Consultation outcome

ACBS policy on standard adult ready-to-drink oral nutritional supplements: consultation response

Updated 22 August 2024

Executive summary

Introduction

This document presents the response of the Advisory Committee on Borderline Substances (ACBS) to the consultation on oral nutritional supplements (ONS), held between 19 April and 1 August 2021, and plans for next steps.

ONS are usually used to provide additional nutrition in the older adult population when a patient is unable to eat enough food to meet their needs. They are currently available in a number of volume sizes (125ml, 200ml, 220ml and 250ml). The 2023 to 2024 financial spend on all standard ONS in primary care in England was approximately £210 million, representing an increase of £52 million over the last 3 years. This is the largest spend on any type of prescribed nutrition borderline substance.

Figure 1: spend on different types of nutrition borderline substances for financial years 2021 to 2022, 2022 to 2023, and 2023 to 2024

British National Formulary reference	2023 to 2024	2022 to 2023	2021 to 2022
ONS  - standard	£209,991,227	£177,815,307	£157,302,280
Infant formula - condition specific	£79,763,661	£73,895,689	£68,583,028
Tube feed - standard	£60,561,039	£60,561,039	£57,074,079
ONS - standard (paediatric)	£34,622,588	£30,458,942	£28,005,256
Inherited metabolic disorder - protein source	£24,950,120	£20,657,193	£22,124,446
Thickener	£17,893,426	£17,420,550	£18,048,003
Tube feed - standard (paediatric)	£22,232,513	£18,630,071	£16,310,040
Fortifier - energy and protein	£17,965,160	£16,138,315	£14,845,890
Tube feed - condition specific (paediatric)	£15,415,293	£13,152,252	£11,561,376
Tube feed - condition specific	£19,146,988	£13,488,558	£9,642,607

Source: NHS Business Services Authority (NHSBSA), Prescription Cost Analysis – England 2023 to 2024.

Concerns have been expressed about the prescribing of adult ready-to-drink (RTD) ONS, particularly in regard to patient safety. This consultation proposed standardising RTD adult ONS to 2 volumetric sizes (125ml and 200ml) because there are many different sizes on sale, which is likely to be confusing, and lead to errors and inappropriate prescribing that can affect care and be wasteful, with associated financial cost.

Results of the consultation

Three main themes emerged from responses to the consultation as follows.

Theme 1 - patient safety

The arguments against standardisation were that restricting pack sizes may compromise nutritional intake as limiting volume may fail to deliver adequate nutrition. Additionally, manufacturers may find it difficult to optimise products in standard volumes, and this may compromise texture and nutritional composition.

The arguments for standardising volumes were that it may help limit prescription errors and waste as the current availability of so many ONS is confusing, and this is compounded by the number of similar names and packaging designs. Respondents did not reference any published evidence to support standardisation of RTD ONS in reducing prescribing errors - this may be because reporting systems to collect and document errors are underused for these products.

Issues beyond the volumetric size were repeatedly cited. Out of the 75 ACBS-approved standard ONS (of which 61 are RTD), many look and sound similar so patients are at risk of being given the wrong product due to prescribing, dispensing and administration errors based on these similarities (so-called look-alike, sound-alike (LASA) errors).

The NHS England National Patient Safety team approached the ACBS to highlight significant concerns in relation to confusion between ONS products that had resulted in significant harm. Annex A below illustrates the various names and volumes of standard ONS, and demonstrates the potential for mistakes.

Theme 2 - impact on innovation, manufacturing, supply and competition

Products are manufactured globally, so if only 2 pack sizes were recommended, supply to the UK market could be limited, thereby potentially compromising patient choice, preference and compliance.

Condensing nutritional requirements into smaller volumes may also alter the viscosity and organoleptic properties, compromising adherence and nutritional intake.

The popular smaller volume of 125ml came about because of innovation in response to a need to improve patient compliance.

Theme 3 - understanding and communication of prescribing practice

Errors occur due to a lack of understanding and rationale for prescribing ONS.

GPs can have a poor understanding of the function of ONS, their efficacy and the differences between products, particularly those with product name similarities.

GPs also acknowledge the gap in their understanding of ONS and describe dealing with prescriptions as difficult and burdensome.

Conversely, dietitians may lack an understanding of how prescribing works in primary care.

Conclusion

The consultation proposed a change to adult ONS volume size and most people agreed it would improve prescribing and reduce errors. However, ACBS is not recommending action on volume size at this time because responses raised several other important concerns that need to be explored first.

The evidence from respondents highlights confusion around product names that look and sound similar, and a lack of understanding by primary prescribers of the function of ONS. These all have a potential impact on patient safety, leading to errors and financial waste.

Next steps

1. NHS England and the Optimising Nutrition Prescribing Specialist Group of the British Dietetic Association will conduct an audit to determine the scale and nature of patient safety incidents related to nutritional borderline substances by autumn 2024.
2. The findings of the audit and the problems with packaging, labelling and naming highlighted in this report shall then be discussed with industry.
3. ACBS will meet with relevant stakeholders to define the work to address the problems identified with communication of prescribing practice. This will include:

• considering the leadership of the dietetic workforce
• guidance to convey volumes in prescribing systems
• implementing a common approach to categorising nutritional borderline substances

This work will be scheduled after the work on packaging, labelling and naming has concluded.

Background

ACBS outlined its intention to consult about standard adult RTD ONS in its work programmes of 2020 and 2021.

The consultation launched on 19 April 2021 and was updated on 21 May 2021 to clarify the scope and allow representations via post and/or email as well as through the survey that was initially provided. The consultation closing date was extended to 1 August 2021 to account for the changes and allow sufficient time for consideration. Stakeholders were notified that any comments that had already been made before the change on 21 May 2021 would still be considered, and that people who had already commented could do so again.

497 responses were considered for this consultation report. The relative high number of responses and the large amount of free text that needed analysing unfortunately meant it has taken a significant amount of time to publish this report. As the committee comprises volunteers, and because it continued to deliver on its usual responsibilities alongside working on this consultation, this determined the time needed to complete the task.

ACBS decided to consult about these products because it is concerned that an increasing number of various presentations on, and applying to, Part XV of the Drug Tariff are confusing prescribers and resulting in inappropriate prescribing and prescribing errors.

ACBS thought the confusion stemmed from several bases.

Firstly, the products have long been established in standard sizes of 125ml and 200ml, yet many other sizes are being proposed by manufacturers and so ACBS asked stakeholders whether standardising the sizes would improve prescribing and reduce errors. Also, many products are available in various sizes and ACBS wanted to understand any clinical reasons for this.

Secondly, ACBS believes the products that provide 1kcal/ml are often being used inappropriately and it wanted to know when these should be prescribed in the community.

Thirdly, products started to emerge on the market with the intention of providing a patient’s additional nutritional requirements in a single bottle, when common practice has been to prescribe 2 bottles, and ACBS asked about appropriate criteria for the new products.

Finally, many products use the terms ‘complete’ and ‘fibre’ in their brand names, but ACBS was concerned this could be misleading if the respective products are not nutritionally complete to be used as a sole source of nutrition or do not provide fibre in meaningful amounts.

To try and address these concerns, the consultation proposed changes to products that ACBS recommends for listing in Part XV of the Drug Tariff. However, the open questions in the consultation allowed respondents to voice their opinions without constraint and many raised points that ACBS had not considered in its proposals. These provided valuable insights and led ACBS to reassess its proposals and instead identify areas that need further research before considering changes to policy.

The consultation made proposals on all the different issues mentioned above and ACBS has reviewed all the responses. However, ACBS feels pack size proposals should be addressed firstly and separately - discussing all the proposals is likely to double the length of this report, which ACBS thinks is unpragmatic if readers are to assimilate the information in this report and act on it. Therefore, after careful consideration, ACBS has decided it will report on the other proposals later and will issue an addendum accordingly.

As a first step, NHS England will conduct an audit of patient safety incidents in relation to nutritional borderline substances. We will provide a timeline in due course.

Pack sizes

The consultation asked whether respondents:

• agreed that standardising pack sizes of RTD ONS to 125ml and 200ml will improve the prescribing of these products and reduce prescribing errors
• knew of any reasons for or against an RTD ONS product needing to be presented in different sizes

As shown in Table 1 below, of the responses we received:

• 68% (339) agreed that standardising pack sizes will improve prescribing and reduce prescribing errors
• 18% (91) disagreed
• 12% (60) were unsure

Table 1: responses to the question ‘Do you think that standardising pack sizes of RTD ONS to 125ml and 200ml will improve the prescribing of these products and reduce prescribing errors?’

