how are they included? Difficult to enforce Other priorities 6 0 8 6 3 3 3 Examples of ONS demand management initiatives & good practice: Following pt discharge, dietetic assistant calls pt to assess ONS use if still using a letter is sent for follow-up by GP, community or acute dietitian. If not still using no letter to GP requesting script. Dietitians have SOP with GPs allowing them to cease ONS prescription TTO/A directive with pharmacy pts must see dt to receive ONS TTO/As otherwise taken off drug list Out-patient self assessment form pts fill in own details while waiting for appointment referred to dt if assessment indicates Mandatory training for all junior doctors & new staff Acute pharmacists monitor ONS use notify dietitians Going off FP0 money saved Community Trust dietitian visiting discharging hospitals to train and update on prescribing ONS and 59 2 2 2

referring patients on. Development of an e-learning programme through Learning and Development for staff The development of an ONS clinic to provide follow up for patients discharged on ONS Nutrition Link Practitioner Programmes established to provide training and improve monitoring Dietitians hold ONS budget & stock all pts known to department Electronic patient records allow all ONS history to be monitored/audited although have not done so yet 60

Appendix 5: Community Trust ONS Audit Summaries The following report summaries are kindly reproduced with permission from each Community Trust (Greenwich PCT, Hounslow PCT, NHS Kensington and Chelsea, Wandsworth PCT, NHS Westminster) Greenwich PCT Audit 2004 This project was initiated as part of the pharmacy team action plan in an attempt to investigate appropriate prescription & usage of oral sip feeds in Greenwich. Within Greenwich Primary Care Trust (GPCT), the annual expense on these items has been increasing from year to year. The objectives of this audit were to ensure that all patients on nutritional sip feeds have a clinical need for it by identifying inappropriate prescribing; to gain baseline data for trends in sip feeds prescription amongst GP practices in GPCT; investigate whether there is a system /guidelines in place for the prescription of sip feeds and methods for monitoring patients, and to investigate patient understanding and compliance regarding the use of sip feeds. Five criteria were set to examine GP prescribing and monitoring of patients who were issued sip feeds over a one year period (see appendix for criteria) 3 out of the 48 practices within GPCT were audited and a total of 25 patients notes were examined. Results showed that: 57% of prescriptions did not agree with the indications set by the Advisory Committee on Borderline Substances (ACBS) 68% of prescriptions did not include clear dosing instructions for use. 00% of patients notes showed no dietetic follow up for patients on long term sip feeds 69% of patients on sips for >3months were not reviewed before subsequent repeat prescriptions were issued. 68% of patients on sip feeds had not been measured for weight or body mass index (BMI) whilst on sip feeds Of the 25 patients, a small number was interviewed by the dietitian as a qualitative measure; this revealed a generally poor knowledge of the use food in nutrition support and also the correct usage of sip feeds. A large proportion of these patients did not take the sip feeds regularly and some were noted to have no clinical need for them (i.e. not 6

malnourished) From this audit it was concluded that sip feed prescribing in GPCT is not meeting any of the standards set for appropriate prescribing. The report shows that the practices audited are well below standards for complying with ACBS guidance for prescribing, patients are not being reviewed regularly whilst on sip feeds and those on long term supplements are not referred to a dietitian. Weight and body mass index (BMI) which are routine measures are not being carried out. Patients generally have poor understanding of how to enrich their nutritional intake using food (which could be substituted for sip feeds) and how to take sip feeds to gain maximal benefits. Improving nutritional status of patients has economic advantages to the Community Trust as well as health outcomes for the patient. It is recommended that all staff involved in prescribing and/or recommending sip feeds in GPCT undergo practical training in the area of nutritional support, with a focus on the use of nutritional sip feeds, as well as screening for and monitoring those identified as malnourished. Following training and support re-auditing is advised in approximately 9-2 months. Hounslow PCT Nutrition Support Project 2003 Hounslow PCT conducted a project to assess enteral feeding within the Trust both tube and oral support feeding. For the purpose of the LPPCONSP report, this summary focuses on the ONS aspect alone. Background: The majority of spend in drugs budget is on products taken orally. It is estimated the PCT spends 235,000 on these products and the research shows that the clients can waste 50%. The project has also identified that there was ineffective, inappropriate use of products. This is also reported in neighbouring PCTs. Target Groups: - GPs - District Nurses - Practice Nurses - Care home staff 62

