Hungry for change Nutritional care needs to be at the heart of NHS practice. If we are to tackle the scandal of malnourished older patients in our hospitals, every ward in every hospital needs to take action now, says Michelle Mitchell Michelle Mitchell is charity director for Age Concern and Help the Aged New figures uncovered by the Conservatives have found that the number of patients leaving hospital malnourished has risen by record levels in the last year. In 2008/9 185,446 people were discharged from hospital malnourished compared to 175,003 who went in malnourished. This means a record 10,443 patients were more malnourished after being in hospital in 2008/9 Food is one of the basic human needs for healthy well being and survival, yet too many hospitals fail to give nutritional care enough priority in their dayto-day practice. The malnutrition of patients has been and still is a huge problem for NHS trusts and local hospitals across the country. Data from the UK Statistics Authority shows that 2,311 people died from malnutrition in hospitals between 1997 and 2007. This marks a 16% increase in the number of people dying from malnutrition in hospitals since 1997. In the summer of 2006, Age Concern and Help the Aged first brought the scandal of malnourished older patients to the attention of the media, politicians and policy makers through the launch of its Hungry to be Heard campaign. The national award winning campaign highlighted that six out of ten older people are at risk of becoming malnourished, or their situation getting worse, in hospital. Malnourished patients not only stay in hospital for longer but are three times as likely to develop complications during surgery. They also have a higher mortality rate than wellfed patients. The problem stems from people being malnourished in the community, with four out of ten people admitted to hospital malnourished on arrival. Patients over the age of 80 admitted to hospital have a five times higher prevalence of malnutrition than those under the age of 50. Although having a healthy diet is vital for older people to remain well in later life, there are significant lifestyle factors which often create barriers for many older people. Factors such as low fixed incomes, access to shops and restricted mobility can all impact on a person s ability to have a nutritious diet and remain fit and healthy. Polling for the charity shows that a shocking one in five people aged 60 and over are skipping meals to save money on food. This statistic is worrying as it suggests that food isn t considered a necessity for healthy living by older people during difficult economic times. Malnutrition is a preventable problem which often goes undetected. Older people are the largest group of adult users of the NHS and visit health services more often than other age groups. On average they visit GP practices about seven times per year presenting lots of opportunities to identify signs of malnutrition and intervene where necessary, but sadly these are often overlooked or missed. Whether an older person s condition goes unnoticed or untreated within the community, their situation often gets worse if they are admitted into hospital. Up and down the country, older people and their families have told the charity about the problems of malnutrition in hospitals. The charity has been inundated with stories that demonstrate how distressing it is to have your basic needs ignored while in hospital. Many family members describe how they have seen relatives literally waste away, some even halving in weight. They all painfully describe their fight to get basic care, either for themselves or an older relative something which is expected in 21st century healthcare. Two clear problems emerge each time either they do not get food that is suitable for their individual needs or they don t receive the help and support they need to eat and drink. Concerns over inappropriate food served to older patients is deeply worrying. For example, the charity has heard from a patient with celiac disease who was given a meal that contains wheat and regularly hears about people who require pureed food being given whole foods such as sausages. One relative told us: My mother s meals were often placed out of reach and totally inappropriate as she was often given solids to eat after a major bowel operation. The lack of appropriate food often leaves people either struggling to eat or they don t eat at all. Good quality food is also important. Patients need to find the food offered to them appealing and it needs to provide them with the nutrients Cont. overleaf 20 nhe Jan/Feb 10
HUNGRY TO BE HEARD S SEVEN RECOMMENDED STEPS: 1. Hospital staff must listen to older people, their relatives and carers 2. All ward staff must become food aware 3. Hospital staff must follow their own professional codes and guidance from other bodies 4. Older people should be assessed for the signs or danger of malnourishment on admission and at regular intervals during their stay 5. Introduce protected mealtimes 6. Implement a red tray system and ensure that it works in practice 7. Use volunteers where appropriate Jan/Feb 10 nhe 21
