Welcome

NHS LPP and British Dietetic Association Prescribing

Support Dietitians Group Study Day - 27 June 2018

Monica Compton and Vittoria Romano

NHS London Procurement Partnership

Introducing new nutritional

products to the NHS:

can we do better?

Tim Root, Chief PharmacistLPP Nutrition Study Day

June 27th 2018

– Safe & effective care

– Patient centred care

– Equity & consistency of access

– Value for money

• Specialist input

• Patient adherence

• Managed supply chain

• Reduction of waste

Objectives

“Think like a patient, act like a

taxpayer”

Simon Stevens, CEO, NHS England

• Improve health outcomes from medicines and ensure we are

getting the best value from the NHS medicines bill.

• Enable access to treatment that is clinically effective, based on

the latest scientific discovery, at as low a price as possible

• Support people to take their medicines as intended so that

they get the health outcomes they want.

NHSE Medicines Value Programme aims to:

What does (medicines) value mean?

Measurable improvement in patient outcomes while maintaining

an affordable (medicines) bill

Making sure

patients get the

right choice of

medicine

Improving the

safety and quality

of prescribing

and adherence

Making how we

purchase and

supply medicines

more efficient

Medicines Value Programme:

The NHS wants to help people to get the best results from their medicines –

while also achieving best value for the taxpayer

The NHS policy framework that governs access and pricing

The commercial arrangements that influence price

Optimising the use of medicines

Developing the infrastructure to support an efficient supply chain

Next Steps on the NHS Five Year Forward View and Carter Report

Pillars of a value program

Medicines ONS

1. Access DH, NHSE,

MHRA/EMA, NICE,

PPRS, Formulary

DH NHSE,

Formulary2. Commercial &

pricing

PPRS, CMU, Tariff, local

contracts/FOM

3. Optimisation Expert clinicians &

patients; whole system

oversight

Expert clinicians &

patients; whole system

oversight

4. Infrastructure Commissioners,

providers, clinicians

Providers, contractors,

FOM, CCG

commissioners.

A formulary is the output of processes to

support the managed introduction,

utilisation or withdrawal of treatments

within a local healthcare system, service

or organisation

• The formulary process is the cornerstone of good (pharmaceutical) management

and rational (drug) use.

• Choosing the most appropriate therapies and selecting the most cost-effective

good-quality products leads to better quality of care and more efficient, equitable

use of resources.

• Strict adherence to a formulary list alone will not improve treatment practice if drug

selection is not based on treatment guidelines

• Treatments can be used inappropriately if there are no guidelines for disease

management.

• A formulary should be developed after the appropriate treatment guidelines have

been identified or developed.

Formularies:

• improve collaboration

• support high quality prescribing

• reduce unwarranted variation

• facilitate access to cost effective medicines

• support efficient & timely supply

• support value for money

• support patient choice

How does it work for new medicines?

• Discovery

In vitro test

Clinical trials x 4

Regulatory approval

NICE

Commissioning

Local formulary

Medicinal product development

Submission

– Evidence for safety & efficacy

– Patient group & clinical indication

– Place in Rx pathway

– Cost

Multi-D peer review

Decision, recommendation, Tx Guidelines

publication

Local formulary process

• Whole health economy

• Multi-disciplinary

• Clinicians

• Medicines Information pharmacists

• Health economics

• Clinical pharmacologist

• Patient

• Director of Finance

• General Management

Typical DTC membership

• Relative lack of clinical trials & robust evidence

• Lack of market regulation

• Lack of governance & clarity about role of manufacturers and

suppliers

• Incomplete Rx data

• Fragmented supply chain

• Inconsistent access to specialist expertise

• Unclear ownership

• Unmanaged patient choice and expectation

Challenges for ONS vs medicines

• Oral nutritional product formularies should be the norm

• Formularies are about exclusion as well as about inclusion

• The medicines formulary model is proven but needs

adaptation

• Dietitians must play an integral role

• Collaborative working and a consensus model for governance

of relationships with manufacturers and suppliers should be

actively sought are welcomed

Summary: managing the introduction of

new oral nutritional products

• …but a formulary works only as part of a wider approach to optimising nutritional care which should also include:

– Clarification of ownership & accountability

• Clinical and financial

– Improved MDT collaboration and communication

– Agreement on a “reasonable” standard of evidence

– “Prescribing” by dietitians

– Care pathways

– Active supply chain management

Summary: managing the introduction of

new oral nutritional products

The most persuasive argument we can make for

maintaining NHS-funded access to core ONS

products may be to show that putting dietitians

in charge = value for money

and finally……

Presentation to Prescribing Dietitians ConferenceLondon26 June, 2018

• BSNA – Who we are

• Membership

• European & Global Representation

• Key UK Ministries and Agencies

• Conclusions

Overview

• BSNA is the trade association representing the manufacturers of products designed to meet the needs of specific groups of people with very particular nutritional requirements.

• Infant Nutrition – infant formula, follow-on formula, young child formula & complementary foods

• Medical Foods – enteral & oral

• Parenteral Nutrition

• Gluten Free Foods

• BSNA is recognised by Government, regulators, healthcare professionals and the media as the trade association that speaks on behalf of the specialist nutrition industry in the UK.

Who we are

Membership

Associate Members

24

Enteral Plastics Safety Group

Commercial Compounders Group

European Representation• SNE provides contact with EU Institutions (Parliament, Commission, Council of Ministers)

• Recognised stakeholder & voice of industry with membership spanning 18 EU Member States with business represented valued at €24 billion

Represents National and International associations from more than 20 countries over 6 continents

Collaborates with Codex Alimentarius (recognised NGO), the World Health Organisation (WHO) and the Food and Agriculture Organisation (FAO)

• FSA

• DHSC

• PHE

• HMRC and HM Treasury

• HSE

• BEIS

• DEFRA

• NICE

• SACN/SMCN

Key UK Ministries and Agencies

Code of Practice

What is it?

• Voluntary self-regulation standard developed by BSNA’s medical and parenteral food members

• First version dated 2013

• Now being updated

• Signatories likely to be:

Abbott Laboratories Ltd

Baxter

B Braun

Fresenius Kabi

Mead Johnson Nutrition

Nestle Health Science

Nualtra

Nutricia Advanced Medical Nutrition

Code of Practice

What is its aim?

• To demonstrate that activities of signatory companies are responsible, ethical, professional

What does it cover?

• Companies’ commercial activities involving the promotion of:

Parenteral products

Enteral products for patients aged over 12 months

Code of Practice

What does it cover?

• Although still very much in draft, the Code covers:

Information, claims and comparisons

Endorsements and testimonials

Training

Provision of products and samples

Gifts and sponsorship

Scientific meetings and hospitality

Relationships with consultants and patient/carer organisations

Complaints about products

Code of Practice

Thank you!

Katherine Sykes & Declan O’ BrienBSNA10 Bloomsbury WayHolbornLondonWC1A 2SL

Break 10.45-11

Working with Commercial Companies

Jo Lewis

External Relations & Development Officer

Overview

• Process

• Recent review and PARN data

• Client types and recent initiatives

• How members can continue to feed in

BDA Process

Assessment

• Ethos

• Audience

• Policy fit

• Research

Decision

• Risk and opportunity assessment

• Renegotiation

Administration and governance

• Scope / financial grade

• Contracts

Renewals

“Amongst the most comprehensive and thorough set of guidelines that I have come across in over 25 years of working in the sector” Professional Association Research Network

Recent review• BDA Council commissioned an external review in 2017

(conducted by PARN)

• Members generally agree with the BDA’s commercial collaborations

• Not all members agree however and this tension was also found in other healthcare associations who were interviewed

• The BDA was the only one of the healthcare associations interviewed who had a specific strategy, guidelines and documentation openly available.

