Supply Issues with Nutritional Borderline Substances and Ancillaries

26 Oct 2022

The BDA is concerned about supply issues caused by shortages in Nutrition Borderline Substances (NBS), used to manage medical conditions and enteral feeding ancillaries as a result of global supply chain challenges, being felt across all four nations of the UK. These shortages cause distress to patients and have considerable impact on patient safety. The result is a range of impacts on patients from insidious harm caused by increased anxiety to adverse events requiring hospital admission.

A recent BAPEN survey highlights supply issues between January – June 2022 which included problems with adult, paediatric Oral Nutritional Supplements (ONS), enteral feeds and gastrostomy tubes.

In addition to patient and carer distress, these issues are causing significant additional workload across the health and care system, leading to increased waiting times and increased patient risk, whilst alternative products are sourced and new care plans are implemented.  

The BDA is pleased that there is now joint working between health professionals, industry, DHSC and patient bodies to support improved timely communication, clinical decision making in sourcing alternative products and the provision of clinical oversight to mitigate risks where possible. There needs to be a consistent approach to data collection and reporting and managing harm caused by this issue which is affecting all four nations of the UK.

The BDA is calling for greater recognition of the unintentional harm caused by supply disruption, the lack of management processes for NBS products, and that this is both a patient safety issue and a cost pressure for the NHS.

The BDA is also calling for NBS products, including products used to manage medical conditions, to have dedicated clinicians managing supplies in a fair and equitable manner, in the same way the Pharmacists manage medicine resources when supplies are limited, and to ensure there is appropriate advice on clinical and cost effectiveness.

Further Information

  1. Shortages in NBS products used to manage medical conditions and enteral feeding ancillaries are currently being experienced across all four nations of the UK.
  2. NBS products including products used to manage medical conditions and enteral feeding ancillaries are vulnerable to complex global supply chains and wider issues including Brexit, Covid, and war in Ukraine.
  3. A lack of oversight regarding stock availability and re-supply, coupled with regional variations in availability, are resulting in confusion and significant duplication of effort in understanding availability and sourcing products. Uncertainty around supplies of NBS products and ancillary items to support enteral feeding, short notice of supply issues and regional variation in these makes it challenging to ensure safe, effective and timely nutritional treatment to patients across all care settings.
  4. The risks to, and impact on, patients are highly variable and dependent on the condition or reason for which NBS products are prescribed. Some products are used as a sole source of nutrition including specialist infant formulas and enteral tube feeds with patients at significant risk of hunger, distress and even potentially malnutrition if supplies fail. NBS products used to support those with metabolic conditions or epilepsy are critical in preventing a deterioration in the condition with potential for long term and irreversible damage to health and brain function if not received. Other products such as (ONS) are used to manage disease related malnutrition in conditions such as cancer, inflammatory bowel disease or acute illnesses.
  5. Supply shortages can have a range of impacts on patients from insidious harm caused by increased anxiety to adverse events requiring admission.  These also result in additional workload across the system and increased waiting times for patients whilst alternative products are sourced and new care plans implemented with patients, carers and multidisciplinary teams caring for patients in hospital and home (or other places of care within the community i.e., schools, residential care).
  6. Supply issues of NBS products are a particular concern in Primary Care and community settings due to the complexity of the prescribing process which requires both dietetic recommendation and prescription by a qualified prescriber. Patients need to be reviewed on an individual basis by a dietitian to find a safe and effective alternate product. Where a dietitian is unavailable other healthcare professionals may need to make decisions about alternate products. This may result in inappropriate products being prescribed putting patients at clinical risk, or leading to poor health outcomes.
  7. Prescribers may not have access to dietetic expertise and inappropriate, and potentially harmful, switches may be made without timely and expert prescribing supervision.
  8. There are additional risks involved in making product replacements without appropriate guidance. Products may be clinically inappropriate, more costly to the NHS, or both. Dietitians will recommend an alternative product in line with the local contract where appropriate but must be able to prioritise like for like alternatives where this is most appropriate for the patient. Additional ancillaries may be required, at additional cost.
  9. Enteral feeding ancillary items including gastrostomy tubes, replacement ends, adaptors, giving sets and pumps are essential items needed to support and maintain enteral access for nutrition, hydration, and medication. Where these enteral feeding ancillary items are not available this could lead to critical adverse events requiring hospital admission to mitigate or manage.