Work to raise awareness of malnutrition is clearly not before time, with a new survey by HSJ and Nutricia highlighting widespread fears about the low priority the problem is given by many organisations
Nutrition and Hydration Week 2014, which began on Monday, has a clear objective: “To create a global movement that will reinforce and focus energy, activity and engagement on nutrition and hydration as an important part of quality care, experience and safety improvement in health and social care settings.”
According to the results of an HSJ survey, conducted in association with Nutricia, it is a call to action that now needs to be considered urgent.
‘People are anxious about patients losing weight but do not have many strategies in place to manage the issues’
The role malnutrition plays in longer lengths of stay, readmissions to hospital, and increased vulnerability to disease is well known. The scale of the problem has also been widely publicised: charity Age UK believes that nearly 1 million over-65s in England suffer from untreated malnutrition.
Research in 2009 showed that at any time more than 3 million people in the UK are at risk of malnutrition, most of them living in the community.
As far back as 2006, the National Institute for Health and Care Excellence issued clinical guidance 32 on nutrition support in adults “to help the NHS identify patients who are malnourished or at risk of malnutrition.” In November 2012, it added quality standards 24 on nutrition support in adults to its input in the area.
Since then, the Francis report has focused attention on the importance of basic care standards -and found that patients at Stafford Hospital had not been able to eat or drink properly. There has also been the case of 22-year-old Kane Gorny, who died in hospital from dehydration which a coroner recorded “had been contributed to by neglect”.
In spite of all this, 68 per cent of the 69 respondents to our survey said they did not feel the NHS treated nutrition as a high enough priority. “Food needs to be treated as a clinical requirement,” argued a manager from an acute provider in the East Midlands.
‘There is still a long way to go so everybody feels it is part of their business to address at point of contact’
“It [nutrition] is one of the absolutely key tools in prevention as well as helping ill people to recover,” suggested another respondent, a senior manager at a healthcare regulator.
As well as concerns about the NHS’s general focus on nutrition, many of our respondents reported worries about the situation in their local patch and own organisations. Almost half said they felt malnutrition in their area had a not very high or a low priority. Similar numbers reported the same sense when it came to the situation in their own organisations.
Even among those who felt these issues were being given sufficient attention in their local areas and by their organisations, there were some concerns. “[The level of priority] is increasing due to three years of awareness raising,” reported one local authority manager working in Yorkshire and Humberside.
“But there is still a long way to go so everybody feels it is part of their business to address at point of contact.”
Barriers to better nutritional care in the words of HSJ readers
“Poor board engagement.” – Clinician in a community organisation
“Lack of nutrition leadership on a nursing level. There are too many priorities, and nutrition slips down the list easily.” – Clinician in an acute organisation
“Acceptance of the issue at senior management level - that food is a fundamental part of a health or social care package. Prevention costs may occur in one service, with benefit in the other. Joined up thinking, please!” – Local authority manager
“Changing attitudes that nutrition is more than a care aspect; it is integral to the patient’s health and wellbeing.” – Nurse working with primary and secondary care providers
“Lack of staff training for pre- and postgraduates to understand the importance of nutrition to health and wellbeing. It is not seen as a priority unless a patient has very obvious needs. GPs (some, not all) are safeguarding their budgets and not wanting to pay for supplements. Lack of access to dietitians who appear very busy. Where the dietetic service exists it is difficult to access.” – Clinician in a community organisation
“It is not a key focus area of the NHS with established funding flows and responsibility at senior levels of secondary care management.” – Manager, independent sector provider of NHS services
“Inappropriate referrals, non-referrals, poorly trained staff in some care homes, low staffing levels in some care homes.” – Clinician working in a community organisation
So how can we reach that stage? Asked what the barriers were to better nutritional care in their areas, our respondents offered a number of suggestions. Staff availability - not just of dietitians, but of nurses with time to support eating - was raised frequently. So too were the issues of costs and resources.
‘Many reported what they perceived as a lack of awareness and knowledge of malnutrition at board level’
Significantly, however, many said it came down to a simple lack of knowledge and awareness. “People are anxious about patients losing weight but do not have many strategies in place to manage the issues,” reported a clinician working in a community organisation.
It was a point echoed by a manager in a commissioning support unit who described the barriers to better nutritional care as, simply, “lack of information/no awareness.”
“Using the correct tools and understanding how to use them,” said another respondent, a senior manager at a London-based charity organisation.
Interestingly, there seemed to be a disconnect between these sort of responses and those to a specific question on the availability of information on malnutrition. Eighty-two per cent of those to whom the question applied said they had access to NICE clinical guidance, NICE quality standards and other nutrition tools such as the Managing Adult Malnutrition in the Community Pathway.
However, many reported what they perceived as a lack of awareness and knowledge of malnutrition at board level. Perhaps those relatively close to the frontline do have the information they need - but perhaps those above them do not.
The government has made clear it feels lack of awareness is no longer acceptable. In December, it launched a project to make professionals across health and social care more familiar with malnutrition.
The Malnutrition Prevention Project will be piloted in five areas with a view to addressing preventable malnutrition and dehydration in older people. It forms part of the government’s response to the Francis report.
It remains to be seen whether the tide on nutrition has finally turned.
The commissioner’s perspective: John Ferguson
Twenty-five years ago I entered the NHS as student nurse with only one objective in mind: to try to make a difference. In my early tutorials, I struggled to know how I would be able to do so in a practical way. Then one lesson gave me a practical focus that I have used in my NHS career ever since.
It was entitled “Caring for a person through their activities of daily living”. ADLs are the things we normally do: feeding ourselves, bathing, dressing, work, leisure. A person’s ability to perform ADLs can be a powerful measurement of how effectively he or she is functioning. The importance of managing a person’s ADLs has lost no significance in the present day. Yet evidence suggests the importance of one ADL - taking in adequate nutrition - is consistently missed by the NHS.
Malnutrition is common and increases a patient’s vulnerability to disease. People with malnutrition have higher hospital admission and readmission rates and longer length of stay in hospitals. That is one of the reasons it is also expensive. The care costs associated with disease related malnutrition are estimated to be in excess of £13bn per annum.
Currently, knowledge of the causes, effects and treatment of malnutrition among healthcare professionals is poor. The current models of care being commissioned are rarely outcomes-focused around the effective management of malnutrition. The lack of pathways with an adequate emphasis on nutrition is leading to inadequate and sometimes unsafe care.
There needs to be a new drive and focus in commissioning nutritional support. NHS commissioners need to ensure all their providers deliver in this area of high need. They need to clearly understand the assessment and screening that is taking place, what nutritional services are currently provided, and how effective they are.
This could include exploring whether the pathways in place for people at risk of, or suffering from, malnutrition adhere to National Institute for Health and Care Excellence clinical guidelines and quality standards.
Finally, a local commissioning strategy and implementation process needs to be put in place, redesigning services and procuring providers to bring about change.
Can you imagine being in a malnourished state and trying to live a normal life? A responsible and caring NHS cannot let this fundamental activity of daily living go unmanaged. Managing nutrition is not just the business of dietitians - it is the duty of everyone working in the NHS today.
John Ferguson is an experienced manager in NHS commissioning, currently working in a commissioning support unit