Hiding in plain sight: Tackling malnutrition as part of the prevention agenda

Executive summary

Malnutrition affects an estimated 5% of the population in England and is more prevalent in older people, those with major conditions such as cancer, Chronic Obstructive Pulmonary Disease (COPD) and dementia as well as higher rates of deprivation.1 People with malnutrition are more likely to visit their GP, be admitted to hospital and recover from treatment more slowly. Our updated research – based on the original work of the British Association of Parenteral and Enteral Nutrition (BAPEN) but carried out independently – estimates that the additional cost of a person with malnutrition is £7,775 per person per year at a total cost to the healthcare system in England of £22.6 billion.2

The majority of the cost – £15.7 billion – is in secondary care with £5 billion in social care and £1.9 billion in primary care.

The impact is not evenly felt across the country. Poorer, older populations have higher rates of malnutrition including a number of northern and coastal communities. These higher rates mean higher costs with some Integrated Care Boards (ICBs) spending an estimated 20% or more of their budgets on people with malnutrition.

As our population ages and the number with major conditions increases, rates of malnutrition are set to rise. By 2035 the estimated number of people with malnutrition will increase by half a million at a projected cost of an extra £4 billion.

Malnutrition has rarely been a health service or system priority. There is no clear Ministerial or NHS oversight of the issue. An analysis of national Government and NHS policy identifies only a small number of targeted interventions to address this significant challenge. Existing clinical guidance and guidelines is implemented variably and much of it is now several years old.

But opportunities exist to take action, including better screening and access to nutritional support and treatment. Taking such action is cost effective. Treating those at the highest risk of malnutrition has been proven to be cost effective and would deliver much needed health system savings3. A study in Gloucestershire found that screening and treating those with a medium and high risk of malnutrition resulted in a 49% reduction in hospital admissions, 48% reduction in length of hospital stay, 21% fewer GP appointments, 30% fewer antibiotic prescriptions and 13% less healthcare professional contacts.4

There now needs to be a concerted push on changing policy at national, system and patient level.

The political health policy focus on prevention is yet to translate into a set of clear cutting priorities. There is an opening to start to define this through the forthcoming Major Conditions Strategy.5 Patients with the major conditions identified (cancer, COPD, dementia, mental health, stroke and musculoskeletal) are at greater risk of malnutrition and action on malnutrition should be included within the cross cutting prevention actions of the strategy.

Within the NHS, moves towards integrated care create opportunities for systems to use population health management approaches to better identify those with or at risk of malnutrition and shape services in ways that tackle the problem. ICBs with more people with and at risk of malnutrition will need to work with partners in Integrated Care Partnerships (ICPs) to effectively make progress. This could include local authorities screening people going into care homes for malnutrition and incentives for primary care to increase the identification of those at risk.

And the development of digital tools and technologies creates new ways to engage with patients and the public, for example through a new planned digital health check. This could include providing those more at risk of malnutrition with weighing scales to enable people and their clinicians to more closely monitor patient weight gain and loss.

For too long malnutrition has been a major health policy issue hiding in plain sight. This report argues that for policymakers the time for hiding is over.