Nutrition plays an important part in enhancing outcomes. An HSJ roundtable debated how the NHS can ensure it prioritises this basic need in long term conditions. Alison Moore reports
The role of nutrition in preventing illness and helping people recover from it is well known - but is the NHS doing all it can to ensure that the most vulnerable people get the nutrition they need?
An HSJ roundtable tackled the subject of nutrition for patients with long term conditions and what needs to change so it can play its part in improving outcomes for them.
HSJ’s executive editor of Adele Waters set the scene. She said: “There is ample evidence that people are coming into hospital malnourished - about one in four. There are similar problems in the care home sector and also mental health units. We know malnutrition is associated with outcomes such as higher mortality. We know that some people with nutritional problems can overcome this with an improved diet and possibly some extra social care support such as around meal preparation.”
But others such as stroke patients and those with chronic obstructive pulmonary disease might need supplementation, she said. “We need to look across the picture at how we can improve commissioning of nutritional care and support along that pathway and how we can influence decision making.”
- Kieran Brett founder, Improving Care
- Claire Campbell nutrition support nurse, Frimley Health Foundation Trust; and committee member, National Nurses Nutrition Group
- Chris Dungca modern matron, Central London Community Healthcare Trust
- John Ferguson independent commissioner and consultant
- Ceri Green global medical affairs director, Nutricia Advanced Medical Nutrition
- Professor Martin Green chief executive, Care England
- Emily Holzhausen director of policy and public affairs, Carers UK
- Siobhan Lendzionowski leadership support manager - patient experience, NHS England
- Dr Anita Nathan GP and member of the Royal College of GPs’ nutrition group
- Adele Waters executive editor, HSJ (roundtable chair)
Emily Holzhausen, director of policy and public affairs for Carers UK, pointed out the crucial role of families and carers for many patients - both in providing care and in acting as an advocate for them.
“What is very interesting about nutrition is that it is not usually the first issue that crops up in people’s discussions about healthcare,” she said. “However, we find people worry a lot about someone who is not gaining weight or who is losing weight…they really don’t know where to go.”
‘GPs deal with multiple agendas in a consultation and are likely to prioritise the first referral’
Patients and carers were often dealing with multiple healthcare professionals - up to 20 - and might not have all the necessary information or know what to do. Older people often had a small appetite and were underweight and, although public health had done a great job in getting across broad nutritional messages such as having five portions of fruit and vegetables a day, these people needed something different from the general population.
Carers UK found that about 60 per cent of families were worried about nutrition and 25 per cent were caring for someone with a small appetite. In 16 per cent of cases they were caring for someone with a small appetite who was underweight - yet were not getting any nutritional support.
The same survey showed nutritional support did make a difference - 40 per cent said they were happier because the person they cared for was more positive, and 18 per cent said they could do more for themselves.
“There is a real issue around empowering people to get advice across health and social care,” she said. The Care Act would make a difference, Ms Holzhausen added. It changed the eligibility criteria so that, rather than asking people whether they could eat and drink as part of the assessment, it looked at whether they could manage their nutrition. “I think we should be seeing that as an opportunity to integrate the skills we have in different settings.”
But did GPs see malnutrition as a clinical priority, Ms Waters asked Anita Nathan, a GP in London and member of the Royal College of GPs’ nutrition group.
Dr Nathan said that GPs were often dealing with multiple agendas in a 10 minute consultation, and were likely to prioritise the first referral. “I think that where the problem lies is the joined up thinking and education across the board in terms of understanding the problem,” she said. For example, it was important to know how to use the Malnutrition Universal Screening Tool (MUST) but some GPs were not fully aware of it.
They also needed to understand where other healthcare professionals such as nurses and pharmacists could support them.
Patients, too, could lack the knowledge they needed and could sometimes be in denial, she added. Building a relationship with them was important - although most people with a long term condition would have a dedicated GP. But there were things that could help. A prompt came up on her computer if she saw a patient who ought to be screened for dementia - a similar approach could encourage screening for nutritional status, she said.
Modern matron for Central London Community Healthcare Trust Chris Dungca deals with many stroke patients who are transferred from acute care but already malnourished.
A multidisciplinary team looks after them in hospital, but problems sometimes occur on discharge when they are referred to a community dietician - they are limited in number and patients can face a wait to be assessed. Their families may not be involved in their care and patients may not be certain whom to contact, despite the community hospital providing lots of information. Some patients were admitted, released and then readmitted - often with conditions such as pressure ulcers, where there is a link to nutrition.
‘Unless we make nutrition an issue that we have to drive forward, it probably won’t be something that is a priority’
Nutrition support nurse Claire Campbell said: “I know that when you discharge patients you give them a list of people to call and that can be overwhelming. Sometimes they think it is easier to call 999.”