• Members would like more/better information on the aims of individual commercial collaborations

532 responses to a survey, with structured interviews alongside

Key themes from qualitative data

Recent review• Improvements requested by BDA Chair and Chair Elect:

• Guidelines updated to be more consistent and include member attitudes – now completed

• Better communication to members on the impact of these relationships – under way

• More information for the public on these initiatives –coming soon

Corporate MembersStrategic Partner / Key Supporter

Consultancy and insights customerSurveys/Focus Groups/Round Tables

SponsorshipEvents/Dietetics Today

Project PartnersBDA Work Ready/Others

Client Types

How you can feed into this work?

• Keep up to date with new partnerships and initiatives via Members Monthly and Dietetics Today

• Read the assessment sheets for corporate members to understand the process better

• Raise any concerns, questions and good practice in relationships with commercial companies with us at the office

• Contact me at the office: Jo Lewis, External Relations & Development Officer – 0121 2008030 / j.lewis@bda.uk.com

More information

• BDA Working with Commercial Companies Guidelines and Toolkit https://www.bda.uk.com/about/workwithus/strategy

• Current BDA Corporate members and assessment sheets https://www.bda.uk.com/about/workwithus/currentcorpmembers

• PARN review of BDA commercial collaborations https://www.bda.uk.com/about/workwithus/partnership_news_latest

The Trouble with Nutrition Borderline

Substances is…!

Najia Qureshi

Head of Education and Professional Development

Tom Embury

External Affairs Officer

It’s complicated!

Oral Nutrition support patients

Hospital

discharge

GP surgery

Patient

Prescription clerk writes

prescription- lists are extensive

and there is a risk of selecting

wrong product, flavour, quantity.

See attached

GP signs

Patient requests issue

for local chemist to

dispense

Local

chemist

Specialist team-

Pulmonary,

palliative, Gastro,

Neurology

DietitianCare

Homes

Requests can be inconsistent, without evidence of criteria,without goal setting

and ownership of reviewing for effectiveness. Can be without guidance on

quantity, flavours, how to be used and how long Request with evidence, type,

quantity, flavour.

Follow up service is variable

from CCG to CCG depending

on dietetic community care.

Services available may be:

1. Dietitian provides

guidance/action plan for

patient and GP and then

discharges for GP to

manage.

1. Dietitian reviews and

guides patient and GP until

sip feeds no longer required.

GP

Patient

family

request

Community

nursing

Enteral fed patients using a Home company

Delivery once per month

Home Company

Home Enteral Dietitian

Identifies feed, supplies

GP surgeryPatient

Letter sent to GP

Request prescription

Patient registered with home

company-

Quantity of feed, syringes, giving

sets, feeding tubes

Requirements changed if required

Home Enteral Dietitian or Nutrition

nurse with company discuss

process with patient

Identify if feed to be delivered by

local chemist or company.

Patient signs

authorisation for

company to request

prescription

Home company request 28

day supply prescription to

be sentPrescription clerk writes

prescription

GP signs

Prescription clerk sends off in post

Not all companies have capability

of electronic prescribing

Home Enteral Dietitian

Reviews and changes product

Patient can opt for feeds to be delivered by local chemist.

Feeds go through ONS pathway.

Plastics to be delivered from Home company

FIRST DELIVERY MAY BE

WITHOUT A PRESCRIPTION

Metabolic patients

Delivery once per

month

Chemist on line

For some low

protein products

Metabolic Dietitian

GP surgery

Patient

Letter sent to GP

Request prescription

Patient reviewed by the

metabolic team

Changes made

Patient signs

authorisation

for company

to request

prescription

Home company

request 28 day

supply

prescription to

be sent

Prescription clerk writes

prescription

lists are extensive and there is

a risk of selecting wrong

product, flavour, quantity. See

attached

GP signs

Prescription clerk sends off in

post

Home Company

Such as VitafloHome Company

Such as Nutricia

Patient requests issue

for local chemist to

dispense

Patient

requests issue

from home

company

Local

chemist as

and when

required

Home company

request 28 day

supply

prescription to

be sent

On Line chemist

request 28 day

supply

prescription to

be sent

Home company

call patient, stock

check and

organise delivery

Home company

call patient, stock

check and

organise delivery

Patient signs

authorisation

for company

to request

prescription

Patient

requests issue

from home

company

Patient

requests issue

from on line

chemist

Delivery once per

monthDelivery once per

month

There may be only 1 patient in the surgery with this condition and 1 in the professional

