The Cambridge Conference Report

Welcome to Cambridge

The 2019 conference was opened by Professor Sumantra Ray, director of research in food security healthy and society at the University of Cambridge. He introduced us to some of the most notable research produced in Cambridge starting with the discovery of DNA by Watson and Crick. He moves on to discuss the excellent multidisciplinary work of the past seen in the partnerships formed by Elsie Widdowson and the medical team, highlighting partnership working between a dietitian and a doctor. Cambridge University is famous for interdisciplinary working and trying to find solutions to chronic problems in a world of ever diminishing resources. Supported in the UK by an NHS the is now reprioritising nutrition Professor Ray suggests we now in a position with properly placed nutrition in healthcare to make key changes.

What do politicians need to know and how can politics help further improve person-centred nutritional care?

Lord Lansley
House of Lords

Lord Lansley opens by describing his position as both a policymaker and a patient, having recently experienced bowel cancer. He talks about being thankful for being able to eat, and his experiences supporting his elderly mother who wanted to eat but was unable to. He describes the profound effect it had on him as a policy maker. Lord Lansley acknowledges the challenges of constantly being offered food and the reaction of people to his large weight loss of 17kg over a year. Lord Lansley was grateful for his access to a dietitian and nutritional advice. Most notably for him, his starting advice was no fibre, eat crisps and marshmallows.
Lord Lansley describes the “Complex relationship that humans have with food”. He describes the government’s acknowledgement of the prevalence of malnutrition and the commitment to better screening for malnutrition and better standards of food in hospitals. The change that followed was a review of hospital food. The result is not fundamentally about malnutrition in hospitals but about the food, which is less beneficial for patients who cannot eat at all. He describes the focus as still on obesity and not yet balanced with malnutrition. He hopes we can move to combat malnutrition and obesity at the same time. “We need to give people access to food and that is a societal challenge”.
Lord Lansley finishes by acknowledging the need for leadership to support improved outcomes. He suggests that we need to audit current procedures then focus on specific elements to get the desired outcomes. He quotes the reductions seen in cases of Clostridium difficile when this was an NHS focus. This leads to a need to update commissioning guidance. He would like to know if patients receiving treatment from the health service actually recover, their nutritional status and the acknowledgement that in many cases, it is worse.

The new health and social care landscape in the UK: opportunities to
improve nutritional care

Ben Howlett
Managing Director Public Policy Projects

Most important policy papers
Ben Howlett opens by talking about one of the most important policy papers, the 2019 NHS Long Term Plan. The 136-page document only mentioned nutrition 5 times. Ben suggests it may be missing from the bigger picture. Furthermore, The Advancing our health: prevention in the 2020s consultation document suggests the predominant issue is obesity, particularly childhood obesity, suggesting a lack of understanding from the government. Ben suggests that there needs to be more acknowledgement of the scale of the problem – 1.3 million people over 65 are suffering from malnutrition – 93% our in the community.

Ben highlights some potential opportunities for improving healthcare including the general election 2019, the current reforms in the landscape of health care and our ageing population. He makes reference to the document “The importance of nutrition
to the integrated care debate” which recommends better nutrition practice, data collection, education and training alongside a whole system approach. He finishes by highlighting that outreach is needed for solving problems in malnutrition. Changes are needed in acute trusts that can be taken into the community.

Trevor Smith finishes by sharing some nutritional statistics related to malnutrition
• 5% of the population have disease-related malnutrition
• Individuals with malnutrition – 93% free-living, 5% care homes, 2% hospital.
• 1 in 10 older people are suffering from or at risk of malnutrition

Are the needs of individual patients being met?

Monika Malickova
PN patient from the Czech Republic, head of the International patient group PACIFHAN (International Alliance of Patient organisations for Chronic Intestinal Failure (IF) and Home Artificial Nutrition (HAN)

Monika opened with her experience as a patient who has required long term artificial nutrition. Following on from this she introduced us to the 9 countries that are currently members of PACHIFAN including Denmark, Sweden Italy and the UK.
As an organisation PACIFHAN aims to be a trusted international reference on HAN from a patient’s perspective, encouraging peer-reviewed research. Further aims include an increase of awareness and quality of life for HAN patients. PACIFHAN also aims to tackle areas where patients feel their needs have not been met, including training and access to equipment.

Monika closes by inviting us to take part in and promote World Home Artificial Nutrition Day on 15th October 2020.

Optimal Lunch for All

We are introduced to lunch where butter and oils have been prepared in a series of sweet, sour, bitter, salty and umami flavours. We are able to add specific flavours to our meal’s dependant on our own tastes. The taste test initially developed to support oncology patients allows the chef to create a specific taste profile to each person.

Opinions were sought on the key factors to successfully implement human nutrition curriculum in medical schools. As a result, the basic knowledge that should be taught in medical schools was established. The next step for the project is implementation – with a meeting planned in January 2020.

CNA – consulted on the definition of national food policy, involved in 83 policies including food in hospital and food and health.

Influence | Influencing public awareness and policy

Keynote: Rachel Power: What are routes for patients to make their voices heard

Rachel Power is the chief executive of the Patient’s Association and she starts by introducing us to their key values of compassion, collaboration, inclusion and empowerment.

