Optimising oral nutritional supplement prescribing
What was the issue?
Oral Nutritional Supplements (ONS) had become a major area of prescribing spend across Lancashire & South Cumbria ICB, while monitoring data such as weight, height and BMI of patients were often missing or incomplete. This meant some patients continued receiving ONS without clear evidence of ongoing clinical need. In care homes and the wider community, this created financial waste, increased the risk of inappropriate long-term prescribing, and contributed to avoidable environmental impact through product manufacture, transport, packaging disposal and unused supplement waste entering the waste stream. The issue was also important from a clinical governance perspective because national guidance from NICE CG32 emphasises the need to assess, monitor and review nutrition support appropriately.
What action was taken?
The Central and West Lancashire Medicines Optimisation Team delivered a technician-led review programme to improve the prescribing and monitoring of ONS. A standard operating procedure was developed and shared with practices to create a consistent review process. Searches were run to identify care home residents prescribed ONS, and Medicines Optimisation Technicians worked directly with care home teams to obtain accurate height and weight data. Pharmacists then reviewed patients against local guidance and reduced or stopped ONS where patients had reached a healthy BMI or no longer met prescribing criteria. Alongside this, the team trained medicines co-ordinators in all 65 practices on the need for regular monthly weight monitoring, promoted a food-first approach through a Medicines Matters bulletin, enabled OptimizeRx prompts to flag missing BMI or MUST data at the point of prescribing, and worked with a Consultant Dietitian on development of an ONS formulary. The overall approach combined clinical review, better data collection, workforce training and digital prompts to change prescribing behaviour at scale.
What was the delivering a net zero NHS benefit?
The reduced unnecessary ONS prescribing and therefore cut the carbon associated with production, transport, packaging and disposal. Of 266 patients reviewed across 51 care homes, 15% had ONS stopped and 4% had prescriptions reduced. The team calculated a minimum carbon saving of 48 tCO₂e1, the equivalent carbon absorption of 2,190 mature trees for a year2.
This shows that better monitoring and clinically appropriate deprescribing can support both patient care and NHS net zero goals. The next phase is expected to increase this benefit further by encouraging a shift, where clinically suitable, from ready-to-drink products to powdered ONS, which has been identified as having materially lower transport-related emissions than ready-to-drink alternatives.
What are the wider benefits?
Reducing ONS prescribing has generated an estimated annual financial saving of ~£42,000, alongside delivering a range of wider clinical, operational and system benefits.
For patients and clinical care, the programme improved identification of individuals with a genuine nutritional need and reduced the risk of inappropriate long-term supplementation. It reinforced the principle that ONS should supplement rather than replace normal dietary intake, supporting a stronger food-first approach and more personalised, appropriate care.
For the system and commissioning, the work reduced unwarranted variation across localities and strengthened assurance against NICE guidance. It improved value from prescribing budgets by ensuring interventions were targeted where most effective, and provides a scalable, repeatable model that can be applied to other high-cost prescribing areas across the ICB.
Operationally, the programme improved the quality and consistency of monitoring and helped ensure patients are not maintained on ONS after returning to a healthy weight. It also reduced administrative burden for clinical staff through clearer processes, better-trained medicines co-ordinators and the introduction of real-time prescribing prompts.
For workforce and integration, the initiative demonstrated effective matrix working across technicians, pharmacists, dietitians, care home staff and primary care teams. It strengthened collaboration between stakeholders and built sustainable capability within practices through training and shared processes, supporting a more joined-up and resilient model for nutritional care.
As the programme is scaled across the wider ICB, it offers a practical and sustainable approach to improving prescribing quality, releasing resources and embedding best practice across primary care and care home settings.
Link for further information:
The further information could either be a website, press release, board report, blog, youtube video, presentation etc.
- Carbon equivalent emissions saving calculated by ICB in line with NHS London Procurement Partnership methodology nhs-lpp-scoping-the-sustainability-impact-of-oral-nutritional-supplements-v2.pdf
- From Arbor Carbon Equivalent Calculator, assuming over one year, a mature tree will take up about 22 kilograms of carbon dioxide (CO₂) from the atmosphere. Arbor's Carbon Equivalent Calculator Tool
