Inadequate nutrition of the elderly in care homes has been an issue for decades. In the first part of our in-depth look at healthcare, we ask if the long-awaited implementation report on the 2007 Nutrition Action Plan could finally usher in change? Janie Stamford reports.
"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health."
Two and a half millennia after Hippocrates first came up with this solid piece of common sense - a favorite quote of Rick Wilson, director of dietetics and nutrition at King's College Hospital - providing adequate nutrition for the rising number of elderly people in the nation's care homes remains a chronic problem. Malnutrition affects more than 10% of older people in the UK, and costs an estimated £7.3b each year.
Elaine Cass, practice development manager at the Social Care Institute for Excellence (SCIE), is exasperated by these statistics. "It's not rocket science," she points out. "Food is a basic human need. Ill people need appetising food and the consequences of malnourished older people are severe."
Wilson agrees. "We want to tackle malnutrition as early on as possible because it keeps people independent and it's good for the taxpayer," he says. "As independence is lost, care becomes more expensive. Malnutrition is not inevitable - it can be dealt with."
But the question remains: if the solution is simple and the benefits are huge, both to the individual's health and the NHS purse, why is malnutrition in care homes still such an issue?
NUTRITION ACTION PLAN
The Nutrition Action Plan, published in October 2007, has moved a little way towards a resolution of some of the key issues. The plan delivery board, chaired by Age Concern director general Gordon Lishman, sent the implementation report for the plan to Health Minister Phil Hope on 21 May this year, and the industry is now waiting impatiently for this document to be published.
NUTRITION AND HEALTH
So what does the plan suggest? The first aim is to raise awareness of the link between good nutrition and good health. This is vital, says Cass, who feels that as a nation the UK is still poorly educated when it comes to food, nutrition and care. "We have failed as a society to address the underlying issues: the discriminatory attitudes towards people using social care services, and worrying trends in terms of general ignorance about food, nutrition and resources - affecting training, staffing levels and food procurement."
To address this, the plan delivery board has developed a broad communications strategy, aimed at health and social care professionals as well as the general public. Articles have been published across a number of healthcare publications, and the Royal College of Nursing has delivered more than 40 workshops as part of its Nutrition Now Campaign.
The SCIE was called in to help with the second priority - ensuring there is guidance for the social care sector that is simple and user-friendly. "Our role is to translate academic information so that it is easily understood by social care practitioners," explains Cass. This has been made available on the website within the existing Dignity in Care Practice Guide and includes a resources section with links to a wide range of information, training resources and tools to support good nutritional care.
The third point of the plan is to "strongly encourage" nutritional screening for users of health and social care services. The idea is simple enough - by identifying the most vulnerable individuals, such as the elderly, malnutrition can be nipped in the bud before it develops. Staff in care homes and hospitals will, ideally, be trained and encouraged to screen residents and patients, using body mass index to identify those at risk and provide appropriate treatment.
"If the cause of malnutrition is recognised, then it can be dealt with accordingly," explains Cass. "Early identification is key, but just as important is getting the right, personalised help," she adds. "Older people face discrimination as far as food is concerned. There is an assumption that they lose their appetite or just can't be bothered to eat, whereas often there is an underlying cause of malnutrition that can be dealt with."
The plan also encourages the provision and access to relevant training for frontline staff and managers on the importance of nutrition for good health and nutritional care. A new two-level NVQ qualification aimed squarely at the care industry is to be launched in December. In addition to producing meals for large cultural groups, students will learn skills to meet specific needs, such as catering for those with allergies.
The encouragement of screening and training may be laudable, but commentators question the viability of this ambition given that salaries in the care home sector remain extremely low. Public sector funding is tight across all areas and competition with other catering jobs means there is a shortage of suitably qualified workers within care catering.
"Many providers have identified this and go a long way towards addressing this issue," says John Hilton, principal catering and contracts manager at Bristol City Council. "But unfortunately a lot of local authorities and third-sector care providers are unable to match the levels of pay on offer in other sectors of the industry."
