Still Hungry to be Heard

Can we end Malnutrition in London’s hospitals?

A day of Ideas and Action

A joint event organised by Age UK, Age UKLondonand the Greater London Forum for Older People (GLF)

Tuesday, 8th November 2011

Woburn House, 20 Tavistock Square, LondonWC1H 9HQ

Conference report

Morning session

The Chair for the morning session, Tony Tuck, chair of Wandsworth Older People’s Forum,welcomed everyone to the conference, telling them they were “in for a treat”. He introduced Samantha Mauger, Chief Executive Age UK London.

Welcome – Sam Mauger, Age UKLondon

Sam welcomed everyone to the joint conference. She said:“We’ve worked together very successfully in the past to bring people together on important issues. A lot of us will remember back in 2006 when Age UK’s campaign Hungry to Be Heard was first launched. The campaign highlighted issues of malnutrition in hospital. It’s a shame that we still have to think about this issue –something that’s so simple and straightforward – having enough to eat in hospital and dignity issues around that.”

Sam talked about Age UK London’s regional report, which was published earlier this year, looking at London hospitals and how they had implemented Age UK’s sevenrecommended steps. She said that 25 out of 29 Londonhospital Trustshad responded to the report and Age UK London found from the responses that there was a massive variation in how the steps had been implemented. Sam also commented on the Care Quality Commission’s (CQC) reports released in March-July this year, which found that a whole range of issues around malnutrition were still there and still very important. Sam said:“It’s a terrible thing that there are a significant number of older people who still aren’t being given the support they need in hospital.”

She said: “We want today to be a day of ideas and action. We have some really good speakers with a range of knowledge. After we’ve heard from them, we’ll have the opportunity to discuss how we can work together locally and make a difference. We all know how important food is in our daily lives and we know that many people going into hospital are already malnourished. We need to make sure that people in hospital are given all the support they need to get the nutrition they need. In hospitals the amount spent on food is far less than the amount spent on drugs. So we all have a lot to do.”

Setting the Scene.Why are we still Hungry to be Heard? – Mary Milne, Age UK

Mary introduced herself and thanked the conference organisers for inviting her. She gave examples ofsome of the stories about malnutrition Age UK had received in the last few months.

Mary asked a very important question:“Why at the start of the 21st century in a relatively affluent nation in global terms, are people starving in our hospitals? It simply shouldn’t be happening.”She explained that since the launch of Hungry to Be Heard, many hospitals and wards have started to change their practices and introduce some of Age UK’s seven steps, but the reality is poor practice still exists. She said:“There’s still a lack of consistency and a long way to go to ensure people receive the food they need and the help they need to eat it.”

Mary explained that as part of Still Hungry to be Heard, Age UK called the CQC to undertake a special review of hospital mealtimes. 100 hospitals around the country were selected – many of which had been asked to make changes to their practice following previous inspections, as well as some hospitals chosen at random. Mary explained that one of the key things about the CQC inspections was that they looked at actual practice on the wards; they didn’t just go with what managers said. Practising nurses and Experts by Experience were part of the inspection teams, looking at nutrition and dignity by observing two wards over the course of one day.

83 out of the 100 hospitals were found to be compliant with the CQC’s essential standards of quality and safety – but for 32 of those 83, the CQC suggested improvements could be made.Mary said: “The message that can be taken from these inspections is that clearly some hospitals are getting things right – perhaps not all the time but there is clearly good practice. Others, however, are not.”

Mary outlined the various problems around malnutrition found in the CQC reports. These were: patients weren’t given the help they needed to eat; they were interrupted during their meals and had to leave their food unfinished; the needs of patients weren’t always assessed properly; and records of food and drink weren’t kept accurately.

Mary asked why hospitals were failing. She cited Dame Jo Williams, Chair of the CQC’s reasons, which were staff attitudes, resources and a lack of priority given to nutrition.

Mary focused on the lack of priority given to nutrition. She said that one reason for this was because there was“no push from senior managers.” Nurses were asked why they didn’t sit down with patients to help them, but they were worried that if they did this, their managers would see them as “slacking off”.

Age UKhas gathered small amounts of data on people being weighed in hospitals. Only 30 per centof people are being weighed in hospital, when actually every patient should be getting weighed, but it’s simply not a priority for hospitals. Age UK is making a call for hospitals to publish their malnutrition data.Mary said: “The CQC spot-checked 100 hospitals this year and they’re going to spot-check another 50 next year, but that’s a drop in the ocean compared with how many hospitals there are in the UK.”

