Fit for a feast

Food is fundamental to health so all staff within hospitals and other areas of residential care must work closely with caterers to ensure their patients receive the nutrition they require for recovery and wellbeing.
    
Although health is a devolved issue, all the home nations recognise the importance of food in hospitals and care homes in the battle against malnutrition. Each country has a distinctive approach to nutrition in hospital patients but this review shows there are common themes throughout all these plans:

• setting standards for care and food
• screening for risk of malnutrition
• training for all staff so they understand the importance of nutrition in care.

England – Nutrition Action Plan
This plan was produced as a result of two summit meetings of stakeholder groups called by the Department of Health in 2007. Its strength is that it is the work of around 50 government and non-government stakeholder groups and this means that improving nutritional care is on many agenda.
    
In January 2008 a Delivery Board was set up to facilitate delivery of the actions set out in the Plan. The Delivery Board is chaired by Gordon Lishman, Director General of Age Concern, and in October ministerial responsibility passed from Ivan Lewis to Philip Hope MP (Minister of State for Care Services).
    
It is important to remember that the Nutrition Action Plan covers both health and social care.

The Delivery Board has published its mid-term report and this can be downloaded from the Department of Health website at www.dh.gov.uk/en/SocialCare/Socialcarereform/Dignityincare/DH_082909.
    
The work of the Delivery Board has been divided into five main areas:

1. Raising awareness – this group is chaired by Rick Wilson representing the British Dietetic Association (BDA) and the Council of Europe Alliance (UK). The group has been working on developing the ten Key Characteristics of Good Nutritional Care so that they are applicable across all care settings. The group has also developed a communications plan to be implemented in 2009.
2. Ensuring guidance is accessible and appropriate – this work has been led by the Social Care Institute for Excellence (SCIE) and a guidance library is being developed on their website www.scie.org.uk. 
3. Encouraging nutritional screening – this group is led by Professor Marinos Elia and has been facilitating the National Nutrition Screening Weeks through the British Association for Parenteral and Enteral Nutrition (BAPEN) who have developed the Malnutrition Universal Screening Tool (MUST).
4. Encouraging provision and access to relevant training – this work has been led by Ros Speight of the National Association for Care Catering. Working with the Sector Skills Councils for England they are establishing a national occupational standard for nutritional care. This group has also worked with the NHS Core Learning team to develop a package of e-learning focused on the basics of nutritional care.
5. Clarifying standards and strengthening inspection and regulation – this group is led by Ginny Storey from the Commission for Social Care Inspection (CSCI) and Rekha Elaswarapu from the Healthcare Commission (HC). In April 2009 CSCI and the Healthcare Commission merge to form the new Care Quality Commission. Registration standards in this new body will have more definite nutritional standards, which will come into force in 2010.

Over the next two years the focus of attention for development in health and social care will be on quality and outcomes. The Nutrition Action Plan will ensure that all the tools are in the box to facilitate improvements in nutritional care for patients and clients across the care community.

Northern Ireland
Get Your 10 a Day! – The Nursing Care Standards for Patient Food in Hospital has been developed as a collaboration between the DHSSPS Directorate of Nursing and Midwifery and the Royal College of Nursing (RCN) as a Northern Ireland response to the RCN’s national Nutrition Now campaign.
    
The Standards, based on the work of the Council of Europe Alliance have been developed for use across all in-patient facilities in the health and social care Trusts across Northern Ireland

The ten nursing care standards are as follows:

1. All patients admitted to hospital are screened for risk of malnutrition.
2. Following screening by nurses, patients who are identified as malnourished or at risk of malnutrition are referred for and receive a nutritional assessment appropriate to their level of need.
3. Patients who require nutritional intervention will have a nursing care plan devised, implemented, evaluated and renewed to reflect the patient’s nutritional and physical care needs. This documents both the dietetic plan and the nursing care assessment.
4. Patients who require food and/or fluid intake to be monitored will have that activity carried out in a way that is informative, accurate and up-to-date.
5. Patients who require support with eating and drinking are clearly identified.
6. Patients who require support with eating and drinking receive assistance when it is required.
7. Patients will be served their food and allowed to eat their meals without disruption.
8. Patients receive their meals in a physical environment that is conducive to enjoying their food.
9. Patients are offered a replacement meal if they miss their meal for whatever reason and can access snacks at ward level.
10. The patient receives food presented in a way that is appealing and appetising.

An implementation group is working with trusts to ensure screening of patients to identify patients needing nutrition support or help with feeding so this can be included in care plans.

Scotland
Health Facilities Scotland will be working with NHS boards to help support implementation of the National Catering and Nutrition Specification for Food and Fluid Provision in Hospitals in Scotland. The specification has been developed to support NHS boards in implementing the NHS QIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, specifically standards 3, 4 and 5 which aim to address the risks of malnutrition is hospitals and, secondly, to deliver a healthy balanced diet for patients.
    
‘Food in Hospitals’ has standards for nutrient and food provision for patients within hospitals. It provides guidance on how these standards can be met through assessment of the population’s dietary needs, menu planning, guidance and practical suggestions on food choices suitable for different dietary needs, including special and therapeutic diets.
    
All NHS Boards are required to audit compliance with the specification twice yearly. The first audit has already been undertaken and the first audit report will be available in June 2009.
    
The document ‘Supporting NHS Scotland staff through practice development and education’ was developed by NHS Quality Improvement Scotland (NHS QIS) and NHS Education for Scotland (NES) to support staff through both practice development and education to improve the nutritional care for the patients that they care for. A core nutrition pathway was developed in consultation with staff across NHS Scotland and incorporates the Malnutrition Universal Screening Tool (MUST). This pathway will clarify what patients should expect in terms of effective nutritional care and identifies six key stages.
    
A multi-agency group has been set up comprising key staff from four organisations: NHS QIS, NES, Health Facilities Scotland (HFS) and the Scottish Government who have a responsibility in delivering this agenda to support NHS boards and staff to improve nutritional care for their patients.
    
The Scottish Government has provided funding for each of the territorial boards to employ a Nutrition Champion. These Champions will support their NHS board in the delivery of food, fluid and nutritional care. A feature of this role will be the ability to influence a wide range of staff to implement and monitor the NHS Board’s nutritional care policy and to drive forward change within their own organisation. A national network of Nutrition Champions will be established and will be a strong link in the success of this important piece of work.

Wales
The Welsh Assembly Government published Healthcare Standards for Wales in 2005. This set out a common framework of healthcare standards that is fundamental to the Welsh quality agenda. Healthcare Standard 9 relates to food and nutrition, and an annual self-assessment process is carried out.
    
The Welsh Assembly Government has provided funding to the RCN Wales to deliver the All Wales Hospital Nutrition Campaign. Multidisciplinary workshops were held across Wales from September 2008 until January 2009 to raise awareness of the importance of a multidisciplinary approach to nutritional care. In addition, “train the trainer workshops” are being held across Wales so that health care staff can deliver further workshops within their organisation.

Dietitians
Across England, Scotland, Wales and Northern Ireland dietitians are working with nurses, caterers and other care staff to reduce the incidence of malnutrition in hospitals and social care. Food should be the first choice to reduce the incidence of malnutrition and dietitians, with their understanding of both the art and the science of food, play a pivotal role in this work. This can be ensuring menus meet nutrition needs, that the most appropriate food is available to patients and training other care staff so they understand the importance of food to all patients.

Eileen Steinbock is a dietitian and chair of the British Dietetic Association Food Counts specialist group.