A Pioneering Partnership
in Nutrition Prescribing for
Rotherham
Jill Ward
Clinical Director
Nutrition and Dietetics
The Rotherham NHS Foundation
Trust
4 Strategic Themes
AHP 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
NHS Rotherham
Population 254,000
39 Practices
(Size range 1,505 – 20,819 patients)
1 Secondary Care Provider located in the
Borough
63 Community Pharmacists
Spearhead PCT
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
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
• 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.
Agenda
• 2004-2006 Audit/Information
• April 2006 Took responsibility for budget
Development of Contract
• April 2007 Contract Tender
•
Discussion with Companies
• April 2008 3+2 Contract (FRESENIUS)
• April 2013 New Contract
Commissioner Involvement
•
NHS Rotherham is a stake holder in
the nutrition contract and Community wide
•
Maximising the benefit of that contract.
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
But what's the Carrot
Project development
Jan 2006-development of 2 posts:•
•
•
•
Band 7 Oncology post
Band 4(25hrs) Clerical post
Pump primed
Paid for out of project
Hand over of patients
• Medicines Management identified
patients on ONS/Feeds
• List developed per practice
• Current Workload
(In excess of 1000 patients)
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
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”
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
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
2 copies forwarded
to the pharmacy
1 copy is
retained by
the Dietetic
Department
Return one
copy to the
Dietetic
department
for payment
Letter sent to GP for
Information only re
Patient care
1 copy
retained
by the
pharmacy
Challenges to Practice
Internally within our service we
had to change!
PATHWAYS AND PROCESSES
Raising awareness
• Local Pharmacy Committee
meetings-Pharmacy staff
• TARGET events-GPs/HCP
NO SAMPLES
• Meetings-Local Dietetic services
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%)
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
4.4 WTE Community Dietitains have been
appointed from budget
( money not spent on sip feeds)
1 WTE band 7 Oncology Dietitian
3 WTE band 6 Dietitians –Community Paediatric
Mental Health
Oncology
0.4 Band 7 Diabetes Dietitian
2x P/T Admin and Clerical posts-Band 4(25hrs)
Band 2 (15hrs)
Clerical
• Essential
• Increased hours to accommodate
increase in work
• Administrative Function
• Data capture/Information
• Contract /budget information
External Relationships with
colleagues in other hospitals
•
•
•
•
•
Presentations
Information
Challenging( Act like GP)
Contract products
Feedback on patient care
Internal relationships
•
•
•
•
•
NHSR part of Contract
Better Communication
Better information
High profile-FT/NHSR
HSJ Efficiency Awards
(Sept 2011/12)
Highly Commended
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
Audit
• Enteral Feed Company Contract
Audit
• Patient feedback-Phone
Letters
Complaints
• Patient Satisfaction Survey
• Patient Opinion
Project outcomes
•
•
•
•
•
•
•
Patient opinion
Data base-patient care
Continuous seamless pathway
Screening for patients
Regular Follow up
Financial management
Ordering control-no abuse
NHS Rotherham Nutrition Prescribing Costs
£300,000
£513,092
£452,141
£589,489
£490,142
£400,000
£568,571
£500,000
£539,291
£600,000
£632,541
£700,000
£707,638
£800,000
£200,000
£100,000
£0
03/04
04/05
05/06
06/07
07/08
08/09
09/10
10/11
NHS Rotherham’s nutritional costs if
the had followed national cost growth
trends
would in 09/10 = £858,991
Actual costs 09/10 = £452,027
Potential saving = 90.0%
Further expansion to the model
Board 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.
Challenges for Dietetics
• QIPP Agenda
– Quality
– Innovation
– Productivity
– Prevention
Follow the themes of your strategy