LACK OF LEGISLATION
Hilton is particularly animated about the fifth and final point of the plan - to clarify standards and strengthen inspection and regulation in the care home sector. "Like many providers we have many regulations and service criteria set by recognised organisations such as Ofsted," he explains. "However, when you have many organisations out there advising you what you should be doing, it can be overwhelming, confusing and, at times, seems disjointed."
He believes a lack of legislation is responsible for inconsistencies in care catering across the country. "There are no specific criteria like there are in children's services, although the use of documentation produced by the National Association of Care Catering (NACC) has helped to standardise many providers' services."
But Caroline Bunning, food and nutrition officer at Nottinghamshire County Council, is unconvinced a prescriptive approach would be successful in care catering for adults. "It wouldn't work," she says adamantly. "You can offer a full range of balanced meals, but you can't force an adult to eat it."
CHAMPIONING THE CAUSE
There is no doubting the passion of those involved in the care home sector. But will the implementation report for Nutrition Action Plan really be enough to remedy this perennial problem? Who has ultimate responsibility for delivering its aims? Care homes themselves? The Government? Society as a whole?
Commentators strongly believe the issue of care home catering needs a champion if real progress is to be made. "We need someone to do for the care home sector what Jamie Oliver did for school dinners," says Hilton, echoing the words of Liberal Democrat MP Paul Burstow, who called for the same back in 2006.
There has been some response - Michael Parkinson was last year named as the government's "dignity ambassador", with a mission to raise awareness of the importance of compassion in care services. But his remit is broader than nutrition, and the veteran broadcaster lacks Oliver's astonishing media allure.
Until this issue is dragged into the headlines, the UK's most vulnerable people will continue to face the risk of a malnourished old age.
By identifying the most vulnerable individuals, such as the elderly, malnutrition can be nipped in the bud before it develops
KEY AIMS OF THE NUTRITION ACTION PLAN
- To raise awareness of the link between nutrition and good health and to make it clear that malnutrition can be treated
- To ensure that accessible guidance is available across all sectors and that the most relevant guidance is appropriate and user-friendly
- To strongly encourage nutritional screening for all people using health and social care services, with particular attention to those groups known to be vulnerable
- To encourage provision and access to relevant training for frontline staff and managers on the importance of nutrition for good health and nutritional care
- To clarify standards and strengthen inspection and regulation
A HISTORY OF HUNGER
Rick Wilson on why malnutrition has remained such a chronic problem.
"There was a golden age of nutritional care and development in the 1920s and 1930s when we discovered the chemical nature and function of many food components - vitamins, proteins, carbohydrates, minerals and so on.
"School meals and school milk came in, and we were well equipped to devise the ration for the Second World War. In 1947, penicillin came into widespread use and suddenly we were in a new technological age of pharmaceuticals. We were all sick to death of being told what to eat by the Government and the rationing system and nutritional care was thrown out. Instead, the message was ‘no matter what you eat or do not eat, we can fix you with a pill for every ill'.
"Only recently, in the late 1970s, have we begun to unravel the link between poor nutrition and the diseases of the modern age. The medical and caring professions have yet to catch up with this."
Staff in care homes and hospitals will be trained and encouraged to screen residents and patients
KEY NACE CONFERENCE MESSAGES
Rick Wilson, Elaine Cass and Gordon Lishman are keynote speakers at the National Association of Care Catering Conference and Exhibition 2009, to be held on 9-11 September at the Hilton Blackpool
Cass's key messages will be:
- Malnutrition affects more than 10% of older people
- Malnutrition is estimated to cost the UK over £7.3b a year
- Malnourished patients stay in hospital for much longer, are three times as likely to develop complications during surgery and have a higher mortality rate
- It is estimated that up to 90,000 people who receive home care services could be at risk of malnutrition
- Simple routine screening and follow-up actions can prevent malnutrition and improve health and quality of life
- Food and mealtimes are a high priority for older people and affect their quality of life
- Giving older people the time, help and encouragement they need to eat can help tackle malnutrition
- Older people's preferences, plus dietary and cultural requirements, need to be taken into account when planning meals
View the other two articles in our healthcare focus: