Malnutrition and the NHS

– in the House of Commons at 8:39 pm on 25 April 2022.

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Motion made, and Question proposed, That this House do now adjourn.—(Miss Dines.)

Photo of Martyn Day Martyn Day Shadow SNP Spokesperson (Health and Social Care) 8:42, 25 April 2022

Mr Deputy Speaker, you have no idea how pleased I am to be making this speech now, mainly because I originally thought it would be at 12.55 am. Having made the shortest speech of my political career earlier today, I now have the opportunity to perhaps make my longest. But I think I can do it in a normal measure and we can all get away home. I thank Mr Speaker for granting the debate and the Minister for attending.

Malnutrition is a word that often conjures up images of undernourished children in developing or war-torn countries; not surprising really, when we consider it is linked to 45% of deaths among under-fives worldwide. That the UK Government have reduced nutrition-specific international aid by 70% is certainly concerning. However, that is not the focus of what I will be discussing today. It is equally concerning that in the UK, the fifth-richest country in the world, malnutrition has tripled since 2010. However, although they are undoubtedly related, neither will I specifically be discussing food insecurity, nor the exponential rise in food poverty, which has been widely argued in this place to be a political choice. Instead, I want to take this opportunity to highlight the direct impact that malnutrition has on our NHS and to ask the Minister to consider some of the ways that the Government could potentially mitigate those negative impacts.

I am pleased to have secured this Adjournment debate for two main reasons. First, it is an opportunity to draw attention to the most recent survey of malnutrition and nutritional care in adults, which was carried out by the British Association of Parenteral and Enteral Nutrition, otherwise known as BAPEN. It is relevant to point out that 83% of the individuals who took part in this survey were living in England. BAPEN hopes to include all four UK nations in future surveys, but I am referring to this one as I understand it is the most recently published. Using the malnutrition universal screening tool, the survey demonstrated that 40% of the participants were at medium or high risk of malnutrition, and that disease-related malnutrition at that time affected 1.3 million people over the age of 65. I will refer to further findings of the survey throughout this speech.

The second reason that I am happy to be able to raise the issue of malnutrition and the NHS specifically concerns the Advisory Committee on Borderline Substances, which, for ease of reference, I will refer to as “the committee”. That scientific advisory committee is responsible for reviewing applications for substances that are specifically formulated by manufacturers to manage medical conditions. Malnutrition is one of these medical conditions and the substances that the committee reviews may be nutritional or dermatological products.

The committee plays a pivotal role in the NHS, as it is also responsible for advising the Secretary of State for Health and Social Care on the prescribing of borderline substances in NHS primary care. The committee’s advice covers two main areas: borderline substances policy; and the clinical and cost-effectiveness of borderline products.

Before I talk more about those areas, I will give a bit of background about malnutrition and its many implications for the NHS. Being malnourished does not simply mean being underweight; it can also affect overweight people and take many forms. For example, if someone does not consume enough energy and nutrients, perhaps because of social, economic or age-related factors, they become undernourished and consequently suffer from undernutrition. Undernutrition can affect all ages; it is indeed a “cradle to grave” scenario that the NHS was set up to provide healthcare for.

Then there is disease-related malnutrition, whereby a disease creates specific nutritional needs that result in an insufficient intake of energy and nutrients. Examples of disease-related malnutrition include some types of cancer or cardiovascular disease. There is also micronutrient-related malnutrition, which can be either a deficiency or an excess of important vitamins and minerals.

Being malnourished can lead to: poor growth and/or development in children; weaker immune systems and increased risk of infection, and indeed reinfection; muscle and bone weakness, or becoming more frail and likely to fall; poor wound healing; and slower recovery times. It is because of those common effects that, compared with the average well-nourished person, those who are malnourished are twice as likely to visit their GP, have three times the number of hospital admissions and, on average, stay in hospital for three days longer.

Malnutrition affects more than one in 20 people in the UK, which is a similar prevalence rate to well-known, treatable illnesses such as asthma. However, the rate increases to one in 10 people over the age of 65. It is also more prevalent in those with existing illnesses. Outside those two groups, malnutrition is disproportionately concentrated in lower-income regions and households, and undernutrition is more common in children from less well-off backgrounds.

Hon. Members can see how this mounts up to be a significant cost to the NHS that equates to around 15% of the total UK healthcare budget. That is quite a staggering figure. Additionally, those who are malnourished divert scarce healthcare resources unnecessarily, which brings me to the committee’s advice on the cost-effectiveness of borderline products.

