Commissioning a Malnutrition Service in Greenwich

Rachel Oostra

Dietetic Advisor NHS Greenwich CCG

30.09.2015

Situation

• In 2013/2014 Greenwich CCG spent £700k on sip feeds in the

 community

• There was only a skeleton Community Dietetic Service to

address malnutrition

• Greenwich did not have a Home Enteral Feeding Team which was

 identified as both a clinical and financial risk

• There was no training or support in primary care to address

malnutrition for mobile patients

Task

• To develop a high quality,cost effective service to address malnutrition

 for the population of Greenwich

• To develop innovative ways of integrated working with the

local authority to identify malnutrition early  

• To gather data and evidence to demonstrate how this service could 

meet Greenwich CCG’s QIPP agenda

• To reduce the spend on sip feeds by addressing the variables  in 

prescribing trends  among general practices

Actions

• Meeting with stakeholders and identifying the gaps in nutritional

services in Greenwich

• Through networking with dietetic colleagues and sharing

models of good practice 

• Collecting  evidence from dietetic colleagues to calculate a 

projected saving that could be achieved by introducing a new 

service

• Successful QIPP proposal

• Developing funding streams through the Better Care Fund

Nutrition Support/ Food First Team

Food first Project in nursing homes training all nursing home staff on MUST and Food First to address QIPP

• Providing nutrition support for housebound patients with a MUST score ≥2

• LA and community based training for early identification to increase awareness and address malnutrition in the community

• Team consisting of 1.5 dietitians and 1 nutrition assistant .

Deliver practice nurse / HCA training for care pathway referral.

GP clinics to review :- • Mobile malnourished patients

on sip feed: stroke, dementia• Gastroenterology patients –

Coeliac, IBS plus others• Weight management clinic for

patients with a BMI ≥40 or ≥35 with a comorbidity

• Team comprising of 3.5 dietitians and a nutrition assistant

Home Enteral Nutrition Team (HEN)

Multidisciplinary service to review all adult patients receiving enteral nutrition via a tube.

• All HEN patients including housebound and nursing / care homes

• Team comprising of nutrition nurse. speech and language therapist, dietitian, admin

• Support of nasogastric fed patients in the community

MMMMMalnutrition Service

Primary Care Team

Results

Costs 

The projected additional budget for the service was £417 000 with

an estimated annual saving of £262 000

Benefit Realisation Plan 

1.1  Key Outcome / Benefit 1 – Reduction in spend on HEN feed and equipment

1.2  Key Outcome / Benefit 2 – Reduction in spend on SIP Feeds  

1.3  Key Outcome / Benefit 3 – Reduction in avoidable admissions

1.4  Key Outcome / Benefit 4 – Reduction in total unscheduled bed days

1.5  Key Outcome / Benefit 5 – Reduction in preventing non – red flag referrals

Outcomes

Quality

• Develop an integrated

Malnutrition Service

• Provide easy access to a

dietitian

• Provide early intervention

and treatment across all areas

• Increase awareness of 

malnutrition and dehydration  in

the community

Innovation

• Involve professionals from

health and social care

• Work with catering teams to

introduce ‘Food First‘ in care

homes 

• Support domiciliary care

workers to identify the early

signs of malnutrition

• Deliver specialised dietetic

service at local GP practices

Outcomes

Productivity

• Equip staff to identify

causes of malnutrition and

dehydration early

• Deliver safe nutritional care 

across all areas

• Reduce hospital admission,  

length of stay and

inappropriate investigations

• Avoid waste of nutritional

products

Prevention

• Reduce the risk of infection and 

complications

• Improve wound care in

those patients with pressure

sores

• Tackle malnutrition to improve

nutritional status, clinical

 outcomes and

reduce healthcare use