Laura Clarke, Specialist Dietitian, and Jayne Brocklehurst, Dietetic Prescribing Lead, tell us about the great work that is being done in Doncaster to tackle malnutrition.
Malnutrition is a real issue in the UK and in Doncaster we were concerned about the rising levels of dietetic waiting lists, poor levels of screening in the community and increasing spend on Oral Nutritional Supplements (ONS). As a result the Doncaster Clinical Commissioning Group (DCCG) and Rotherham Doncaster and South Humber NHS Foundation Trust’s (RDaSH) Dietetic Service worked in partnership to tackle the issues.
We wanted to change the way we approached nutrition support and reduce the unnecessary use of prescribed supplements in care homes and the community, in favour of a ‘Food First’ approach (fortified, homemade food and drink).
We worked with care homes and GP practices across Doncaster to review the use of ONS. We delivered training on screening and the Food First approach to care home staff, community nursing teams and domiciliary care. Our findings not only showed reduced dietetic referrals and positive feedback. The new approach also resulted in over a £1million cost saving and below national average in care homes for malnutrition risk and pressure ulcer occurance.
Care homes
The first area we focused on was care homes. It is vital that care home staff are able to identify malnutrition. Between November 2016 and March 2017 all care homes received training on how to use the Malnutrition Universal Screening Tool (MUST). Staff also trained to implement nutritional action plans, which included food fortification, high calorie snacks and homemade alternatives to prescribed ONS.
Results from the implementation of the new pathway have been very promising. All 301 patients on prescribed ONS were reviewed and transitioned onto a Food First approach.
Residents and their relatives enjoyed the Food First approach. We received excellent feedback, which included:
“I have never eaten so well in my life.”
“No longer needs unpleasant supplements.”
“Skin and general health are best they have been in two years.”
Nine months after the Food First transition, Doncaster was below national averages in care homes for malnutrition risk and pressure ulcers. The number of residents with malnutrition risk and pressure ulcers were 25% and 3.2% respectively, compared to national averages of 35% and 4.3%. From 2015-2018, we also saw an 80% reduction in care home referrals to dietetic services.
Primary Care
Through the partnership, we also identified inappropriate prescribing of ONS in primary care. We worked with all 42 GP practices in Doncaster to identify patients using prescribed ONS in their own homes. Each person was offered a review by a Dietitian and 595 out of 735 were successfully transition onto a Food First approach and homemade alternatives. We received excellent feedback from participants who felt they were offered an appointment in a timely manner, written information was adequate, and the service provided them with enough information to manage their own diet and weight at home. Comments included:
“We will be trying these tips straight away”
“Positive information and advice”
“Very satisfied”
“Kind and helpful”
Our review showed that approximately 70% of patients using ONS were not known to the Dietetic Service. They had been prescribed in the community without advice from a Dietitian, or discharged from hospital on ONS with no follow up. To resolve this, community nursing teams and domiciliary care providers were given additional training on recognising malnutrition and implementing a Food First Nutritional Action Plan. This resulted in an impressive 65% reduction in referrals from community nursing teams.
Results and future plans
We are very pleased with the results so far on the impact this new approach has had on individual’s wellbeing. A saving of £1million per annum also shows that this approach has far-reaching benefits.
We are determined to continue this great work in making malnutrition everyone’s responsibility with the continued education of care home staff, GP practices, community staff teams and domiciliary care providers. We continue to raise awareness of malnutrition through training and support to health care providers and their patients.
For more information, please visit our website https://www.rdash.nhs.uk/services/our-services/adult-doncaster-community-integrated-services/dietetic-service/