Hard to stomach – the malnutrition emergency in the NHS
Despite having the tools to prevent disease-related malnutrition, the UK is facing an increase in cases.
“Today, malnutrition affects at least 3 million people in the UK.”
This was the sobering statistic shared by Declan O’Brien, Director General of British Specialist Nutrition Association (BSNA), as he addressed an early morning roundtable in the House of Commons. The BSNA event, sponsored by David Tredinnick MP, brought together parliamentarians and concerned health professionals to discuss the challenges faced by patients at risk of malnutrition and how the NHS can shape greater support for the future.
Chairing the event, Mr O’Brien laid out the reality of the situation.
“Currently one in three people in care homes, one in 10 visiting their GP and one in four people admitted to hospital are malnourished,” he said. “We know the number of malnourished people is increasing rather than decreasing, so we have a real problem.”
For a country with the fifth highest GDP in the world, such statistics are seen as shocking; they are made even more alarming when one realises that the number of deaths from malnutrition has risen by more than 30% in the last decade.
Anne Holdoway, a dietitian from the British Association for Parenteral and Enteral Nutrition, said that the media tends to focus on hospital food and people not wanting to eat it, but for many it is disease-related malnutrition - where an illness prevents patients from eating or absorbing nutrients normally - that is the main concern.
“This is where the food for special medical purposes, properly administered by a team who has the knowledge as to how to use it, translates into saving lives,” she said.
Foods for Special Medical Purposes (FSMPs), otherwise known as medical foods, are a vital tool in managing disease-related malnutrition as they are designed to meet the nutritional or dietary needs of people who are temporarily or permanently unable to get enough nutrition from normal foods.
Yet simply having the tools to combat malnutrition is not enough to solve the problem if medical professionals do not know how to use them. Holdoway cited cases where patients have received thousands of pounds worth of chemotherapy, but their basic nutritional needs were neglected.
JOSHUA, 24 yrs old
Suffering from Crohn's disease, Joshua opted for an elective surgery to remove a section of his colon in a bid to improve his condition. Unfortunately, after the surgery Joshua suffered from several severe side-effects including infection, septicaemia, internal bleeding, and pnemounia. He was quickly put on intensive care, but getting the right nutritional support was not straightforward. When it was requested that he be fed intravenously, there was a severe delay in getting the treatment to the ward. After three weeks he was discharged in a very malnourished state, unable to swallow and was physically weak. Despite his weakened state, there was no continuity of care in the community regarding providing nutrition at that stage in his rehabilitation. Four weeks later he died of disease related malnutrition.
Holdoway cautioned that even amongst the medical professional community there are myths around nutrition and malnutrition that are still being propagated, like the belief that feeding a patient feeds their cancer, or palliative patients should not be fed if they are not hungry.
She said that it was a mistake for medical professionals to see malnutrition as “just a small vitamin and mineral deficiency."
“It is actually quite profound – these patients can’t eat and drink.
“These patients week after week suffer from poor appetite and without the right products and the right expertise, they continue to suffer from malnutrition, and as a consequence of that the cost of healthcare and social care increase,” warned Holdoway.
Yet, the direct costs of the medical foods themselves is stopping GPs from prescribing them.
One group that suffers as a result are people born with PKU – an inborn error of metabolism – of which there are 3,000 - 6,000. The roundtable heard how this disorder forces patients to be dependent on artificial products for their whole lives, with the only other alternative being brain damage.
Suzanne Ford, a dietitian advisor to PKU charity NSPKU, said many clinical commissioning groups dismiss medical foods for their costs without examining why they are essential. A recent survey by NSPKU showed that more than 10% of the PKU population attending clinics in the UK are having prescription blocks or problems, with half of the patients finding the GPs to be actively blocking access to these products. Two thirds of the cases involved children and over half were going on for over a year.
“So, our patients in these cases are facing a failure in the duty of care to them in preventing the best outcome, which is to safeguard their brain growth and development,” Ford said.
A potential solution is to train GPs on how to appropriately prescribe medical foods so that they get to the right patients at the right time.
“There is the evidence to support these products. It is a small investment, 8-12 weeks treatment to get this person through this stage and get them independent again,” said Anne Holdoway.
The cost of malnutrition is high. Nearly £20bn is spent by health and care services to treat it each year. It costs over £5,000 more to treat someone who is malnourished than well-nourished and it affects all parts of the country regardless of relative wealth.
NICE suggests that better nutritional care could provide the sixth largest cost saving to the NHS. The use of oral nutritional supplements can help reduce the rate and length of hospital stays, as well as reducing complications such as infections and wound breakdown by 70% and mortality by 40%.
JOYCE, 83 yrs old
Joyce, who lived alone, had a fall. The following three weeks in the hospital led to her losing 17% of her weight due to loss of appetite. She was discharged home without any consultation with a dietitian or continued plan that involved nutrition in her care. Considered to be end of life, she was picked up by a palliative care nurse. The nurse identified that she was severely undernourished and after a regime of two nutritional drink supplements a day for 12 weeks she was taken off the end of life register and went back to living independently.
Ms Holdoway said that if the Government wants us to deliver world class healthcare, “nutrition should be an immutable part of that.”
“We do have the solutions, but we need to raise the profile of the importance of nutrition and embed it into all of our pathways. Because if we look at the priorities of the ten year plan – diabetes, cardiovascular disease, high blood pressure, cancer – all of those areas should have nutrition as an immutable part of care.”
Ex-Health Secretary Lord Lansley agreed that nutrition must be integrated into the preventative structure, especially when it comes to caring for the vulnerable and aging population.
“If we can’t be sending loads of people in to look after everybody at earlier stages, that does not mean we should simply ignore them,” he said. “There are actually things that can be part of health and social care interaction with older people at an earlier stage to try to promote better nutrition – such as a nutritious drink or simply drinking enough water.”
Worryingly, there currently is not a senior accountable officer for nutrition and hydration in NHS England with appropriate ministerial oversight.
“At the moment if I ask at the NHS who is responsible for medical foods – nobody puts their hand up. I cannot find anybody responsible,” said O’Brien of BSNA.
The roundtable discussion concluded with several key action points:
- NHS England and CQC need to give nutrition and hydration services greater priority, by appointing a senior accountable officer to raise the importance of this part of care for patients.
- Better identification, recording and management of malnutrition across health and care settings is needed – with more effective commissioning of nutritional support and prescribing of nutritional supplements.
- A joint strategy and campaign to tackle malnutrition needs to be developed by NHS England and Public Health England, recognising the particular issue of disease related malnutrition in all care settings.
- Health and care staff need to be able to identify a person at risk of malnutrition or who is already becoming malnourished, to know what support is needed and what medical intervention may be required to manage patients.
David Tredinnick MP, commended the work of the BSNA as “a critically important group in the health landscape.”
If you are parliamentarian who is interested in discussing these issues further, please contact Declan.OBrien@bsna.co.uk.
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