career of a GP- this can lead to inconsistent practice

Prescribing 101

POMs NBS

Medicines legislation (POMs)

Prescribing Frameworks Supply and Administration

Frameworks

Independent, Supplementary PGDs, PSDs, Protocols,

Prescribing Exemptions

2 per day

• Advanced practice only

• Masters level skill

• Clinical Management Plan (CMP) for every patient

What’s it all about?!

“Noproblem”

Medicines & Healthcare Regulatory Agency

(MHRA)

“My understanding is that they are treated as medicines so

they can be prescribed at NHS expense. If they are not

POM or P there wouldn’t be anything in the HM Regs to

prevent dietitians supplying them”

(MHRA)

It’s all about the money money money!

Dietitian Vs Procurement

practices

&

Prescribing

Legislation

Issues!

• Can’t write on the drug chart

• Can’t access the electronic prescribing system

• Products without prescription

• Off script,

• Scotland

• Gluten Free

• Metabolic products

• Prescribing rights

• Out of date contracts

• Legal action

And there’s more…!

• acute vs community pricing

• Posts and equipment

• Online system too complicated for GPs

It’s complicated but …

Discussions and closing remarks 11:30am-12:00

Lunch break 12-12.45

Audit of prescribing of nutritional Borderline

Substances at discharge

Rebecca Fisher

Dietetic Project Manager LPP and BDA PSDG study day

27th June 2018

IMS data incomplete for London hospitals

Commercial Medicines Unit: Product choice in secondary care cannot influence prescribing in primary care

Why audit?

Literature search : a

lack of work in this area

LPP and GSTT have produced

guidance on best practice

Complex procurement model with nutrition supply contracts pricing offset by the cost of FP10

Whole health care economy

approach?

Audit

Audit aim

• To use a standardised tool to assess the quality and quantity of prescribing at discharge and obtain baseline data on prescribing (or requests to others to prescribe) of nutrition borderline substances (NBS) at discharge (or transfer of care) from acute hospitals. The data will enable a greater understanding of best practice across the care pathway, and should inform both local practice and the strategy for London.

Audit objective

• To obtain data on the quality of prescribing at discharge (or transfer of care).

• To obtain quantitative data on the volume of prescribing at discharge (or transfer of care).

Designing the audit tool – 2 different case identification methodsConvenience sampling – dispensing data available Basic search methods

20 cases 4 themes

Summative data on hospitals and patients audited, and number of products

224Patients identified on

NBS

218 adults

6 paediatric

Dietitian assessed Other HCP assessed

6Acute hospitals 92 Hospital A 82% (n 82) 18% (n 10)

47 Hospital B 28% (n 16) 72% (n 31)

40 Hospital C 68% (n 26) 33% (n 14)

20 Hospital D 90% (n 19) 10% (n 1)

13 Hospital E 46% (n 12) 54% (n 1)

12 Hospital F 58% (n 7) 42% (n 5)

252NBS products identified 189 prescribed one product

32 prescribed two products

3 prescribed three products

Product choice (density, presentation)

0 10 20 30 40 50 60 70 80 90

Compact 2.4kcal/ml

1.5kcal/ml

Modular ONS

Pudding style

Juice

Powder 57-61g

2.0kcal/ml

Other Specialist Adult ONS

Powder >61g

1kcal/ml

Product choice by healthcare professional

Dietitian Other HCP

Product choice (contract supplier or other)

0% 20% 40% 60% 80% 100% 120% 140% 160% 180% 200%

Contract product specified on discharge

Non-contract product specified on discharge

Product choice

Dietitian Other HCPs

Dose frequency and rationale

9%

62%

22%

6%

16%

47%

30%

7%

0%

10%

20%

30%

40%

50%

60%

70%

Once daily Twice daily Three times daily Four times daily

Dietitian Other HCP

Quality criteria for communication on discharge, by profession.

