In previous years, with school food frequently commanding the headlines, the public sector ‘most influential’ (PSMI) top 20 annual debate has focused on nutrition for young people and the opportunities for public sector caterers to tackle obesity and diet-related diseases common to a high-fat and sugar diet.
But our recent cover story on malnutrition, which looked at the hidden plight of millions affected by poor access to food and poor nutrition, highlighted the enormous cost implications to the NHS in treating them, and confirmed this as an issue that is topical and hugely significant.
It was just one of a number of times during 2014 when the shortcomings of the social care sector threw a harsh light on the consequences for the health and welfare of vulnerable people. One problem that figured regularly throughout the year was the impact on local authorities of cuts in funding from central government. This has meant that community meals services are now in the firing line of services expected to take a hit as councils try to balance their books.
Seeking insights from those on the front line of food service delivery to those most in need – often the elderly in the community, whether in care or in hospital – Cost Sector Catering editor David Foad (right) detailed the estimated one million people over 65 thought to suffer from malnutrition and the further two million at risk, plus the £15-billion annual cost to the NHS of treating the effects of under nutrition.
Chair of the National Association of Care Catering Neel Radia agreed the issue was a huge concern. He said: “We recently conducted some research that showed that a third of UK councils had closed their meals on wheels service. Of the 212 top-tier councils, 74 had already closed down the services.
“Additionally, the research showed that of the two thirds that are currently providing the service, 51% have indicated that, by April 2015, they’re looking at considerable reductions in the service, if not removal.”
He added: “There is no statuary obligation to provide the meals on wheels service, but there is a responsibility to ensure access to the provision of food. These services are really vital in the community.
“As was pointed out the cost of malnutrition is double that of obesity, yet we hear a lot more about obesity in the news. Plus, treating malnutrition costs more than preventing it, so it’s a huge concern for us, and as an association, we’re working quite hard behind the scenes to try to get this issue raised.”
Attending in place of top-20 member Dianne Jeffrey of Age UK, charity colleague Ruthe Isden said: “We’ve just revised upwards the latest figures of how much local authority spending has declined on all social care services over the past five years, from £700 million to now over £1 billion since 2010, and the impact of that has predominantly been felt in at-home, and domiciliary and community services.”
She continued: “It’s seen the withdrawal of meals on wheels, day centres and lunch clubs; a lot of the community-based services that supported older people particularly with regard to their nutrition have been hit first and hardest.”
Sarah Wren, chief executive of Hertfordshire Community Meals (pictured left with Ruthe Isden of Age UK), said: “I think that we really need to be raising a challenge to local authorities that are axing the meals on wheels services.
“The statutory responsibility is in the Chronically Sick and Disabled Persons Act from way back in 1970, and, at best, it is vague. It says that there is a responsibility to provide meals in the home and elsewhere to the chronically sick and disabled.
“To me, that means there is a statutory responsibility to get meals to people if they need them, and a local authority putting a list of takeaways on its website is not sufficient.”
She added: “It may be a quick win this year to slash half a million or a million from a budget and remove a meals on wheels service, but the cost falls elsewhere, not only in social care but to the NHS as well; increased residential care, people attending hospital more, more falls, urinary tract infections… There is proof where the services are working, such as the service that we have in Hertfordshire, that people genuinely stay healthier, they are visiting their GPs less, they would be in care according to the people who are reporting, so we do need to raise this challenge together.”
But Caroline Lecko patient safety lead at NHS England asked: “What do we need to say to people to get them to understand? I’ve heard for probably the past six years the cost of malnutrition, how many people are affected, and to be perfectly frank, I’m bored of hearing the same statistics.
“I think we need a different message to get it out there so people will listen.”
Emma Rose of the Soil Association wondered whether there was data available on the true cost of malnutrition that might drive the argument.
Wren said she believed statistics were available, particularly following the work of the Malnutrition Taskforce. She speculated, however, that attention might not be garnered until a tragic death had occurred: “It must be going on every year; hundreds, maybe thousands of old people are dying in their homes, in their communities with no one supporting them for the basic needs of life, and in a country like ours, it is shameful.”
William McCartney, head of catering services at Sussex Partnership NHS Foundation Trust, said he thought many councils had shifted the burden onto the NHS: “My trust is a mental health trust, and we’re finding huge pressure now on all our services because we’re seeing individuals who’ve got malnutrition.
“We’ve got patients coming in – elderly patients who are very anxious because they’ve had no food, they’ve not been looked after, have been ignored – and I was shocked recently on seeing some people who had left our rehab services in really great health and then a year to 18 months later, they’ve come back in from a social care environment and look very unwell.”
Chair of the Hospital Caterers Association Andy Jones (right) said: “William [McCartney]’s right, I think there was a tendency to give this problem to the NHS, but our budgets are also being squeezed.
“The only way we’re going to solve this is to join together and ‘evidence-base’ it. I really do feel that the time has come to stop talking and say, ‘we’re going to put some money behind this’.
