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Health: Malnutrition in Hospitals

My Lords, this has been an excellent, although rather short, debate. I am very grateful to the noble Baroness, Lady Neuberger, for enabling this discussion to take place. It is an extremely important issue. I very much regret that it has not provoked the interest I believe it deserves. However, this evening we have quality here. The challenges of providing good nutritional care are huge. For that reason, last Friday, my honourable friend, the health Minister Ivan Lewis, announced a new national plan for older people and nutrition. He is passionate about the issue. The announcement followed a nutrition summit held on 14 March, which was attended by leading charities, clinicians, nutrition experts and care home representatives. That was not an emergency meeting. It was set up as part of the dignity and care campaign because feedback from the various listening events that have taken place showed that attention to food is so important to patients. The issues that were under discussion at the meeting included raising awareness, setting nutritional standards, streamlining guidance, training for staff and managers—the noble Baroness, Lady Greengross stressed the importance of that—and a clearer focus in inspections. Water UK was one of the organisations involved in the summit. I can assure the noble Baronesses, Lady Greengross and Lady Knight, that the important issue of hydration will be properly considered and dealt with. The action plan will be further developed in close consultation with frontline workers, including Age Concern and other organisations that attended the summit. We can expect the plan in the not too distant future. A great deal has already been achieved. For far too long food was not treated with the priority that it deserves and for too long food and feeding were neglected. In 2000, the NHS Plan accepted that, despite the sterling efforts of dedicated catering staff, food had somehow slipped off the agenda for too many NHS staff. More importantly, the plan acknowledged that food really matters to patients, not just as a source of fuel, but as a way of making their hospital stay more pleasant. It made it clear that improvements in food and nutritional care were needed. The noble Baroness, Lady Neuberger, is absolutely right to talk of the importance of enjoying food. We want to include roast dinners, steam puddings as well as the many other varied menus that are available. Of course, there is still a place for traditional dishes. Catering managers and dieticians are best placed to understand what their local populations need. They must talk to patients themselves to see what they want. We have to ensure that patients, such as the Indian lady cited by the noble Baroness, Lady Verma, are aware that different dishes are available—vegetarian, kosher or whatever—and that their relatives can bring food into hospital. Soon after the NHS Plan was published, we evaluated the quality of hospital food, via Patient Environment Action Team Assessments—PEAT assessments. We have continued to assess food quality ever since. Every year, things have got better—from 17 per cent ““good”” in 2002 to over 34 per cent ““excellent”” last year. The Age Concern report acknowledges that, speaking of food that would grace any restaurant. Of course, we have to ensure that the food provided is the sort of food that people want to eat. If one is feeling poorly or ill, one has a very special palate. The noble Baroness, Lady Verma, spoke of the Better Hospital Food programme. Its remit was not to provide fancy menus, but to do much more. It accomplished some very specific things; for example, more food is now available round the clock. We have introduced 24-hour services, snack boxes and daily snacks. For the last year in which statistics were collected, 2004, 89 per cent of hospitals had introduced ward kitchen services to provide light snacks, 80 per cent were providing snack boxes and 84 per cent were providing extra snacks during the day. In most cases, patients can now choose a hot meal in the evening, whereas before, many only had soup and a sandwich; 94 per cent of hospitals reported that they provided that service. Many hospitals have also improved the visual appearance of their menus, providing more information and a professional appearance. Another key plank of the Better Hospital Food programme was the introduction of protected mealtimes. In partnership with the Royal College of Nursing, we introduced the concept of an oasis of calm at mealtimes; a period when all unnecessary activity on the ward stops, and everyone—staff and patients alike—can concentrate on the meal. Once patients have the time to relish their food, and staff have the time to help them to eat, food intake increases and so does enjoyment. Good food is important, but it is not enough. The best food is of no value if it is not eaten and for many older people, it will not be eaten if the requisite assistance is not there. That is at the very heart of the Age Concern report. Stories of food left out of reach, or taken away uneaten are shocking. Such care is unacceptable. When it happens, we must roundly condemn it. But it is not the norm. Most patients receive the help they need to eat. The Healthcare Commission in-patient survey found that 83 per cent of patients sometimes or always got the help they needed to eat. This is not good enough and there must be improvements, but the situation is not as disastrous as some would have us believe. I warmly welcome the Age Concern report as a generally thoughtful and considered piece of work. In particular, I value the way in which it has identified its seven essential steps to improved nutritional care. We accept much of what it recommends, but already we are taking steps to make things better—for example, Ivan Lewis’s Dignity in Care campaign. Nutrition and support when eating were among the top 10 concerns that people raised when describing their experiences of being treated with dignity. We have also focused attention on how nurses can improve the care of older