they need to get better. It not only needs to be appropriate for their dietary and cultural needs but it also has to be food they are familiar with and like. For some older people encountering navarin of lamb with couscous and grilled vegetables for the first time when sick and frail could be off putting. Menus need to reflect the needs of older people and provide choice. Asking patients for their opinions is the only way to find out what they like and want. Many older people, especially those recovering from operations often need help at mealtimes. This usually ranges from ensuring appropriate cutlery is available, having someone open the lids off food containers, help with cutting up food or just someone who can offer encouragement and support to eat a meal. One relative told us: My mum was blind so she couldn t see the food tray in front of her. She was also deaf so couldn t hear the nurses properly. They just thought she was stupid and awkward and so didn t bother to help her. All too often, we hear about similar stories like this one. It is on hospital wards where the problem of malnourished older people can be most effectively tackled. Research undertaken for the launch of Hungry to be Heard revealed that nine out of 10 nurses think that they do not always have time to help patients who need assistance with eating. This is unacceptable and needs to be urgently addressed by implementing new systems to help ward staff deliver better nutritional care. We believe much can be done to improve nutritional standards in our hospitals and continue to promote effective ways to help enable health professionals to make it happen. Hungry to be Heard set out seven recommended steps to end the scandal of malnourished older patients on hospital wards. Through local Age Concerns, the campaign continues to urge every ward in every hospital to adopt these steps and bring about much needed change. Soon after the campaign launched, Ivan Lewis, the then care services minister, paid tribute to the campaign and also announced that nutrition would be a key component of the Department of Health s Dignity in Care Campaign. Soon after the launch, 147 MPs signed an Early Day Motion 388 that was tabled in the House of Commons in support of the Hungry to be Heard campaign. Numerous debates in Parliament have also been held to discuss the issue of malnutrition in hospitals and how it can be stamped out on a wider national level. In October 2007, as a direct result of the campaign, the government launched Improving nutritional care - A joint action plan between the Department of Health and nutrition summit stakeholders. This action plan set out how the Department of Health and other organisations could work collaboratively to address nutritional care within hospitals, care homes and the community. The board regularly met for a year and produced a final year report outlining its recommendations to continue the good work already being done As part of the national grass roots campaign, the charity created useful resource packs for nurses and other health professionals, backed by the Royal College of Nursing, to support them in making positive changes that can make a difference to ward practice. Additional funding from a corporate sponsor also allowed the charity to produce an innovative viral marketing campaign. With the help of celebrities like Steve Mangan from the hit sit-com series, The Green Wing, Age Concern released three short video clips on You Tube, which generated more than 150,000 online hits. It also won a 2009 Communiqué Award for Best Use of New Media. Each video clip showed how simple solutions like red trays, protected mealtimes and the use of volunteers can help to improve nutritional standards on hospital wards. Many hospitals and universities have now incorporated the short clips into their staff and volunteer training programmes and more than 1,000 DVDs have now been ordered and distributed to health professionals who directly work with older people. Although the issue has gained much political support and good work is being delivered on a local level, evidence shows there are still huge inconsistencies across the country. Monitoring undertaken by Age Concern and Help the Aged shows that 43% of NHS Trusts have still not FOR MORE INFORMATION For further information about Age Concern s Hungry to be Heard campaign please visit: T: 0208 765 7656 E: HTBH@ace.org.uk W: www.ageconcern.org.uk/htbh introduced protected mealtimes. One in three NHS trusts are still to introduce red tray systems and despite the effectiveness of volunteers in helping out with mealtimes, eight of ten NHS trusts have not rolled out volunteer schemes. Despite everyone recognising that there is a problem, it still persists. The problem does not need more legislation and more guidance. It needs to be tackled by changes in culture and practice within the NHS. The Care Quality Commission introduced new nutrition and hydration registration requirements it s now time for all hospital and care providers to meet a set national standard and be rated accordingly. As the country s population continues to age, it s shocking that many older people still find themselves trapped within a postcode lottery of commitment to improve nutritional standards on hospital wards. The government and NHS trusts must continue to place a high priority on ending malnutrition in all care settings. Each and every hospital must take responsibility for its patients to provide good quality care and ensure no older person goes hungry in hospital. 1 Malnutrition within an ageing population: A call to action, European Nutrition for Health Alliance, August 2005. 2 Ibid 3 Polling for Age Concern and Help the Aged, April 2009 4 Age Concern s monitoring is based on the 110 NHS Trusts in England that have responded to the campaign since it was launched. The figures used are based on data supplied by these trusts. To watch our viral campaign visit: www.youtube.com/ AgeConcernEngland Jan/Feb 10 nhe 23