Across the UK, the cost of malnutrition to the health service is currently estimated to be a staggering £23.5 billion. As the population ages, the costs of failing to put in place proper systems for the diagnosis and treatment of malnutrition are likely to rise. The cost of treating a malnourished patient is two to three times more than treating a non-malnourished patient. It has been calculated that treating a non-malnourished patient amounts to £2,155, whereas treating a malnourished patient comes to £7,408. That is reported to be driven largely by poorer outcomes leading to increased healthcare needs.

Reducing the prevalence of malnutrition would therefore be a significant way to get the best from our NHS in monetary terms and relieve pressure on the healthcare system and NHS staff. Most importantly, in human terms, it would improve patient outcomes. That point leads me on to the committee’s advice on borderline substances policy.

On 1 April 2016, the United Nations General Assembly proclaimed 2016 to 2025 as the United Nations decade of action on nutrition. It stated:

The Decade is an unprecedented opportunity for addressing all forms of malnutrition.”

Led by the World Health Organisation and the United Nations Food and Agriculture Organisation, the United Nations decade of action on nutrition calls for policy action across six key areas:

“creating sustainable, resilient food systems for healthy diets;
providing social protection and nutrition-related education for all;
aligning health systems to nutrition needs, and providing universal coverage of essential nutrition interventions;
ensuring that trade and investment policies improve nutrition;
building safe and supportive environments for nutrition at all ages;
and strengthening and promoting nutrition governance and accountability, everywhere.”

We are now just three years away from the end of the decade of action on nutrition, yet the most recent survey of malnutrition and nutritional care in adults found that

“disease-related malnutrition continues to be prevalent.”

Indeed, although the findings were similar to those of BAPEN’s survey the previous year, the prevalence of disease-related malnutrition was found to be higher than in surveys carried out in the years before the decade of action on nutrition was declared. That suggests that instead of seizing the opportunity to address all forms of malnutrition, as the UN advocates, the UK has either avoided tackling the problem or failed in its efforts. It also raises the question of the role of the committee’s advice on borderline substances policy in addressing malnutrition.

Last year, the UK Government published an open consultation that outlined proposed changes to the committee’s policy on oral nutritional supplements, which are a key part of management strategies in the treatment and prevention of malnutrition—incidentally, it would be helpful if the Minister could clarify when the response to the consultation will be published. The changes proposed in the consultation have a considerable potential impact on clinical practice, but not necessarily a positive one.

In reference to the consultation, the British Specialist Nutrition Association concluded that oral nutritional supplements

“are a clinically and cost-effective way of managing disease-related malnutrition. As clinical experts in nutrition, dietitians should maintain their autonomy in being able to make the best decisions for their patients. The new ACBS consultation on ONS is at risk of limiting dietitian autonomy, impacting patient safety and care, and limiting the ability of industry to innovate.”

That point leads me on to some available ways to tackle malnutrition. I hope that the Minister will agree and will recognise them as opportunities to address malnutrition across the UK in the spirit of co-operation that is intended.

After leaving the EU, the Prime Minister asked some former Ministers to identify how the UK could take advantage of its new-found regulatory freedoms, so the Taskforce on Innovation, Growth and Regulatory Reform was convened. The taskforce reported its recommendations to the Prime Minister on 16 June last year. In relation to nutraceuticals and the consumer health sector, it stated:

“Our traditional silos of regulatory classification (food/medicine/diagnostic/device) are being challenged by the pace of bioscience and technological convergence of biological and digital platforms…science is starting to point the way to a new sector of nutritional products with increasingly explicable and/or verifiable medicinal benefits, which needs to be reflected in our regulatory framework.”

The taskforce report included a headline proposal:

“Create a new regulatory framework for the fast-growing category of novel health enhancing foods and supplements”.

However, that proposal was rejected. I recently received a written parliamentary answer confirming that

“the United Kingdom already has in place the legislation and processes required for the regulation of such products. As such, there are no current plans to implement a new regulatory framework.”

Given the lack of progress on tackling the prevalence rate of malnutrition across the UK, I urge the Minister to revisit the proposal. I am mindful that it would also address one of the key areas that the United Nations decade of action on nutrition calls for:

“ensuring that trade and investment policies improve nutrition.”