Profession	Agree	Disagree	Not sure	Did not answer
Dietetics	158	57	44	0
General practice	10	2	1	0
Manufacturer	1	7	0	1
Nursing	1	0	0	0
Other or did not say	95	24	13	6
Pharmacy	74	1	2	0
Total	339	91	60	7

As shown in Table 2 below, of the responses we received:

• 30% (148) knew reasons for an RTD ONS product needing to be presented in different sizes
• 42% (209) knew reasons against a product needing to be presented in different sizes
• 26% (128) were unsure of reasons for or against an RTD ONS product needing to be presented in different sizes

Table 2: responses to the question ‘Do you know of any reasons for or against an RTD ONS product needing to be presented in different sizes?’

Profession	For	Against	Not sure	Did not answer
Dietetics	93	97	63	6
General practice	4	5	4	0
Manufacturer	8	0	0	1
Nursing	0	0	1	0
Other or did not say	36	52	46	4
Pharmacy	7	55	14	1
Total	148	209	128	12

However, respondents were also given an opportunity to explain their answer in writing. Thematic analysis of the responses led to the identification of 3 key themes as set out in the remainder of this report.

Theme 1 - patient safety

Areas that need further research before considering changes to policy:

• an audit of cases to determine the scale and nature of patient safety incidents related to nutritional borderline substances
• patient safety incidents have been linked to problems with packaging, labelling and product names, and there is no nationally agreed guidance on the packaging and labelling of nutritional borderline substances. Once the audit has concluded, ACBS, the Department of Health and Social Care (DHSC) and NHS England will commence dialogue with industry about the problems with the packaging, labelling and naming of borderline substances

Patient safety reflects both the need for safe prescribing practice and the scope of healthcare professionals, particularly dietitians, to have a range of products to use to best meet an individual patient’s clinical and nutritional need.

Advantages and disadvantages of the range of oral nutritional supplements

Responses mentioned that an appropriate range of ONS energy or nutrient density and volume is required to enable patients’ clinical and nutritional needs to be safely met. For example, a range of ONS volumes is required to support the differing needs of patients around hydration, enabling those on fluid restrictions or experiencing acute illness to meet their nutritional needs through low-volume products.

Importantly, there was the view that an appropriate range of ONS energy or nutrient density and volume is also required to support patient choice, preference and compliance. The point was made that standardising pack sizes would limit the range of ONS, negatively affecting choice, preference and compliance, and in turn could compromise patient safety (106 responses) with the majority of those comments from respondents who disagreed with standardising pack sizes (18% - 91 responses) and who knew reasons for ONS products needing to be presented in different sizes (30% - 148 responses).

Conversely, a similar proportion of those who agreed with standardising pack sizes (68% - 339 responses) and who knew reasons against ONS products needing to be presented in different sizes (42% - 209 responses) suggested instead that the vast range of ONS is problematic and detrimental to patient care and safety because there is too much variety (52 responses) and that products look and sound alike (38 responses).

The published evidence of prescribing errors and on patient safety

Manufacturers and industry representatives stated that they were unaware of any evidence to support that standardising pack sizes and ONS volume would be beneficial for prescribing and reduce errors. The sentiment was shared by some consultation respondents (23), although a similar number of respondents said they had experienced errors owing to ONS volume and pack sizes (26).

Instead, manufacturers pointed to the prescribing of medicines where a range of pack sizes and presentations are available and cited Slight and others (2013) and Tudor-Car and others (2016), which looked into causes and solutions for prescribing errors. These studies did not identify presentation or pack size as a cause for prescribing errors, or limiting pack sizes and presentation as a solution.

It must be acknowledged that there is no evidence in peer-reviewed literature of over- and under-prescribing of ONS volumes, or of varying pack sizes causing prescribing errors or this being detrimental to patient safety. However, a lack of published evidence does not mean that such errors do not occur - it simply means that there are no published papers to demonstrate their occurrence. Therefore, it is not possible to show using published literature that patient safety is impacted, but equally it is not possible to demonstrate that patient safety is not impacted for exactly the same reason, and a lack of evidence does not equate to a lack of a safety issue.

Anecdotal evidence of prescribing errors and on patient safety

However, there is a significant amount of anecdotal evidence, which ACBS was aware of and that for the first time has been captured via this consultation, demonstrating the problems with ONS pack sizes or volumes, presentations and prescribing. Although it is not published scientific evidence, most clinicians would accept that the views of experts are preferable to no information at all on any given area of care.

As experts in prescribing practice, a number of prescribing support dietitians and medicines optimisation pharmacists responding to the consultation mentioned the problems that are experienced with prescribing ONS, which is summarised here and will be discussed below:

• a huge variety of LASA products causes confusion, delays and errors in prescribing and dispensing with some patients being given the wrong amount of a product and being at risk of harm
• incidental over-prescribing wasting NHS resources

This opinion may be reflected in the overall result that 68% of responses we received agreed that standardising pack sizes will improve the prescribing of these products and reduce prescribing errors.

In addition, significant safety issues were raised by the NHS England Patient Safety team relating to incorrect selection of products leading to allergic reactions and serious patient harm.

Standardisation of pack sizes was proposed by the committee in part to ensure patient safety. ACBS recognises the concerns of many respondents (106 responses) that standardising pack sizes would limit the range of ONS options available to meet the patients’ clinical needs and their preferences, and ACBS is of the opinion there is a need for both an appropriate range of ONS and prescriptions of the right product and volume to enable the safe management of varying nutritional and clinical needs.

While ACBS is still of the view that the range of pack sizes is problematic, and a large majority of consultees concur, the qualitative evidence gathered by the consultation, as we will show, indicates it is not just pack sizes but also other factors causing problems for prescribing ONS.

Although the consultation and survey did not directly address or ask about the number of different ONS products on the prescription market, or the similarity of their appearance or names, many responses mentioned that these factors were either the main or a contributing cause of prescribing errors in ONS products. Helpfully, those that disagreed with, or were not sure of, the proposal that standardising pack sizes would reduce prescribing errors illustrated the issues:

I find that the prescribing errors are mainly related to the name of the product rather than to the volume it is presented in (i.e. Ensure Shake, Enshake, Ensure Plus milkshake).

I don’t [think] the volumes often cause the issues, it is names of products - especially as often similar - and what is picked and ensuring it is the correct supplement for the individual. For example, Nutricia have Fortisip Compact, Fortisip Compact Protein and Fortisip Compact Fibre [and] they are all 125ml so standardising pack sizes does not reduce the error that someone will select the incorrect one of these.

… For example products that have lower potassium and higher protein content such as Fortisip Compact Protein are confused with Fortisip Compact which have the same volume but different protein and potassium levels.

I don’t necessarily agree that it is the pack sizes that are the issue - I think it is the fact that all the companies have gone for corporate branding, which makes all the bottles look the same! So, milkshakes, juices, yoghurt style etc are all the same colour (usually the lids), with very little difference between flavour pictures…

And those that agreed with ACBS’s proposal echoed similar concerns:

I am currently a student dietitian and trying to commit to memory all of the different types, flavours and brands of available ONS supplements, as well as their nutritional value (protein/kcal per bottle) is difficult. Personally, I believe adding more sizes into the mix would lead to confusion over the nutritional content of what is supplied to patients. Therefore, a standardisation of sizes would in theory lead to less confusion.

… Re: errors, there is enough confusion already amongst medical staff re: the differences.

… The range of products with similar names causes confusion, resulting in inappropriate products being selected and prescribed…

… Errors could be reduced further if supplements were given different names rather than just adding or excluding words such as protein or fibre e.g. Fortisip is often confused with Fortisip Compact…

There is already confusion around many ONS with many being referred to generically (like ‘Hoover’ being used for any make of vacuum cleaner!), so removing varying volumes can only help reduce the confusion.

I think standardising volumes will go to lengths to help - however I don’t think this is the main issue. Many products from the same brand have similar names or packaging (for example Fortisip Compact, Fortisip Compact Protein and Fortisip Compact Fibre) and in my experience it is this that tends to cause confusion and lead to inaccurate prescriptions.

Though the naming and branding was specifically singled out by some as being problematic to prescribing, it is understood that this only really exists when considered in the context of the number of products, which some state is the real issue:

It will also allow healthcare professionals to navigate the increasing variety of products on the market more easily. Within this market there are so many similarly named products that any assistance to aid accurate prescribing is welcomed.

The variety of products is very confusing for prescribers in general practice who are not experts in this field.

My job role involves auditing GP practices on their prescribing of ONS products. We see time and time again that prescribers find it difficult to prescribe appropriate volumes of ONS products because of the variety of presentations. It would really help prescribers and therefore patients to get the right volumes of products if these were standardised.

The vast array of different ONS products makes it very difficult for GPs, who are not nutrition specialists, to accurately choose the correct product when presented with the huge drop-down list on GP prescribing systems.

Brown and others (2017), Slight and others (2019) and Bryan and others (2020) corroborate these accounts of errors occurring owing to drop-down lists with too many similarly named products and product packaging looking and sounding alike. 

When considering that there are currently 75 standard ONS listed on Part XV of the Drug Tariff, and the trend that is occurring with the names of products (as illustrated briefly in the list at Figure 2 below and fully in Annex A), it is clear why there were specific concerns that the vast range and similar presentation of the products causes confusion and delays in issuing and dispensing prescriptions correctly (129 responses), resulting in over- and under-prescribing of the volume of ONS (95 responses), giving rise to a risk of errors and potentially causing harm.

Figure 2: a list showing the trend in the similarity of standard ONS product names

• Altrajuce
• Altraplen Compact
• Altraplen Compact Daily
• Altraplen Energy
• Altraplen Protein
• Aymes 2.0kcal
• Aymes Actacal Crème
• Aymes ActaGain 600
• Aymes ActaGain Complete 2.4 Maxi
• Aymes
• Actajuce
• Aymes Actasolve Delight
• Aymes Actasolve High Energy
• Aymes Actasolve Protein Compact
• Aymes Actasolve Smoothie
• Aymes Complete
• Aymes Shake
• Aymes Shake Compact
• Aymes Shake Fibre
• Energieshake 2.0
• Energieshake Advance
• Energieshake Complete 1.5kcal
• Energieshake Dessert
• Energieshake Powder
• Enshake
• Ensure
• Ensure Compact
• Ensure Plus Advance
• Ensure Plus Crème
• Ensure Plus Fibre
• Ensure Plus Juce
• Ensure Plus Milkshake Style
• Ensure Plus Yoghurt Style
• Ensure Shake
• Ensure Twocal
• Foodlink Aqua
• Foodlink Complete
• Foodlink Complete Compact
• Foodlink Complete with Fibre
• Foodlink Extra
• Foodlink Smoothie
• Forticreme Complete
• Fortijuce
• Fortisip 2kcal
• Fortisip Bottle
• Fortisip Compact
• Fortisip Compact Fibre
• Fortisip Compact Protein
• Fortisip Extra
• Fortisip Plant Based 1.5kcal
• Fortisip Yoghurt Style
• Fresubin 2kcal Crème
• Fresubin 2kcal Drink
• Fresubin 2kcal Fibre Mini Drink
• Fresubin 2kcal Fibre Drink
• Fresubin 2kcal Mini Drink
• Fresubin 3.2kcal Drink
• Fresubin Dessert Fruit Puree
• Fresubin Energy
• Fresubin Energy Fibre
• Fresubin Jucy
• Fresubin Original
• Fresubin Powder Extra
• Fresubin Powder Fibre
• Fresubin Protein Energy
• Fresubin Yocreme
• Fresubin Yodrink
• Nutricomp Drink Plus
• Nutricomp Drink Plus Fibre
• Resource Energy
• Resource 2.0 Fibre

Safety incidents relating to prescribing errors

The NHS England Patient Safety team recently made ACBS aware of 7 serious incidents with borderline substances resulting in anaphylaxis, where they assessed that LASA packaging design and labelling seemed to have contributed to prescription, supply, picking and administration errors. (One incident involved an ONS and the other 6 were enteral feeds.) Fortunately, most of the incidents occurred in hospital so patients could receive immediate emergency medical treatment, otherwise their outcomes may have been more significant and potentially fatal. The ONS incident reads:

Anaphylaxis reaction to strawberry documented in notes, patient ingested strawberry [product name], given in error … Patient complained of throat tightness and indicators of anaphylaxis … 2222 call placed. Patient received 0.5mg adrenaline and 500ml stat…

Serious incidents also attributed to LASA have occurred with other types of borderline substances. Another incident reads:

Known metabolic patient (Maple Syrup Syndrome) [5 years old] been on the ward for 2 days, become confused and not acting like his usual self, Mum discussing with Metabolic Team over the phone, alerted staff that the wrong type of feed has been given. [Product name 1] prescribed as advised from metabolic team. [Product name 2] sent from pharmacy and given to patient. [Product name 2] contains isoleucine - this is toxic to patient’s brain. Possibility this could cause irreversible brain damage. Conscious level slowly dropping, anaesthetic team called – patient currently on PICU [Paediatric Intensive Care Unit].

NHS England asked that ACBS consider these issues and mitigating actions, so it is pertinent to mention in this report when consultees raised similar concerns.

ACBS response

Although most consultees agree standardising pack sizes would be beneficial for prescribing and reduce errors, ACBS feels it would not be sensible to recommend action on pack sizes because, in isolation, it is unlikely to improve prescribing when clearly the issue is also attributed to other factors.

ACBS was aware these matters were causing confusion for prescribing and that errors are occurring so ACBS is of the view that patient safety is at risk. However, the prevalence of these safety issues has only been raised because of the consultation.

The National Reporting and Learning System (NRLS) was originally designed primarily for use within secondary care, where local risk management system software is common. This created a barrier to primary care participation and, as a result, the majority of reported incidents via the NRLS are from secondary care and therefore relate to the hospital sector. This indicates that the true picture of errors, such as discussed in the consultation, may not be clear.

The Learn From Patient Safety Events (LFPSE) service is more suitable for use across all healthcare settings, and it has been designed with this in mind. However, providers have always been encouraged to take ownership of safety within their organisation.

ACBS believes that if the LFPSE service is used effectively to record safety concerns in relation to the prescribing of borderline substances then the outputs from this may help in building a clearer picture of the perceived problems with prescribing ONS and inform whether further research into this area is needed.

This consultation exercise has captured information that indicates there are issues with ONS pack sizes, presentations, naming and variety, but these should be explored in greater depth.

NHS England and the Optimising Nutrition Prescribing Specialist Group of the British Dietetic Association have agreed to conduct an audit of cases by autumn 2024. This will aim to determine the scale and nature of patient safety incidents related to nutritional borderline substances, and will report findings to ACBS.

ACBS will subsequently commence dialogue with industry about the problems identified and reported with packaging, labelling and product names, taking into account any outcomes from the audit of patient safety incidents.

Theme 2 - impact on innovation, manufacturing, supply and competition

There was little mention of the impact that standardising pack sizes might have on manufacturing, innovation and supply. This is probably because responses to the consultation were almost exclusively from clinicians and healthcare professionals and these areas are unlikely to be their primary focus.

However, they feature prominently in manufacturers’ responses and are important to consider, especially as members of the trade association are aligned on these matters.

Global supply concerns

Some respondents are concerned that standardising pack sizes will affect the supply of products to the UK and other countries.

The sector is a global market: companies operate across different countries to ensure their manufacturing processes and supply chains with products serving the UK and other markets. Products may only be viable to produce and sell when manufactured in this way.

Therefore, in a global market, the proposal may not be seen as standardisation but instead as the UK wanting bespoke products, and UK sales may not be lucrative enough, meaning products have to be withdrawn or may never make it to market.

It might be fair to assume then that industry shares the views of some consultees mentioned above that limiting the range of ONS would affect optimisation of nutritional management, patient choice and compliance (106 responses).

Disincentivising innovation

The point is made that the proposal to standardise ONS pack sizes has not considered what may be possible in terms of technology and manufacturing. Restricting pack size limits the possibilities for delivering a patient’s nutritional requirements in a form that is palatable and will be accepted. The smaller the volume, the more dense, viscous and unpalatable a product is likely to be unless there is innovation in the area.

Industry advises that advancement in the field should be guided by their expertise.

As an example, ONS previously tended to be presented in volumes of 200ml and 220ml but, following innovation in response to efforts to improve patient compliance and nutritional intake, 125ml is now also widely used and accepted in clinical practice. Therefore, standardising pack size does not provide manufacturers with any incentive to innovate and improve care.

