Prescribing in primary care: a new dietitian-led medicines management team model of practice

Oral nutritional supplements (ONS) are borderline substances that may be prescribed on the NHS for the management of certain conditions (eg disease-related malnutrition, intractable malabsorption, bowel fistulae etc), if the product has Advisory Committee on Borderline Substances (ACBS) approval (NHS Business Services Authority, 2020). ‘Standard’ ONS provide energy, whole proteins (as opposed to peptides or amino acids), micronutrients (vitamins and minerals) and sometimes fibre. There are over 70 ‘standard’ nutrition products with ACBS approval listed in the NHS Drug Tariff (NHS Business Services Authority, 2020).

There are a number of complicating factors associated with the appropriate prescribing of ONS in primary care. GPs have limited training in nutrition and may have received only 8 hours' teaching on nutrition in total as part of their medical degree (Fisher, 2019). The number of available products and their different formulations (Table 1) can be confusing for prescribers. Dietitians understand the nutritional differences between products but do not have prescribing processes or appropriate prescribing included in their standard training (Fisher, 2019). ONS are used within secondary care, but the products available are determined by the nutrition company's contract with the hospital and may differ from those on the local primary care formulary, leading to issues at the point of transfer of care. The cost of ONS in secondary care is determined by the contract between a hospital and nutrition company, but in 2011/2012 the daily cost of ONS in hospital (based on twice-daily administration) was reported as £0.01–0.04 (Elia, 2015). In contrast, the cost of ONS listed in the NHS Drug Tariff varies widely between products and product types (Table 1). In 2018/2019, £150 066 733 on prescribed ONS was spent in England and Wales, a 3.3% increase from 2017/2018 (NHS Digital, 2019).

In contrast to medicines, ONS (borderline substances), provide energy, protein, fibre and micronutrients, which can all be added into the diet using dietary modification techniques, such as food fortification, extra snacks and homemade milkshakes. The National Institute for Health and Care Excellence (NICE) (2017) clinical guideline (CG) 32 is the main national guideline that has considered the evidence base for the use of ONS. However, the majority of the evidence base reviewed in NICE CG32 for the use of ONS in hospital and the community (72% of the studies included, excluding studies in surgical and dysphagia patients) compares ONS with standard diet (rather than comparing ONS with fortified diet or extra snacks). As the 2011 Cochrane Review clarifies, ‘national policy in the UK on the management of disease-related malnutrition is based on analysis of data from patients receiving ONS compared with usual care’ (Baldwin and Weekes, 2011). The evidence base for the cost effectiveness of the use of ONS is also based on studies that compare ONS with standard diet (Elia, 2015). The author highlights ‘from a nutrition perspective there is no major reason to suppose that ingestion of the same amounts of extra nutrients from a diet as opposed to ONS would produce significantly different effects on healthcare utilisation’. Recently published evidence demonstrating the effective use of food fortification to manage malnutrition in a high-risk population group shows long-term benefits (12 months) for clinical and quality of life outcomes that are significantly better than the ONS arm of the study (Ingadottir et al, 2019). The European Society For Clinical Nutrition And Metabolism (ESPEN) 2018 guidelines on clinical nutrition and hydration in geriatrics recommend dietary counselling and food modification be used before ONS (Volkert et al, 2019).

As with all prescribed medicines, prescriptions for ONS should only be issued where there is an objectively defined clinical need. The North Derbyshire Nutrition Support Project showed that 30% of ONS prescriptions reviewed were inappropriate, in terms of the patient's existing nutritional needs (Robinson, 2018). Inappropriate prescriptions are a waste of NHS resources and contribute to the patient's medicine burden and financial pressures for the local NHS. To assess the risk of malnutrition, the use of the Malnutrition Universal Screening Tool (MUST; BAPEN, 2003) score for patients with disease-related malnutrition is recommended (NICE, 2017; Volkert et al, 2019). Additionally, for 2020/21, the NHS CQUIN targets in the prevention of ill health domain focus on the use of validated tools for malnutrition screening in primary care (NHS England, 2020).

