Select Committee on Health Written Evidence


Memorandum by the Infant and Dietetic Foods Association (PS 05)

PATIENT SAFETY

EXECUTIVE SUMMARY

  1.  Undernutrition is a major health and economic concern costing the UK £7.3 billion a year—of which around £3.8 billion arises in hospitals[61]. Those with the condition suffer many healthcare complications; the effects of undernutrition include prolonged hospital stays, delayed recovery, and poor respiratory function.[62]

  2.  In some studies, undernourished patients have a mortality rate up to eight times higher than that of well-nourished patients.[63] Effective management of nutrition in both primary and secondary care should be regarded as a patient safety issue.

  3.  Undernutrition has historically been under-recognised, although there has been an increased focus on the condition in recent years. In particular, the Department of Health's recent Nutrition Action Plan—which draws on lessons learnt from earlier work undertaken by the National Patient Safety Agency—should help to tackle the burden of undernutrition in institutional settings, when implemented.

  4.  However, since 2000-01, the number of patients being admitted to hospital in an undernourished state has increased by 67%.[64] This indicates an urgent need to tackle nutrition. The Infant and Dietetic Foods Association (IDFA) advocates: embedding nutrition in the registration requirements of the new Care Quality Commission; improved inspection regimes; use of sanctions against non-compliant providers; increased training and support for healthcare professionals in identifying and managing nutritional needs.

SUBMISSION OF EVIDENCE

  5.  The Infant and Dietetic Foods Association (IDFA) is the trade association representing UK manufacturers of specialist nutrition products (infant, clinical, sports and slimming foods)—a category of foods specially formulated for adults and infants with particular nutritional requirements, such as those used in enteral nutrition (nutritional feeds taken by mouth or tube directly into the gastrointestinal tract). Specialist nutrition products are highly regulated by European Union and UK legislation.

  6.  The IDFA welcomes the Committee's Inquiry into Patient Safety. The findings and conclusions of the Committee will assist the Department of Health, the NHS, the NPSA, Care Quality Commission, and other Government departments and agencies in delivering improved patient safety.

  7.  The IDFA believes that undernutrition has a critical bearing on patient safety, and would like to bring evidence in support of this to the Committee's attention.

  8.  Undernutrition is estimated to cost the UK £7.3 billion every year, with over half the cost expended on people over the age of 65.[65] Up to 14% of people aged over 65 are undernourished, while patients admitted to hospital over the age of 80 have a prevalence of undernutrition five times higher than those under the age of 50.[66]

  9.  Evidence suggests that undernourished patients are three times as likely to develop complications during surgery,[67] and have a mortality rate up to eight times higher than well-nourished patients.[68] Undernutrition has been connected to deprivation, with a 2006 study suggesting that undernutrition may be a factor in explaining why people admitted to hospital from deprived areas are more likely to die in hospital.

  10.  The importance of improved nutrition in tackling ill-health has been recognised by the Department of Health in several key policy documents[69],[70] Despite this, the burden of undernutrition appears to be increasing. Data drawn from the Hospital Episodes Statistics database show that, in 2000-01, 77,988 patients were admitted to hospital with a diagnosis of a nutritional deficiency, but by 2006-07 this number had increased to 130,594 (an increase of 67%).[71]

  11.  These figures are likely to significantly under-report the scale of undernutrition: a study conducted in September 2007 by the British Association for Parenteral and Enteral Nutrition (BAPEN) (and backed by the Department of Health[72]) suggests that one in four adults admitted to hospital are at risk of undernutrition.[73] In 2006-07, this equated to 3.2 million patients.[74]

  12.  In addition, recent media reports have noted that the number of patients leaving hospital undernourished has increased by as much as 85% since 1997.[75] Department of Health figures provided to Parliament showed that last year 130,594 patients were admitted to hospital with a diagnosis of undernutrition, but that 139,127 patients were discharged from hospital with a diagnosis of undernutrition, suggesting that the nutritional status of 8,500 patients worsened while they are in hospital. This is a matter for serious concern.

  13.  In October 2007, the Department of Health published Improving Nutritional Care—a nutrition action plan designed to address nutritional care in hospitals, care homes and the community.[76] We welcome the plan and press for its speedy implementation, supported by the Department of Health and its agencies, with ongoing monitoring from the Nutrition Action Plan Delivery Board.

  14.  We also welcome the establishment of the Care Quality Commission. We believe that nutrition should be a core registration requirement, and therefore support the registration requirement Making sure people get the nourishment they need. We hope that this will help to create a more focused and determined effort to tackle undernutrition amongst health and social care providers than has historically been the case, and will also help to reinforce the Improving Nutritional Care action plan.