Mary explained that Age UK is starting to get its message across to the Government, but it needs to keep up the pressure. On Monday 10th October, it handed over 2000 campaign cards to the Department of Health. Mary explained that there would be more campaign cards and template letters that people could send as individuals and groups respectively. She finished her talk by saying: “As a population we’re all getting older – the number of older people in this country is growing. This is an issue we need to tackle now, as it’s only going to get more and more difficult.”

Questions

Six questions from the audience were put to the keynote speakers.

Q1.It’s interesting to hear about the number of people who’ve suffered or died from malnutrition in hospital. Are there any figures available? I’ve also heard that members of ethnic communities are being particularly ignored.

Q2. I nursed in hospitals in the 1940s, when the sister came into the ward and dished out the food for everyone and was there for the feeding. Apart from technical treatment,the two most important things to help people recover are food and sleep. Don’t you think that the ward sister plays a vital role in helping other people?

(Mary Milne) Figures on malnutrition are very hard to come by and to get authoritative figures is even more difficult. The figures we had in our report were obtained by asking a Parliamentary question – and I’m trying to find out the methodology behind those figures. There are particular issues with people from ethnic groups with special diets. Debbie will pick up on that later. It isn’t straightforward, but someone who’s vegetarian must be given a vegetarian meal and most importantly, if there is a problem with this, why? And why isn’t it rectified? It’s about prioritising nutrition and taking responsibility for ensuring that good nutrition happens.

Q3. What training do nurses get and at what stage in that training are they taught about diet and malnutrition?

(Debbie Dzik-Jurasz) In terms of undergraduate nurse training, there is a module on nutrition that was introduced two years ago. Prior to that it wasn’t included and we spent a long time lobbying to get that in. We’re beginning to get far more of a priority on that – which has been demonstrated by the undergraduate registration process but also by Chief Nursing Officers. The other area that we need to focus on in terms of education is healthcare assistants – you’ll meet many of them in hospitals. They’re not regulated and therefore employers are responsible for outlining what competencies they need to have and what the bigger work is that they need to do. We need a nationally agreed competency framework including the underpinning healthcare education.

Q4. It seems to me that people think the answer to this problem is to throw money at the NHS and all that seems to provide is administrative staff. There aren’t a sufficient number of nurses. Don’t you think we need more people on the ground to oversee nutrition?

(Mary Milne) In terms of money being thrown at the NHS and where that’s directed, I think you can have poor practice with plenty of resources, but if you don’t have enough resources, it’s a sure path to not get things right. We know that money is tight so it needs to be prioritised – resources follow priorities. We need to highlight this.

(Ian Robinson) There is no correlation between quality and expenditure. We shouldn’t hide behind the money.

Q5. Do you think it would be a good idea to have CRB-checked volunteers with basic training to go into hospitals and help people eat?

(Mary Milne)Absolutely, we have to use volunteers. Age UK has helped set up volunteer schemes around the country, but it’s not always easy, as some hospitals frankly have been quite resistant to volunteers, but where you can have volunteers, it can be an incredibly valuable thing.

Q6. No one seems to discuss dentists. Could they be a contributing factor to malnutrition?

(Debbie Dzik-Jurasz) Absolutely, dentistsare key. It’s part of the need for hospitals to treat the whole person – hospitals were set up to divide into specialties but actually hospitals need to see people and all of their problems. Hospitals need to get better at joining up and seeing the whole person. That’s probably the biggest challenge facing the NHS at the moment.

Improving Nutritional Care - Debbie Dzik-Jurasz,Assistant Director of Nursing, WhippsCrossUniversityHospital

Debbie introduced herself and thanked everyone for involving her in the discussion. She explained that Whipps Cross was a very busy hospital and showed the statistics to prove it. She added that they had a very diverse population in Walthamstow/Leytonstone, so it was difficult tomanage everyone’s nutritional needs. This presented a particular challenge when it came tocooking hospital food in bulk.

Debbie said: “We want people to come in, use our services and feel that they’re well cared for and go home.” However, she explained that up to 40 per cent of all patients admitted to hospital are undernourished and if you lose 5 per cent of your bodyweight in three months, your body won’t respond to treatment and you’ll end up spending longer in hospital. So it’s very important to assess everyone’s nutritional status on arrival.

Debbie said: “We’re trying to get the message across at our hospital that nutrition is a priority and if we don’t get this right, we haven’t got a hope of getting anything else right.” She admitted that the hospital faced a lot of challenges, such as the limited choice of food available,catering for cultural diets and special diets, and the fact that people who need help eating and drinking don’t always get it. She made the point that everyone has different needs when they’re feeling ill; she prefers to eat toast and marmite, but other people have other preferences!