Tackling undernutrition from a regional perspective Rachael Masters believes it is essential for the NHS to address undernutrition as a public health issue and that putting appropriate systems in place to identify and treat those at risk will save the NHS money Why should NHS organisations be concerned Our aim is to ensure the timely about tackling detection and treatment of undernutrition? Undernutrition is an alarmingly common problem which affects over three million people in the UK at any one time 2. The symptoms of this condition are often unrecognised or overlooked and therefore remain untreated. This can have a substantial impact on health and disease and evidence clearly shows that ignoring undernutrition leads to more serious health problems and heavier financial burdens for the state an estimated 13 billion-plus annually 2. A simple, cost effective answer is to implement nutritional screening using MUST (Malnutrition Universal Screening Tool 3 ) with appropriate treatment for patients identified as undernourished. How do County Durham and Darlington address the issue of undernutrition? In 2000, I established a unique service called Focus on Undernutrition 1 a local project which implemented MUST in six care homes. The pilot was so successful, that FoU has expanded to a permanently funded team of eight people and has been commissioned by NHS County Durham and Darlington to incorporate MUST into all areas of health and social care across the region. What is Focus on Undernutrition? undernourished patients. We promote MUST in a variety of care settings, where we provide support and accredited training on how to identify and treat undernutrition. More importantly, we advocate the use of nourishing drinks, snacks, multivitamin and mineral tablets and where appropriate, oral nutritional supplements such as Complan Shake, Fortisip, Ensure Plus. Could you elaborate on some FoU objectives and successes? We have devised and effected a series of initiatives. We have implemented our services into at least 65 elderly care homes, where over 75 per cent of healthcare staff have been trained using accredited open learning workbooks and catering staff attended six-week college courses on special diets. Implementation of FoU into care homes is linked to funding from the PCT commissioners and social services. In GP surgeries we facilitated nurseled clinics to review patients on oral nutritional supplements which has lead to annual cost savings of 2,900 per surgery. To support this initiative, we used Scriptswitch to encourage cost effective prescribing and a protocol for the prescribing and monitoring of nutritional supplements in adults was ratified by the PCT, which promotes the use of Complan Shake as a first line nutritional supplement due to its cost and nutritional benefits. We developed a policy for the identification and treatment of undernutrition in community nursing services, making it mandatory for all PCT community staff to complete FoU training and screen patients for undernutrition using MUST. In community hospitals, as well as compulsory training, we have established nutrition-link nurses and other systems to identify and treat undernutrition in hospitals. Of particular interest is the development of the MUST alternative measurement tape 4, which determines a patient s height when sitting. I recently received an Inspirational Improvement Award for the tape and have been inundated by requests for tapes nationally by dietitians and health professionals. How did Focus on Undernutrition gain support from the PCT? Since our inception, everyone at the PCT has advocated our mission and encouraged FoU to become an integral part of the organisation. This relationship has been mutually beneficial enabling us to be innovative in developing policies, standardised care pathways, guidelines, training, IT systems and commissioning of other services in effect facilitating a seamless, standardised approach to undernutrition. What are the next steps for the Focus on Undernutrition service? The delivery of FoU into other areas, including private care agencies, sheltered housing, prisons and community pharmacies and ultimately to commission FoU nationally to other organisations. Rachael Masters is team lead dietitian Focus on Undernutrition, part of County Durham and Darlington Community Health Services 1 Nutrition and Dietetic Service 1. For details on Focus on Undernutrition contact dar-pct.focuson-undernutrition@ nhs.net 2. Elia, Metal (2009) C o m b a t i n g M a l n u t r i t i o n : Recommendations for Action. BAPEN 3. For further details on MUST see www. bapen.org.uk 4. To receive free copies of the MUST alternative measurements tape free of charge, email tape@ complannutrition. com. 24 nhe Jan/Feb 10