If a prescription is necessary, cost-effective products should be used to optimise NHS resources (NHS England, 2019). To promote cost-effective prescribing, local formularies increasingly list powder ONS as the first line products for use in primary care. These products are more energy and protein-dense than standard liquid ONS, as well as being considerably more cost-effective (approximately £0.49 per unit vs £1.11 per unit). However, powder ONS are often not available for use in secondary care, because hospital contracts and their use may not be practical on hospital wards.

The rationale for this project was based on the knowledge described above. Additionally, a local audit (unpublished) by a community dietitian seconded to Brighton and Hove clinical commissioning group (CCG) in 2016 showed that 50% of ONS prescriptions reviewed by the dietitian in 12 GP practices could be stopped, as there was no clinical necessity for their ongoing prescription. Inappropriate ONS prescribing was contributing to the local NHS financial burden and reflected practice that did not promote the local care pathway, which centred on patient care through an objective measure of malnutrition (MUST score) and the local formulary. The project reviewed here represents a pragmatic approach that maximised the available skills and resources within the local medicines management team (MMT). MMTs in primary care are principally made up of pharmacists and pharmacy technicians (PTs). Dietitians are being introduced into MMTs, but there may be only one dietitian covering one or more CCG. PTs are skilled in GP practice system searches and reviewing prescription detail and work within the limits of defined operating procedures.

The specific aims of this dietetic-lead project were to develop the knowledge and the skills of the PTs, so that, with ongoing clinical support from a dietitian, they could calculate a patient's MUST score and identify inappropriate ONS prescribing in a defined cohort of adult patients. PTs would address inappropriate prescribing in line with the recommendations from the dietitian. Reducing inappropriate prescribing would result in financial savings for the NHS CCGs. The data collected from this review process would develop a picture of local ONS prescribing that would be used to inform dietetic teaching sessions with local prescribers, nurses and dietitians.

Methods

At the time of the study (September 2018), the MMT covered two CCGs, Brighton and Hove CCG and High Weald Lewes Havens CCG. Table 2 describes the composition of the local MMT, as well as the number of GP practices and local population size covered, and the ONS spend for 2017/18 (the year prior to the project).

The project was lead by the MMT dietitian. As part of their workstream, the PTs would review ONS prescriptions in GP practices under the supervision of the MMT dietitian. Figure 1 summarises the stages of the project.

Figure 1. Stages of project development and implementation

ONS prescribing is not usually addressed by PTs and, therefore, skills development formed the first stage of the project implementation. The supporting resources (including formulary, ONS guidelines, and Food as Treatment patient information leaflet (Table 3), were designed by the dietitian so that the PTs had easily accessible, relevant information. These documents, as well as MUST score calculation (Table 4), the SOP and excel data collection sheet, and food fortification were covered by the dietitian in 2-hour group training sessions, delivered once in the BH office and once in the HWLH office. The SOP and data collection sheet guided the PTs through the process of assessing the clinical necessity for the ONS prescription, based on the patient's MUST score and the local care pathway detailed in the ONS guidelines. From the data collected, the PTs could determine whether the prescription had been appropriate when initiated and whether it remained appropriate at the point of review.

Once the PTs had consent from their GP practices to begin the project, the dietitian went into practice with each PT to do half-day individual training sessions, focusing on the data collection process, communication with patients and record-keeping. The prescription searches within the GP record systems identified adult patients who had received a prescription for ONS within the previous 6 months. Specialist ONS products (such as for renal or gastrointestinal conditions) were not included in the search. Once the search had been completed, PTs manually excluded from the review any patients who met any of the exclusion criteria (Table 5). The PTs reviewed the remaining ONS prescriptions in line with the SOP and with clinical support as necessary from the dietitian. Where necessary information was not available in the GP system (such as current weight, MUST score) PTs contacted the patient (initially by phone and, if unsuccessful, by letter) to obtain the information. Changes to prescriptions were discussed with the patients during this phone contact. Patients currently under the care of a dietitian, but where prescribing did not follow the local guidelines, were discussed with the MMT dietitian who then contacted the dietitian concerned for further information.

Prescriptions were deemed clinically inappropriate and could be stopped if the patient had a MUST score of 1 or 0. If the patient had a MUST score of 2 or more, prescriptions could be switched to first-line formulary options if there was no clinical reason that precluded their use and they had not previously been trialled. If the prescription was clinically appropriate, it was left unchanged. All patients whose prescriptions were stopped or changed were sent written information explaining the change and the Food as Treatment patient information leaflet. Patients were advised to monitor their weight and were provided with the PT's phone number for contact should they experience weight loss within the following month. In this case, the PT would refer to the MMT dietitian.

