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Health: Malnutrition in Hospitals

asked Her Majesty’s Government what plans they have to prevent malnutrition in hospitals, as highlighted in the Age Concern report Hungry to be Heard. The noble Baroness said: My Lords, I thank the noble Baroness, Lady Amos, who is leaving the Chamber, for going on slightly longer than she needed, I gather, to give me time to get down from my office. I apologise. There has been considerable news coverage of Age Concern's Hungry to be Heard campaign, started in August last year. It showed just how serious the issue of nutrition for older people in hospitals is, with six out of 10 older people at risk of becoming malnourished or their situation getting worse in hospital, and patients over 80 admitted to hospital having a five times higher prevalence of malnutrition than those under 50, with all the accompanying horrors. Age Concern came up with a list of seven steps to end malnutrition, including some fairly obvious things, one might say, such as listening to older people, their relatives and carers; all ward staff becoming ““food aware””; hospital staff having to follow professional codes; assessing signs of malnutrition; introducing protected mealtimes; implementing a red-tray system to give staff warning that the patient has trouble eating; and using volunteers where appropriate. All those seem remarkably sensible, and I very much hope that the Minister will be able to tell us that many of them have come about, eight months on. I want to take a longer look. In all the concern that there has been over recent years about malnutrition, particularly among older people in hospital, little attention has been paid to the enjoyment of food and to what older people like to eat. Long-stay wards for older people, which are not necessarily the sorts of wards that we would like to see come back, nevertheless often used to provide food that older people particularly liked. Steamed puddings, for instance, which we also get in your Lordships’ House, were an old favourite, and a traditional roast dinner was another. As chairman of a big community health services NHS trust in central London in the mid-1990s, I was only too well aware of the likes and dislikes of many of the patients on the old long-stay ““care of the elderly”” wards. Steamed pudding was a great favourite and some of the older women, with bird-like frames, would lap it up in huge portions as though their lives depended on it. Of course, in a way, they did. Steamed pudding is easy to eat—soft, sweet, nourishing and very familiar. It takes relatively little agility with cutlery for frail older people to manage it and, washed down with plenty of custard made with full cream milk, it probably provided most of the calories they needed for a day. I certainly could not have managed the sorts of portions they were given as of course; nor would I have wanted them. But that is precisely the point. At that stage, on those wards we still had our own cooks preparing the food; wonderful men and women who would come in at 3 am on Christmas morning to get the turkeys into the ovens ready for a slap-up meal. They also knew, as they watched the carving or did it themselves, that cutting things up into small pieces was essential, even though what was being served was the favourite of all time—a roast dinner followed by a steamed pudding. In more recent years food in hospitals has been of varying quality, often pre-frozen and brought in ready to be thawed and cooked. There is neither the time nor the staff available to help older people to eat what has been provided. Anecdotes abound about older people in hospital being given a meal, it being left at the end of the bed and then cleared away later, with a cheery remark such as, ““Didn’t fancy it, then, darling? Don’t blame you—don’t fancy it much myself””, without the realisation that the older person may or may not have ““fancied”” it but actually could not reach it. Had they been able to reach it, they could not have fed themselves anyway, and no nurse or care assistant seemed to notice. It is as though what patients eat is of no interest in a modern healthcare setting. Paying attention to what older people eat has not been high on the agenda. In terms of what makes for successful ageing, old people rate diet and enjoying food very highly. They may well cook the foods they like for themselves when they are at home, but when they cannot do so, either due to frailty or because they are in hospital, questions need to be asked about how good it could be if real attention were paid to it. Since we know that older people rate food as a key part of successful ageing, it might be argued that hospitals and other institutions such as care homes have to catch up with the population’s different views on food these days. If people, including older people, want organic and vegetarian food, they should have it without argument in precisely the same way as no one would argue with a demand for kosher or halal food. The English Community Care Association, one of the representative bodies for care homes in England, held a high-level symposium in July 2006 focusing on just these issues. The chief executive of ECCA, Martin Green, went on record as saying: "““There are many elements to ensuring that a resident is well nourished, but there is no nutrition in a meal that a resident doesn’t eat””." All this comes in the wake of a report by CSCI entitled Highlight of the Day?, arguing for the likes and dislikes of care home residents to be explored and catered to, and for older people to be encouraged to participate in decisions about meals and their presentation. Given the extent to which older people describe meals and good food as an essential part of ageing