Corrina Grimes
AHP Consultant
Public Health Agency

A Public Health Problem …
 Malnutrition originates in the community
 Malnutrition affected 29% of Adults admitted to hospital (BAPEN
2014)
 Malnutrition contribute to and also occurs as a result of illness

Identify Your Dolls

Regional Medicine Management
Dietetic Initiative…
Working Smarter- Not Harder
Identify the Dolls we could affect change

 Pharmaceutical Clinical Effectiveness Programme
 NICE Guidance CG32 Nutritional Support For Adults & QIPP
 Promoting Good Nutrition Strategy

The Pharmaceutical Clinical
Effectiveness Programme (PCE)

(PCE) Programme is an umbrella term for a suite of medicines management initiatives, initiated by DHSSPS and now implemented by the HSC Board which include:
 The PCE Programme's initiatives continue to contribute to the
Department's efficiency strategy
 It is based upon the principle that IMPROVEMENT IN THE QUALITY
AND SAFETY OF SERVICES WILL LEAD TO HEALTH GAINS AND
ASSOCIATED EFFICIENCIES.

£12
£10
£8
£2
£0
£6
£4
England
UK regions: spend per head
Wales
Oral nutrition
Scotland NI

NICE CG32
Nutrition support in adults:
Oral nutrition support,
Enteral tube feeding &
Parenteral nutrition & QIPP
 Nutritional support to reduce or prevent malnutrition
 Utilised skills of a Dietitian to ensure appropriate use of Oral nutritional supplements with a food first approach

Promoting Good Nutrition Strategy
Scope


Strategy relates to adults in all health and social care settings including individuals in their own home .
agree in this, that thousands of patients are starved in the midst of plenty, from want of attention to the ways which make it possible for them to take food.”
For the purpose of this strategy malnutrition will be considered as under-nutrition and does not cover obesity or eating disorders

Synergy and Symbiosis..
Work Smarter – Not Harder
A joint Initiative
Synergy
The interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects:

Working Harder Not Smarter…
Demonstrating Symbiosis and Synergy

Utilisation of:
Dietetic skills and competencies to ensure appropriate clinical assessment and intervention
 Medicines Management (pharmacy) Team’s process and practice experience in other therapeutic areas and their operational and strategic support for this initiative

Data analysis, Informatics,Health Intelligence
 Organisation and professional networks

Initiative Structure
 Medicines Management Dietitians employed as part of Medicines
Management team, professionally responsible to AHP Public Health
Agency
 Five Dietitians working across Northern Ireland integrated within the
HSCB Medicines Management Team

Supported by four prescribing support assistants
 Regional Medicines Management Dietitian Initiative Steering Group with key stakeholder membership

Initiative Overview
 Dietetic assessment of patients in identified cohort
 Implement prescribing change where appropriate
 Provide training resource for primary care healthcare professionals
 Evaluate the impact


Patient Cohort
Patients are identified within each practice who are prescribed Oral
Nutritional Supplements (ONS)
 Exclusions – patients under the care of a Trust Dietetic Department or last days of life
 These patients are offered an appointment with the Medicines Management
Dietitian :
 within the practice (Clinic)

 in the care home domiciliary setting
Care home
28%
Clinic
48%
Home
24%

Prescribing Cost of ONS/1000NIPUs for each practice in N.Ireland

Prescribing indicators for ONS for individual GP practices across N.Ireland

Inappropriate Prescribing
Criteria used by London Procurement Partnership (LPP) to classify a prescription as appropriate:






Patient is at risk of malnutrition (MUST ≥2)
ACBS Indication
Trial of food first has failed
Applying this criteria to these 150 patients in the initial cohort
96% of ONS inappropriately prescribed
LPP data = 75% inappropriately prescribed

 Total number of practices contacted = 47 across Northern Ireland
 27 complete
 Total number of patients offered an appointment = 946
– 506 complete

Following assessment and tailored dietary advice by the medicines management dietitian the following prescribing changes were recommended:
 56% of ONS discontinued
 8% ONS amended
 36% ONS continued

“ agree in this, that thousands of patients are starved in the midst of plenty, from want of attention to the ways which make it possible for them to take food.”
(Florence Nightingale)

Annual efficiencies of £315k to date
– This will be a rolling figure moving forward
1000000
900000
800000
700000
600000
500000
400000
300000
200000
100000
0
Total cost Exclusions Inclusions Efficiencies

‘
The GPs want me to pass on their appreciation with this initiative.
They have found it really worthwhile’
Practice Manager E-mail

Settles the stomach when having acid reflux (1 milkshake ONS)
Thought it was a vitamin/mineral drink , patient didn’t realise kcal content and didn’t want to gain weight (ONS was calogen)
Appetite stimulant

Patient Perceptions of ONS
Examples of how patients are using their ONS:
 Calogen (a calorie supplement) being used as an emollient
 Ensure Plus Juce used as a laxative
 Thought GP gave it to her as she is not drinking enough fluids and doesn’t like water. Thought it was like Ribena (juice style ONS)
 Pro-Cal perceived to be a calcium supplement as opposed to a calorie and protein supplement

Build up/tonic

The Rubik’s Cube Effect
 Change on one size will have an impact on the others
 Be mindful of the impact

The Rubik’s Cube Effect
 Regional Medicine
Management Dietetic
Steering Group
 Key stakeholder to share learning and identify solutions

Linkages with other local and regional initiatives

 Identify your dolls
 Find your nemo and synergise

Remember the Rubik’s
Cube effect……