Limitations

Quantifying volume of prescribing because of the sampling issues (not meeting minimum number, variability in case selection and population audited) was not possible – did not meet this aim

Relatively small sample size, variable results and cannot extrapolate

Just 6 paediatric patients were audited, however there were nil concerns reported and the tool was designed for use in all patient groups. In areas where there is concern regarding acute ration of amino acid to extensively hydrolysed formula and product choice would be valid to do a targeted audit

This audit was not designed to capture information on errors in prescribing

Sources of error of prescribing (or authorising/requesting)• Within the hospital:

• Lack of understanding of different products – incorrect product prescribed on verbal request

• Transcription errors – incorrect product prescribed on medicine chart but correct product identified in patient notes

• Lack of accountability and clinical governance in prescribing choices (if dietitians are specifying products but not receiving recognition, training, feedback or supervision)

• Community: • At the GP surgery risk of incorrect product selection and amounts/28 days

especially if not adequately clear on discharge documentation

Recommendations• Clarification and consensus about the right of dietitians to authorise

to administer nutritional products on medicine charts should be sought for hospitals that lack clear policy.

• Understand barriers to optimising NBS at discharge

• Dietitians have the knowledge and skills in nutrition care planning but require the autonomy, recognition and support to develop further skills and a culture of evaluation and accountability in prescribing behaviours.

• Develop culture of stewardship for nutritional prescribing (authorising/requesting) – link with the Medicines Value Programme

How should NBS be managed?

• It is the safety to the health economy which should be addressed by managing in a similar way to POM (not immediate safety to health).

• Named HCP with dedicated time to supervising the use of NBS

• Newer versions of Cerner and new EPR systems such as EPIC are as yet untested for what features can support appropriate NBS prescribing, e.g. will EPR systems start including MUST in discharge summary automatically?

Next steps….

• Re- audit annually?• Other questions arising from the audit:1) Can we assess the frequency of the assumption that a dietitian will have

been involved in nutritional prescribing?2) Controlling for numbers of patients seen, do dietitians and doctors have

similar prescribing behaviours?• How as a profession can we develop a culture of authorising/prescribing

request accountability?

Any questions?

Monitoring nutritional prescribing

Rebecca Fisher

Rakesh Dodhia

Monica Compton

We need to talk about data

Change from ePACT 1 to ePACT 2

TAG and category

dependent

Monitored nationally

Unit of measurement (cost, item, NIC)

Tags

Do not need to create an analysis each month and

it will generate most recent month

Items Actual Cost BNF Presentation Quantity X Items

3 148.39 Aptamil_Pepti 2 Pdr 6,800.0

3 534.37 Infatrini Peptisorb_Liq 31,400.0

5 736.87 Infatrini_Infant Feed 63,700.0

7 166.54 Milupa_Aptamil Lactose Free Pdr 12,400.0

3 388.14 Neocate Active_Pdr Sach 63g (Blkcurrant) 5,670.0

2 379.60 Neocate Active_Pdr Sach 63g (Unflav) 5,544.0

4 398.63 Neocate Advance_Pdr Sach 100g (Unflav) 7,000.0

4 745.28 Neocate Jnr_Pdr (Unflav) 11,200.0

21 4,084.76 Neocate LCP_Pdr 59,600.0

25 1,112.65 Nutramigen 1 + LGG_Pdr 42,800.0

2 40.79 Nutramigen 1 LIPIL_Pdr 1,600.0

29 1,726.05 Nutramigen 2 + LGG_Pdr 66,400.0

Can now calculate the number of bottles/packs

Nutrition dataPrimary care prescribing

Rakesh Dodhia, Strategic Analyst

Thursday, 26 July 2018

Net ingredient cost (NIC)