The anonymised excel data collection sheets were reviewed by the MMT dietitian and used as the basis for individual feedback sessions to GP practices by the dietitian. The data collected (Table 6) on the patient's place of residence, duration of prescription, dietitian involvement and health professional who had initiated the prescription built detailed picture of local prescribing trends. Financial savings were recorded by the PTs using MedOptimise (a medicines optimisation activity gathering and reporting tool). The financial savings were used to assess the impact of the project and were reported as part of the MMT QIPP savings.

Resource development began in March/April 2018. Group education sessions took place in June/July 2018 and PT ONS prescription reviews in GP practices began in September 2018. Minor modifications were made to the data collection sheet in response to PT feedback in September/October 2018. The results reported relate to reviews carried out September 2018–March 2019. Data are reported as percentages, for the combined CCGs and for individual CCGs, and as sample size (n). Data on ONS spend is drawn from ePACT2 (NHS Business Services Authority, 2020) and data on savings achieved by PT review is taken from MedOptimise.

Results

The ONS reviews formed part of the PTs' annual work stream. In total, ONS prescriptions for 684 patients were reviewed in 46 GP practices (480≥patients in Brighton and Hove CCG and 204 patients in High Weald Lewes Havens CCG). Implementation of the project within individual GP practices and across the CCGs varied (Figure 2). All patients receiving ONS on prescription in 34.6% of GP practices were reviewed and no reviews were carried out in 11.5% of practices. The project was partially implemented in 53.8% of practices, as not all patients on ONS within these practices were reviewed.

Figure 2. Implementation of ONS prescription review project within GP practices

Local prescribing trends (Figure 3) showed that the majority of patients receiving prescription ONS were ≥65 years old and living in their own home. GPs initiated over half of prescriptions (the remaining prescriptions were requested by dietitians, followed a hospital discharge request or were initiated by a prescribing nurse or pharmacist). There was incomplete adherence to the local care pathway. Only 27.6% of prescriptions reviewed had a MUST score recorded at prescription initiation. BMI calculation was recorded more frequently (67% of prescriptions) but food fortification advice was given in less than half of cases prior to providing an ONS prescription. Nearly half of ONS prescriptions lasted for more than 6 months and just over half the patients had a follow-up weight recorded if the prescription lasted more than three months. Prescribing trends across the two CCGs were consistent despite differing local population demographics.

Figure 3. Local ONS prescribing trends, identified from ONS prescription reviews

Only 15% of the ONS products prescribed prior to PT review were first-line products (Figure 4). The most frequently prescribed ONS products (41%) were the specialist (dietitian) recommended products, including the compact liquid products (Figure 4; as a number of patients were prescribed more than one product, the number of products is greater than the number of patients; 684 patients, 762 products prescribed). The local formulary recommends that these products only be prescribed by GPs following recommendation from a specialist (ie dietitian). Dietitians initiated ONS prescribing in only 33% of cases (25.6% in Brighton and Hove CCG and 50.5% in High Weald Lewes Havens CCG) but these products were prescribed more often than could be accounted for by dietetic input.

Figure 4. ONS product category prescribed prior to ONS prescription review (based on local formulary categories)

Over 60% of the ONS prescriptions reviewed were stopped, as they were no longer clinically necessary or the product choice did not follow local prescribing guidance, and so they were switched to a more clinically and cost-effective formulary product (Figure 5).

Figure 5. Outcomes from ONS prescription reviews

The 12-month savings generated by these ONS prescription reviews totalled £234 089. This is equivalent to 23.9% of the CCGs' combined ONS spend in 2017/2018 (Table 8). During the period of this project, the MMT dietitian carried out 60 training sessions (covering MUST, food fortification and the local formulary and care pathway), with 459 participants, with local GPs, practice nurses, community nursing teams, pharmacists, care homes and home care providers.

