Situation
Oral nutritional supplements (ONS) are Foods for Special Medical Purposes and are prescribable in the UK under indications as specified by the Advisory Committee for Borderline Substances (ACBS).
Observation
In 2016, a review of ONS prescribing across Scotland demonstrated growth in ONS volume use and spend, with considerable variation between NHS Boards. At that time the average annual increase in ONS volume use across Scotland was 3.68% and prescribing expenditure was approximately £16m per year. A proposal to form a Scottish ONS Short Life Working Group (SLWG) to support a review of ONS prescribing and identify ways to drive forward high quality, effective and efficient ONS prescribing was accepted in 2016. This initiative was supported by the Effective Prescribing Programme Board (EPPB).
What did AHPs do?
The SLWG was formed with representation as follows:
- Lead dietetic representative for each territorial NHS Board in Scotland
- Effective Prescribing and Therapeutics Branch, Scottish Government
- The British Dietetic Association
- Scottish Practice Pharmacy and Prescribing Advisors Association (SP3AA)
- Primary Care and Community Pharmacy Group
- Community Pharmacy Scotland (CPS)
- Care Inspectorate
- NHS National Services Scotland (NSS) National Procurement
- Dietetic Project manager
GP membership was also requested but unfortunately was not fulfilled.
How did they do it?
The ONS SLWG met bi-monthly between December 2016 and February 2018. It was agreed that the work taken forward would be shared with NHS Boards and would support the Once for Scotland approach described within the Scottish Government’s 2020 strategic narrative for the health sector. Three sub-groups were formed to drive forward key actions and outputs of the national group; ‘Prescribing Information’, ‘Formulary’ and ‘Process’.
Assessment
The prescribing information sub-group reviewed current national ONS prescribing data. A categorised list grouping equivalent / similar type products was devised and a series of initial data measures were supplied by NHS NSS Information Services Division (ISD) for each NHS Board. Based on this review of prescribing information, opportunities were identified to maximise the quality, safety and cost effectiveness of ONS treatment for patients. Recommendation letters were distributed to Boards asking them to plan and implement local improvement activity in relation to the use of specific types of ONS product (‘1kcal per ml’ and ‘ONS dessert’ products) and ‘long term’ ONS prescribing. Across Scotland, a larger proportion of patients than expected were found to be prescribed ONS long term. Evidence shows that benefits of ONS are seen typically with 2-3 months supplementation in the community, although for some patients supplementation periods may be shorter or longer according to clinical need (multi-professional consensus panel, 2017).
A second sub-group reviewed current NHS Board ONS formulary arrangements. The subgroup produced Best Practice Guidance for Adult ONS Formulary Development to help reduce variation in formularies. A national Guideline for appropriate prescribing of Oral Nutritional Supplements in adults (oral use) was also produced and is intended for use by colleagues working in all health and care settings across Scotland.
The third sub-group’s key aims were to review systems, clinical processes and guidelines relating to nutritional support and ONS use. Through interviews and an e-survey, data was collected from seven of the fourteen territorial NHS Boards in Scotland. This was to provide insight into current dietetic services, processes, practice and associated variation across Scotland. Variation between dietetic services was confirmed. Recommendations were produced based on the data collected, including the development of national Dietetic Best Practice Principles for patients who require Nutritional Support with associated training, and a Once for Scotland approach to patient information and resources for nutritional support through NHS Inform.
Taking it forward
The work of the ONS SLWG has resulted in a greater understanding of ONS prescribing across Scotland and why there is variation between NHS Boards. It has also developed key outputs and recommendations to reduce this variation and improve quality of care for patients. A final report has been produced for which final approval and distribution is expected in July 2018.
It is intended that national, collaborative and multi-disciplinary working will be sustained and further developed to take the group’s recommendations forward, support sharing of best practice between NHS Boards and maximise the quality and effectiveness of nutritional product prescribing. The continued support and contributions of colleagues from across Scotland will be vital to maintaining the successes achieved so far, and promoting and enabling further improvement.
For further information:
- Lynsey Robinson, Lead Prescribing Project Dietitian, NHS Greater Glasgow & Clyde email: Lynsey.Robinson@ggc.scot.nhs.uk Twitter: @LynsRobinsonRD
- Carole Noble, Dietetic Prescribing Advisor, NHS Grampian email: carole.noble@nhs.net
- Janie Gordon, Professional Head of Service, Nutrition & Clinical Dietetic Service, NHS Fife email: janie.gordon@nhs.net Twitter: @GordonJanie
Ref: Multi-professional consensus panel (2017) Managing Adult Malnutrition in the Community Including a pathway for the appropriate use of oral nutritional supplements (ONS). Available: http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf [Accessed 16th February 2018]
AHPs across health and social care. 