Combating Malnutrition: Recommendations for Action. Output of a meeting of the Advisory Group on Malnutrition, led by BAPEN. Editors: M Elia and CR Russell.
Launched at the House of Commons on 10th February, 2009 with a speech from Stephen O'Brien, Shadow Health Minister & Eddisbury MP.
- Malnutrition is an under-recognised and under-treated problem facing the UK, to the detriment of and cost to individuals, the health and social care services, and society as a whole. Public expenditure on disease-related malnutrition in the UK in 2007 has been estimated at in excess of £13 billion per annum, about 80% of which was in England.
- Although the risk of malnutrition is most commonly associated with older people, the majority of people at risk of malnutrition are aged less than 65 years.
- Malnutrition is associated with a number of socioeconomic factors, including poverty, social isolation and substance misuse. It therefore potentially exacerbates health inequalities. This may help to explain why the burden of malnutrition is greater in areas of high deprivation, and why there is a clear North-South divide in its prevalence.
- At any given point in time, more than three million people in the UK are either malnourished or at risk of malnutrition. The vast majority of these (c. 93%) are living in the community (including c. 2-3% of whom are in sheltered housing), with c. 5% in care homes and just c. 2% in hospital. However, given the throughput of patients in hospital, hospital care provides a vital opportunity to identify malnutrition and initiate treatment which can then be continued in the community following discharge.
- A number of societal trends look set to exacerbate the burden of malnutrition in the future. These trends include: an ageing population; a relative increase in care provided informally in the community (as opposed to formally in institutional settings); continuing shifts in the pattern of food distribution; and an increase in conditions associated with malnutrition, such as dementia, chronic obstructive pulmonary disease, and stroke.
- The effectiveness of Government policy is at present being impeded by the way in which it falls overwhelmingly under the responsibility of the Department of Health. Other Government departments, agencies and public, private and voluntary sector organisations should also play a role. Consultation with patients, carers and service users is also important in developing patient-centred health and social care services.
- There is a paucity of Department of Health data relating to the burden of malnutrition. Some Department of Health data which have been collected are incomplete, inconsistent and difficult to interpret.
- Although screening for nutritional risk – using validated nutritional screening tools – is recommended by the Department of Health, the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA), hospitals, care homes and primary care settings are failing to screen patients as they should. This impedes the initiation of appropriate care. One of the obstacles to undertaking nutritional screening is the lack of suitable, accurate equipment to implement it.
- The education and training needs of health, housing and social care professionals are not being met in the area of nutritional care, and awareness of their needs is poorly understood. This is exacerbated by the multitude of providers involved in both health and social care delivery, and by the way in which patients are increasingly being cared for by multidisciplinary teams (MDTs) (with the associated diffusion of responsibility for nutritional care). In addition, the training of informal carers in the importance of nutritional care is virtually non-existent.
- Although Government-funded financial incentive schemes exist in health and social care to encourage the provision of high-quality care, none are at present being used to support the provision of high-quality nutritional care in either primary or community, or secondary care settings.
- Commissioners are not holding providers to account for delivering nutritional care due to the absence of nutritional care commissioning guidelines and a lack of awareness amongst commissioners of the needs of their populations. Establishing clear and meaningful commissioning guidelines would help to facilitate more effective commissioning.
- Existing regulatory systems – across both health and social care providers – need review and improvement with respect to patients and service users.
A long-term national, strategy to tackle malnutrition
- The Cabinet Office’s Strategy Unit should build on its recent work in food policy by initiating the development of a comprehensive, joined-up nutrition strategy. This strategy should have the aims of combating: food poverty; nutritional inequalities; poor quality nutritional care; and gaps in service provision.
- A new cross-departmental Public Services Agreement (PSA) target to combat malnutrition in the general population, and against which ministers can be held accountable, should be considered for introduction from the start of the next Comprehensive Spending Review period. Oversight of this PSA target should be led by the Cabinet Committee on Health and Wellbeing, to ensure co-ordinated cross-Government action.
- The Department of Health should reconstitute the Nutrition Action Plan Delivery Board more formally as one of the Government’s standing advisory bodies and ensure that it draws together the wide range of organisations working to tackle malnutrition, including NHS bodies, local government, academia, the charitable sector, professional bodies, regulators and government. The Delivery Board should publish regular reports to Parliament setting out its recommendations for future policy action, and the progress being made across Government in tackling malnutrition.
- A Strategic Delivery Framework should be introduced to underpin the delivery of the PSA target, ensuring that the importance of tackling malnutrition is shared by local government and by organisations across the public, private and voluntary sectors.
- The Department of Health should initiate a programme of awareness-raising on malnutrition for the general population.
