Impact assessment

Helping older people maintain a healthy diet: A review of what works

Published 2 February 2017

1. Executive summary

The evidence suggests that malnutrition causes significant and long-lasting health conditions. In an ageing society where the cost of long-term care is increasingly unaffordable, we need to ensure that older people age well. Being malnourished increases the risk of frailty and is therefore detrimental. Identifying and treating malnutrition is an important prevention programme which will, in the long term, reduce the need for both health and social care.

It has been estimated that the greater use of healthcare because of malnutrition results in:

• 65% more GP visits
• 82% more hospital admissions
• 30% longer hospital stay [1]

1.1 Definition of malnutrition

Malnutrition, for the purposes of this review, can be identified as low body weight and weight loss. The National Institute for Health and Care Excellence (NICE) defines a person as being malnourished if they have:

• a body mass index (BMI) of less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the past 3 to 6 months
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% in the past 3 to 6 months [2]

The literature highlights four main areas on which programmes can focus to reduce the burden of malnutrition:

• how do older people access healthier food and drink
• can older people prepare a healthy balanced meal
• are older people functionally able to eat a healthy balanced meal
• what support systems are available to ensure older people can help themselves

The Malnutrition Task Force (MTF) provides a good platform to support initiatives, by sharing experiences, practice, what works and, perhaps more importantly, what doesn’t work. The case studies show that prevention is important and that many initiatives are underway. It is important that providers evaluate the outcomes of all these programmes and develop the evidence base.

The NHS Five Year Forward View, PHE’s Evidence into Practice series and plans to integrate health and social care all point to a new focus on prevention. This review aims to give local decision makers enough information to begin conversations around malnutrition, health and older people. It pulls together examples of promising practice and attempts to depict work ongoing across the country.

2. Introduction

This review of evidence aims to consider ‘what works’ in supporting older people to maintain a healthy diet and reduce the risk of malnutrition in a community setting. It is intended for anyone working on older people’s health, particularly those working on nutrition and those supporting older people in daily living. It reviews the relevant national standards, such as nutritional and catering standards, relevant NICE standards and guidance, national and international evidence (in English language, in the past 10 years). Finally, it looks at promising practice from England, to see what others are doing and the impact their work is having. For the purposes of this study older people are defined as being aged 65 or over. The study was initiated to support one local authority, Buckinghamshire County Council, with its work on malnutrition and older people.

2.1 Approach to the study

The study has two main components:

A. Literature review

A literature review was undertaken looking at national guidelines, primary research and grey literature.

B. Expert interviews and emerging practice

Public Health England (PHE) national leads for older people and diet & obesity, and PHE centre leads for older people, were asked to identify examples of promising or emerging good practice in the community in older people’s nutrition. Experts in the field, including local authority, local Academic Health Science Networks (AHSNs) and third sector colleagues were contacted by email and telephone to collect input on their current programmes of work, which included a selection of projects described by the Malnutrition Task Force (see section 3.2). Telephone interviews took place with programme leads, who were then asked to complete a template. The case studies were reviewed and a selection of different and promising practice was identified and included.

2.2 Limitations

The projects were identified for inclusion during January and February 2016. Some, but not all, of the projects used as examples of promising practice have been evaluated. PHE cannot endorse any projects that have not been evaluated through a peer-reviewed process. Hence, this report does not make recommendations.

3. Context

The majority (93%) of people at risk of malnutrition are living in the community, 5% are in care homes and 2% are in hospital. Consequently, the focus of this paper is on older people in the community. More information is available from the MTF.

It has been estimated that at any one time more than 3 million people in the UK are at risk of malnutrition and yet it continues to be an under-recognised and under-treated problem. Furthermore, the health expenditure on disease-related malnutrition in the UK in 2007 was calculated to be in excess of £19 billion per annum, about 80% of which was in England. This is a heavy health burden and financial cost to bear, not only for individuals, but for health and social care services, and society as a whole. [3]

The literature [5, 6] shows that those living in deprived or isolated circumstances are at greater risk of undernourishment and malnutrition. This means there is an important health inequalities dimension to the subject.

Buckinghamshire has an estimated 99,251 people over the age of 65. Estimates suggest that 27% of the population are at risk from malnutrition. In Buckinghamshire, this equates to 26,798 older people at risk from malnutrition, of whom, 24,922 (93%) will live in a community setting.

3.1 Definition of malnutrition

Malnutrition, for the purposes of this paper can be identified as low body weight and weight loss. NICE defines a person as being malnourished if they have:

• a BMI index of less than 18.5 kg/m2
• unintentional weight loss greater than 10% within the past 3–6 months
• a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the past 3–6 months

3.2 Obesity and malnutrition

It is important to recognise that the problem of malnutrition and undernourishment is not limited to those who are underweight. Much research, particularly in the United States, has found that malnutrition can also be associated with obesity. While this is important, particularly as it affects predominantly Black, Asian, and minority ethnic populations, this study has not examined this issue.

3.3 Why is tackling malnutrition important?

Malnutrition impacts on every system of the body. It reduces the ability to fight infections, increasing the risk of pneumonia and septicaemia. Muscle density reduces, decreasing mobility and increasing the risk of falls. The heart is a muscle, so severe malnutrition will eventually lead to heart failure. [7] Wounds heal more slowly and there is an increased risk of pressure sores/ulcers. Finally, malnutrition can impact on the body’s ability to regulate temperature, leading to an increased risk of hypothermia.