The NIC is the basic price of a drug, i.e. the price listed in the Drug

Tariff or price lists

Source: HSCIC (NHS Digital), General Practice Prescribing Data: Frequently Asked Questions

The total net ingredient cost for Nutrition & blood has increased +68% in 10 years

Source: NHS Digital, Prescription Cost Analysis, England 2017. (Prescription Cost Analysis 2017 – Trends – NIC)

The total net ingredient cost for Nutrition & blood has increased +68% in 10 years

£0

£1b

£2b

£3b

£4b

£5b

£6b

£7b

£8b

£9b

£10b

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Net Ingredient cost by BNF chapter, 2007-2017Anaesthesia +393% Preps used in diagnosis +188%

Appliances +182% Stoma appliances +87%

Endocrine system +53% Incontinence appliances +39%

Obs. gyna. & urinary +31% Respiratory system +24%

Skin +19% Eye +11%

Ear, nose & oropharynx +9% CNS +5%

Infections -1% Gastro-intestinal system -4%

Musculoskeletal & joint -5% Immuno & vaccines -15%

Other drugs and preps -31% CV system -34%

Malig. & immunosup. -40% Dressings +8%

Nutrition & blood +68%

Source: NHS Digital, Prescription Cost Analysis, England 2017. (Prescription Cost Analysis 2017 – Trends – NIC)

£0

£100m

£200m

£300m

£400m

£500m

£600m

£700m

£800m

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Net Ingredient cost for Nutrition & blood, 2007-2017

Nutrition & blood

7%

CNS, 20%

Endocrine system, 15%

CV system, 13%

Respiratory system, 12%

Gastro-intestinal system, 5%

Net ingredient cost for 2017

The total net ingredient cost for Nutrition & blood has increased +68% in 10 years

Nutrition & blood, 168%

Respiratory system124%

Infections 99%

Cardiovascular system66%

Endocrine system153%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Ind

exe

d 2

00

7 N

et in

gre

die

nt co

st

Chapter 9 breakdown by BNF sectionNet Ingredient Cost for London 2017/18

£49,568,717

£22,795,911

£7,135,666

£4,071,297

£2,453,573

£1,387,953

£807,500

£715,206

£499,345

£111,592

£8,025

£20

Oral Nutrition

Vitamins

Anaemias + Other Blood Disorders

Minerals

Foods

Fluids And Electrolytes

Metabolic Disorders

Health Supplements

Compound Vit/Mineral Formulations

Other Health Supplements

Bitters And Tonics

Intravenous Nutrition

Enteral Nutrition

£36m72%

Foods For Special Diets£14m28%

Source: NHS BSA ePACT2

Spend on adult oral nutrition supplements per 10,000 cost-based ASTRO PUs, March 2018

£0 £100 £200 £300 £400 £500

South East

North East

North Central

South West

North West

STPs£0 £100 £200 £300 £400 £500 £600

Lewisham

Islington

Kingston

Barking & Dag

Havering

Wandsworth

Bexley

Tower Hamlets

Merton

Waltham Forest

Bromley

Newham

Harrow

Redbridge

Camden

Lambeth

Enfield

Barnet

Haringey

Brent

Greenwich

Hounslow

Ham & Fulham

Sutton

Southwark

Central London

Hillingdon

Croydon

Richmond

West London

City & Hackney

Ealing

CCGs

2.4 to 4 kcal/ml

1.5kcal/ml

Powdered ONS(<63g)

Modularmilkshakes(>63g)

Break 1.45-2.00

Alison Smith

Prescribing Support Consultant Dietitian

Herts Valleys CCG

International Dysphagia Diet Standardisation Initiative (IDDSI)

What is IDDSI?