well, it is extraordinary that this has been far from fully grasped by the hospital sector and the care home sector. The issue goes wider than simply being in hospital. The malnutrition advisory group, an expert group of doctors and other health experts, has warned that one in seven people over 65 in the UK is malnourished or at severe risk of malnutrition. Apparently, it is most pronounced in the north-west of the country, where one in five over 65 year-olds is undernourished. Despite a north-south divide in the case of general malnutrition, when it comes to nursing homes, where around one in four older people is likely to spend their last days, malnutrition rates are more generally one in five. Added to this, around 60 per cent of those over 65 admitted to hospital are found to be malnourished, and if anything it seems to be getting worse. Some people have said that the figures that have been adduced in all of this in the various reports—Age Concern’s and others—show special pleading on the part of the experts in the field. The counter-argument has come from Professor Marinos Elia and others in the group, who say that the statistics come from an analysis of data obtained from the national nutrition and diet survey conducted as long ago as 1998. More importantly, Professor Elia and others describe this as a public health problem costing the country anything between £2 billion and £4 billion pounds a year, mainly through increased or return hospital stays. I have read a huge number of stories about people being neglected and simply not fed. I do not have time in this short debate to go through them, but you can read in the Age Concern report and elsewhere stories of people who weigh something like 7 stone when they go into hospital, but in a three-month stay lose something like a stone, anything between 2 and 7 kilograms, which is really quite appalling. Food and feeding are generally rather neglected, and we have not taken on board just how serious that is. People who visit older people at home, people who work in care homes, home helps, district nurses and family members all ought to be aware of the risk of malnutrition. As we are increasingly obsessed with obesity, we have somehow lost sight of malnutrition as an issue, particularly for older people. If someone is not overweight, we somehow perceive that as a good thing. That they might be seriously underweight, or not eating adequately, often does not cross even the experts’ minds, let alone the rest of us. What can we do? Age Concern came up with a very good list of things that we could do. When I raised this in November, the then Minister, the noble Lord, Lord Warner, told me that, "““the better hospital food programme has improved the quality and availability of hospital food””," but he was not clear precisely how that had helped older people. He also said that it was down to people at local level to make the best use of experience gained from allowing staff to focus on helping patients to eat, through the protected meal-times initiative. He suggested that it was up to local decision-makers to, "““put ward housekeepers in place when they think it is appropriate””.—[Official Report, 6/11/06; col. 590.]" I accept that it is down to local decision-makers; as a former NHS trust chair, I would have been very irritated if it had not been, but we need to see some central passion behind guidance and speeches. If it was clear that this was something that shocked Ministers, doctors and nurses, we would see a rapid change. If Ministers were pressing for it, we would see all trusts sign up to Age Concern’s seven steps. If Ministers felt strongly, the Commission for Patient and Public Involvement in Health would not have found the results of its survey of food in hospitals so disappointing, with a third of people abandoning their food and 40 per cent having food brought in by visitors. Until we get away from nine out of 10 nurses saying that they do not have time to help people eat properly, it will be impossible to get real changes. Which? magazine found that only 18 per cent of people surveyed over the past 12 months were satisfied with the food quality, compared with 57 per cent in private hospitals. It cannot be a coincidence that the Commission for Patient and Public Involvement in Health food watch survey and the Which? survey show such different results from the Government’s own patient environment action team survey compiled by hospitals themselves, and it takes some explaining. The Healthcare Commission reported in October that 96 per cent of hospitals were meeting core standards on hospital food, but that same commission is also adding a focus on food and help with eating in its dignity assessment programme carried out early this year, which suggests that it, too, was not wholly satisfied, especially as all this affects vulnerable people. No one thinks that this should be a national programme, but the setting and monitoring of standards is something on which Ministers, doctors, nurses’ leaders and others could and should set a lead. There was an emergency meeting on malnutrition in hospitals last week, on 14 March, and it would be good to hear what came out of it. I know that encouraging an ““army of volunteers”” to help feed patients is one key idea that was discussed. As chair of the Commission on the Future of Volunteering in England, I would be very interested to know how the Government would propose planning the recruitment of such a large army, its training, supervision and retention and how they would recognise the contribution that such an army of volunteers would be making to the NHS in particular and to our public services more generally. I very much hope that the Minister will be able to give me some comfort as a result of this short debate.