A partnership to improve outcomes for malnourished older patients has had a positive impact on this vulnerable and often marginalised group.
Tackling the crisis
There is no ignoring the significant challenges facing the NHS. Rising demand is stretching the limits of health and social care providers and there now exists a higher than manageable number of older, sicker, people with more complex conditions, living in the community.
In common with most systems nationally, it is often the most vulnerable in society who disproportionately experience the impact of these pressures. Malnourished, dehydrated elderly people are the most vulnerable and disadvantaged cohort across health and social care systems. Urgent action is needed to address this.
There have been numerous efforts to address nutrition and hydration challenges through policy and service development. However, this has not always translated into necessary service change on the ground or resonated with the practitioner on the operational front line.
However, the 10 Point Plan pilot programme – a partnership between healthcare professionals, whole systems and a range of provider organisations and other healthcare organisations – demonstrates what is possible with energy, focus, commitment and, above all, a willingness to think and deliver care differently.
The aim is to transition the older person to full independence as quickly as possible, transferring them home from hospital as soon as they are medically fit, with core rehabilitation and support provided by an integrated health and social care team in a home setting.
This Programme demonstrates that there is a place for industry and partnership working, enabling that transition from supplier to partner.
Malnutrition is estimated to cost the public purse £19.6 billion in England alone; this is 15% of overall health and social care expenditure.1 It is estimated that £5,000 could be saved per patient through better nutrition management.The provision of nutritional support to 85% of patients at medium and high risk of malnutrition could lead to a cost saving of between £325,000 and £432,000 per 100,000 people.2
This is not just a health crisis, but a social and economic one too, which has the potential to disproportionately harm our most vulnerable citizens, negatively impacting our health and social care sector and society as a whole. A paradigm shift is required in the way that policy makers, commissioners, providers and professionals think and operate.
The goal of the 10 Point Plan was to create a multi-organisational, pan-sector comprehensive care pathway for frail older people, recognised and applied by all. Bringing together the acute hospitals, community care, social care, third sectors and industry, it is hoped that the plan will be endorsed by key stakeholders and rolled out in clinical commissioning groups up and down the country.
The organisations involved in the 10 Point Plan pilot programme have shown what is possible through partnership working, thereby enabling that ‘supplier to partner’ transition.
1 Elia, M, (on behalf of the Malnutrition Action Group of BAPEN and the National Institute for Health Research Southampton Biomedical Research Centre), The cost of malnutrition in England and potential cost savings from nutritional interventions, 2015
2. Forgotten not fixed – A blueprint to tackle the increasing burden of malnutrition in England – published by BSNA , Feb 2018
The 10 point plan
Ten steps to commissioned care pathway for frail older people
1. Understand the challenge through case reviews
- Spotlight failures and breakdown of care at the interface
2.Create regional and sector champions
- Clinical and operations
3. Involve the sectors
- Industry, NHS, healthcare professionals, third sector
- Opportunity to cost pathways (eg opportunity cost, avoidable cost, cost of management in own home versus hospital)
- Opportunity to run pathways (eg B2B industry/care providers)
- New products
- Risk shares and lead accountable provider (LAP)
- Voluntary sector and the ‘brefriender and carer’
- Incentives – evaluate products in a different way?
- Key specialist expertise
4. Grasp the key challenges
- Prioritise main disease areas
- Apply financial targets
5. Increase awareness
- Mandate nutritional health check
- Screening on admission
- Signposting to key groups (eg dietitians, pharmacists)
6. Change point of care
- Don’t rely on one point of entry to system
- Joint reviews: dietitians and community pharmacists
- Include voluntary sector and the unpaid cover
- Don’t neglect GPs either
7. Reset the workface
- Role of the prescribing dietitian in the multi disciplinary team – and pharmacists
- Elevate role of voluntary sector as prompters
- Opportunity to educate/retain
8. Minimum standards required
- Ensure NICE CG32 and QS24 are recognised and implemented
- Ensure MUST and malnutrition pathway is followed
- Mandate oral nutritional supplements in certain situations
- Create specific timelines and milestones for patient monitoring and review
- Create risk profiling guidance/set of common sense indicators
- Targets to encourage compliance
- Sanction for non-compliance
10. Pilot the new pathway in one or more CCGs
To test the concept, the plan was piloted in Kent, Essex and the South-West (Wiltshire and Gloucester) over an eight-month period from April to November 2017.