Outcomes: Outcome Status % of Patients No of patients still on supplements 3% No of patients needing supplements 3% No of patients discontinued supplements after being seen 2% No of patients benefiting from first line advice only 3% No of patients seen who didn t need supplements but were 22% having them Interventions: - Training sessions for nurses and enteral feeding companies not to leave samples of supplements. - Multi agency, multidisciplinary training days have been held for acute and community staff and have been oversubscribed at all events - An evening session about service for the community pharmacists however only seven attended the session - Care homes have been trained on the resource file - Visits to care homes have been increased due to several serious untoward incidents at a care home in 2002 Barriers to Success: - Project started during the time the PCT was being formed which was a great time for change for all primary care staff - Diabetes and Coronary Heart Disease National Service Frameworks have a higher priority in primary care at present and therefore the referral rate to the project has been low - A universal nutritional assessment tool is required to assess malnutrition within Hounslow PCT Future Plans/Recommendations - The project should continue after March 2003. Annual cost 3K, which will include travel resources and materials - Practices that use the service halt rise in expenditure and increase effective use of products. Increase the level of monitoring on spend. - One enteral feeding company has begun to leave free samples of products to district nurses again and already families are asking for products on prescription 63

because it s convenient. This must cease but primary care staffs need alternative strategies. - Training on strategies to prevent malnutrition for primary care teams and health professionals should continue regularly and should include care homes. - Good quality, non-commercial resources e.g. leaflets, diet sheets, should be available for use by all primary care teams and health care professionals. - Additional audit of service - Extend the project to Brentford, Chiswick and Isleworth locality - Extend the products reviewed to include soya milks and vitamin/mineral supplements NHS Kensington and Chelsea Report 2007/08 Oral Nutrition Support (ONS) prescribing costs within NHS Kensington and Chelsea have been increasing yearly from 97,493 in 2005/06 to 27,272 in 2007/08. This indicates a 37% ( 73,779) increase over the 3 year period from 2005 to 2008. In response to this year on year increase in spend on ONS in NHS Kensington and Chelsea an audit project was initiated to investigate appropriate prescribing & usage of oral sip feeds. A joint initiative between the NHS Kensington and Chelsea Nutrition and Dietetics Service and Prescribing Team (with the support of the GPs) commenced in 2007. Five GP practices with the highest spend on ONS were audited. The results highlighted variation in prescribing practices across the organisation with very few prescriptions being in line with ACBS indications, very few patients receiving any dietary advice prior to being commenced on ONS and very few patients receiving any monitoring after ONS were initiated. Many of the patients highlighted were receiving a prescription for ONS that was deemed by the Dietitian to be inappropriate. On completion of the audit clinical and strategic recommendations were made in order to achieve clinically effective prescribing practice and improve patient care. Following on from the audit one WTE Band 6 Community Dietitian was funded for 0 months (by industry) to work in partnership with the Prescribing Team, GPs, District Nurses and Acute Trust Dietitians. The ONS Prescribing Project commenced in December 2007 for an initial 0 month period. To date (at the time of writing) all patients highlighted to be receiving a prescription for ONS have been reviewed by the dietitian in 8 out of the 43 GP Practices within the Trust. 64