She saw a lot of people in the acute sector who were malnourished and benefited from oral nutritional supplementation and sometimes nasogastric feeding. “We know that, when we take the nasogastric tube out and they go into the community, whatever weight they have gained they are likely to lose. You end up with a group of people who are admitted repeatedly. There are not the resources in the community dietetic support, and it is not picked up as a priority in patients with complex conditions.”
Her trust - Frimley Health Foundation Trust - has a nutritional support team, which was common in many trusts but there was variation in what teams covered, as some would just look at the most complex nutritional support, not basic oral nutritional support.
Global medical affairs director for Nutricia Advanced Medical Nutrition Ceri Green said: “There are [National Institute for Health and Care and Excellence] guidelines and pathways but the fact is they don’t seem to be implemented…If they were, I think we would prevent these people falling through the gaps.”
Assessment would allow these patients to be treated in some way, whether it was through better food or supplementary nutrition. Ms Green said: “The whole prevention approach is that we catch people before that. Unfortunately some patients fall quite a way down the cliff.”
Ms Campbell pointed out that rates for nutritional screening were quite high but it was what happened after someone had been screened that was important. Patients’ conditions could change for a variety of reasons. This should prompt action. “It is a matter of recognising that things have changed and rescreening,” she added.
Many people with long term conditions are living in some form of residential care - possibly with nursing care and some NHS input. How easy is it to identify and meet their nutritional needs?
Martin Green, chief executive of Care England which represents the independent care sector, said that people often came into care homes with very severe needs because their previous arrangements had broken down.
“People are not coming in with one or two conditions - they are coming in with eight or nine,” he said. “People need to have good nutrition for some of the drug regimes they are on. If you get nutrition right you give people a much better life.”
Natasha Bye on new pathways for COPD
The challenges facing the NHS - balancing the budget while coping with increasing demand from an aging population and more chronic disease - are widely recognised.
There is consensus that we need to focus on preventing ill health where possible, on integrated patient centred care, and delivering healthcare closer to home.
A significant factor among the 20 per cent of the population who drive 70 per cent of the NHS spend is nutrition. Tackling this could drive down costs and improve patient outcome.
Evidence shows that nutritional status is an important independent predictor of clinical outcome. Patients who are at risk of being clinically malnourished have more complications, higher mortality and longer length of stay in hospital.
Addressing nutrition could help stop some hospital admissions due to complications of pre-existing conditions.
A chronic condition and/or co-morbidities can put people at risk of malnutrition and therefore nutrition support should be integral to their management. A key example of this is chronic obstructive pulmonary disease.
People with COPD account for approximately 30,000 deaths each year in the UK, overwhelmingly among over-65s. The mortality rate for respiratory disease in the UK is almost double the European average. COPD is among one of the most costly inpatient conditions treated by the NHS, with an estimated direct cost to the UK healthcare system of £810m-£930m a year. It is the second largest cause of emergency admission and accounts for more than a million “bed days” each year in hospitals in the UK.
Malnutrition in COPD can have serious consequences and may be more severe in advanced disease: studies report 30-60 per cent of inpatients and 10-45 per cent of outpatients with COPD are malnourished.
This is because these individuals may have increased resting energy expenditure and may eat less, putting them at risk of malnutrition.
Medical nutrition should play a part in care where a clinical condition results in an increased or specific demand for nutrition.
Medical nutrition is tailored nutrition support through healthcare, encompassing everything from tube feeding, oral nutritional supplements or specific oral feeds, to food fortification and dietary advice strategies.
In addition to National Institute for Health and Care and Excellence Clinical Guidance (CG32) and Quality Standards (QS24) there is NICE Commissioning Guidance - estimated to save £78,000 per 100,000 of the population - and clear pathways for the use of medical nutrition in the community such as the Managing Adult Malnutrition in the Community pathway.
Implementing these pathways and integrating them into care plans for individuals with chronic conditions will yield benefits, including fewer hospital admissions and re-admissions, fewer visits to GPs, better
recovery, and a better patient and carer experience.
With guidance in place and the burning platform of the NHS challenge, it is now time to elevate nutritional care to a fundamental strategy of the NHS.
Natasha Bye is public and strategic affairs director, Nutricia Advanced Medical Nutrition
Most people were coming into a care home for between 16 and 24 months, he said, and good nutrition could help with a “good death” as well as enhancing their life during this time. There were specific issues around some patients’ nutritional needs, such as those with dementia who often became quite agitated and restless. “You need to identify how they are getting the correct level of nutritional input to maintain that level of activity,” he said.
But there were also social aspects to nutrition. People were not likely to eat foods they had never encountered before.
“Tempting people to eat is very important; when they are ill and get older their appetite often changes.” Sight, smell, appearance and portion size were all important.
