Tackling malnutrition: more work needed to meet standards

Almost half of hospitals in England are not meeting mandatory food and drink standards, according to a new report. 

Almost half of hospitals in England are not meeting mandatory food and drink standards, according to a new report

One third of people aged 65 years or over are at risk of malnutrition on
admission to hospital.        Picture: Charles Milligan

The Hospital Food Standards Panel (HFSP), an independent group established by the Department of Health, introduced five standards in 2014 that it said all hospitals should meet to improve the quality and availability of food for patients. These standards include having a food and drink policy in place and making the timing of meals and drinks flexible.

The report from the HFSP says that ‘substantial progress’ had been made in the past two years, but there is more to do to improve nutrition and hydration in acute care.

The Mid Staffordshire NHS Foundation Trust inquiry heard that some patients had resorted to drinking water from vases and relying on relatives to bring in meals. Newspapers have frequently published photographs taken by patients of unsatisfactory hospital food.

Malnutrition risk

Around three million people in the UK are believed to be either malnourished or at risk of malnourishment in the UK, one million of whom are aged over 65.

3 million 

people in the UK have or are at risk of malnutrition 

According to British Association of Parenteral and Enteral Nutrition (BAPEN) research, one third (32%) of people aged 65 years or over are at risk of malnutrition on admission to hospital, rising to half of people admitted from care homes. 

In January, the Office for National Statistics (ONS) said that malnutrition was an underlying or contributory cause in almost 1,000 deaths in England and Wales in 2015, the vast majority of which occurred in hospitals and care homes. The ONS stressed that the statistics did not provide sufficient information to link the deaths to poor care, particularly as patients may have arrived malnourished or been in hospital only briefly.

A report said more than half of hospitals reported that all patients were screened with a tool such as the Malnutrition Universal Screening Tool (MUST). 

Help with eating

Age UK’s interim head of health influencing, Lesley Carter, who is also a nurse, says she believes that awareness of malnutrition in hospitals has improved significantly over the past couple of years.

The use of MUST or similar tools is becoming more embedded in the culture of hospitals, Ms Carter says, as it is now monitored by the Care Quality Commission (CQC). She added that problems occurred when results were not acted on.

‘There are still quite a few concerns, such as packaging issues, unsuitable food and patients who are unable to feed themselves being left unassisted,’ Ms Carter says. ‘If patients on a ward have dementia, then most will need help with feeding. Different coloured trays, protected mealtimes and instructive signs are helpful, but they don’t get the food into people. Feeding isn’t seen as a clinical intervention and it should be. If people don’t eat, they won’t get well.’


of patients say they always receive enough help with eating in hospital

Increasing numbers of patients have told the CQC’s annual inpatient survey that they get enough help eating their food, but more than a third did not have the help they needed, according to the 2015 survey.

Nutritional care tool 

As feeding each patient can take 45 minutes, initiatives that encourage management staff and patients’ relatives to help during mealtimes are useful, RCN professional lead for care of older people Dawne Garrett says. ‘It takes time to assist somebody, and that is difficult in the current climate.’ 

BAPEN is encouraging hospitals to use its nutritional care tool, an audit that is run four times a year. It checks with each patient if MUST was completed, tracks weight loss, and asks for feedback about the help they received at meal times. 

This is intended to provide a UK-wide picture of malnutrition in hospitals, and provide some benchmarks for hospitals and wards to compare themselves against.

Community link

Using MUST should be the absolute minimum, says Kingston University and St George’s University of London honorary principal lecturer Christine Eberhardie. She adds that a fuller assessment should be carried out on those with or at risk of malnutrition.

£19.6 billion 

the estimated cost of malnutrition in England

‘It is important to a do an assessment of their current status, and what they can and can’t do. MUST can’t tell you if someone can’t go to the shops, can’t cook, or is depressed or bereaved,’ she says. 

The whole multidisciplinary team is responsible for nutrition in hospital, Ms Eberhardie says, and with many people arriving in hospital already malnourished, action is needed in the community.

‘If we don’t do better assessments and engage with the person’s place in the community, then they will come back into hospital with worse conditions,’ she says.

Case study: East Kent Hospitals University NHS Foundation Trust

At East Kent Hospitals University NHS Foundation Trust, patients can choose from 24 hot meals and receive their food at a time that fits in with their care.

Matron for nutrition and quality improvement Wendy-Ling Relph says that the trust has worked closely with its catering supplier to provide tempting food at a time the patient needs it.

Rather than ward-based protected mealtimes, which can interrupt medical appointments or scans, the trust aims to protect the individual’s mealtime, so that a meal is ready when they return to the ward.

Other changes include having a housekeeper to serve food on wards, freeing up nursing time to help feed patients. 

Wards with dining areas run dementia cafes, where patients sit together at mealtimes. This gives a social aspect to meals, and encourages patients with dementia to eat by seeing other people eating around them.

Families are encouraged to help support their relatives during mealtimes, as they often understand how someone likes to be helped.

‘Nutrition is particularly important in hospital because when patients are at an acute stage of an illness they need more calories and nutrition,’ says Ms Relph, an executive member of BAPEN.

‘People want to graze, especially older, frail people, so we provide three meals a day and three snacks. We now get far fewer complaints about people not getting a hot meal and it feels much better for patients and staff.’

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