A Pioneering Partnership in Nutrition Prescribing for Rotherham

1. A Pioneering Partnership in Nutrition Prescribing for Rotherham Jill Ward Clinical Director Nutrition and Dietetics The Rotherham NHS Foundation Trust

2. 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

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

4. 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

5. 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

6. 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.

8. Agenda • 2004-2006Audit/Information • April 2006Took responsibility for budget Development of Contract • April 2007 Contract Tender • Discussion with Companies • April 2008 3+2 Contract (FRESENIUS) • April 2013 New Contract

9. Commissioner Involvement • NHS Rotherham is a stake holder in the nutrition contract and Community wide • Maximising the benefit of that contract.

10. 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

11. But what's the Carrot

12. Project development Jan 2006-development of 2 posts:- • Band 7 Oncology post • Band 4(25hrs) Clerical post • Pump primed • Paid for out of project

13. Hand over of patients • Medicines Management identified patients on ONS/Feeds • List developed per practice • Current Workload (In excess of 1000 patients) • Funny antidotes

14. 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

15. 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”

16. 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

17. 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 2 copies forwarded to the pharmacy Letter sent to GP for Information only re Patient care 1 copy is retained by the Dietetic Department

18. Challenges to Practice Internally within our service we had to change! PATHWAYS AND PROCESSES

19. Raising awareness • Local Pharmacy Committee meetings-Pharmacy staff • TARGET events-GPs/HCP NO SAMPLES • Meetings-Local Dietetic services

20. 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%)

22. Funding freed up from the project Pump primed initial posts Quality for patients Reinvestment in the N&D Services • Dietetic staff • Clerical staff • Data base • Prescription charges • Postage/Stationery Exact budget is known

23. 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 Dietitian2x P/T Admin and Clerical posts-Band 4(25hrs) Band 2 (15hrs)

24. Clerical • Essential • Increased hours to accommodate increase in work • Administrative Function • Data capture/Information • Contract /budget information

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

26. Internal relationships • NHSR part of Contract • Better Communication • Better information • High profile-FT/NHSR • HSJ Efficiency Awards (Sept 2011/12) Highly Commended

27. 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

28. Audit • Enteral Feed Company Contract Audit • Patient feedback-Phone Letters Complaints • Patient Satisfaction Survey • Patient Opinion

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

31. 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%

32. Further expansion to the modelBoard 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.

33. Challenges for Dietetics • QIPP Agenda • Quality • Innovation • Productivity • Prevention Follow the themes of your strategy