A small number of consultees shared industry’s view on innovation (2% - 11 responses):

While I agree it will make prescribing easier/reduce prescribing errors, there is the potential that this restriction will stifle potential development of new products as companies will only concentrate on these pack sizes.

I understand rationale and agree that this could help to reduce prescribing errors. However manufacturers, might struggle to get a once-a-day, palatable product into 200ml or less volume.

I think that sizes should be considered on a case-by-case basis. Standardising pack sizes across the board without consideration would be a barrier to innovation within the industry.

ACBS response

Although these consultees still indicate that pack sizes are problematic, we understand from the assessment above that the issue with prescribing these products is not just because of pack sizes.

Theme 3 - understanding and communication of prescribing practice

Areas that need further research before considering changes to policy:

• industry, healthcare professionals and ACBS all share the view that better dietetic leadership is required in primary care to improve prescribing. ACBS will commence dialogue with relevant stakeholders to further explore the issues and solutions
• the issue of miscommunicating volume and whether there is a need for guidance for clinical record and prescribing systems (such as SystmOne and EMIS Web) so that primary care and secondary care use the same method for prescribing ONS
• the feasibility of the British National Formulary (BNF) using the same categorisation of all nutritional borderline substances as now established by NHSBSA

As discussed earlier, the consultation has identified that standardising pack sizes alone is unlikely to improve prescribing because the number of ONS products, and the similarity of their appearance and names also causes confusion.

However, the problems with prescribing are further compounded by a lack of understanding of the products, and the differences in prescribing practice between hospital and primary care settings. This is often inconsistent, lacks clear information sharing, and results in confused communication about required nutritional products and the volume needed to support nutritional and clinical requirements.

Poor understanding of ONS in primary care

Some consultees said they thought GPs and those working in primary care have a poor understanding of ONS (7% - 34 responses), with those comments coming from respondents that agreed standardising pack sizes will improve prescribing (22 responses), disagreed (9 responses) or were unsure (3 responses).

Given GPs are primarily responsible for the prescription of ONS in the community, and that approximately £210 million of ONS was prescribed by primary care and dispensed in the community in the 2023 to 2024 financial year (the highest prescribing spend of any type of ACBS listed product in the community), a lack of understanding about these products in general practice certainly results in poor prescribing practice, errors, harm to patients and considerable waste of taxpayers’ money:

There is currently too much choice and variation. Often prescribing of ONS is down to GPs who are not as up to date as other healthcare professionals and therefore patients can receive the wrong product from a clinical perspective, which also contributes to waste/ineffective use of resources.

In most areas of the country, in the community GPs [are] prescribing these products following the recommendation of another HCP [healthcare professional], usually the dietitian or community nurse or the patient’s relative or carer. The range of products with similar names causes confusion, resulting in inappropriate products being selected and prescribed. The ongoing management of patients on RTD ONS products is often poor, which can result in excessive weight gain or GI [gastrointestinal] issues.

… Prescribing errors usually occur because of a lack of understanding of the nutritional profile of different products. For example, products that have lower potassium and higher protein content such as Fortisip Compact Protein are confused with Fortisip Compact which have the same volume but different protein and potassium levels…

… Many GPs do not have much knowledge about ONS, and prescribing can be difficult.

… Prescribers in primary care generally have very little understanding of ONS. Prescriptions are often left to run long after they should have been stopped. Waste is significant…

GPs and those working with GPs appear to acknowledge the gap in their understanding, and some describe dealing with a prescription for ONS as difficult and burdensome and, ultimately, that this impacts on colleagues and patients (2% - 10 responses):

… There is an added work burden on primary care in issuing these (on GPs and admin), with endless to-and-fro letters from dietitians/care home asking for these, often without the proper assessment. Patients and carers then have to wait several days for prescriptions…

As a GP, I frequently encounter prescribing errors due to the odd numbers/volumes involved. This leads to increased workload for the GP practice and community pharmacy and delay for the patient.

… Odd pack sizes (e.g. 210/220/250ml) make prescription errors more likely, as you need you to make odd calculations to prescribe, which can lead to delays in obtaining prescriptions if the calculation is done incorrectly. Prescription requests in primary care are often processed by non-clinical administrative staff and queries such as this take a significant proportion of their time.

The lack of understanding in primary care means prescribing of ONS is likely inefficient and ineffective. Consultees identified 2 dominant reasons why understanding may be poor and what might be done.

Lack of education and training

Firstly, education and training is cited as not being good enough (3% - 13 responses):

Too often supplements are prescribed by those with too little nutrition training…

… If there are prescribing issues then this has to addressed by having more training put in place.

… I think more education on the actual products, content, names and ingredients is needed.

As a pharmacist, we were provided with a single 2-hour workshop on ONS and nutrition during a 4-year degree. Following that, I have completed numerous training courses on total parenteral nutrition etc but nothing further on ONS despite it being a community pharmacist’s job to supply these products…

Consultees suggest dietitians have a role in educating and training of other healthcare professionals and administrative staff, and that dietitians should be more directly involved in prescribing. Therefore, it is not surprising a proportion of consultees were critical about the lack of dietitians involved in ONS prescribing in primary care (7% - 33 responses):

… It was only coming into the CCG [clinical commissioning group] role and working closely with a team of dietitians that I came to fully understand their [ONS] place in therapy fully. After working closely with them over the last 2.5 years to roll out very detailed guides, crib sheets and run training events in primary care, it has become absolutely clear that this lack of understanding and training extended to many other professions including GPs, nurses, care homes staff…

What would be even better is [if] prescriptions were directly prescribed by dieticians [rather] than having to go through GP and waste GP [time] and effort. Less likely for errors to be made this way.

These errors can occur due to a wider range of issues than just the pack size. Often there is a lack of dietetics involvement within GP practices…

If ONS were prescribed routinely by a dietitian following a full assessment, I would have fewer concerns but, as it stands, we rely heavily upon GPs to prescribe ONS often without dietetic input and therefore keeping prescribing options as simple as possible would be safest.

Industry stakeholders similarly commented that “opportunities to embed dietetic-led care pathways into primary care … have great potential to impact on current issues…” and that doing so would be a more appropriate way of managing the prescribing instead of standardising pack sizes:

… Dietetic involvement at the primary care level is critical in reducing inappropriate prescribing, not just through dietetic management of the process but through better education and support of other healthcare professionals led by dietitians.

Miscommunication in prescribing

Secondly, the communication of the prescription hinders understanding and makes the task of prescribing ONS difficult. It is clear healthcare professionals are not communicating in a way that all can understand and, in some cases, they blame one another’s knowledge and understanding:

… GPs simply have to copy what is requested on our prescription request letters.

… The prescriber should clearly state what they are [prescribing], and the dispenser make sure they clearly read the prescription.

… Dietitians should give clear guidance about the product description on letters and know the local prescribing system that is used…

… There is an added work burden on primary care in issuing these (on GPs and admin), with endless to-and-fro letters from dietitians/care home asking for these…

Clearly, they cannot all be at fault and so many consultees rightly pointed out challenges that are causing the confusion and miscommunication.

Causes of confusion and miscommunication

Firstly, as has been discussed earlier, the huge variety of ONS (10% - 52 responses) that all look alike and sound alike (8% - 38 responses) is one cause.

Secondly, a mismatch between the way ONS are requested and prescribed was identified. ONS are commonly requested in terms of the number of bottles or sachets per day or month while community prescribing systems require prescribing in millilitres (2% - 11 responses) or grams. This can result in communication problems around how much to prescribe, with the risk of miscalculation of ONS volume and incorrect prescribing:

I experience frustration when patients do not receive what I have requested generally because the prescriber is requesting in ml rather than packs as I have requested.

… The prescriber (or commonly administration staff) has to calculate the total ‘number of ml’ per 28/d, as opposed to the number of bottles required, i.e. 11,200 ml vs 56 bottles (200ml), which from experience results in significant errors and inappropriate prescriptions through excess quantities or inadequate for a therapeutic dose…

… We have seen first hand huge amounts of over-prescribing when quantities are issued as total ml rather than individual bottles/cartons despite detailed clinical letters from dietitians…

Finally, the issue of requesting a prescription in bottles and prescribing is millilitres is compounded by the coding of prescribing systems (3% - 13 responses), which expresses the volume of product in various ways or not in any way that directly translates to how the product can be dispensed. This causes issues for communication between the dietitian requesting the prescription, the prescribing GP and the dispensing pharmacist:

Electronic prescribing requiring quantity in ml and not pack size makes prescribing cumbersome already. Non-standard sizes would be an additional risk for prescribing errors.