Debbie outlined the steps her hospital was taking to combat malnutrition, including identifying people who are at risk of malnutrition, implementing the ‘red tray’ system and ensuring that people do not become dehydrated. She emphasized the need for everyone to worktogether to prevent malnutrition from all levels of an. She said that at her hospitalthey were required to have an executive lead on nutrition –the Director of Nursing. They also have patient representation in a nutrition action group, which meets monthly.

To conclude, she said: “All of us have such a role to play in improving nutrition and hydration. Our behaviours will make a difference for the future.”

Meeting Nutritional Needs - Ian Robinson, General Manager, Hotel Services, Salisbury NHS Foundation Trust

Ian thanked everyone for inviting him to speak. He explained that protected mealtimes came in in 1859, when Florence Nightingale said: “Nothing shall be done in the ward while the patients are having their meal.” Ianthen summarised the main criteria of the CQC’s Outcome 5: needs, reasonable requirements and support. He stated the need to see food “as an integral part of healthcare, not as a support service.” He explained that hospital food is often seen as an ad-on ora non-core service, but there was a need to challenge that. He cited Dr John Edwards, the Head of the Sustainable Development Research Group at BournemouthUniversity, who said: “We can never improve the perceived quality of institutional food until we address people’s expectations of it.”

Ian gave an overview of a paper he worked on for the NHS in 2005, on managing food waste. He emphasized the need to promote innovation and creativity in hospital food by recognising and championing best practice, promoting effective collaborative working, introducing ‘flexi menus’, small appetite meals, gold trays, green trays and gold tops. He also encouraged the access to and scope of the food service in hospitals, endorsing mealtime assistants, the texture modification of food and service development.

Also important, Ian added, were the management processes that supported food and nutrition. These included establishing food and nutrition high on Trust board agendas, promoting clinical leadership and motivating and supporting caterers, for example. He also underlined the necessity to support and promote ‘champions for change’ and engaging with stakeholders through PPI involvement.

Ian’s key arguments were that we needed to empower patients; develop the capacity to deliver expectations; develop teams and effective collaborative working; ensure assistance at mealtimes; make improvements in the ‘whole meal experience’; challenge attitudes and perceptions and change the culture around food and mealtimes; develop guidance and policy and champion best practice.

Questions

Three questions from the audience were put to the keynote speakers.

Q1.You mentioned the importance of clinical leadership. Do the speakers think that hospital consultants might start to think of food as an integral part of treatment or care? Food could be prescribed like medication. Also is there a way of getting around NHS rules, like not being able to get water for patients?

Q2.I spent five months in hospital in 2010 and came out borderline anaemic and vitamin deficient. How can you change mealtimes and that way of working in order to implement the changes that we’re talking about?

Q3.What attention is being paid to the emotional regression that people who are sick make while in hospital?

(Ian Robinson) We love rules in the NHS – like the red tray system – which can be a danger, but you have to look at the greater good. The same goes for the access to the kitchen to get water, I mean obviously there is a need to manage the kitchen environment, but the risk of a patient not drinking is actually much greater than the risk of disrupting the kitchen. At the end of the day, it’s about the greater good. Rules are there to be broken. With regards to consultant engagement, at our hospital we have a consultant who’s a nutritional champion among the consultant body.

(Debbie Dzik-Jurasz) Really to build on Ian’s points, one of the key things we need to do is to change the hearts and minds of staff – around where food and hydration becomes a real priority. Historically, the giving out of meals at hospitals hasn’t fallen into the standard duties of nurses. What all this work is doing is helping us to take back the control that the nursing team have and that the clinical leadership didn’t use to have. In our hospital, a registered nurse is required to lead the meal service.In the 1940s and 1980s the complexity of the care was much simpler than it is now. People are generally much sicker in hospital now than they were 30 or 70 years ago. We have to continue with good role models and champions at all level to take back control. Medics often get a really bad time – as the people that stop mealtimes from happening – and this is an ongoing challenge for everyone. Guidance says you must stop doctors from interrupting but the reality is this isn’t always possible.

Table discussion 1

The first table discussion began just before lunch. Delegates had already been seated around 12 tables, with each table representingtheir local area, covered by one or two local hospitals. The primary purpose of the discussion was to look at the CQC report(s) for the hospitals in the delegates’ local area and to consider the findings.Not all London hospitals had received a nutrition inspection by the CQC, in which case delegates looked at a report for the nearest to them. The secondary purpose of the discussion was to give people around each table the chance to air their experience and knowledge of mealtime services and patient experience at their local hospital.