References
Prescribing in primary care: a new dietitian-led medicines management team model of practice
Abstract
Oral nutritional supplements may be prescribed for the management of disease-related malnutrition, but there is a large variety of nutritionally differing products available. ONS prescribing in primary care is an area of uncertainty for GPs and prescribing of ONS on the NHS in England and Wales in 2018/2019 was over £150000000. Clinically appropriate prescribing of oral nutritional supplements are supported by the use of validated malnutrition screening tools to assess the patient's risk of malnutrition. Local prescribing formularies promote the use of cost-effective oral nutritional supplements products in primary care which are often not available for use in secondary care. A new medicines management model of practice that uses pharmacy technicians, with clinical support from a dietitian, to address inappropriate oral nutritional supplements prescribing in primary care is described here. The model maximises the skills within the medicines management team and promotes a food first, ageing-well approach to managing malnutrition in primary care.
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).
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