SOCIAL CARE
Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with The BDA and innovative work. She currently holds a unique role in the Highlands. @evelynnewman17
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TRANSFORMING THE LANDSCAPE OF ONS PRESCRIBING IN THE HIGHLANDS In common with most NHS posts, my role encompasses a number of different but complementary components. My job title appears to suggest that I only work with care homes when in fact I also work with care at home services, unpaid carers and I have the organisational lead for ONS prescribing and the negotiation, implementation and monitoring of our enteral feeding contract. Plenty to keep me busy. In 2018, the growth in use of ONS products across Scotland is reflected in a report from a national short life working group.1 It was no different in Highland and our multidisciplinary prescribing group (including representatives from dietetics, pharmacy, SLT, GP and nurse prescribing) grappled with the best way of tackling the variation in use, the appropriateness of prescribing and the escalating cost to the organisation. AIMS AND PROCESS
We started by taking a number of steps to try and improve consistency in the rationale for prescribing ONS. After extensive consultation, we reached agreement that we would progress to: • proactively promoting a food-first, person-centred approach, which we have since built into our MUST care plans to reinforce a change in clinical practice; • offering patients self-management advice and literature as well as redirecting people to purchase overthe-counter ONS if they did not meet the criteria to have them on prescription (not ACBS); • recommending that prescribers stop the use of high energy, low volume (HELV) products, such as puddingstyle products, with some clinical exceptions, eg, liver, renal and some paediatric cases;
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• developing a revised, much restricted ONS prescribing formulary, with a preference for the use of ‘shake-style’ products, where patients were able to reconstitute products themselves; • stopping the use of ONS in all care homes. COMMUNICATION AND FEEDBACK
All information about the food-first approach, associated literature, formulary changes and HELV products now sits on a treatment and medicines (TAM) digital app, which has been well received by prescribers. Regular updates are communicated out to prescribers to reinforce the change in practice needed to reduce the use of ONS and associated costs. I am delighted to say that we had no complaints about the above from GPs, nurse prescribers, care home managers, dietitians, or patients themselves. We did however complete a mitigated risk assessment, to provide assurance to The Board, given the extensive change in practice across all areas. As with all transformational change, there were a few people who were reluctant to implement an agreed change to practice. However, assurance from executive board members encouraged us all to forge ahead. It is reassuring to all that 18 months down the line, we have no evidence of any detriment to people
SOCIAL CARE
Reliance on prescribed ONS is putting a burden on health budgets and must be proactively challenged.
annual savings (>£300k) for all ONS products being prescribed for adults. CONCLUSION
This transformational piece of work has been hugely successful and continues to be embedded and monitored. The model used for this work is transferable to other areas of prescribing practice and is now being replicated in areas of continence and tissue viability. It has been widely publicised in local and national media2 and is recognised by colleagues across Scotland, with many other boards keen to replicate our results. Poster presentations were selected for: the annual NHSH R@D conference in 2018, focused on the CMOs theme of Realistic medicine;3 EFAD 2018, in Rotterdam; and the NHSS R@D conference in November 2018. Reliance on prescribed ONS is putting a burden on health budgets and must be proactively challenged. We encourage others to be bold in supporting and delivering a truly person-centred food-first approach across health and social care settings and to return to the basics of good dietetic practice by promoting nutritional care, which is appetising and maximizes health, wellbeing and social interaction at mealtimes.
stopping ONS, or using a food-first approach. Care home managers and owners are happy to support our approach too and many have commented that the change hasn’t cost more for catering budgets; it has saved staff time managing the use, administration, storage and recording of ONS; residents prefer to take fortified food and drinks than take ONS (there was a great deal of waste previously); and quality of life has improved. MONITORING AND RESULTS
For anyone who has tried to understand or manage trends in ONS prescribing, the need to have a robust set of data is paramount. When I was asked to take on this role several years ago, this was certainly lacking and it wasn’t just a Highland problem. The national short life working group started to develop a standardised dataset for Scotland, which has since transformed our ability to scrutinise, monitor and take focus the work. It has also greatly improved the understanding and engagement of clinical groups, who have the greatest influence on the use of these products. The quarterly use and spend of HELV products has dramatically reduced and sits within an overarching picture of recurrent
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