A Pioneering Partnership in Nutrition Prescribing for Rotherham

Jill Ward

Clinical Director

Nutrition and Dietetics

The Rotherham NHS Foundation Trust

4 Strategic ThemesAHP Strategy 2012-2017

• Promoting person –centred practice and care

• Delivering safe and effective practice and care

• Maximising resource for success• Supporting and developing the

AHP workforce

NHS Rotherham Population 254,00039 Practices(Size range 1,505 – 20,819 patients) 1 Secondary Care Provider located in the Borough63 Community PharmacistsSpearhead PCT

GP opinion (2004)• We are constantly being requested by

dietitians and nurses to provide prescriptions for items that we are unable to assess whether they are appropriate for the patient

• We are only the mechanism of supply we rarely initiate or make any alterations to these prescriptions.

• We feel we are being bullied into prescribing

Solution =• Prescribing and Financial responsibility

should reside with the health care professional that is recommending the intervention.

• Nutrition = Dietitians

–Wound Care = Tissue Viability Nurses–Continence = Continence Adviser–Stoma = Stoma Nurses

• Getting the evidence• Audits confirmed

– 50% of patients not known to the dietitians– Of those not know in excess of 90% had not received a

review in the past 6 months– Majority would not have received supplements if initially

assessed by the dietitian.• GPs

– Unhappy about prescribing• Cost Growth

– Exceeded overall prescribing inflation.

Agenda

• 2004-2006 Audit/Information

• April 2006 Took responsibility for budget

Development of Contract

• April 2007 Contract Tender • Discussion with Companies

• April 2008 3+2 Contract (FRESENIUS)

• April 2013 New Contract

Commissioner Involvement

• NHS Rotherham is a stake holder in

the nutrition contract and Community wide

• Maximising the benefit of that contract.

Advantages to the PCT• Improved patient management• Increased dietetics service• Improved control of the prescribing and

supply of supplements• Ownership of the budget• Compliance with NICE guidance• PCT now a stakeholder in the nutrition

contract

But what's the Carrot

Project development

Jan 2006-development of 2 posts:-

• Band 7 Oncology post• Band 4(25hrs) Clerical post• Pump primed• Paid for out of project

Hand over of patients

• Medicines Management identified patients on ONS/Feeds

• List developed per practice• Current Workload

(In excess of 1000 patients)

• Funny antidotes

What did we Find?

Patients were receiving supplements for:-• Loose teeth• Meal replacement (low income)• Bereavement• Didn’t like, but giving to pets• Put on weight, so son using for body

building

Dietitians

“Assess, diagnose and treat diet and nutrition problems at an individual and wider public health level

Dietitians translate public health and scientific research on food, health and disease into practical guidance to enable people to make appropriate lifestyle and food choices”

Process

• Patients were notified of changes in practice-to contact N& D services

• Phone call monthly-hand written script• Each practice checked by myself and

clerical post for compliance

- Pt stopped (letter)

- Pt continued-follow up arranged

- Pt visit to assess

All Supplements are initiated & “Prescribed” by the Dietitian*

Dietitian completes attached order form which is sent directly to the patient or a pharmacy nominated by the patient for nutrition contract provider

Return one copy to the Dietetic department for payment

1 copy retained by the pharmacy

1 copy is retained by the Dietetic Department

2 copies forwarded to the pharmacy

Letter sent to GP forInformation only re

Patient care

Challenges to Practice

Internally within our service we had to change!

PATHWAYS AND PROCESSES

Raising awareness

• Local Pharmacy Committee meetings-Pharmacy staff

• TARGET events-GPs/HCP

NO SAMPLES• Meetings-Local Dietetic services

Nutrition Project Demand Management

• Prior to April 06 xs 1000 patients were receiving a nutritional supplement

• April 06 = 856 Patients• April 07 = 651 Patients• April 08 = 506 Patients• April 09 = 543 Patients (↓ 36.6%)• April 10 = 583 Patients (↓ 31.8%)• April 11 = 452 Patients (↓47%)

Funding freed up from the projectPump primed initial postsQuality for patientsReinvestment in the N&D Services

• Dietetic staff• Clerical staff• Data base• Prescription charges• Postage/Stationery

Exact budget is known

4.4 WTE Community Dietitains have been appointed from budget ( money not spent on sip feeds)1 WTE band 7 Oncology Dietitian3 WTE band 6 Dietitians –Community Paediatric Mental Health

Oncology 0.4 Band 7 Diabetes Dietitian

2x P/T Admin and Clerical posts-Band 4(25hrs) Band 2

(15hrs)

Clerical

• Essential• Increased hours to accommodate

increase in work• Administrative Function• Data capture/Information• Contract /budget information

External Relationships with colleagues in other hospitals• Presentations• Information• Challenging( Act like GP)• Contract products• Feedback on patient care

Internal relationships

• NHSR part of Contract• Better Communication• Better information• High profile-FT/NHSR• HSJ Efficiency Awards

(Sept 2011/12)

Highly Commended

Benefits to Dietetics

• Partnership working NHSR/GPs/Local Pharmacies

• Dietetic responsibility• Budget problem solved for NHSR• Increase in Dietetics staffing-quality of

patient care/changes occur• No rep influence over prescribing• Control of Care homes/Community staff• Compliance with NICE

Audit

• Enteral Feed Company Contract Audit

• Patient feedback-Phone

Letters

Complaints• Patient Satisfaction Survey• Patient Opinion

Project outcomes

• Patient opinion• Data base-patient care• Continuous seamless pathway• Screening for patients• Regular Follow up• Financial management• Ordering control-no abuse

03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11£0

£100,000

£200,000

£300,000

£400,000

£500,000

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NHS Rotherham Nutrition Prescribing Costs

NHS Rotherham’s nutritional costs if the had followed national cost growth trendswould in 09/10 = £858,991Actual costs 09/10 = £452,027Potential saving = 90.0%

Further expansion to the model

Board approval in September 2010 to transfer GF + PKU products & specialist baby milks to the dietitians

(With funding for 0.6 WTE Band 7 Dietitian and P/T clerical support at band 3 funded from current budget.

Challenges for Dietetics• QIPP Agenda

– Quality– Innovation– Productivity– Prevention

Follow the themes of your strategy