Establishing accurate and reliable information
- The Department of Health, as part of the programme of work initiated by the recent publication of its Health Informatics Review, should undertake the following five-point programme to improve the information it holds on malnutrition:
Audit the data currently collected in relation to malnutrition;
- Assess what additional data need to be collected, and what current information requirements can be discarded;
- Develop a new data collection model so that effective information on the burden of malnutrition is collected, with the minimum of bureaucracy;
- Ensure a rigorous programme of standard-setting in the collection of data, using a common definition of malnutrition, so that the data are comparable across all care settings and between all care providers; and
- Use the new data standards and collection model to conduct an annual audit of the quality of nutritional care delivered by all care providers – including by hospitals, care homes, and GP practices.
- The Government should continue to support the National Patient Safety Agency (NPSA) both in promoting nutrition as a matter of patient safety, and in encouraging better reporting of nutrition-related incidents as adverse events. The House of Commons Health Select Committee’s current inquiry into patient safety is an excellent opportunity to consider further, specific action in this area.
Removing the barriers to screening
- The Department of Health should expand on its existing alert to NHS organisations on the weighing scales they possess, and re-issue guidance to all health, housing and social care providers detailing both the weight and height measuring equipment they should possess in order to undertake nutritional screening, particularly in the community.
- The Department of Health should promote use of the same screening tool for an individual patient between care settings, so as to ensure that – throughout a patient pathway, and regardless of the setting in which a patient is treated – an individual’s risk of malnutrition is assessed in a consistent way.
- NHS organisations should be encouraged to use the next generation of software underpinning the NHS IT system (Connecting for Health), which is set to include the ‘Malnutrition Universal Screening Tool’ (‘MUST’).
Educating the workforce
- The Government should task the UK Commission for Employment and Skills with developing a national educational strategy in order to help prevent malnutrition arising in the community, and to ensure that the highest-quality care is provided in institutional settings. This strategy should be supported by adequate resources.
- For health, housing and social care professionals, the strategy should ensure that nutrition-related training is included in both undergraduate and postgraduate courses, and that appropriate nutritional care forms a core part both of continuing professional development requirements, and of the fitness to practice procedures operated by the professional regulatory bodies.
- The strategy should reflect the increasing trend towards caring for patients in institutional settings by MDTs, in order to ensure that each multidisciplinary team (MDT) is equipped with the necessary training and expertise.
- Skills for Health and Skills for Care should establish formal, national occupational standards as soon as possible for health and social care workers involved in delivering nutritional care.
- The Department of Health should ensure that appropriate nutritional care is included in its training programme for carers, and that the carers’ national information service is fully engaged in signposting carers to effective information and services on nutritional care.
- Requirements to conduct nutritional screening should be included in the Quality and Outcomes Framework (QOF) of the GP contract. This will help both to ensure better care for patients, and deliver an improved dataset to inform future policy.
- Nutritional screening should be incorporated as a Directed Enhanced Service in the community pharmacy contact.
- The importance of nutritional care should be reflected in the system of Payment by Results, both for secondary and for primary care. The NPSA should also consider including a serious instance of poor nutritional care in their list of ‘Never Events’ (when a provider delivers care of a particularly poor standard, such as wrong-site surgery).
- In order to encourage commissioners to prioritise malnutrition in their planning of local services, consideration should be given to inclusion of malnutrition indicators in the next Joint Strategic Needs Assessment (JSNA) indicator set. Members of the Advisory Group would be happy to discuss with the Department of Health and the Department for Communities and Local Government the specific indicators which could be included.
- To overcome inconsistencies in the care pathway between different care settings, the Department of Health should issue guidance, drawing on the ‘four levels of care’ principle pioneered successfully in diabetes care, describing how a patient’s nutritional care needs should be identified and then managed between primary and secondary care providers, social care providers, and across all components of the care pathway. This guidance should make clear what national standards must be adhered to and what discretion commissioners have to develop services locally. It should also clearly set out the preventative services which should be commissioned in order to minimise the risk of malnutrition in the general population.
- Primary Care Trusts (PCTs) should be facilitated in holding providers to account for adhering to this guidance by including a requirement to meet it both in the standard model contract for secondary care services, and in the standard model contract for community care services.
- PCTs should be audited in their performance in enforcing this guidance through the World-Class Commissioning assurance framework. Local authorities should be exposed to the scrutiny of similar audits through the Audit Commission’s inspection process.
- From April 2010, when full registration with the Care Quality Commission commences, health and social care providers should be obliged to undertake nutritional screening, and to participate in national audits assessing the extent to which they are undertaking it in hospitals, care homes and the community.
- To deliver a clear line of accountability in larger institutions, all large care providers should have a nominated individual at board level responsible and accountable for the delivery of effective nutritional care within their organisation. This will ensure that there is a single, named person who can be contacted by patients, service users and staff if they have concerns with the standards of nutritional care delivered by a health or social care organisation.
- The Royal College of General Practitioners’ accreditation scheme for GP practices should reflect the importance of ensuring that GPs screen their patients for malnutrition, in line with existing NICE guidance.