• An international group of volunteers from various fields who came together in 2013 to develop international standardised terminology and definitions for texture modified foods and thickened liquids for people with dysphagia

• Current evidence base for managing dysphagia with modified texture food/fluids is surprisingly small

• Descriptors, both between and within different countries, are different and non-comparable

Who are the UK IDDSI External Reference Group?

• IDDSI International Steering Group members

• NHS Improvement

• Royal College of Speech and Language Therapy

• BDA (England, Scotland, Northern Ireland & Wales)

• Nursing

• Hospital Catering

• Nursing Home Catering

• Manufacturers of thickeners and pre-thickened drinks and supplements

• Manufacturers of modified texture foods

UK Implementation plan

Aware

• From October 2017• Build awareness

• Communicate IDDSI adoption to all national stakeholders e.g. charities, manufacturers, professional associations

• Identify local IDDSI champion

Prepare

• From October 2017 • IDDSI compliant labels, foods and products being developed

by product manufacturers and caterers

• An ‘Implementation toolkit’ is being developed and will be available by April 2018

• Local institutions to review iddsi.org website and resources

• Local healthcare professionals to discuss and begin the process of planning local implementation (IDDSI Implementation Checklist available in January 2018)

Adopt

• April 2018 – April 2019• Healthcare professionals plan and lead local implementation

from April 2018

• IDDSI compliant products, foods and labels start to become available after April 2018

• All manufacturers and health care settings are fully IDDSI compliant by April 2019

“Leaves a thick coat

on the back of a

spoon…”“Leaves a thin coat on

the back of a

spoon…”“Leaves a coating

on an empty

glass…”

“Needs to be taken

with a spoon…”

The IDDSI Levels are clearly

defined by measurement using

the flow test for Levels 0-3 and

the spoon/fork tests for Level 4.

The descriptors broadly match

the IDDSI levels 0-4. However

these are subjective, not

specific.

Use IDDSI tests or new

product guidelines to

determine IDDSI Level.

Product labelling with National

Descriptors was not definitive.

✓

LIQUIDS: Comparing the UK National Descriptors with

IDDSI

www.iddsi.or

g Don’t assume a certain product maps across

directly to a certain IDDSI Level.

Stage 3

Stage 2

Stage 1

Thin

Naturally Thick

“Leaves a thick

coat on the back

of a spoon…”

“Leaves a thin

coat on the back

of a spoon…”

“Leaves a

coating on an

empty glass…”

“Needs to be

taken with a

spoon…”

The IDDSI Levels are clearly

defined by measurement using

the flow test for Levels 0-3 and

the spoon/fork tests for Level 4.

The descriptors

broadly match the

IDDSI levels 0-4.

But descriptors

are subjective,

not specific

Use IDDSI tests or revised

product guidelines to determine

IDDSI Level

Product labelling with

National Descriptors was

estimated - not definitive

www.iddsi.org

Stage 3

Stage 2

Stage 1

Thin

Naturally Thick

How thick is

your drink?

Moving from

National

Descriptors to

IDDSI

“Leaves a

thick coat on

the back of a

spoon…”

“Leaves a

thin coat on

the back of

a spoon…”

“Needs to be

taken with a

spoon…”

“Leaves a

coating on an

empty glass”

10 ml

8 ml

4 ml

1ml

Subjective,

estimated

The categories

were not clearly

defined

Objective,

measured

The IDDSI Levels are

defined by measurement

using the flow test for

Levels 0-3 and the

spoon/fork tests

for Level 4

LIQUIDS:

From UK National Descriptors to IDDSI

www.iddsi.org

The descriptors

broadly match the

IDDSI levels 0-4.

But descriptors are

subjective, not

specific

Subjective

Some criteria

weren’t

specifically

defined

Objective,

measuredThe IDDSI Levels are

defined by measurement

FOODS:

From UK National Descriptors to IDDSI

www.iddsi.org

Define how soft.