people. There are now 85,000 more nurses in the NHS than in 1997 and67 per cent more nurses entered training between 1997 and 2004. More nurses means more nursing care, and it should also mean more time for patients. The challenges identified by Age Concern are not unique to this country, hence the resolution from the Council of Europe on food in hospitals. We are actively supporting the Council of Europe Alliance, a group of interested bodies including the Hospital Caterers Association, the British Dietetic Association, the Royal College of Nursing and the British Medical Association, who have taken the recommendations of the Council of Europe’s resolution on food in hospitals and translated it into straightforward, practical actions. Its 10 key characteristics of good nutritional care on the ward directly support much of the Age Concern report. Step one of Age Concern’s seven steps is about listening to older people. We are listening to older people. We have introduced the modern matron with the authority to take action to improve care. Nurse leaders in hospitals all over the country are taking the lead for care, listening to patients and their families and working with nurses and their teams to deliver better care. We have also increased the time students spend learning in practice settings so that they gain the necessary practical skills they need to be equipped to provide personal care for patients. Step two is that all staff should be more food aware. We certainly accept the need for all ward staff to become food aware. Food is an essential part of treatment, and everyone needs to recognise it. Florence Nightingale spoke of the, "““thousands of patients [who] are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food””." We must not fall into the trap of seeing food as an add-on, a luxury, a nice-to-have. Food is a must-have, and we will continue to spread that message. Step three relates to professional codes and guidance. The Age Concern report rightly charges hospital staff with responsibility for following their own professional codes and guidance. This, of course, is where the work of the Council of Europe Alliance could be so productive. Each organisation within the Alliance is jointly committed to the 10 actions, but each will work with its own members in the way that is right for them. The Government wholeheartedly endorse the need for good practice, but delivery of that practice lies in the hands of NHS staff. Step four concerns screening on admission. As the noble Baroness, Lady Greengross, rightly informed us, up to 40 per cent of hospital patients are at risk of malnourishment on admission. Studies suggest that it is even worse for admission to the social care sector. This is a problem for the community as a whole, not just for care homes and hospitals. I am therefore pleased to endorse Age Concern’s recommendation that older people should all be screened on admission. Indeed, we emphasise the importance of screening within the Better Hospital Food programme and further work on this is still going on within the National Patient Safety Agency. Again, Age Concern itself is actively involved in this work. Steps five and six cover the introduction of protected mealtimes and a red tray system. The National Patient Safety Agency is taking forward the work on protected mealtimes. We fully support allthe actions being taken in this area. Along with the red tray system, it offers a proactive solution to a long-standing problem. I now turn to Age Concern’s final recommendation—the use of trained volunteers to support patients at mealtimes. We have long recognised the enormous value that volunteers make to patients’ experience of the NHS. We have supported the sector in developing its potential contribution through the Opportunities for Volunteering scheme, and by providing funding through the Section 64 scheme. I know that some trusts are already using volunteers to support patients at mealtimes, and I am sure they will continue to do so. In response to the noble Baroness, Lady Neuberger, this is not something that we will act on centrally, but we are going to encourage all trusts to make better use of volunteers. The noble Baroness, Lady Knight, raised some important issues in her contribution. I must respond to the point made about nil-by-mouth orders. The most common reason for a nil-by-mouth order would be for patients awaiting surgery, as it is important that a person has an empty stomach before an anaesthetic. Another common reason in older people would be if somebody has had a stroke and lost the ability to swallow. In this circumstance it is important that a dietician speech and language therapist is involved so that the patient gets the appropriate treatment. I know that the noble Baroness and the noble Lords, Lord Carlile and Lord Patten, have met the noble Lord, Lord Hunt, and Professor Ian Philp, the national director for older people’s services and neurological conditions, to discuss concerns about the deliberate withholding of food and drink and that the noble Lord, Lord Hunt, has agreed to make a Statement on the Government’s position. I do not wish to pre-empt that Statement. I endorse much of what the Age Concern report said. Its recommendations are sound and sensible, and with partners in the NHS, we have actions in place to maintain improvement. However, I do not accept the suggestion that nutritional care is currently in disarray. Much has already been achieved, but there is much more to do. As my honourable friend Ivan Lewis said last week, "““there is no excuse for vulnerable, older people not receiving the food they require and the necessary help to eat that food””." We have already done a huge amount to improve the quality of food in hospitals, but there are challenges in relation to the support of frail, elderly people who need encouragement to eat. We recognise that, and, as I hope I have demonstrated, we are not complacent and that, rather, we are taking action. Finally, I pay tribute to the many NHS staff who have worked so hard to bring nutritional care up the agenda and who continue to make it their priority.