Of the patients reviewed 70% have had their prescription for ONS discontinued following dietetic assessment as deemed to be inappropriate and unnecessary. This has not only resulted in a reduction in the cost of unnecessary prescribing but has also improved the quality of care for patients within the Trust. In addition to reviewing all patients receiving a prescription for ONS the dietitian has: - Developed and implemented a care pathway for nutrition support. Implemented training sessions around malnutrition screening (MUST), first line/food first advice and appropriate prescribing of ONS for District Nurses and Nursing Home staff. Imbedding MUST screening into DN contact assessment Implemented systematic screening throughout the Trust. Developed strong links with local acute Trusts around the discharging of patients on ONS. Developed new referral criteria for those receiving a prescription for ONS or being discharged from hospital on ONS to ensure all patients are referred to the Nutrition and Dietetic Service for assessment prior to the prescription for ONS continuing. Developed and implemented new resources for health professionals to Manage Malnutrition in the Community. This work has allowed the trust to support more cost effective and clinically effective care pathways for appropriate prescribing and monitoring of ONS within the Trust as well as working towards implementing recommendations set out in the NICE Guidelines for Nutrition Support (2006). The project will continue in 2009 with recurrent funding secured for an additional two WTE dietitians. Future plans include the continuation of the above work as well as providing training for GPs, Practice Nurses, Care Agency staff and Social Workers. The catering provision within the Trust will also be reviewed as well as providing ongoing training and support for catering staff working throughout the Trust. Wandsworth PCT Pilot Project 2003 Aims 65

To investigate the prescribing patterns and usage of nutritional supplements in four GP practices in the Wandsworth South Locality and make recommendations for future audit and monitoring. Results The final number of patients included in the audit was 3 (7 adults and 23 children plus 9 receiving gluten free products). 40 of these were individually assessed. Of the whole sample: 52% had been seen by a dietitian at least once while taking supplements, only 35% had nutritional assessment by a dietitian prior to prescription. Of the 40 patients individually assessed: 65% had not received any dietary counselling and education on fortification of their ordinary diet with energy and protein rich foods, 36% were recommended to be referred to the dietitian for further assessment and monitoring. Conclusion The findings emphasise the need for funding of dietetic time to allow further audit, development of policies and procedures and training to ensure nutrition support is provided effectively. Estimated savings from appropriate prescription of nutritional supplements equate to 220,553 which could provide an additional 6.3wte Senior dietitians per annum. NHS Westminster ONS Project 2007/08 The objectives of this project (2007) were to assess patients receiving ONS in the top spending GP practices to ensure there is a clinical need; to develop an integrated care pathway for the appropriate use of ONS; to educate healthcare professionals in appropriate prescribing practices and to investigate the need for dedicated ONS Dietitianled clinics. Five top spending GP practices within NHS Westminster agreed to participate in this project. Results indicated: 75% of patients receiving ONS inappropriately 79% of prescriptions did not meet the indications set by the Advisory Committee on Borderline Substances (ACBS) 46% of patient records did not have documented indications for commencing ONS 00% of patients receiving ONS did not have documented treatment goals and/or monitoring plans 66

20% of prescriptions did not include clear dosing instructions for use 00% of patients reviewed had no record of a dietetic referral or follow up for patients on long term sip feeds 00% of patients were not screened for malnutrition using the Malnutrition Screening Tool (MUST) 68% of patients had no record of being weighed in 2007 74% of patients were within their healthy weight range, overweight or obese Estimated cost saving of 2, 622.42 annually across these five practices, giving a predicted cost saving of 47, 398. 64 across the Trust Of the 7 patients identified, only a small number attended the Dietitian led clinic for nutritional assessment and review of ONS prescription. Of those patients there was a general lack of understanding of the use of food in nutrition support and also the correct usage of ONS. A large proportion of these patients did not take ONS as prescribed and the majority were noted to have no clinical need for them (i.e. not malnourished) This project provided further evidence that ONS prescribing in WPCT is not meeting the standards set for appropriate prescribing by National Institute for Clinical Excellence (NICE) (2006). ONS project work has continued in 2008 with the development and implementations of an ONS care pathway and Resource Pack. The project will continue in 2009 with recurrent funding secured for an additional two WTE dietitians to ensure improved patient care and cost efficiency is sustained. 67