Limit size of lumps to

reduce choking risk

Thin

Purée

Thick

Purée

Pre-

Mashed

Fork

Mashable

Define moistness

and particle size

Define moistness and

cohesiveness

Define flow properties

(IDDSI flow test)

Textures B to E map to IDDSI Levels 3 to 6 after adding detail and

measurement

What’s happening nationally?

• Packaging will change

• Amount of thickener needed to produce specific texture may change

• Pre-thickened drinks/supplements consistency may change

• Texture/appearance of modified texture pre-prepared food may change

Concerns raised

• Statement on the implementation of the International Dysphagia Diet

Standardisation Initiative (IDDSI)

• Manufacturers issuing advice to prescribers/users that speech and language

therapists (SLTs) should reassess all patients and provide training across all sectors

and settings. SLTs are commissioned to provide specific services, and so this

expectation is not realistic or acceptable

• The lack of a co-ordinated approach locally and nationally to support implementation

across a range of providers, including hospitals, nursing and care homes,

rehabilitation units, social care units and educational settings, as well as individuals

in their own homes

Concerns raised

• The implications for some care homes where a range of thickeners may be used for different patients and the

potential confusion this may cause, as some manufacturers have changed their instructions to comply with IDDSI,

while others have not

• Concerns for those individuals living alone or unsupported as they may not be able to fully understand the changes,

with consequential risks to their health

• The inability to directly correlate the stages used in the UK National Descriptors with the new IDDSI Levels for some

products where instructions have changed. As a result, a drink may be thicker or thinner than the patient was

previously prescribed

• Different approaches by manufacturers which can lead to confusion. Thickener companies are moving directly to

IDDSI labels from April 2018 onwards. However, some food manufacturers are putting on transitional labels showing

both the current UK national descriptors and IDDSI for a period of time

What might help?

• Find out what is happening with regards to IDDSI in your area

• Support the change (it is evidence based)

• Ensure that prescribers understand how much thickener they need to prescribe for each patient

• In care homes, use this as an opportunity to change prescriptions for residents so that only 1 type of thickener is used in each Home

• Ask questions

Where to get more information

• www.iddsi.org

• www.bda.uk.com/professional/ IDDSI Framework

• Thickener manufacturers

• Modified texture food manufacturers

• Alison Smith

• Prescribing Support Consultant Dietitian

• Herts Valleys CCG

• 07342 073994

• alison.smith47@nhs.net

Nutrition Formularies

Prescribing Support Dietitians 27/6/18

Emily Rose Lead Dietitian Primary Care BHCCG

In the context of Medicines Optimisation

Effective nutrition formulary development to address NHS England’s Goals of Medicines Optimisation:

• improve patient outcomes

• take medicines correctly

• avoid taking unnecessary medicines

• reduce wastage of medicines

• improve medicines safety

Goals align with HCPC Code of Conduct

Formulary allows Equitable Prescribing

• Large number of prescribers

o GPs

o Pharmacists

o Nurses

o Dietitians (recommend)

• Responsibility to wider health economy

• Reduce inequality: prescribing driven by agreed formulary

• Clinically effective

• Cost effective

• ACBS approved products

Formulary as interface between 1ry & 2ry care

• Barrier between acute and community

• Pressures of 1ry care are different to 2ry

• Reduce transfer of care issues

• Formulary as a tool to drive consistent practice

• Formulary discussion as an opportunity to emphasise Food First

• Marry bureaucratic procedure with patient outcome

Where does your formulary sit?

• Nutrition formulary integrated into Joint Formulary

• Joint Formulary across 1ry and 2ry care

• Robust governance structure to agree formulary

• Hospital contracts vs 1ry care

• Non-specialist vs specialist recommendation only

• Know where geographic boundaries lie

What do I

prescribe????

Formulary choices

to emphasise good

practice, food first

& dietetic skill

Formulary choices

vsvs

vs

Discussions, closing remarks and evaluation

3:30-4:00

Prescribing Support Dietitians BDA Subgroup

Annual meeting -members only