“There is a challenge in how we support and train the staff to understand the importance of nutrition and when we need to bring in a professional who will look at this in the context of health, wellbeing and drug interactions,” he said. Working with primary care and specialists, such as speech and language therapists who could help with swallowing difficulties, was also important but there were sometimes not enough of them. “The care home sector needs to understand that this is central to what they do,” Professor Green added.
‘We have to get the whole system working together’
But in some respects, the challenges were just as big around those supported to live at home. “There are some big challenges for commissioners about how they commission domiciliary care - it should be outcomes based, not a task approach,” he said. “In the community, people are getting very short visits from domiciliary care. They are not supported to eat a meal… some may forget to eat.
“The notion of nutrition is important for us as professionals. But for the ill, it is about how we eat and how we are tempted to eat. We have to get the whole system working together.”
The Care Quality Commission should do a thematic inspection on nutrition which would look across the system, Professor Green added. John Ferguson, an independent commissioner and service redesign consultant who has worked for a number of primary care trusts, clinical commissioning groups and the Greater Manchester Commissioning Support Unit, added: “Because it is seen as a basic need, there is almost a view that this will just happen. From a commissioner’s perspective there are just so many competing issues.
“Commissioners have been managing organisations through a contractual basis - what is in the contract? What are the levers to do this? It is not recognised as a priority.”
He said that, even if managing nutrition was prioritised in commissioning, the questions of how it was measured and managed would remain. The CQC already looked at aspects of nutrition, he added, and asked how well organisations reacted.
Dementia, however, had a national profile with policies and procedures. “We don’t have that for malnutrition. Unless we make it an issue that we have to drive forward, it probably won’t be something that is a priority.”
He said the economic evidence on the impact of malnutrition was clear - it just needed acknowledgement. “There is a lot of talk about managing long term conditions that is very disease based rather than nutrition based,” Mr Ferguson said. “In some ways it is about what button we need to press to make people react in a different way. When you look at the NHS standard contract there is a clear line about managing nutrition. But it is about whether it is pushed up the priority list.”
Kieran Brett, founder of Improving Care, said there were opportunities to improve outcomes and reduce costs through nutrition.
“People often make a moral case for change. There is a strong moral case to do this and that is great and necessary but probably not sufficient.”
The economic case could be important in persuading the NHS to implement changes as well, he said, highlighting the disproportionate spend by the NHS on a minority of people with the highest needs - 20 per cent of patients drive 70 per cent of health and social care costs (£85bn). He suggested it might be worth targeting some of these people. “We could probably create care plans for these 10 million people. Can we do care plans where NHS England makes it very clear that nutrition is considered? If nutrition is part of the care plan, that’s a way that makes sense.”
Patients identified as needing nutritional support through this could be referred for specialist advice before they deteriorated. Identifying patients particularly at risk could lead to proactive intervention and there were also opportunities to “retrofit” nutritional care for patients who were already unwell and costing the NHS a great deal, he said.
A study of COPD patients over 65 has shown that the use of oral nutritional supplements could reduce length of stay by 21 per cent - a reduction of around £1,000 each episode, he said.
Ms Waters said the local authorities would have to be interested in this because of the Care Act. Professor Green said the public health side of local authorities was concerned about obesity but there also needed to be a prevention agenda which looked at the importance of nutrition in recovery.
‘Commissioners need to see this as a priority for 2016 and 2020’
Siobhan Lendzionowski, leadership support manager - patient experience for NHS England, said: “We are working with commissioners around guidance on nutrition and hydration. We are looking along acute [pathways] and within the community and nursing homes.” She was also working with the public and patient groups around what they wanted to see from commissioners.
There were examples of good practice from commissioners, such as in Stafford where community volunteers used the MUST tool to screen people in a project involving commissioners and Age UK. In Greenwich, work with nursing homes had come up with quality standards around nutrition and hydration.
Ms Lendzionowski said the NHS Five Year Forward View was about integration of care and looked at pathways. But changes to the NHS standard contract would also help as it featured nutrition and hydration and the “6Cs” also provided a framework for nutrition.
Mr Ferguson welcomed these moves but said: “Commissioners still need to do it. They need to see this as a priority for 2016 and 2020. It is about translating it into the doing, making it happen and monitoring.”
Professor Green said regulatory interest in a particular area would drive change.
Ms Campbell said choice was important for people on supplementary feeds. They might have preferences over flavour, for example. Some might prefer to use them in a different way, such as incorporating them in smoothies.
Professor Green agreed it could be helpful to incorporate oral nutritional supplements into people’s normal eating patterns and to work with their food preferences.
Summing up, Ms Waters said it was encouraging to see that there were some levers coming into the system that could lead to improvements in patient care in this important area.