Appendix 6: Community Trust ONS Case Studies ONS Initiated By Hospital Doctor ACBS Indication None recorded in medical records; appears to be post operative DRM Length of time on ONS 7 years ONS Prescription Dose 220ml tetrapack QDS Assessment BMI: 35kg/m 2 MUST: 0 Previous Dietetic Input No Consultation Details & Recommendations History Patient unaware of appropriate use of ONS taking 4/day for 7 years, continues to do so to avoid hypoglycaemic episodes. Now eating a normal diet. Obese. Never referred to Dietitian. Outcome Recommended to continue to see Dietitian for diabetes & wean off ONS and adjust medication for Diabetes. Cost* 662.96 (over 7 years) ONS Initiated By Dietitian the patient was initially enterally fed ACBS Indication Dysphagia post surgery Ca mandible Length of time on ONS 20 months ONS Prescription Dose 220ml 7 x per day Assessment BMI: 22.2kg/m 2 MUST: 0 Previous Dietetic Input Was seen by the acute and community dietitians. The patient was discharged from the community after 6 months of care at which time it can be assumed that ONS was recommended to be stopped. Consultation Details & Recommendations History Pt was initially started on ONS when progressing from an enteral feed to oral intake. The community dietitian was seeing the patient however discharged the patient 4 months ago. Pt now eating well, has maintained weight over the past year. Uses ONS when goes out for coffee as finds it convenient to have an ONS than food, has taken x day. Cost* Outcome Recommended to stop ONS as able to tolerate food and using purely for convenience. Recommended to use over the counter alternatives. Pt happy to have script stopped as she felt she did not need these drinks any longer. 4849.25 (over 4 months) ONS Initiated By GP / hospital consultant ACBS Indication None recorded in notes. Acute pancreatitis so can question for disease-related malnutrition Length of time on ONS 9 years ONS Prescription Dose 250ml Ensure / 220ml Ensure Plus / 220ml Enlive Plus tds (changed from Ensure to Ensure Plus to then Enlive Plus over the years) Assessment BMI: 9.5 kg/m 2 MUST: Previous Dietetic Input No Consultation Details & History Recommendations Reason for initial prescription in 999 not provided. Patient was depressed, on methadone as previous IVDU and contracted Hep C. Continued on Ensure/Ensure Plus for 8 years until admitted in to hospital with pancreatitis where was seen by liver specialist and advised to cut out fat and commence on Enlive Plus tds. Outcome Seen by Dietitian in community and provided food first advice while adhering to low 68

fat diet. Encouraging to make nourishing drinks and stop Enlive Plus. Reviewed patient in 6 weeks patient feeling well, had increased weight so BMI = 20.5 kg/m 2 and continued with food first and no ONS. Cost* 6 09.64 ONS Initiated By GP ACBS Indication None recorded in notes, and on assessment no ACBS indication noted Length of time on ONS 3 years ONS Prescription Dose 220ml Ensure Plus bd Assessment BMI: 32.6 kg/m 2 MUST: 0 Previous Dietetic Input No Consultation Details & History Recommendations Patient has history of alcohol abuse and began taking Ensure Plus because was not eating and wanted something to drink. GP tried several times to stop Ensure Plus as patient obese, but she became abusive and violent, so ONS prescription was continued. Outcome Patient reviewed by Dietitian found out pt depressed about weight and did not want to be overweight. Wanted Ensure Plus for vitamins and minerals. No one had explained to her that Ensure Plus contained calories and that vitamins and minerals would not provide her requirements of micronutrients. ONS stopped, multivitamin started and commenced on small regular low fat meals. Referred to obesity service. Cost* 3559.92 ONS Initiated By GP ACBS Indication None recorded, patient doesn t meet ACBS criteria. Length of time on ONS 3 years ONS Prescription Dose 200ml tetra pack three times daily Assessment BMI: >25 (unable to weight) MUST: 0 Previous Dietetic Input In hospital (as reported by patient) Consultation Details & Recommendations History: Patient has been taking Fresubin Original in place of regular meals. Pt is bed bound therefore unable to prepare her own meals and her carers don t make her appropriate textured meals so give the ONS and other ready made foods e.g. yoghurts. Outcome: Recommended to discontinue ONS as patient does not meet the ACBS criteria. Given education to carers re appropriate meals and snacks for patient. Cost* 5,339.88 69

