Food for Thought

High levels of malnutrition and under-nourishment among hospital patients is an issue of major concern throughout Europe. In the UK alone, it is estimated that some 40% of patients are malnourished on admission.

In August 2006, Age Concern published the findings of its "Hungry to be Heard" report, which showed that malnutrition among elderly patients was still not being satisfactorily addressed and that the toll of malnutrition on health costs in the UK was estimated to exceed £7.3bn per year – much more than the cost of obesity.

To tackle this issue, the Council of Europe published a report on food and nutritional care in hospitals in 2002, which contained over 100 recommendations for improvement. A Committee of Ministers adopted these recommendations in November 2003, since when it has been up to EU member states to implement the recommendations in their hospitals.

The report highlighted an "unacceptable number of undernourished hospital patients in Europe" and pointed out "the fact that under-nutrition among hospital patients leads to extended hospital stays, prolonged rehabilitation, diminished quality of life and unnecessary costs to healthcare".

The Council of Europe resolution covers a broad range of meal service and eating environment recommendations, in addition to those for nutritional risk screening, identification and prevention of under-nutrition and nutritional support. The former includes aspects such as adjusting the serving system to meet patients’ needs – taking into consideration their physical and mental condition – and allowing patients to choose their eating environment, which could involve sitting at a table to eat.

HIGHER STANDARDS AT WARD LEVEL

The Hospital Caterers Association (HCA) has been voicing its concerns over the unacceptable levels of malnutrition and undernourishment among hospital patients for some time, arguing that the key to achieving greater nutritional intake is establishing higher levels of food service at ward level. It believes that the previous focus of the Better Hospital Food Programme on "cuisine" and "menus" should turn towards the issues associated with creating a joined-up delivery and service process. This will increase opportunities for patients to receive appropriate meals and assistance to eat where necessary.

Since the introduction in the UK of Shifting the Balance of Power, a policy aimed at giving more influence and decision-making powers to front-line staff, it was acknowledged that the Council of Europe resolution recommendations were unlikely to be implemented centrally by the Department of Health. The HCA, therefore, joined forces with the British Dietetic Association (BDA) to take implementation forward and develop a workable framework for the introduction of standards throughout the UK.

The HCA and BDA agreed that caterers and dietitians should be working more closely with nurses and doctors, that the essential priority is to get food into patients’ mouths, and that if patients need assistance with eating, they should get it.

Nutritional screening – a simple matter of measuring body weight and height to assess a patient’s risk of malnutrition – is not currently carried out uniformly in all hospitals in England and Wales, but is mandatory in Scotland. Although government legislation to enforce nutritional screening is unlikely in England and Wales, guidelines were issued by the National Institute of Clinical Excellence in February 2006, which, together with a structured framework of standards across the UK, would help to ensure that nutritional screening became a priority for all patients on admission.

However, it is also recognised that implementation of the resolution recommendations will not be achievable without engaging all members of clinical and non-clinical teams. A group representing both non-government (HCA, BDA, RCN, RCP, BMA and RCSLT) and government organisations (the NPSA and Departments of Health in England, Wales and Northern Ireland) was, therefore, formed to draft the framework.

UK-WIDE HOSPITAL SURVEY

To help kick-start the consultation process, the HCA and BDA conducted a UK-wide survey of hospitals, the results of which were outlined at a study day called to debate the Council of Europe resolution in late 2004. The survey sought to highlight the measures that were already being taken by hospitals and the issues and difficulties that might arise with implementation of each of the resolution’s key clauses.

Lloyd Grossman, chair of the now-disbanded Better Hospital Food Panel and the HCA’s honorary patron, spoke at the study day. He said that, although the resolution was not a statutory document, there was a powerful economic argument for implementing it in terms of value for money – a clinical argument, as it reasserted the value of food as part of the entire healing process, and also an ethical argument because it put patients at the centre of the service.

There was a general consensus that the Better Hospital Food Programme targets had largely been achieved and that it was time for hospital caterers to shift their emphasis to nutritional outcomes and improvements in food delivery, to enhance the whole of the patient mealtime experience and create a guest-host relationship.

ORDINARY FOOD FIRST

Although the first joint HCA/BDA survey was simply the start of building a workable implementation plan, it was clear there was almost unanimous agreement that the oral route should be the first choice of nutritional provision.

There was wide agreement among those who attended the study day that all patients should be screened using a nutritional assessment tool and that, ideally, an individualised nutritional care plan should be developed. It was also agreed that nutritional support should be routinely considered as an element of clinical care and that clinical nutrition education should be included in the under- and postgraduate education of physicians.

There was also support for the provision of food being flexible and individualised and for the concept of protected mealtimes, whereby interruption of patients’ mealtimes by ward rounds, teaching and diagnostic procedures should be minimised. It was felt that more research was needed to evaluate how the eating environment affected patients’ food intake. Patients should also be given clear, easy-to-understand information about how the food service works and what is available to them.

Overall, there was admiration for the sophistication and relatively advanced position of the Scottish model and any future work in England, Wales and Northern Ireland will very likely be directed towards establishing a similar framework. It was also agreed that, in the absence of any central standards-setting body, the HCA and BDA would jointly develop their role as a non-governmental organisation in the area of campaigning and setting standards.

CLINICAL BUY-IN REQUIRED

However, no implementation is achievable without the full cooperation and commitment of nurses and clinical staff. A food strategy is needed that takes into account the dietary and nutritional needs of a wide variety of hospital patients, and that includes some practical support for achieving its aims.

There is significant support among caterers and dietitians for a structured framework of clinical standards for food, fluid and nutritional care that is consistent across the UK and provides a level playing field for all hospitals. An important step forward in achieving this goal will be determining how food and nutritional care can engage with the clinical agenda. Work is continuing to identify existing research, to assess the barriers and obstacles to implementation within the existing NHS structure, policies and procedures, and to establish the necessary protocols and targets for an effective workable framework.