Across the UK, one of the basic problems with malnutrition is that it is an underdiagnosed and therefore undertreated condition. For example, the one in 10 of over-65s who are at risk of, or suffering from, malnutrition in Scotland equates to about 103,000 people, but just a fraction of them are identified and offered support or products to treat their condition, and the same clearly applies throughout the rest of these islands.

Screening patients for malnutrition is not currently standard practice across the NHS. If a screening programme were introduced for people being admitted to hospital, patients on wards and those in a social care setting, it would allow for intervention to limit malnutrition in the most vulnerable patients. That simple measure would constitute a policy aligning with several of the key actions called for by the United Nations decade of action on nutrition. Identifying the problem at the earliest opportunity would allow treatment to reduce malnutrition and its associated problems.

Given the UK’s increasingly ageing population, I am sure the Minister will agree that it is important for more resources to be devoted to preventive care, which would reduce pressure on the healthcare system. Reducing malnutrition by improving diets, promoting campaigns to spot the signs of malnutrition and testing through GPs and in care homes could also play an important role in a preventive care model.

Another available way of addressing malnutrition is provided by the health and social care reforms that are currently taking place across the UK. Improving links in the healthcare system between hospital and community or social care is vital. What better opportunity could there be to showcase joined-up healthcare by not only better diagnosing malnutrition, but prescribing products that treat it and then monitoring a patient’s progress in their home, community or social care setting?

I have already mentioned that undernutrition is more common in children from less well-off backgrounds, and the World Health Organisation expands on that eloquently:

“Poverty amplifies the risk of, and risks from, malnutrition. People who are poor are more likely to be affected by different forms of malnutrition. Also, malnutrition increases health care costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty and ill-health.”

This resonates with the regional inequality that the UK Government’s levelling-up agenda aims to address by

“giving everyone the opportunity to flourish. It means people everywhere living longer and more fulfilling lives and benefitting from sustained rises in living standards and well-being.”

Malnutrition does not give anyone the opportunity to flourish and live longer; in fact, the opposite is true. Should it not therefore be a key target for the agenda of the Office of Health Improvement and Disparities to tackle inequalities in health and care?

Concerns have been raised with me about the impact of delays by the committee on patient choice in respect of malnutrition treatment products and additional costs to the NHS. However, I was recently advised that the Department of Health and Social Care had

“made no assessment of the potential impact of application processing delays by the Advisory Committee on Borderline Substances…on patient choice for malnutrition products and additional costs to the National Health Service.”

The British Specialist Nutrition Association has noted that

“Unlike most prescribed drugs, palatability and choice of ONS”

—oral nutritional supplement—

“products are critical in meeting different patient preferences and supporting patient compliance and, as such, dietitians require access to a wide range of different product styles, flavours and volumes.”

May I finally urge the Minister to prioritise the treatment of malnutrition and effective management strategies that include better support and facilitation of the medical nutrition sector?

Photo of Maggie Throup Maggie Throup The Parliamentary Under-Secretary for Health and Social Care 8:59, 25 April 2022

I congratulate Martyn Day on securing this important debate tonight. As he rightly said, we were expecting to be quite late, so it is good to be able to debate this matter while people might still be watching. I know that he has shown a keen interest in it, especially through his work on the Health and Social Care Committee.

Malnutrition is a common clinical health problem, affecting all ages and all health and care settings. However, it is also a complex issue and its root causes may be clinical, social or economic. I know from personal experience, and from the difficulties of those close to me, how critical it is for disease-related nutritional problems to be identified and treated early. I also appreciate how important it is for healthcare professionals to have a wide range of options available to meet each patient’s unique needs. Supplements can provide a lifeline to those already struggling with debilitating illness. Whether it was the nutritional supplement drink provided to me by a practice nurse when I could not swallow due to chicken pox, those that my mother could drink when severe breathing problems made eating a serious struggle, or the yoghurt-type products that sustained my father after his stroke, these treatments were not just life-saving; they relieved the worry of hunger at some of the most difficult times in the lives of ourselves and our loved ones.

The hon. Member has highlighted the significant cost of malnutrition in the NHS, as cited in the British Association of Parenteral and Enteral Nutrition report. The report indicates that malnutrition costs to the health and care system in the UK are estimated to be over £23 billion each year, including £19.6 billion in England, with the majority of those costs—some £15.2 billion—being in NHS secondary care settings, and around £4 billion in social care settings. It is therefore right that we hold the NHS and care services to the highest standards. It is essential that patients receive the right nutritional support to meet their needs.