Appendix 7: Letter of Introduction East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast London Procurement Programme Pharmacy & Medicines Management th June 2008 Dear Colleague, London Procurement Programme Clinical Nutrition Support Project I am writing to notify you that the London Procurement Programme (LPP), through the Pharmacy & Medicines Management Steering Group, has established a Clinical Nutrition Support Project. The focus of this project is to assess demand management initiatives for oral nutritional supplements (ONS) across all London acute and primary care trusts. Primary project objectives: Assessing current demand management initiatives for ONS Assessing compliance with NICE Guidance for Nutrition Support (2006) Develop recommendations for implementing demand management strategies Louise Wilkie and Catherine Forrest (Community Dietitians) will be leading this six-month project from June November 2008 on behalf of the LPP. They will be seeking support form all Acute NHS Trust and Primary Care Trust Dietetic and Pharmacy departments to participate in this clinical exercise. You will be asked to complete a questionnaire and participate in a short interview; this will be made at your convenience over the next two months. You will be contacted shortly by either Louise or Catherine with further details. Should you have any queries please contact Phil Aubrey, the LPP Pharmacy & Medicines Management Operational Project Lead, at philip.aubrey@nwlh.nhs.uk, or on 07795 84694 Kind Regards, Peter Sharott Director, East & South East England Specialist Pharmacy Services Strategic Lead, Pharmacy & Medicines Management, London Procurement programme Email: peter.sharott@chelwest.nhs.uk 70

Tel: 020 8846 4 Appendix 8: List of Acute and Community Trusts Invited to Participate London Acute Trusts: Northwest London Hospitals Central Middlesex, Northwick Park & St Marks West Middlesex Hospital Royal National Orthopaedic Chelsea & Westminster Kingston Hospital Imperial College Healthcare Trust Hammersmith, Charing Cross Hospitals Imperial College Healthcare Trust - St Mary s Hospital Royal Brompton & Harefield Hospital Royal Marsden Hospital Mayday University Hospital St Helier Hospital Epsom Hospital Ealing Hospital Hillingdon Hospital & Mount Vernon Hospitals St Georges Hospital Royal Free Kings College Hospital Trust Guys Hospital St Thomas Hospital Barts & the London Queen Elizabeth Lewisham University Hospital UCL Homerton Chase Farm & Barnet Hospital Newham Hospital North Middlesex Hospital Whittington Redbridge Acute Hospital Whipps Cross Queen Marys Sidcup Private and Paediatric Hospitals excluded London Community Trusts: Barking & Dagenham Barnet Bexley Care Trust Brent Teaching Bromley Camden and Islington City & Hackney Teaching Croydon Ealing Enfield Greenwich Teaching Hammersmith & Fulham Haringey Teaching Harrow Havering Hillingdon Hounslow Islington Kensington & Chelsea Kingston Lambeth Lewisham Newham Redbridge Richmond & Twickenham Southwark Sutton & Merton Tower Hamlets Waltham Forest Wandsworth Teaching Westminster 7

