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elderly man eating hospital food

Key challenges and improvement actions

Malnutrition and dehydration are common but often go unrecognised and untreated (Age UK). More than 10 per cent of people aged 65 years and over are malnourished and 70 per cent of undernutrition in the UK is unrecognised (ENHA). 

Malnutrition and dehydration were identified as underlying causes and contributing factors in the deaths of more than 650 care home residents between 2005 and 2009 (ENHA).

Human cost

Malnutrition and dehydration greatly increase an individual's vulnerability to illness, clinical complications and death (BAPEN). Dehydration is one of the risk factors for falls in older people and is associated with pressure ulcers, faecal impaction and cognitive impairment.The clinical effects and consequences of malnutrition are wide ranging. Impaired immune response can weaken the ability to fight infection. Reduced muscle strength and fatigue can impede self-care and may result in falls. In bed-bound patients this can result in pressure ulcers and blood clots.

Financial cost

According to Malnutrition Pathway, disease related malnutrition costs the NHS  more than £13 billion per year based on malnutrition figures and the associated costs of both health and social care. A saving of just one per cent of the annual health care cost of malnutrition to the NHS would amount to £130 million annually.

Public awareness

A report from Carers UK based on the experiences of more than 2,000 carers says that malnutrition can be a hidden issue. Carers may be unaware of where best to seek help, and can feel isolated and guilty that the person they are caring for is becoming malnourished, according to the report.

The state of services

Screening and planning for effective nutrition and hydration, coupled with quality food and beverage services and appropriate nutritional support are needed in all care settings. This includes considerations around enteral and parenteral as well as oral nutrition. Evidence collected by Age UK suggests that the reality falls short of what is needed. Concerns have also been raised about monitoring and reviewing processes in the administration of parenteral nutrition to ensure effectiveness and safety.

Identifying factors, targeting actions

Several factors reduce the effectiveness of services. These include lack of prioritisation of nutritional care, lack of awareness of the multiple impacts of malnutrition and hydration and the lack of trained staff.

Research literature from the University of Birmingham has noted the need to move from identifying concerns about nursing performance to targeting actions designed to alleviate contributing factors. This includes an understanding of the pressures of the healthcare environment and the demands of productivity and performance.

Nutrition and hydration present a specific set of challenges and need the attention and visible effort given to other patient safety issues. Early identification and intervention are essential.

Guidance documents and tools have been developed across the UK in response to these challenges. 

Key challenges

How to improve nutrition and hydration

The CQC’s Dignity and nutrition inspection programme: national overview identifies three key points:

  • the role of leadership throughout an organisation in creating a culture that prioritises dignity and nutrition and supports staff to deliver care that meets the expected standard
  • the importance of staff attitudes in preserving, or diminishing, dignity.
  • the risks associated with under-resourcing that make poor care more likely.

Concerns identified in the report:

  • patients not given the help they needed to eat, meaning they struggled to eat or could not eat
  • patients being interrupted during meals and having to leave their food unfinished
  • patients' needs not being properly assessed, meaning they didn’t always get the care they needed – for example, specialist diets
  • records of food and drink not being kept accurately, so progress was not monitored
  • patients not being able to clean their hands before meals.

What organisations can do

To raise the standard of nutritional care, organisations must make sure:

  • malnutrition is actively identified through screening and assessment
  • malnourished patients and those at risk of malnutrition have appropriate care pathways
  • frontline staff in all care settings receive appropriate training on the importance of good nutritional care
  • management structures are in place to ensure best nutritional practice.

Many trusts have done one or more of these but have not achieved sustainable improvement across all four areas. A strength in one area (good screening rates consistently achieved) can mask a deficit in another (failures in delivering the care plan that is required for patients identified at risk).

Recommended Actions:

According to the British Association for Parenteral and Enteral Nutrition (BAPEN) and the National Patient Safety Agency (NPSA) organisations should:

  • appoint a clinical lead with responsibility for nutrition supported by a senior manager
  • encourage patients and carers to help design nutrition services
  • form dedicated teams to carry out improvement programmes
  • secure top level backing for improvement programmes to help spread best practice
  • create educational opportunities around nutritional care and set related appraisal objectives.



Page last updated - 29/06/2023