A watchful eye on malnutrition

Older people with social care support often need help to eat healthily. But is this best achieved by providing them with good advice and personal budgets or nutritious food, asks Vern Pitt

Whether it’s losing weight or improving health, nutrition and diet are concerns for many people, but one within their control. For older people in need of social care support, however, it is often more difficult to take command of their situation.

Mobility, isolation, injury and loss of appetite can all become barriers to getting food or to eating itself. This can result in increased risk of falls, susceptibility to infection and frailty.

In its final report in February, the Department of Health’s Nutrition Action Plan Delivery Board said the nutrition of vulnerable people living in their own homes remained a priority, despite the board working in this area since January 2008.

The food issue: why food is at the heart of social care

It concluded there had been progress on nutrition in institutional settings but those outside them remained at risk. The British Association of Parenteral and Enteral Nutrition (Bapen), which works to tackle malnutrition, estimates 93% of malnourished people live in their own homes. But, with the board itself disbanded by the last government after its final report, the torch has been passed to providers and councils to drive the action needed.

The evidence suggests that investment in work to prevent malnutrition can reduce pressures on acute health and social care services. However, Gordon Lishman, ex-chair of the Nutrition Action Plan Delivery Board, says that, despite improving outcomes, preventive actions do not tend to reduce costs across the system, with investment in one part balancing savings in another. “Now that’s worth doing, but the money-people tend to be less interested in it,” he says.

Still, if services are to improve, what action is required?

A study by the DH in 2009 concluded knowledge was lacking on what constitutes a balanced diet, such as how much fruit makes up a portion of your five a day.

However, there is a tendency from the food industry and the DH to equate healthy eating with a low-calorie intake, says Lishman, despite this being inappropriate for older people. “The DH is unthinkingly undermining its own plans to tackle malnutrition,” he says.

Lack of understanding of a balanced diet could cause problems which, in combination with personalisation, will put back decisions about nutritional care, according to Janet Lawrenson, head of food services at WRVS, a major provider of meals services for councils. “If Mrs Jones gets money from the local authority she might just decide to have a pizza each time,” she says.

Central government has to take a lead on education, says Sue Ullman, former chair of the National Association of Care Caterers (NACC). “We need some kind of campaign to raise awareness, not just with service providers but with everybody.”

However, there is still a role for frontline staff, says Elaine Cass, practice development manager at the Social Care Institute for Excellence. “Your responsibility is to give the right advice,” she says.

Client screening

To tackle malnutrition those at risk need to be identified and monitored. For this reason Cass and Scie have been promoting the screening of clients by social workers.

Cass’s test of choice is Bapen’s Malnutrition Universal Screening Tool (Must), which uses body mass index, recent unplanned weight loss and current illness to calculate risk of malnutrition.

There are, however, question-based assessments that, while they lack the scope of Must, might be better incorporated into a social work assessment, says Derek Johnson, chair of NACC. “Everyone tends to develop their own, though, and it’s a case of trying to get a bit of joined-up thinking around that,” he says.

After the assessments comes the monitoring of what people eat, a process that is easier in residential settings than in the community, where staff time can be limited.

Vigilance by staff is the key. Johnson says there has been a tendency to view meal delivery services as couriers who offer no extra support. But gradually social workers and other professionals are recognising these staff can bring back valuable information if they are trained to do so – assuming the staff stay in post. “In the community there is a much bigger issue with transient staff,” says Cass. “If staff don’t know the person how would they notice whether this person has lost weight?”

High turnover

Lawrenson feels WRVS has broken the back of the problem, for instance by keeping delivery rounds as fixed as possible so that clients see a familiar face. “It’s a relatively high turnover but we find that if we look after our staff they will put themselves out for the clients because they have a relationship,” she says.

If staff are to have enough time to tackle malnutrition this will need to be commissioned into the service, whether this is meal delivery services or home care provision that involves food preparation.

“What I hear from care workers and managers is that they are usually given 15-30 minutes to provide food services,” says Kim Grove, head of resources at the United Kingdom Homecare Association (UKHCA).

The NACC hopes to help solve the problem by producing minimum standards for meal providers, including the food itself and the service. At present there is no universally accepted measure in the sector even though standards exist for hospital and school meals.

Johnson hopes this will provide a benchmark against which commissioners and customers can judge and compare providers and drive up standards. “Later this year, we hope to get a standard, which is out for discussion,” says Johnson. “How we get government to accept it is another challenge.”

However, good commissioning, training and education will be insufficient if the food served is not appetising.

Sizable portion

UKHCA has produced guidance on food provision which devotes a sizable portion to presentation of food. Grove says this is important if you are to provide incentives for older people to eat properly.

Cass agrees: “There is all this concentration on what the nutritional factors of the food are and if the food is not going into anybody it’s of no use to them whatsoever.” Ideally, this should involve having meals cooked from fresh ingredients.

Although this might seem like a resource-intensive option, Grove believes it is possible. She explains that direct payments may lead to people choosing a service that can offer them something freshly cooked in their own home, even if it means cutting back in other areas.

Grove is keen to see improvements in nutritional care before her own old age. “Many meal providers buy something and bung it in the microwave. If they do that to me when I get older, I will throw it back at them,” she says with a chuckle.

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(Illustration credit: Simon Cooper/Organization)