Appendix 9: Community Trust ONS Expenditure Data Community Trust 2005/06 2006/07 2007/08 Barking & Dagenham 30,093 278,450 292,060 Barnet 424,885 526,240 606,433 Bexley 302,673 34,630 372,233 Brent 454,725 539,860 573,75 Bromley 445,257 486,382 567,244 Camden 388,096 409,984 399,83 City & Hackney 334,943 348,787 385,85 Croydon 323,22 383,707 436,994 Ealing 59,904 434,695 376,384 Enfield 303,364 374,366 407,646 Greenwich 382,58 407,348 456,842 Hammersmith & Fulham 304,53 344,564 383,765 Haringey 338,69 380,897 390,99 Harrow 270,950 279,689 34,97 Havering 37,083 379,759 40,273 Hillingdon 307,609 36,278 32,72 Hounslow 367,364 377,385 437,796 Islington 372,007 372,222 356,793 Kensington & Chelsea 97,493 223,63 27,272 Kingston 4,584 76,69 74,283 Lambeth 53,780 578,22 594,335 Lewisham 560,55 632,67 599,482 Newham 385,607 453,583 438,639 Redbridge 332,546 382,006 404,40 Richmond & Twickenham 237,060 249,004 26,47 Southwark 47,37 470,026 493,72 Sutton & Merton 336,866 384,279 430,483 Tower Hamlets 353,662 405,48 423,876 Waltham Forest 294,764 34,040 362,892 Wandsworth 43,679 445,986 437,36 Westminster 329,748 394,284 426,384 72

Appendix 0: Examples of Discharge / Communication Letters 73

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Glossary Advisory Committee on Borderline Substances (ACBS) In certain conditions some foods (including ONS products) have characteristics of drugs and the Advisory Committee on Borderline Substances advises as to the circumstances in which such substances may be regarded as drugs. Prescriptions issued in accordance with the Committee s advice and endorsed ACBS will normally not be investigated Actual Cost The actual cost is the Net Ingredient Cost (NIC) minus a national, average discount figure calculated from the discount deducted from each pharmacy account plus a container allowance. The actual cost gives a closer reflection of the real cost paid by the NHS and is therefore of the most value for monitoring budgets. Acute Trust Throughout this document Acute Trust has been used to describe an NHS hospital trust including foundation trusts. It is any NHS Trust that provides secondary care health services within the NHS in England. Age-Sex Temporary Resident Originated Prescribing Units (ASTRO-PUs) These were developed as a more sophisticated weighting system than PUs. The number of prescriptions/head weighted according to geographic and demographic variations. ASTRO PUs weight individual practice populations for age (in a number of different bands), by sex (male or female) and by the number of temporary residents and are based on the cost of overall prescribing and they are used in the setting of prescribing budgets. Community Trust Throughout this document Community Trust has been used to describe any NHS Trust providing primary and community services. epact Provides information about prescribing in General Practice in England and allows Community Trust prescribing advisors to monitor the use of controlled/prescribable drugs dispensed by their organisation s pharmacy contractors. epact can allow prescribing advisors to identify practices with high prescribing rates for specific products highlighting the presentations involved. 78

FP0 A prescription form used by GPs and other prescribers for NHS patients. Index of Multiple Deprivation (IMD) Score In 2000 as part of the UK Neighbourhood Statistics programme, a project to create a new Index of Multiple Deprivation (IMD) for England was commissioned. This 'index' combines information relating to income, employment, education, health, skills and training, barriers to housing and services and crime into an overall measure of deprivation at a small area level. London Procurement Programme (LPP) A pan-london project, launched in April 2006 and sponsored by NHS London, to identify opportunities for achieving cost savings in non-pay expenditure. The Pharmacy and Medicines Management workstream is led by pharmacists and has developed a range of initiatives to improve cost effectiveness through clinical engagement across primary and secondary care. Malnutrition Universal Screening Tool (MUST) A universal screening tool validated for use in both the acute and community settings. It is used to screen individual s malnutrition risk. For further information please go to: - http://www.bapen.org.uk/must_tool.html Net Ingredient Cost (NIC) The NIC of a drug is the basic price listed in the Drug Tariff. If the product is not in the Drug Tariff the price published by the drug s manufacturer, wholesaler or supplier is used. Prescribing Units (PUs) The PU was developed to take into account that elderly patients have greater need for medication than younger adult patients. Each patient on a GPs list over the age of 65 years is counted as three Prescribing Units (Pus) whereas each patient under 65 years and temporary residents are counted as one Prescribing Unit (PU). 79