… Products are also often presented in multipacks, e.g. 4 x 125ml bottles, so the prescribing volume for these can be described as 500ml. Monthly prescribing volumes are also used by computer systems to give a total volume over the month, and from practical experience this is where discrepancies in prescribing often occur, for example an individual is prescribed a product to be taken 3 times a day, but the total volume prescribed per month is only adequate for twice a day due to prescriber confusion.

I am the Medicines Optimisation Lead for a CCG and through regular audit identify inappropriate quantity prescribing due to a lack of clarity on the GP clinical systems and pack sizes…

Consideration also needs to be given to the way these products are listed on clinical systems at the time of prescribing. I have experienced multiple errors in prescribing and/or dispensing because of confusion caused by these listings, e.g. one product may be listed as ‘4 x 200ml’ whereas another may be listed as ‘1 x 800ml’. The presentation is the same - 4 bottles of 200ml - but packed in such a way that they cannot be prescribed or supplied as individual bottles. Consistency in these descriptions would be beneficial.

ACBS response

The discussion above suggests that understanding of ONS and communication of prescribing practice for these products is likely the cause of prescribing errors rather than pack sizes in itself. Again, ACBS feels it would not be sensible to recommend action on pack sizes because that alone is unlikely to improve matters when understanding of and communication about ONS generally is poor.

The observations about understanding and communication of prescribing practice above concur with those of Slight and others (2013), which looked at causes of prescribing errors in general practice and was cited by industry in their consultation response. The study stated 7 categories of high-level error-producing conditions, of which 4 have been identified by this consultation exercise and are summarised in Table 3 below.

Table 3: categories of high-level error-producing conditions observed by Slight and others (2013) that were also observed in this consultation’s responses

Slight and others (2013) findings	ACBS ONS consultation observations
The prescriber (therapeutic training, drug knowledge and experience)	– GPs and those working in primary care have a poor understanding of ONS (7% - 34 responses) – Education and training is cited as not being good enough (3% - 13 responses)
The task	– GPs and those working with GPs describe dealing with a prescription for ONS as difficult and burdensome (2% - 10 responses)
The computer system (issues associated with mis-selecting drugs from electronic pick-lists)	– Requesting a prescription in bottles and prescribing in millilitres is compounded by the coding of prescribing systems (3% - 13 responses), which expresses the volume of product in various ways or not in any way that directly translates to how the product can be dispensed – An overwhelming amount of product options (10% - 52 responses) with similar names (8% - 38 responses)
The primary-secondary care interface	– ONS are commonly requested in terms of the number of bottles or sachets per day or month while community prescribing systems require prescribing in millilitres (2% - 11 responses)

Similarly, in relation to the prescriber and the computer system, an independent survey of 101 dietitians conducted by Sermo on behalf of Nutricia for the purpose of responding to this consultation found that dietitians’ perception was that community prescribing errors related to adult ONS were caused by GP error due to inadequate GP knowledge (34%) or GPs selecting an incorrect product from the system (30%).

Dietitians are the experts on product types, but other healthcare professionals and administrative staff are the experts in prescribing, and there is general acknowledgement that training, knowledge and understanding about each other’s area of expertise is not good.

Although training in the area could and should be improved, it is unrealistic to expect that other healthcare professionals’ knowledge of these products should ever match that of dietitians. However, increasing dietitians’ knowledge and understanding of how prescribing is undertaken by other healthcare professionals, particularly in primary care, would support improved communication regarding prescribing between professions. In 2021, the Royal Pharmaceutical Society published A Competency Framework for all Prescribers, which can support both those healthcare professionals who advise prescribers of what to prescribe (such as dietitians) as well as those with either supplementary or independent prescribing rights.

In addition, and in line with the views of the healthcare professionals and industry representatives that responded to the consultation, ACBS advocates for greater dietetic leadership in primary care, including the need for embedded dietetic-led care pathways in primary care.

Dietitians should take the lead for supporting and enhancing other professionals’ knowledge and understanding of appropriate prescribing for nutritional borderline substances by advocating simple, consistent prescribing guidance, and provision of ongoing education, training and audit of practice that encompasses the use of a ‘food-based approach’ prior to, instead of and alongside the use of ONS. Greater dietetic leadership would also actively support primary care commissioners to ensure that commissioned dietetic contracts are fit for purpose and fully meet the needs of each population.

Consultees that agree standardising pack sizes will improve prescribing and reduce prescribing errors (68% - 339 responses) seem to agree in part because they hope standardisation will make understanding and communication easier. However, responses reveal that the problems with communicating a prescription are much wider than just pack sizes including:

• an overwhelming amount of options to select from in a saturated market (10% - 52 responses)
• similar names (8% - 38 responses)
• the different ways healthcare professionals communicate product volume (2% - 11 responses)
• information on clinical and prescribing systems that, similarly, does not align with how healthcare professionals identify and understand the products (3% - 13 responses)

These factors appear to be the cause of prescribing errors. The overall effect seems to be confusion and delays in the issuing and dispensing of prescriptions (25% - 129 responses), and both over- and under-prescribing (19% - 95 responses).

Improvements in understanding and communication are required considering there is detriment to patients, inefficient ways of working and waste in the largest area of nutritional borderline substance prescribing, which is currently costing the NHS about £210 million a year.

ACBS advocates that there should be better dietetic leadership in primary care. This should aim to support appropriate prescribing of ONS, and enable dietitians to support, educate and train primary care staff to improve their understanding of prescribing these products.

ACBS and DHSC will explore whether there is a need for guidance for clinical and prescribing systems to address the existing issue of miscommunicating volume, and whether prescribing systems should be coded to aid in delivering on this.

Finally, what also came to light from responses to the consultation was clinicians misunderstanding the meaning of standard adult ONS products, with many respondents (including dietitians) mentioning tube feeds, paediatric ONS and condition-specific ONS. Since the consultation was launched and closed, a considerable piece of work has been completed by NHSBSA (working with DHSC and specialist dietitians) to clearly categorise all nutrition borderline substances, including standard ONS.

To further support improvements in communication about and prescribing of these products, ACBS will discuss with the National Institute for Health and Care Excellence whether the same nutrition borderline substance categories now used by NHSBSA can be replicated within the BNF, as that is the publication most recognised and used by prescribers. Currently, the way nutrition borderline substances are categorised within the BNF has the potential to exacerbate inappropriate selection and prescription.

Conclusions and next steps

The consultation proposed a change to adult ONS volume size and most people agreed it would improve prescribing and reduce errors.

However, ACBS is not recommending action on volume size at this time because responses raised several other important concerns which need to be explored first.

Firstly, the reported patient safety incidents. ACBS is proposing an audit to determine the scale and nature of incidents. NHS England and the Optimising Nutrition Prescribing Specialist Group of the British Dietetic Association have agreed to undertake this work with a view to reporting outcomes by autumn 2024.

Following this, ACBS and others will commence dialogue with industry about any problems identified and reported with packaging, labelling and product names, taking into account any outcomes from the audit of patient safety incidents. ACBS will then decide whether to advise on changes.

Separately, ACBS will work with stakeholders to improve communication of prescribing practice. The work to categorise nutritional borderline substances by the NHSBSA has laid the foundation to replicate this in the BNF and ensure consistency across the system.