Discussion

This review describes a new MMT model of practice. It addresses inappropriate ONS prescribing across two CCGs by using a multi-disciplinary approach that combines the skills of a dietitian with those of pharmacy technicians. This project requires the support of the MMT operations manager, but is a model of practice that can be replicated in other MMTs with practice-based PTs and clinical support from a dietitian. The differences in the extent of the implementation within GP practices reflect that the project is time intensive for PTs (gathering clinical information, speaking to patients, decision making, sending written information to patients) and depends on PTs having good working relationships with their GP practices. The use of a validated malnutrition screening tool to assess whether or not ONS prescriptions are appropriate is central to the quality and clinical effectiveness of the project. Continued implementation of the project, which increases awareness of MUST screening within primary care, will contribute to the CCGs' ability to meet the 2020/21 CQUIN targets for prevention of ill health (NHS England, 2020).

Anecdotal evidence that ONS are principally used by patients resident in care homes is not supported by the prescribing trends identified by this project (Figure 3). The majority of ONS are prescribed for patients living independently, which suggests that more work promoting an effective food fortification approach needs to be undertaken with health professionals working in primary care (eg GPs, practice and community nurses, community rehab, physios and speech and language therapists). An international review highlights the lack of confidence among doctors in providing nutritional care (Crowley et al, 2019). Ongoing prescription of ONS without review or a nutritional care process does not provide optimal care (Fisher, 2019). Increased emphasis on the identification and management of malnutrition should be included as part of GP training and for practice-based nurses.

The local prescribing formulary supports the local care pathway for the management of malnutrition. Powder ONS are first-line products recommended after a food fortification approach has been trialled, however, these were the least frequently prescribed products from the formulary (Figure 4). This perhaps reflects the influence of secondary care nutrition contracts on primary care prescribing. The most frequently prescribed products (compact liquid ONS) are widely used in secondary care. Within secondary care, first-line powder ONS are often not available, because of the exclusive nature of the contracts between the nutrition companies and secondary care providers. These factors may limit prescribers' familiarity with first-line powder products. Combined with a lack of knowledge about the similarities or differences between ONS products, lack of familiarity may result in prescribers (GPs, nurses and pharmacists) most often prescribing products recognised from local primary care discharge summaries or from experience working within primary care. Table 9 compares the nutritional content and cost of compact liquid ONS commonly used in secondary care with powder ONS products. A change in prescribing culture (including among dietitians) is needed to promote adherence to local formularies and to embed an understanding that primary care prescribing options are likely to be different to those in secondary care. Improved communication with patients prior to discharge would help to make the change in ONS prescribed post-discharge better understood. Appropriate prescribing principles and use of local formularies should be included as standard in dietetic training.

This project reviewed whether or not the ONS prescription was appropriate at initiation and at the point of review. Nearly two thirds of the ONS prescriptions reviewed (60.6%) were found to be inappropriate (no clinical necessity or product choice not supported by the formulary) at the point of review. As less than a third of prescriptions reviewed had a MUST score recorded at prescription initiation, it follows that in over 70% of cases there was no objective measure of whether the prescription had been clinically appropriate when it was initiated. The 12-month savings for these two CCGs from correcting these inappropriate prescriptions were £234 000, which represents 24% of the CCGs' 2017/18 ONS spend. However, across England and Wales £150 066 733 was spent in 2018/19 on ONS (NHS Digital, 2019). Some of these ONS will have been used for enteral feeding via a gastrostomy tube, however, if only 20% of national prescriptions were inappropriate, this would equate to a waste of NHS resources of £30 013 346 in one financial year.

Many factors contribute to inappropriate ONS prescribing (limited GP nutritional knowledge, limited dietetic prescribing knowledge, poor adherence to local formularies and care pathways). In addition, ‘the endemic financial entanglement […] distorting the production and use of healthcare evidence, causing […] waste for health systems' described in medicines (Moynihan et al, 2019) must also be considered for borderline substances, such as ONS, where much of the published evidence consists of trials funded by the nutrition industry.

Conclusions

The model of practice reviewed here addresses inappropriate ONS prescribing pragmatically. It maximises the skills within an MMT and promotes a food first, aging-well approach to managing malnutrition in primary care. It is a model that can be replicated in other MMT with a dietitian and practice-based PTs and will contribute to the CCGs' ability to meet the 2020/21 CQUIN targets for prevention of ill health.