The organisations gave their time for free and willingly and positively engaged in the pilots as they recognised the value of this approach not just within their own settings, but nationally.
An unrestricted grant was directed by the British Specialist Nutritional Association (BSNA), the voice of the specialist nutrition industry in the UK, representing the manufacturers of high-quality foods designed to meet the needs of people with very special nutritional requirements. The BSNA and its members were keen to support the programme in an unrestricted way and consider system-wide innovative ways to address the impact of medical malnutrition and ensure the issues associated with malnutrition are recognised by key decision makers on a regional and national basis. Without the support, insight, expertise and flexibility of the BSNA and its industry, this would never have been achieved.
Real challenges, practical solutions
The aim of the 10 Point Plan was to develop a practical service improvement guide for the health and care sector to ensure an increased understanding of the challenges generated by insufficient focus on malnutrition and dehydration, and provide the evidence and tools by which patient experience can be enhanced.
• Engaged with providers who collectively provide health and social care services
for a population in excess of 1.5 million.
• Uniquely pulled together acute hospitals, community services, primary care (GPs and pharmacists), nursing and residential care, domiciliary care, voluntary, independent and private sector, patients and relatives into a connected service pilot.
• Engaged directly with individual nursing and residential homes and also consulted with organisations representing 125 nursing and residential homes.
• Engaged with over 250 front-line professionals (covering a range of disciplines).
• Put in place a range of new service initiatives in areas such as assessment, training, technology and integrated working.
• Demonstrated through action and example what is possible in developing new approaches and practices.
• Engaged a range of patient organisations to ensure that the patient and carer view was at the heart of all activity.
• Left a strong legacy for change and improvement locally, nationally and, perhaps more importantly, on a personal level for the individual practitioner.
Moving the plan off the page
Pilot stage approaches
Key to the pilot programme’s success has been the active involvement of health and care professionals, voluntary sector, trade, the public, subject matter experts, service directors and leaders. It’s critical we engage, inspire and motivate those at the sharp end of care delivery so they feel empowered to change things for the better for the patients they serve.
The 10 Point Plan pilot programme has left a clear legacy of change and improvement. Some examples of its achievements across regions include:
Wiltshire and Gloucester
• Community matrons and district nurses receive annual training led by specialists on nutrition and hydration for patients on an End of Life Pathway.
• All patients receiving domiciliary care as part of the Urgent Care at Home Service run by Medvivo are now being screened for malnutrition and dehydration within 48 hours of being discharged home.
• Screening questionnaires now form part of the triage process for NHS 111 and out of hours services.
- The presence of the Patients Association Nutrition Checklist has encouraged GPs to undertake an assessment for risk of malnutrition through the annual health check process for the over 65s.
- Community pharmacy-led screening for malnutrition and signposting, advice and support given.
- Intention to align more dietitian input and capacity to established integrated teams.
- Module on identifying malnutrition and dehydration now a mandated part of all staff inductions.
- Public health-led prevention programmes focused on malnutrition and dehydration.
- Launched the ideal comprehensive care pathway for the frail older people which has been developed as part of the 10 Point Plan.
Adopting and scaling the innovation generated as part of the 10 Point Plan programme is absolutely critical and working in partnership with organisations such as the Allied Health Science Networks (AHSN), NHS Right Care, and NHS Improvement will help to achieve this. Clear benefits will be gained if professionals from across the system work together to develop a common plan and a common solution.
An industry perspective
Adam Brown, National CCG Sales Manager for Fresenius Kabi Ltd, a member of the BSNA:
“We wanted to see how the current service could be changed to improve what is being provided for patients in an area. By understanding what was needed we could then work with the NHS to support change.
The impact on market access is positive as it shows that by doing things differently you can make a difference in an area. It is ‘grown-up’ working, being open and transparent without hidden agendas. By doing this it means that we can work towards a common goal with the right patient receiving the best products.
Industry brings value in a number of different ways. This is not about financial value. It is time and expertise from a company in terms of data, knowledge and skills. By understanding fully the local environment, challenges and opportunities you can do things differently. It was about the NHS as customers and benefits for the patients.”
• The full report and its key recommendations will be launched nationally in March 2019
• A range of engagement events
• All documents and supporting resources will be made publicly available.
James Roach is Director of Conclusio Limited. The author extends his sincere thanks to all those involved.