Making headlines

I’m sure most readers will be familiar with the Healthcare Commission investigation into the appalling standards of care at Mid-Staffordshire NHS Foundation Trust. Publication of the report on 18 March was followed by a public outcry and the hospital and its users became the centre of a media storm. Behind the headlines were the stories of real patients and their families.
    
The Patients Association has been supporting Cure the NHS, the local campaign group, and we’ve had the chance to hear these stories first hand. One particularly worrying image unfortunately comes as no surprise to the Patients Association as we often hear other stories on the same subject and review worrying statistics from across the NHS.

A support network
One family was determined to keep a 24 hour watch at their relative’s bedside. They found many other patients on the ward lacked a support network of their own to help the overwhelmed nursing staff make sure their loved one was receiving basic care. As a result, at mealtimes, the younger members of the family helped other occupants of the ward, otherwise complete strangers, to eat their meals. The idea that as a patient you would have to rely on the kindness of other ward visitors to receive nutrition adequate to ensure your comfort and recovery is abhorrent. The scale on which this was happening at Mid-Staffordshire NHS Foundation Trust was almost certainly unusual, but we know patients suffer malnutrition during hospital stays up and down the country.
    
The NHS Information Centre published statistics in March showing that in 2007-08, 148,946 patients were admitted to hospital suffering from malnutrition but 157,175 were discharged with the same diagnosis. Not only is the total number of patients rising but these figures suggest patients are becoming malnourished whilst in hospital. This worrying news was further compounded by information on what hospitals spend on food; it turns out some spend as little as £1 a day. The newspapers were captivated by the fact this is actually less than is spent on food for prisoners.

A recurring problem
There is a long history of discouraging figures on malnutrition for the NHS. The Royal College of Physicians published a report in 2002 that found the prevalence of malnutrition amongst hospital inpatients was high, up to 40 per cent for those over 65 and recommended that nutritional screening be an integral part of clinical practice. In August 2006 a Royal College of Nursing poll found that nine out of ten nurses said they did not always have time to help patients who needed assistance with eating and drinking. A 2007 report from Age Concern warned that 60 per cent of older patients were at risk of becoming malnourished.
    
The above and numerous other publications have generated headlines such as “Shock rise in hospital deaths from malnutrition,” “Fatal toll of our failure to feed elderly patients, by NHS bosses” and “Malnutrition crisis in UK hospitals.” The most recent quantitative information comes from the Care Quality Commission inpatient survey 2008. 18 per cent of patients who needed it said they did not get enough help from staff to eat their meals which is the same figure as 2002. That is almost one in five hospital inpatients feeling they have not received what should surely be seen as a fundamental part of good hospital care-help with eating.

Nutrition action plan
As a result of this the Department of Health launched a “Nutrition Action Plan” in October 2007 that gave a number of clear recommendations to hospitals to improve the nourishment of patients. These included admission screening or malnutrition. Others have put forward further measures for improvement such as Age Concerns Seven steps to end hospital malnutrition. One of the steps is to introduce a ‘red tray’ system where those patients that need help to eat are served their food on coloured trays to highlight to staff that they will need assistance.
    
Programme managers are due to submit their evaluation of the project to the Department of Health this summer but, along with the results of the Care Quality Commission survey, the Health Service Journal asked its member their views on the strategy. The results were not encouraging. Over 400 health service workers completed the survey and nearly 25 per cent said the Department of Health’s nutrition action plan had improved care “not much” or “not at all”.
    
It is naive to accept the figures without criticism. Low spending on hospital food may well be because of improved contract negotiations from NHS managers and the increasing number of patients diagnosed with malnutrition might actually be explained by improved screening and diagnosis, not increased incidence. However, arguments like these are unlikely to explain everything and at the Patients Association we hear first hand stories that allow us to be sure that hospital mealtimes are still a problem. When so many outlets are telling you there is a problem over sustained period of time it is unwise to ignore the alarm bells.

Benefiting both parties
The business case for feeding patients is overwhelming. Well nourished patients will recover from illness quicker, respond better to treatment and be able to leave hospital sooner. In the drive to reduce inpatient length of stays this outcome is beneficial to both the NHS as a whole and the patient.
    
Providers and commissioners who embrace good nutrition for patients and show real leadership on the issue can expect improved patient experience and outcomes to be reflected quickly in patient surveys and quality indicators. This is because food or lack of it is a very real, very visceral experience for patients. They may not notice if their doctor failed to use the correct aseptic technique whilst inserting an intravenous drip and they will often be completely unaware if they waited far beyond the recommended time for a CT scan after a stroke. But they will be firmly dissatisfied if they haven’t had a good meal that day, if they had to struggle to eat it and if they spend their time in hospital hungry. And rightly so!
    
The Patients Association asks all in the field to reconsider whether they are addressing the issue with enough seriousness and critical appraisal. In reality, it is simply a matter of time and energy. For catering providers for example, why not offer ward level feedback on whether meals are being left uneaten – ten million last year according to figures published by the Conservative Party - and collect feedback from patients. This could help distinguish your services from competitors through the much vaunted patient experience focus that should be sought by NHS commissioners in the 21st century.

Be proactive
All hospital managers should review both the Department of Health Nutrition Action Plan and Age Concerns laudable Seven steps to end hospital malnutrition. It is absolutely vital that patients receive nutritional support throughout their hospital stay as an integral part of ensuring high quality safe care. Wander on to one of your wards at lunchtime and see if the red trays are being used. Speak to a few patients and ask them whether they’ve been able to eat as much as they needed. You might also consider introducing nutrition as a performance indicator, perhaps working on conjunction with a catering company taking up our earlier recommendation on collecting feedback.
    
The whole of the NHS must work together to solve this persistent problem and only when its millions of staff and contractors give it the highest priority and properly integrate good nutrition into the caring agenda will it be successfully overcome.