ACBS will also engage with others to:

• consider the role of dietitians in primary care
• determine how knowledge and communication issues might be addressed
• explore further the reported problems with prescribing systems and ONS

Annex A: list of all standard ONS

Product	Volume
Altrajuce Starter Pack liquid	4 x 200ml
Altrajuce liquid apple	200ml
Altrajuce liquid blackcurrant	200ml
Altrajuce liquid orange	200ml
Altrajuce liquid strawberry	200ml
Altraplen Compact Daily Starter Pack liquid	4 x 250ml
Altraplen Compact Daily liquid banana	250ml
Altraplen Compact Daily liquid hazel chocolate	250ml
Altraplen Compact Daily liquid strawberry	250ml
Altraplen Compact Daily liquid vanilla	250ml
Altraplen Compact Starter Pack liquid	4 x 125ml
Altraplen Compact liquid banana	4 x 125ml
Altraplen Compact liquid hazel chocolate	4 x 125ml
Altraplen Compact liquid strawberry	4 x 125ml
Altraplen Compact liquid vanilla	4 x 125ml
Altraplen Energy Starter Pack liquid	4 x 200ml
Altraplen Energy liquid banana	200ml
Altraplen Energy liquid chocolate	200ml
Altraplen Energy liquid strawberry	200ml
Altraplen Energy liquid vanilla	200ml
Altraplen Protein Starter Pack liquid	2 x 200ml
Altraplen Protein liquid strawberry	4 x 200ml
Altraplen Protein liquid vanilla	4 x 200ml
Aymes 2.0kcal Starter Pack liquid	3 x 200ml
Aymes 2.0kcal liquid banana	200ml
Aymes 2.0kcal liquid strawberry	200ml
Aymes 2.0kcal liquid vanilla	200ml
Aymes ActaCal Creme Starter Pack dessert	2 x 125g
Aymes ActaCal Creme dessert chocolate	4 x 125g
Aymes ActaCal Creme dessert vanilla	4 x 125g
Aymes ActaGain 2.4 Complete Maxi Starter Pack liquid	3 x 200ml
Aymes ActaGain 2.4 Complete Maxi liquid banana	200ml
Aymes ActaGain 2.4 Complete Maxi liquid strawberry	200ml
Aymes ActaGain 2.4 Complete Maxi liquid vanilla	200ml
Aymes ActaGain 600 Starter Pack liquid	3 x 250ml
Aymes ActaGain 600 liquid banana	250ml
Aymes ActaGain 600 liquid strawberry	250ml
Aymes ActaGain 600 liquid vanilla	250ml
Aymes ActaGain Juce Starter Pack liquid	4 x 200ml
Aymes ActaGain Juce liquid apple	200ml
Aymes ActaGain Juce liquid cranberry-raspberry	200ml
Aymes ActaGain Juce liquid mango-passionfruit	200ml
Aymes ActaGain Juce liquid orange	200ml
Aymes ActaSolve Delight Starter Pack powder	3 x 57g
Aymes ActaSolve Delight powder 57g sachets butterscotch	7 x 57g
Aymes ActaSolve Delight powder 57g sachets lemon	7 x 57g
Aymes ActaSolve Delight powder 57g sachets mixed berries	7 x 57g
Aymes ActaSolve High Energy Starter Pack powder	4 x 85g
Aymes ActaSolve High Energy powder 85g sachets banana	6 x 85g
Aymes ActaSolve High Energy powder 85g sachets chocolate	6 x 85g
Aymes ActaSolve High Energy powder 85g sachets strawberry	6 x 85g
Aymes ActaSolve High Energy powder 85g sachets vanilla	6 x 85g
Aymes ActaSolve Protein Compact Starter Pack powder	5 x 57g
Aymes ActaSolve Protein Compact powder 57g sachets banana	7 x 57g
Aymes ActaSolve Protein Compact powder 57g sachets chocolate	7 x 57g
Aymes ActaSolve Protein Compact powder 57g sachets neutral	7 x 57g
Aymes ActaSolve Protein Compact powder 57g sachets strawberry	7 x 57g
Aymes ActaSolve Protein Compact powder 57g sachets vanilla	7 x 57g
Aymes ActaSolve Savoury Starter Pack powder	3 x 57g
Aymes ActaSolve Savoury powder 57g sachets chicken	7 x 57g
Aymes ActaSolve Savoury powder 57g sachets potato and leek	7 x 57g
Aymes ActaSolve Savoury powder 57g sachets vegetable	7 x 57g
Aymes ActaSolve Smoothie Starter Pack powder	4 x 66g
Aymes ActaSolve Smoothie powder 66g sachets mango	7 x 66g
Aymes ActaSolve Smoothie powder 66g sachets peach	7 x 66g
Aymes ActaSolve Smoothie powder 66g sachets pineapple	7 x 66g
Aymes ActaSolve Smoothie powder 66g sachets strawberry and cranberry	7 x 66g
Aymes Complete Starter Pack liquid	4 x 200ml
Aymes Complete liquid banana	200ml
Aymes Complete liquid chocolate	200ml
Aymes Complete liquid strawberry	200ml
Aymes Complete liquid vanilla	200ml
Aymes Shake Compact Starter Pack powder	6 x 57g
Aymes Shake Compact powder 57g sachets banana	7 x 57g
Aymes Shake Compact powder 57g sachets chocolate	7 x 57g
Aymes Shake Compact powder 57g sachets ginger	7 x 57g
Aymes Shake Compact powder 57g sachets neutral	7 x 57g
Aymes Shake Compact powder 57g sachets strawberry	7 x 57g
Aymes Shake Compact powder 57g sachets vanilla	7 x 57g
Aymes Shake Fibre Starter Pack powder	5 x 57g
Aymes Shake Fibre powder 57g sachets banana	7 x 57g
Aymes Shake Fibre powder 57g sachets chocolate	7 x 57g
Aymes Shake Fibre powder 57g sachets neutral	7 x 57g
Aymes Shake Fibre powder 57g sachets strawberry	7 x 57g
Aymes Shake Fibre powder 57g sachets vanilla	7 x 57g
Aymes Shake Starter Pack powder	6 x 57g
Aymes Shake powder 57g sachets banana	7 x 57g
Aymes Shake powder 57g sachets chocolate	7 x 57g
Aymes Shake powder 57g sachets ginger	7 x 57g
Aymes Shake powder 57g sachets neutral	7 x 57g
Aymes Shake powder 57g sachets strawberry	7 x 57g
Aymes Shake powder 57g sachets vanilla	7 x 57g
Aymes Shake powder banana	1,600g
Aymes Shake powder chocolate	1,600g
Aymes Shake powder neutral	1,600g
Aymes Shake powder strawberry	1,600g
Aymes Shake powder vanilla	1,600g
EnergieShake 2.0kcal liquid banana	200ml
EnergieShake 2.0kcal liquid strawberry	200ml
EnergieShake 2.0kcal liquid vanilla	200ml
EnergieShake Advance 1.3kcal oral liquid chocolate	200ml
EnergieShake Advance 1.3kcal oral liquid vanilla	200ml
EnergieShake Complete 1.5kcal liquid banana	200ml
EnergieShake Complete 1.5kcal liquid chocolate	200ml
EnergieShake Complete 1.5kcal liquid strawberry	200ml
EnergieShake Complete 1.5kcal liquid vanilla	200ml
EnergieShake Powder Starter Pack oral powder sachets	5 x 57g
EnergieShake Powder oral powder 57g sachets banana	4 x 57g
EnergieShake Powder oral powder 57g sachets banana	7 x 57g
EnergieShake Powder oral powder 57g sachets chocolate	4 x 57g
EnergieShake Powder oral powder 57g sachets chocolate	7 x 57g
EnergieShake Powder oral powder 57g sachets neutral	4 x 57g
EnergieShake Powder oral powder 57g sachets neutral	7 x 57g
EnergieShake Powder oral powder 57g sachets strawberry	4 x 57g
EnergieShake Powder oral powder 57g sachets strawberry	7 x 57g
EnergieShake Powder oral powder 57g sachets vanilla	4 x 57g
EnergieShake Powder oral powder 57g sachets vanilla	7 x 57g
EnergieShake dessert caramel	3 x 125g
EnergieShake dessert chocolate	3 x 125g
Enshake oral powder 96.5g sachets banana	6 x 96.5g
Enshake oral powder 96.5g sachets chocolate	6 x 96.5g
Enshake oral powder 96.5g sachets strawberry	6 x 96.5g
Enshake oral powder 96.5g sachets vanilla	6 x 96.5g
Ensure Compact liquid banana	4 x 125ml
Ensure Compact liquid cafe latte	4 x 125ml
Ensure Compact liquid strawberry	4 x 125ml
Ensure Compact liquid vanilla	4 x 125 ml
Ensure Plus Advance liquid banana	220ml
Ensure Plus Advance liquid chocolate	220ml
Ensure Plus Advance liquid coffee	220ml
Ensure Plus Advance liquid strawberry	220ml
Ensure Plus Advance liquid vanilla	220ml
Ensure Plus Crème banana	4 x 125g
Ensure Plus Crème chocolate	4 x 125g
Ensure Plus Crème vanilla	4 x 125g
Ensure Plus Fibre liquid banana	200ml
Ensure Plus Fibre liquid chocolate	200ml
Ensure Plus Fibre liquid raspberry	200ml
Ensure Plus Fibre liquid strawberry	200ml
Ensure Plus Fibre liquid vanilla	200ml
Ensure Plus Juce liquid apple	220ml
Ensure Plus Juce liquid fruit punch	220ml
Ensure Plus Juce liquid lemon-lime	220ml
Ensure Plus Juce liquid orange	220ml
Ensure Plus Juce liquid peach	220ml
Ensure Plus Juce liquid strawberry	220ml
Ensure Plus milkshake style liquid banana	200ml
Ensure Plus milkshake style liquid chocolate	200ml
Ensure Plus milkshake style liquid coffee	200ml
Ensure Plus milkshake style liquid fruits of the forest	200ml
Ensure Plus milkshake style liquid neutral	200ml
Ensure Plus milkshake style liquid peach	200ml
Ensure Plus milkshake style liquid strawberry	200ml
Ensure Plus milkshake style liquid vanilla	200ml
Ensure Plus yoghurt style liquid orchard peach	200ml
Ensure Plus yoghurt style liquid strawberry swirl	200ml
Ensure Shake oral powder 57g sachets banana	7 x 57g