We are asked to consider the question of why patients need to be empowered?
Rachel reports that when patients are empowered, we have better physical and mental wellbeing, improvement in services, maximise impact, promote inclusivity and respond to change. The Patient’s Association has a helpline that gets around 3500 calls and a range of projects for the patient voice.

Integrating nutritional care into the patient pathway across health and social care systems: Why and how?

Dr. Rebecca Stratton

Dr Rebecca Stratton, the chair of the Malnutrition Action Group, British Association for Parenteral and Enteral Nutrition (BAPEN) introduces us to the benefits of integrating nutritional care for malnutrition into the patient pathway. Dr Stratton starts by highlighting why we should integrate – improving identification of malnutrition leads to the right nutritional care to improve outcomes, primarily benefitting patients but also saving money and therefore benefitting society.

She informs us that there are 5000 uses of the MUST tool per month on the website. Better identification can be seen through Integrating these tools into hospitals and NHS software packages. Furthermore, we need to move towards embedding decision making and management pathways into disease-specific guidelines. In regard to raising awareness, she re-iterates that dietitians need to be the voice, empowering other professionals and patients to act.

Dr Minha Rajput-Ray and Dr Harrison Carter: Nutrition Education in Healthcare Practice: Implementation Pathway Project

The second day of the conference started with a talk from Dr Minha Rajput-Ray and Dr Harrison Carter on behalf of the NNEdPro Global Centre for Nutrition and Health think tank specifically highlighting their focus on the need for strategic partnership between disciplines and keeping patients and carers at the core of their research.

A large focus of their talk focused on their ‘Junior Doctors Study’ carried out in 2018 in which 20 trainee doctors were surveyed to explore their observations and attitudes on current nutrition care in Addenbrookes Hospital (Cambridge) to identify possible gaps in the management of hospital malnutrition and lack of training.

They shared some very interesting results, most notably that there was agreement amongst the Junior Doctors about the importance of nutrition in health and appreciation of the doctor’s role in nutrition care and it was felt that there was need for a multidisciplinary approach to achieve this. They reported their nutrition training to be inadequate with a resultant lack of confidence in their nutritional knowledge. One of the most interesting findings was that the Junior Doctors identified Consultants as those best placed to promote nutrition. The main conclusions drawn from the study were that doctors are likely to engage positively with increased nutrition training if the ideal method for its provision can be established and also that Consultants may have a role to play in raising the profile of nutrition care among trainee doctors.

They then spoke about their ‘Patients and Carers Sub-Study’ which focussed on the patient and carer voice. This revealed that half of the participants had never spoken to a Doctor about food or nutrition as felt there was no point in doing so. There was also a belief expressed that Doctors don’t have the knowledge or time to advise patients on food. It was felt that nutrition care in hospital is often Doctor led and so if the Doctor doesn’t mention anything to do with nutrition, the patient and/or carer doesn’t either. It was expressed that they did not feel Doctors could do anything about the quality of hospital food. Perhaps most importantly, it was reported that patients and carers who were provided with nutritional advice often could not follow it due to a lack of understanding of the technical terms used and a lack of guidance on actual food choices especially in conditions which affected their intake.

They then introduced their current and future projects including the ‘Nutrition Implementation Coalition’ which aims to broaden the conversation about nutrition in health for the benefit of the patient through various means including increasing the nutritional knowledge within health professionals’ curricula. They are also in the process of writing a book: ‘Elsevier Essentials of Nutrition in Medicine’ and are also working on parliamentary policy dialogue on raising NHS Food and Nutrition standards.

Dr Clare Shaw: Essential steps in the Nutritional Care Process

Dr Clare Shaw spoke about the essential steps in the Nutrition Care Process (screening for malnutrition, nutritional diagnosis, nutritional assessment and targeted individualised nutrition intervention).

She spoke about the need for nutrition screening to be sensitive and specific so that those at risk of malnutrition are identified and those who aren’t being ruled out. She also highlighted that tools used for screening should be validated and that there must be good training in using these tools to ensure their effective implementation. However, she emphasised that criteria for referral to a Dietitian should be broader than just a screening tool.

It was stressed that identifying a person as at risk of malnutrition is only the first step and once a person is identified, the causes of malnutrition must then be identified. She suggested that using a framework may be helpful such as the Patient-Generated Subjective Global Assessment or the ESPEN GLIM criteria.

The British Dietetic Association’s ‘Process of Nutrition and Dietetic Practice’ was described as an ideal framework to underpin how malnutrition is managed as it allows a thorough nutritional assessment to be performed and allows for targeted and individualised interventions to be used due to its service user focus.

Finally, Dr Shaw emphasised the need for nutritional care to be provided by the multi-professional team.

After the two talks, the focus changed to the ‘Good Practice Exchange Market’ which was designed to elicit good practices from round table discussions. It provided an excellent opportunity to learn from delegates from other countries and gain an understanding of what others were doing to enhance the nutritional care provided. There was noticeable enthusiasm for this amongst delegates.

The next part of the interactive sessions focussed on how the ONCA campaign could be further developed. Delegates were allocated to another table where they brainstormed ideas, strategies or activities which could be used to accelerate the campaign.