The British Artificial Nutrition Survey (BANS) has now gathered sufficient information to allow analysis of trends in enteral tube feeding (ETF) and parenteral nutrition (PN) over the last five years. The rapid growth of home enteral tube feeding (HETF), which had been over 20% per year, has recently been showing definite signs of slowing down.
The age distribution of adult patients on HETF, which was already skewed to the older age range, with a peak in the 70-80 year group, has shifted even further towards the older age range, to include patients who are generally more disabled and require more support. Cerebrovascular accident has remained the commonest diagnosis in adults on HETF, but cancer has become progressively more important over the last five years. It accounted for one in four patients who started HETF in 2000, and one in 6 patients who received it at the end of 2000.
For HPN the situation is very different. Cancer accounted for less than 5% of all diagnoses, and the peak age for adult HPN was 40-60 years, with only about 5% older than 70 years at the end of 2000. However, like HETF, there has been a shift towards an older age range. In contrast, in children starting and receiving either HETF or HPN there has been little change in age distribution, so that more than half of them starting HANS continued to be less than two years of age.
Several of the trends in hospitals have been less dramatic than in the community. ETF has continued to be practised 3-5 times more frequently than PN, and the proportion of centres with nutrition support teams has remained about 40%.
The above trends, together with information suggesting sub-optimal standards of care in hospital and the community, have implications for patients, health care workers, including health planners and economists, and community carers, who are often family members. A recently published paper by the committee of BANS (Elia et al 2001) provides examples of the potential value of BANS data to such individuals. However, these developments also need to keep pace with organisational changes within the NHS.
The budget for patients on HPN is currently managed by Health Authorities, although care is provided by only a few specialist centres. HPN is one of a group of high cost, low volume treatments for which funding was to switch from Health Authorities to Regional Commissioning groups from 1st April 2002. It now seems likely that funding will be devolved to the PCTs instead.
To date, there has been no official guidance or statement to this effect. However, an agreed definition of HPN and the requirements for such services is now being considered by the Department of Health and will form the basis for future commissioning of HPN services in England and Wales. The new commissioners will then be able to purchase HPN services from established specialist centres or more local centres able to conform to the agreed definition of HPN. In Scotland, HPN services are provided by a Managed Clinical Network, centrally funded since 2000.
The arrangements for provision and funding of patients on HETF are quite different from those for HPN. Patients on HETF, who number 30-40 fold more than those on HPN are managed by almost all NHS Trusts within UK using different health care models. In the majority of cases, services are provided and managed by the dietetic department, with resources funded by the NHS. However, not all trusts have dedicated personnel to manage the service and provide ongoing monitoring of patients on HETF.
In an attempt to overcome this problem, some trusts have secured funding from enteral feeding companies to enable them to appoint staff required to co-ordinate HETF services. A few trusts have taken an alternative approach and created a central budget to purchase feeds and supplies for both primary and secondary care. By purchasing products directly from suppliers, they have been able to avail themselves of lower prices and use the monies saved to employ staff to manage the service. However, arrangements for centralised budgets held by Health Authorities may need to change as Health Authorities will cease to exist by April 2002.
This approach is extremely complex and requires much thought, time and planning. Above all, it requires total co-operation from all involved and a commitment from the Trust(s) to provide adequate funding to cover the growth of HETF year on year. The issues involved and the points that need to be considered have been described in an excellent review by Howard and Bowen (Howard & Bowen 2001).
To keep pace with these developments BANS plans to obtain further information from centres around the country. The BANS committee would like to thank all colleagues from registering centres who have contributed to the database over the last five years, and to Nicky Titt for editorial assistance.