“We need evidence of the value of food within the recovery plan, and we can link it with the evidence base of what is in the community.”
He continued: “We see patients coming in under nourished and feed them up, but in some really bad cases, they’re released into the community worse than when they came in because technically what they came in with – bronchitis, for example – is cured.
“As a result, they’re put back out into the community, but there’s no meals on wheels and they’ve got no heating, so within two weeks, they’re back in, and the only way we’re going to get out of that cycle is to start working to get evidence.”
He thought that much could be learnt from the evidence being gathered following improvements in school meals and the director of the School Food Plan, Myles Bremner, felt there was also an opportunity for schools to play a more practical role.
He said: “An investment has been made through the provision of national government and local authority funding of maybe £300-million-worth of food infrastructure in our schools, bringing back kitchens, and I think there’s an opportunity for all public services to look at what infrastructure we have and start pulling together a compelling, positive story about good food, rather than polarising between obesity and malnutrition, because local authorities need to address both as a symptom of bad food and poor access to food.”
Linda Cregan of the Children’s Food Trust said: “One of the things that happened in the school food industry was we knew we needed the evidence, but it was the Jamie Oliver publicity that raised the issue, and suddenly people had to listen and the School Food Trust was set up as a result.
“Then there was more interest in gaining the evidence. Nowadays, I never talk about the cost of free school meals; I always talk about the number of hungry children that get a meal that wouldn’t have had one before, and politicians and people will listen more to the story of that child or that elderly person in the community that’s benefitting from a service.”
Anne Donelan of the British Dietetic Association underlined the point, saying that qualitative evidence would help provide the right story that captured people’s imaginations.
Rose added: “I think we’ve done a really good job in the schools sector and increasingly in the hospitals sector, and it’s got a lot of coverage. There’s appetite for action, and I think generating a narrative around it does create a mandate to go to the decision-makers and say ‘something needs to change’.”
But chair of LACA Carrieanne Bishop asked: “How do we get the decision-makers to come and sit with us and listen to this conversation. How do we lobby them?
“We need to get everybody who is involved in feeding these people or understanding their care to come together and lobby ministers.”
Wren mentioned that other factors contributing to elderly malnutrition were loneliness and a lack of community. Isden agreed, saying that issues of frailty and disability were also involved, calling it ‘a wicked problem with no simple solution’.
She said it needed to be framed in a wider debate about a crisis in social care.
“There is no way we can support older people adequately if we have a social care system that’s fallen apart and expecting the NHS to pick up the pieces. We need to take a community approach,” she said.
She added that the Malnutrition Taskforce, headed by Age UK’s Dianne Jeffrey, had worked with social, health and voluntary sectors in its five pilot areas, and had discovered some ingenious, low-cost solutions.
Former dinner lady Jeanette Orrey, now school meals policy adviser at the Soil Association, offered an example of one low-cost community-based solution she was familiar with – a lunch club for senior citizens that brought children and older people together via a school kitchen.
Mark Taylor (left, centre) of Premier Foodservice cited the London Borough of Tower Hamlets, which created a central production unit that enabled the council-run catering operation to provide a school meal and a community meals service.
He said: “This actually saved money because the costs of running multiple kitchens throughout the borough were reduced. And the human contact a community meals service provides to older people is also invaluable.
“I think Tower Hamlets is a really excellent example of a local authority that’s got their wits about them.”
Bremner added: “I think there are opportunities to show a positive story of brilliant people doing brilliant things where it does work within the existing system and to come up with the qualitative examples.
“I do think we need to look at school kitchens that have had huge investment; a lot are only operational for 191 meals a year. How can local authorities start using some of that infrastructure of the dining room and the kitchen, and show some good community stories?”
Taylor thought there was also an opportunity and wisdom in making better use of school dining facilities throughout the year, and he sounded a note of optimism.
“Five years ago, if we’d sat here, we would never have thought that this year we’d be giving school meals to every infant school child, so there is money available.”
Bishop noted that such ideas could create staffing issues because many kitchen workers were contracted only for term time.
“But such problems are not insurmountable, the facilities are there, it’s getting the buy-in from the head teachers and their local authority to do it, but I think the will is there.”
Jones noted: “People like to see the figures, but how can you put a value on somebody’s life? Hospitals are the community heart; hospitals, schools and the care sector are at the heart of the community.”
He went on to talk about the pending hospital food plan and of concerns that not many of his HCA members were reporting they already had a policy in place.
He concluded that there were lessons to be learned from the School Food Plan, and how the information about it had been disseminated to caterers and clients.
Wren reminded people why all the issues under discussion were important.
“Most of the people we look after are elderly, frail or vulnerable. Many of them have had problems in the past with drugs or mental health problems… [there are] many reasons why people become vulnerable, but they are a group that are not heard, and we need to stand up and say this issue cannot be pushed under the carpet again. We need to act and we need to act together on their behalf.”