We expect NHS services to be provided in line with the National Institute for Health and Care Excellence best practice guidelines. NICE has published guidance on “Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition”, which covers identifying and caring for adults who are malnourished or at risk of malnutrition in hospital, in their own home or in a care home. It offers advice on how oral, enteral tube feeding and parenteral nutrition support should be started, administered and stopped. It also aims to support healthcare professionals in identifying malnourished people and to help them to choose the most appropriate form of support. The Care Quality Commission also sets quality standards that the NHS and care settings must meet. Regulation 14 sets the quality standards for meeting nutritional and hydration needs. The standard requires that people must have their nutritional needs assessed, and food must be provided to meet those needs, including where people are prescribed nutritional supplements and/or parenteral nutrition.

We are implementing several initiatives to ensure that the highest nutritional standards are met. The Malnutrition Task Force—a partnership of Age UK, Apetito, BAPEN, Nutricia and the Royal Voluntary Service—has published a series of guides offering expert advice on the prevention of and early intervention in malnutrition in later life. These guides draw together principles of good practice to offer a framework developed to help those in a wide range of health and care settings to make the changes needed to counter malnutrition. This includes a guide for care homes on integrating good nutrition into daily practice.

We have published a comprehensive review of hospital food and are working to implement its recommendations. Every hospital has a responsibility to provide the highest level of care for its patients, and thar includes the quality and nutritional value of the food that is served and eaten. Hospitals must comply with five mandatory food standards, including a requirement to screen patients for malnutrition and covering the nutrition and hydration needs of patients. The Government have invested in primary care networks to ensure that the NHS has the specialist staff it needs to provide in-depth assessments of patients’ nutritional requirements. Through the primary care network direct enhanced service, primary care networks have recruited hundreds of additional health and wellbeing coaches and dieticians since March 2019.

The hon. Member raised concerns about medical nutrition for people who require clinical intervention to treat or address the risk of malnutrition. As he will be aware, foods for special medical purposes are developed to feed patients who are malnourished because of specific medical conditions that make it impossible or very difficult for a patient to satisfy their nutritional needs through the consumption of other foods. These products are developed in close co-operation with healthcare professionals and must be used under medical supervision.

We are working with stakeholders, including industry and the NHS, to update the processes and guidance of the Advisory Committee on Borderline Substances to support fairer, more accurate, more consistent and faster decisions. The ACBS works to assess malnutrition products to ensure they are both clinically effective and cost-effective for the NHS. With the ACBS recommending a total of 209 products available through prescription for the management of malnutrition, the current system offers a wide choice to patients and clinicians.

The hon. Gentleman talked about the rise in the number of people diagnosed with malnutrition, the reasons for which are complex. It is likely to be partly due to improved screening and reporting and an ageing population. The issue was probably there before, but we are now identifying it more because of the NICE and CQC guidelines. The evidence also suggests that the rise in malnutrition is worse in older age groups.

The ACBS is independent of the Department of Health and Social Care and has not yet informed the Department of when it will present the outcome of its consultation. I commit to informing the hon. Gentleman as soon as we are informed. The ACBS is also responsible for advising on the prescription of borderline substances, including food for special medical purposes for use in NHS primary care. The ACBS has authorised 209 products listed on the drug tariff for the management of malnutrition, providing plenty of choice for patients.

The CQC standard on nutrition and hydration clearly sets out that people must have their nutritional needs assessed and that food must be provided to meet those needs, including where people are prescribed nutritional supplements and/or parenteral nutrition. The NICE guideline on nutrition support for adults aims to assist healthcare professionals in identifying malnourished people and choosing the most appropriate form of support. If the NHS and care homes follow the CQC and NICE guidelines, they will help to reduce the number of people in this condition and help to reduce the cost to the NHS.

To address the many complex factors around malnutrition, we need effective strategies for managing malnutrition in health and care settings. The NICE and CQC guidelines and standards clearly set out the care pathways that should be in place to ensure that patients receive the best possible nutritional care. I also agree that, where patients require specialist clinical nutritional support, we must ensure they have access to the right treatments. We will continue to work with the medical nutrition sector to ensure that the most efficacious products are available in the NHS without undue delay.

I reassure the hon. Gentleman that my Department takes malnutrition extremely seriously, and it is an issue that we are determined to continue tackling.

Question put and agreed to.

House adjourned.