Quality and Outcomes Framework (QOF) This is the system for payments for GPs introduced as part of the General Medical Services NHS contract in 2004. QOF rewards GPs for implementing good practice in their surgeries. A typical clinical indicator would be the proportion of patients with CHD who have had their cholesterol levels measured in a year. Standard Operating Procedures (SOP) Written documents designed to ensure consistent practice, quality and high standards in the delivery of services, with which all relevant staff are expected to comply. Unified Weighted Population A weighted capitation or population formula is used to allocate available resources to Community Trusts based on the Trusts share of England s population, and adjusted (or weighted), to account for the population s need for healthcare services relative to that of other Trusts. 80

References. British Association Parenteral and Enteral Nutrition (BAPEN), (online) www.bapen.org.uk 2. British National Formulary (BNF) (2008). Enteral foods and supplements, (online) http://www.bnf.org/bnf/bnf/53/29857.htm 3. Department of Health (2003). Care homes for older people: national minimum standards and the Care Homes Regulations. Third edition (revised). 4. Elia M Artificial Nutritional Support in Clinical Practice in Britain. J. Royal Coll. Phys. 993;27:8-5 5. Forrest C. (2007) Oral Nutritional Supplements Project: A review of patients receiving oral nutritional supplements. Westminster PCT 6. Gall MJ, Harmer JE, Wanstall HJ. (200) Prescribing of oral nutrition supplements in Primary Care: can guidelines supported by education improve prescribing practice? Clinical Nutrition; 20 (6): 5-5 7. Jones I. (997). Nutrition and Drug Misuse, Advisor: 66: 40-43 8. Jones J, Jones I. (2006) A review of nutrition support prescribing practices amongst health care professionals in Kensington and Chelsea PCT and Westminster PCT, published 2006 9. King CL et.al. Prevalence of malnutrition risk using the Malnutrition Universal Screening Tool MUST within a District Nurse referred population. BAPEN Abstract Book 998:OC:54 0. Loane D, Flanagan G, desuin A, McNamara E, Kenny S. (2004) Nutrition in the community an exploratory study of oral nutritional supplements in a health board area in Ireland. Journal of Human Nutrition and Dietetics: 7: 257-266. Martyn CN, Winter PD, Coles SJ et al. (998) Effect of nutritional status on use of health care resources by patients with chronic disease living in the community. Clinical Nutrition; 7: 9-23. 2. Malnutrition Advisory Group (MAG). Explanatory notes for the screening tool for adults at risk of malnutrition, BAPEN Nov 2000 3. McCombie L. Sip feed prescribing in primary care: an audit of current practice in Greater Glasgow Health Board, Glasgow, UK. Journal of Human Nutrition and Dietetics 999;2: 20-22 8

4. National Institute for Health and Clinical Excellence (NICE) published Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition in February 2006. 5. Royal College of General Practitioners (2006). Prescribing in Primary Care Accessed online: www.rcgp.org.uk 6. Russell CA, Elia M. (2008) Nutrition Screening Week in the UK in 2007. A report by BAPEN British Association for Parenteral and Enteral Nutrition. 7. Stratton RJ, Elia M. (999). A critical, systematic analysis of the use of oral nutritional supplements in the community, Clinical Nutrition; 8 (Suppl 2): 29-84 8. Stratton R, Green C, Elia M. (2003) Disease-related Malnutrition: an evidencebased approach to treatment. Wallingford:CABI 9. Stratton RJ. (2005). Elucidating effective ways to identify and treat malnutrition, Proceedings of the Nutrition Society. 64, 305 3 20. The Cochrane Collaboration (2007). Dietary advice for illness-related malnutrition in adults (review), The Cochrane Library; 2. Todorovic V. (2005) Evidence-based strategies for the use of oral nutritional supplements 0 (4): 58, 60, 62-4 82