  15.  Nutritional care is already prioritised in the core standards inspected by the Healthcare Commission under Core Standard C15b. Despite this, there is evidence to suggest that this is insufficient. In 2006-07, none of the 34 NHS Trusts which discharged the highest number of patients in an undernourished state failed the Healthcare Commission's core standard C15b.[77] This may be due to the fact that adherence to C15b is self-assessed by providers, and indicates a need for more robust inspection processes.

  16.  To support this and ensure that safety standards are being met, more extensive data on nutritional care is needed. We believe that the Care Quality Commission could draw on Hospital Episodes Statistics data, the NPSA's Patient Environment Action Team (PEAT) scores, as well as reports of adverse patient safety incidents relating to nutrition reported to the NPSA. Making these data more readily available—including to commissioners, providers and the public—would assist in the inspection and monitoring of the nutritional care offered by NHS providers.

  17.  Adequate nutrition is so fundamental to supporting patients' safety that we believe that sanctions should be applied to those healthcare providers found to be wanting in implementing nutritional screening and nutritional support. The Health and Social Care Act, which recently received Royal Assent, includes a wide range of mooted sanctions for tackling healthcare-associated infections. These include: warning notices; fines; prosecution; and the closure of services. The Committee may wish to consider whether these sanctions should be equally applicable to the area of nutritional care.

  18.  We welcome the recent commitment in the NHS Next Stage Review to establish a series of "Never Events"—adverse incidents so serious that a commissioner will withhold payment—and believe that the case for including undernutrition developed in hospital within these "Never Events" should be fully explored.

  19.  We believe that more should also be done to raise awareness in the community of malnutrition and its implications for health and patient safety. We see a central and active role for the National Patient Safety Agency in this awareness-raising activity.

  20.  To incentivise primary care to better identify and manage nutritional needs in the community, we would support incorporation of nutrition indicators in the Quality and Outcomes Framework (QOF) of the GP contract. Improved nutrition, for example, is known to reduce instances of heart disease, stroke, diabetes and some cancers[78]—all of which are prioritised in the QOF. However, in spite of this, none of the QOF points assigned to these conditions reflect the importance of adequate nutritional care.

  21.  An additional incentive would be inclusion of nutrition indicators (incorporating patient safety) in the National Indicator Set for use in Local Area Agreements, determined by the Department for Communities and Local Government. This would reflect the need for both the NHS and social care services to work together to ensure service users are provided with adequate nutrition support.

  22.  The training and continuing professional development of staff is a particular problem in relation to the care of undernourished patients. An investigation by the National Patient Safety Agency in 2007 identified, "a lack of education and training for medical and nursing staff both pre-qualification and within local NHS organisations" as a major barrier to compliance with the National Institute for Health and Clinical Excellence (NICE)'s guidance of February 2006 on Nutritional Support in Adults.[79]

  23.  Improving patient safety will require increased training and support for healthcare professionals in delivering safe, effective nutritional screening and care. We would support the development of a national occupational health standard for nutritional care to help assess the competence of healthcare workers.

August 2008








61   Cited in Department of Health, Improving nutritional care, October 2007 Back

62   National Patient Safety Agency, Nutritional Screening Structured Investigation Report, 2 July 2007 Back

63   Journal of General Internal Medicine, Protein-energy undernutrition and life-threatening complications among the hospitalised elderly, 2002 Back

64   Hansard, 18 December 2007, Col. 1395W Back

65   Cited in Department of Health, Improving nutritional care, October 2007 Back

66   Cited in Department of Health, Improving nutritional care, October 2007 Back

67   Cited in Department of Health, Improving nutritional care, October 2007 Back

68   Journal of General Internal Medicine, Protein-energy undernutrition and life-threatening complications among the hospitalised elderly, 2002 Back

69   Department of Health, Tackling health inequalities: a programme for action, 2 July 2003 Back

70   Department of Health, Choosing a better diet: a food and health action plan, 9 March 2005 Back

71   Hansard, 18 December 2007, Col. 1395W Back

72   Hansard, 13 December 2007, Col. 883W Back

73   British Association of Parenteral and Enteral Nutrition, BAPEN study reveals that 1 in 4 adults across all age groups admitted to hospital and care homes in the UK at risk of malnutrition, 27 November 2007 Back

74   There were 12.98 million admissions to NHS hospitals in England in total in 2006-07. Source: Department of Health, Hospital Episodes Statistics, 12 December 2007 Back

75   Daily Mail (5 January 2008); Daily Telegraph (5 January 2008); and Daily Express (5 January 2008) Back

76   Department of Health, Improving Nutritional Care, October 2007 Back

77   Hansard, 18 December 2007, Col. 1395W; and Hansard, 30 October 2007, Col. 1236W Back

78   Department of Health, Choosing a better diet: a food and health action plan, 9 March 2005 Back

79   National Patient Safety Agency, Nutritional Screening: Structured Investigation Report, 2 July 2007 Back


 
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Prepared 30 October 2008