Ensure Shake oral powder 57g sachets chocolate	7 x 57g
Ensure Shake oral powder 57g sachets strawberry	7 x 57g
Ensure Shake oral powder 57g sachets vanilla	7 x 57g
Ensure TwoCal liquid banana	200ml
Ensure TwoCal liquid neutral	200ml
Ensure TwoCal liquid strawberry	200ml
Ensure TwoCal liquid vanilla	200ml
Ensure liquid chocolate	250ml
Ensure liquid vanilla	250ml
Foodlink Aqua powder banana	1,764g
Foodlink Aqua powder chocolate	1,764g
Foodlink Aqua powder red berry	1,764g
Foodlink Aqua powder vanilla	1,764g
Foodlink Complete Compact Starter Pack sachets	5 x 57g
Foodlink Complete Compact powder 57g sachets banana	7 x 57g
Foodlink Complete Compact powder 57g sachets chocolate	7 x 57g
Foodlink Complete Compact powder 57g sachets natural	7 x 57g
Foodlink Complete Compact powder 57g sachets strawberry	7 x 57g
Foodlink Complete Compact powder 57g sachets vanilla	7 x 57g
Foodlink Complete Starter Pack powder	5 x 57g
Foodlink Complete powder 57g sachets banana	7 x 57g
Foodlink Complete powder 57g sachets chocolate	7 x 57g
Foodlink Complete powder 57g sachets natural	7 x 57g
Foodlink Complete powder 57g sachets strawberry	7 x 57g
Foodlink Complete powder 57g sachets vanilla	7 x 57g
Foodlink Complete powder banana	1,596g
Foodlink Complete powder chocolate	1,596g
Foodlink Complete powder natural	1,596g
Foodlink Complete powder strawberry	1,596g
Foodlink Complete powder vanilla	1,596g
Foodlink Complete powder with fibre 63g sachets banana	7 x 63g
Foodlink Complete powder with fibre 63g sachets chocolate	7 x 63g
Foodlink Complete powder with fibre 63g sachets natural	7 x 63g
Foodlink Complete powder with fibre 63g sachets strawberry	7 x 63g
Foodlink Complete powder with fibre 63g sachets vanilla	7 x 63g
Foodlink Complete powder with fibre Starter Pack	5 x 63g
Foodlink Extra Starter Pack sachets	4 x 85g
Foodlink Extra powder 85g sachets banana	7 x 85g
Foodlink Extra powder 85g sachets chocolate	7 x 85g
Foodlink Extra powder 85g sachets strawberry	7 x 85g
Foodlink Extra powder 85g sachets vanilla	7 x 85g
Foodlink Smoothie Starter Pack sachets	4 x 66g
Foodlink Smoothie powder 66g sachets orange and mango	7 x 66g
Foodlink Smoothie powder 66g sachets peach	7 x 66g
Foodlink Smoothie powder 66g sachets red berry	7 x 66g
Foodlink Smoothie powder 66g sachets tropical	7 x 66g
Forticreme Complete dessert banana	4 x 125g
Forticreme Complete dessert chocolate	4 x 125g
Forticreme Complete dessert forest fruits	4 x 125g
Forticreme Complete dessert vanilla	4 x 125g
Fortijuce Starter Pack liquid	4 x 200ml
Fortijuce liquid apple	200ml
Fortijuce liquid blackcurrant	200ml
Fortijuce liquid forest fruits	200ml
Fortijuce liquid lemon	200ml
Fortijuce liquid orange	200ml
Fortijuce liquid strawberry	200ml
Fortijuce liquid tropical	200ml
Fortisip 2kcal liquid chocolate-caramel	200ml
Fortisip 2kcal liquid forest fruit	200ml
Fortisip 2kcal liquid mocha	200ml
Fortisip 2kcal liquid strawberry	200ml
Fortisip 2kcal liquid vanilla	200ml
Fortisip Bottle banana (bottle)	200ml
Fortisip Bottle banana (tetrapak)	200ml
Fortisip Bottle chocolate (bottle)	200ml
Fortisip Bottle chocolate (tetrapak)	200ml
Fortisip Bottle neutral	200ml
Fortisip Bottle strawberry (bottle)	200ml
Fortisip Bottle strawberry (tetrapak)	200ml
Fortisip Bottle tropical	200ml
Fortisip Bottle vanilla (bottle)	200ml
Fortisip Bottle vanilla (tetrapak)	200ml
Fortisip Compact Fibre Starter Pack liquid	4 x 125ml
Fortisip Compact Fibre liquid mocha	4 x 125ml
Fortisip Compact Fibre liquid strawberry	4 x 125ml
Fortisip Compact Fibre liquid vanilla	4 x 125ml
Fortisip Compact Protein Starter Pack liquid	8 x 125ml
Fortisip Compact Protein liquid banana	4 x 125ml
Fortisip Compact Protein liquid berries	4 x 125ml
Fortisip Compact Protein liquid cool red fruits	4 x 125ml
Fortisip Compact Protein liquid hot tropical ginger	4 x 125ml
Fortisip Compact Protein liquid mocha	4 x 125ml
Fortisip Compact Protein liquid neutral	4 x 125ml
Fortisip Compact Protein liquid peach-mango	4 x 125ml
Fortisip Compact Protein liquid strawberry	4 x 125ml
Fortisip Compact Protein liquid vanilla	4 x 125ml
Fortisip Compact Starter Pack liquid	6 x 125ml
Fortisip Compact liquid apricot	4 x 125ml
Fortisip Compact liquid banana	4 x 125ml
Fortisip Compact liquid chocolate	4 x 125ml
Fortisip Compact liquid forest fruit	4 x 125ml
Fortisip Compact liquid mocha	4 x 125ml
Fortisip Compact liquid neutral	4 x 125ml
Fortisip Compact liquid strawberry	4 x 125ml
Fortisip Compact liquid vanilla	4 x 125ml
Fortisip Extra liquid strawberry	200ml
Fortisip Extra liquid vanilla	200ml
Fortisip Yogurt Style liquid peach-orange	200ml
Fortisip Yogurt Style liquid raspberry	200ml
Fortisip Yogurt Style liquid vanilla-lemon	200ml
Fresubin 2kcal Crème dessert cappuccino	4 x 125g
Fresubin 2kcal Crème dessert chocolate	4 x 125g
Fresubin 2kcal Crème dessert praline	4 x 125g
Fresubin 2kcal Crème dessert vanilla	4 x 125g
Fresubin 2kcal Crème dessert wild strawberry	4 x 125g
Fresubin 2kcal Fibre Mini drink chocolate	4 x 125ml
Fresubin 2kcal Fibre Mini drink vanilla	4 x 125ml
Fresubin 2kcal Fibre drink apricot-peach	200ml
Fresubin 2kcal Fibre drink cappuccino	200ml
Fresubin 2kcal Fibre drink chocolate	200ml
Fresubin 2kcal Fibre drink lemon	200ml
Fresubin 2kcal Fibre drink neutral	200ml
Fresubin 2kcal Fibre drink vanilla	200ml
Fresubin 2kcal Mini drink apricot-peach	4 x 125ml
Fresubin 2kcal Mini drink fruits of the forest	4 x 125ml
Fresubin 2kcal Mini drink vanilla	4 x 125ml
Fresubin 2kcal drink apricot-peach	200ml
Fresubin 2kcal drink cappuccino	200ml
Fresubin 2kcal drink fruits of the forest	200ml
Fresubin 2kcal drink neutral	200ml
Fresubin 2kcal drink toffee	200ml
Fresubin 2kcal drink vanilla	200ml
Fresubin 3.2kcal drink hazelnut	4 x 125ml
Fresubin 3.2kcal drink mango	4 x 125ml
Fresubin 3.2kcal drink vanilla-caramel	4 x 125ml
Fresubin Dessert Fruit Puree	4 x 125g
Fresubin Energy Fibre liquid banana	200ml
Fresubin Energy Fibre liquid caramel	200ml
Fresubin Energy Fibre liquid cherry	200ml
Fresubin Energy Fibre liquid chocolate	200ml
Fresubin Energy Fibre liquid strawberry	200ml
Fresubin Energy Fibre liquid vanilla	200ml
Fresubin Energy liquid banana	200ml
Fresubin Energy liquid blackcurrant	200ml
Fresubin Energy liquid cappuccino	200ml
Fresubin Energy liquid chocolate	200ml
Fresubin Energy liquid lemon	200ml
Fresubin Energy liquid strawberry	200ml
Fresubin Energy liquid tropical fruits	200ml
Fresubin Energy liquid unflavoured	200ml
Fresubin Energy liquid vanilla	200ml
Fresubin Jucy drink apple	4 x 200ml
Fresubin Jucy drink blackcurrant	4 x 200ml
Fresubin Jucy drink cherry	4 x 200ml
Fresubin Jucy drink orange	4 x 200ml
Fresubin Jucy drink pineapple	4 x 200ml
Fresubin Jucy drink starter pack	2 x 200ml and 4 x 200ml
Fresubin Original drink blackcurrant	200ml
Fresubin Original drink chocolate	200ml
Fresubin Original drink peach	200ml
Fresubin Original drink vanilla	200ml
Fresubin Powder Extra oral powder 62g sachets chocolate	7 x 62g
Fresubin Powder Extra oral powder 62g sachets neutral	7 x 62g
Fresubin Powder Extra oral powder 62g sachets strawberry	7 x 62g
Fresubin Powder Extra oral powder 62g sachets vanilla	7 x 62g
Fresubin Powder Fibre powder	500g
Fresubin Protein Energy drink cappuccino	200ml
Fresubin Protein Energy drink chocolate	200ml
Fresubin Protein Energy drink tropical fruits	200ml
Fresubin Protein Energy drink vanilla	200ml
Fresubin Protein Energy drink wild strawberry	200ml
Fresubin YOcrème dessert apricot-peach	4 x 125g
Fresubin YOcrème dessert biscuit	4 x 125g
Fresubin YOcrème dessert lemon	4 x 125g
Fresubin YOcrème dessert raspberry	4 x 125g
Fresubin YoDrink apricot-peach	200 ml
Fresubin YoDrink lemon	200ml
Fresubin YoDrink raspberry	200ml
Resource Energy liquid - chocolate	4 x 200ml
Resource Energy liquid strawberry-raspberry	4 x 200ml
Resource Energy liquid vanilla	4 x 200ml
Resource Fibre 2.0 liquid neutral	200ml
Resource Fibre 2.0 liquid strawberry	200ml
Resource Fibre 2.0 liquid summer fruit	200ml
Resource Fibre 2.0 liquid vanilla	200ml

