Malnutrition is an under-recognised and under-treated problem facing the UK, to the detriment of and cost to individuals, the health and social care services, and society as a whole. Public expenditure on disease-related malnutrition in the UK in 2007 has been estimated at in excess of £13 billion per annum, about 80% of which was in England.
Although the risk of malnutrition is most commonly associated with older people, the majority of people at risk of malnutrition are aged less than 65 years.
Malnutrition is associated with a number of socioeconomic factors, including poverty, social isolation and substance misuse. It therefore potentially exacerbates health inequalities. This may help to explain why the burden of malnutrition is greater in areas of high deprivation, and why there is a clear North-South divide in its prevalence.
At any given point in time, more than three million people in the UK are either malnourished or at risk of malnutrition. The vast majority of these (c. 93%) are living in the community (including c. 2-3% of whom are in sheltered housing), with c. 5% in care homes and just c. 2% in hospital. However, given the throughput of patients in hospital, hospital care provides a vital opportunity to identify malnutrition and initiate treatment which can then be continued in the community following discharge.
A number of societal trends look set to exacerbate the burden of malnutrition in the future. These trends include: an ageing population; a relative increase in care provided informally in the community (as opposed to formally in institutional settings); continuing shifts in the pattern of food distribution; and an increase in conditions associated with malnutrition, such as dementia, chronic obstructive pulmonary disease, and stroke.
The effectiveness of Government policy is at present being impeded by the way in which it falls overwhelmingly under the responsibility of the Department of Health. Other Government departments, agencies and public, private and voluntary sector organisations should also play a role. Consultation with patients, carers and service users is also important in developing patient-centred health and social care services.
There is a paucity of Department of Health data relating to the burden of malnutrition. Some Department of Health data which have been collected are incomplete, inconsistent and difficult to interpret.
Although screening for nutritional risk – using validated nutritional screening tools – is recommended by the Department of Health, the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA), hospitals, care homes and primary care settings are failing to screen patients as they should. This impedes the initiation of appropriate care. One of the obstacles to undertaking nutritional screening is the lack of suitable, accurate equipment to implement it.
The education and training needs of health, housing and social care professionals are not being met in the area of nutritional care, and awareness of their needs is poorly understood. This is exacerbated by the multitude of providers involved in both health and social care delivery, and by the way in which patients are increasingly being cared for by multidisciplinary teams (MDTs) (with the associated diffusion of responsibility for nutritional care). In addition, the training of informal carers in the importance of nutritional care is virtually non-existent.
Although Government-funded financial incentive schemes exist in health and social care to encourage the provision of high-quality care, none are at present being used to support the provision of high-quality nutritional care in either primary or community, or secondary care settings.
Commissioners are not holding providers to account for delivering nutritional care due to the absence of nutritional care commissioning guidelines and a lack of awareness amongst commissioners of the needs of their populations. Establishing clear and meaningful commissioning guidelines would help to facilitate more effective commissioning.
Existing regulatory systems – across both health and social care providers – need review and improvement with respect to patients and service users.
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