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

2. 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

3. NHS Rotherham Population 254, Practices (Size range 1,505 – 20,819 patients) 1 Secondary Care Provider located in the Borough 63 Community Pharmacists Spearhead 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 2004-2006 Audit/Information
April Took responsibility for budget
Development of Contract
April Contract Tender
Discussion with Companies
April Contract (FRESENIUS)
April 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
2 copies forwarded to the pharmacy
Letter sent to GP for
Information only re
Patient care
1 copy is retained by the Dietetic Department
Return one copy to the Dietetic department for payment
1 copy retained by the pharmacy

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 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)

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 trends would in 09/10 = £858,991 Actual costs 09/10 = £452,027 Potential saving = 90.0%

32. 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.

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