Annex B: methodology

Labelling respondents by profession

All responses or respondents were labelled with one of the following professions or areas of work:

• dietetics
• general practice
• manufacturer
• nursing
• other or unknown
• pharmacy

This was done to provide more meaningful analysis of the responses.

The method for deciding how to label respondents depended, to some extent, on whether the response was completed after the consultation had been updated on 21 May 2021. This is because the update included additional questions asking for the respondent’s name and for their job title or capacity in which they were replying.

For respondents before 21 May 2021, the label was decided by reading their responses to the survey. For example, in response to open questions some started their answer by saying: “I am a dietitian…” In this case, the respondent’s area of work was labelled as ‘dietetics’. Another respondent to the question ‘What is the name of your organisation?’ answered: “GPs interested in nutrition and lifestyle group” so, therefore, the respondent’s area of work was labelled as ‘general practice’.

For respondents after 21 May 2021, the majority could be labelled based on their answer to the question ‘What is your job title or the capacity that you are responding in?’.

Where a determination could not be made based on that answer, or if no answer was given, Google was used to make a search for the individual’s given name and, if disclosed, the name of their organisation. Otherwise, the qualitative answers could be used to make a determination as described above.

Giving respondents a unique identifier

Each respondent was given a unique identifier.

Cleaning the data

We had to clean the raw data because a significant number of entries were nugatory. Our approach has been to be as light touch as possible in cleaning the data.

We have not counted the following:

• responses submitted without an answer to any of the ONS survey questions
• responses where only one free text answer has been given, and it does not relate to the survey (for example, one response just had an unrelated link and others contained Latin text that was used internally to test the survey)

We have counted:

• responses where at least one survey question has been answered
• multiple responses that appear to be from the same organisation or person because the view expressed may represent different parts of the organisation or a response may contain additional feedback. We also announced when the survey was updated on 21 May 2021 that comments made before the change would still be considered and that people who had already commented could do so again

Note: references made above to ‘survey questions’ only relate to the questions on ONS. This does not account for any preliminary questions we asked to collect details about the respondent, such as whether they are responding as an organisation or individual.

After cleaning the data, 497 responses were considered in writing this report.

Responses submitted by email

Seven responses to the consultation were submitted by email. These were assigned a number, and analysed and counted alongside all other survey responses.

How themes were identified, analysed and quantified

We familiarised ourselves with the data by reading and re-reading all qualitative answers to understand the meaning of responses, and to start identifying the different subject matters and issues being mentioned.

Each subject matter or issue was then given a code. The responses were then again reviewed, but this time tagged with the relevant codes of the subjects and issues being discussed by the respondent. We allowed for responses to be tagged with as many codes as necessary.

The number of occurrences for each code was then counted.

The coding frame and a description of the codes is as follows.

Table 4: coding frame

Code	Subject or issue	Meaning
L	Lack of GP or primary care understanding	Knowledge about ONS in primary care and the community is poor or inadequate
D	Dietetic prescribing involvement in GP practices needed	More dietitians are needed in primary care or need to be more involved in prescribing
B	Burdensome for or will help GPs	ONS pack sizes and varying volumes mean dealing with prescriptions is difficult for GPs and practice staff, and ACBS proposals will address the issues
ET	Education and training needed or not good enough	Education and training about ONS is not good and is needed
T	Too much variety	There is too much variety in the ONS prescription market and this is causing problems
S	Shots needed	Modular products, often presented in small volumes and referred to as shots, are valuable and should not be subject to ACBS proposals on standardising pack sizes and volumes
LA	LASA	The names and labels of ONS products look alike and sound alike
E	Experienced errors	Have experienced errors with ONS pack sizes or products being available in different volumes
DC	Delays or confuses prescriptions	Prescriptions for ONS are confusing and this causes delays in issuing the prescription
I	Improve price, nutritional or switching comparisons	ACBS proposals will improve opportunities to make better price and nutritional comparisons of ONS so switching products will be easier
R	Risk to patient safety or compliance	ACBS proposals risk patient safety and/or patient compliance, or the current ONS landscape is a risk to patient safety and compliance
N	Not confusing	ONS products and prescriptions are not confusing
H	Hinder innovation	ACBS proposals will hinder the innovation of ONS products
P	Prescribing systems or code needs improving	The information about ONS on prescribing systems is poor and the way systems are setup should be improved to aid communication
M	Millilitres vs bottles	Prescribing of ONS volumes is sometimes done in millilitres but other times as bottles, resulting in discrepancies in communication
U	Unaware of errors	Have not experienced errors with ONS pack sizes or products being available in different volumes
ST	Stock management	The current position regarding ONS pack sizes causes issues for community pharmacies with stock management, ordering and broken bulk, which may also result in waste
W	Waste, under- or over-prescribing	The problems with prescribing ONS means there is considerable under and over-prescribing of ONS, and resultant waste
F	Food first	There needs to be a greater emphasis on food being used prior to, instead of and alongside the use of ONS
TF	Tube feeding	ACBS proposals will affect tube-fed patients that use ONS for bolus feeding as different pack sizes allow feeding planes to be tailored to individuals
HF	Hydration or fluid (fluid restriction)	Some clinical conditions require fluid restrictions so different-sized ONS of the same product are beneficial

Annex C: responses

The individual responses to the consultation have not been published with this response.

If you are interested in the individual responses, you can request this information in an anonymised format by emailing acbs@dhsc.gov.uk.