Malnutrition and the NHS

Martyn Day Excerpts

Monday 25th April 2022 Commons Chamber

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

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?