All these conditions are significant threats to older people who may have co-existing morbidities. Malnutrition could therefore have a considerable impact on older people’s health and social care needs and a wider impact on their overall health and wellbeing, independence and quality of life. [8]

4. National guidelines and standards

NICE guidance CG32 on nutrition support in adults covers the care of patients with malnutrition or at risk of malnutrition, whether they are in hospital or at home. It doesn’t cover malnutrition or its treatments in detail.

Explanation of this type of nutritional support can be found here

NICE quality standard QS24 defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. This quality standard covers adults (18 years and older) in hospital and the community who are at risk of malnutrition or who have become malnourished, and adults who are receiving oral nutrition support, enteral or parenteral nutrition. It can be used in contracts with care providers to support better nutrition in older people.

4.1 Malnutrition Task Force

The MTF is an independent group of experts from across health, social care and local government that aims to address avoidable and preventable malnutrition in older people. Established in 2012 to share expertise, the task force works with partners in hospitals, care homes, local authorities and private and voluntary organisations. The MTF website contains resources and studies to help agencies supporting older people.

4.2 PHE and the British Dietetic Association (BDA)

PHE has published catering guidance for those serving food to older people (in residential care), which provides advice for serving food to meet the nutrient needs of this age group in care and other settings. The BDA Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services also gives advice on good nutrition in care settings. They are not specifically aimed at older people living at home.

4.3 Workforce Competence Model in Nutrition for health and social care

The Workforce Competence Model in Nutrition provides a framework that benchmarks competences and underpins standards for expanding the skills of the nutrition workforce. The model, developed by the Association for Nutrition, will help to ensure that workers are demonstrably competent and able to practise in accordance with defined standards of proficiency, conduct, ethics and training.

5. Literature review

The literature search was undertaken by PHE’s Knowledge and Library Services using the search topic: What are the success criteria for community programmes encouraging healthy eating for people over 65 years? References from this search are at the end of this report.

5.1 Primary research

The majority of the primary research studies were from overseas, notably the US, Japan, Canada and Australia. Only limited research was found in the UK or Republic of Ireland.

5.2 Grey literature

The grey literature search discovered reports and guidance from the UK, most notably studies from MTF, as mentioned above. The BDA [9] and Age UK [10] websites were also reviewed.

6. Emerging themes in the literature review

While many issues were not covered in the literature review, four major themes did emerge:

• access to healthier food and drink options and food poverty
• ability to prepare healthier food
• functional and cognitive impairment and ability to eat healthier food including poor oral health
• food and dietary resilience

These themes are areas to consider when shaping future interventions to improve older people’s nutrition.

6.1 Access to healthier food and food poverty

It is important to set the issue within a socio-ecological context and examine the whole ‘food environment’. For many older people, accessibility and affordability are the initial barriers to healthier eating and meeting their dietary requirements.

For example, out-of-town supermarkets are often not easily accessible without the use of cars and many older people, for reasons such as poverty or disability, do not have cars or are unable to drive. Although they may have access to local shops, these tend to be more expensive and may offer less choice of healthier options.

A report by Age UK in 2012 highlighted the barriers affecting older people throughout the shopping journey. [11] These factors included:

• difficulty getting to the shops
• difficulty in store
• shopping for one
• age-unfriendly packaging
• bad weather

An Australian study in 2006 identified the extent of food insecurity (defined as running out of food in the last 12 months and being unable to afford to buy more) among older Australians, and the characteristics of those who experience such food insecurity. [12] The study found that those most at risk of food insecurity were likely to report poorer health, limited financial resources, not owning their own home and living alone. Gender and age differences were also found to be relevant.

A further survey [13] of more than 1,000 people aged 65 plus found:

• two-thirds (66%) budget carefully and spend within their means
• 15% go from shop to shop to find the cheapest food
• 15% shop for food in the reduced section or wait for food to be discounted at the end of the day
• 7% of all aged 65, and 16 per cent of those in the lower socio-economic groups, cannot afford to buy a healthy balanced diet

One way of measuring accessibility to food is to map food access and food poverty. This study describes food poverty in Oxford.

Case study: Gwen

Gwen, aged 72, is on a low income. Her weekly shop at the local supermarket used to cost £65. She was able to buy good quality ingredients, fresh vegetables and meat and was able to plan meals for the week which she could prepare. Gwen is no longer able to drive and can only shop locally at convenience stores within walking distance from home. She is unable to carry heavy shopping and therefore has to shop every day, which is increasingly expensive. The convenience store has a limited supply of fresh food so Gwen is buying more and more tinned and ready meals.

6.2 Ability to prepare healthier food

Research shows that many older people have difficulty with food preparation. [14] The weight, packaging and opening mechanisms of food containers and the ability to physically prepare and cook healthier food can be problematic. Mobility and other physical impairments such as arthritis are seen to be factors that affect ability to prepare food. It is estimated that at least 80% of older people have some form of arthritis. [15]

Other physical challenges for older people include cutting food, standing for long periods, carrying and pouring food and liquid without causing injury or spilling, as well as cooking and being able to use the oven safely.

Case study: Patrick

Patrick, aged 79, has arthritis, poor mobility and impaired sensation in his hands following a stroke. Although his son is able to buy a range of nutritious food for Patrick, he is not able to physically prepare and cook the food. Patrick’s arthritis means he cannot open the food or carry utensils and his poor mobility and lack of sensation put him at risk of stumbling and burning himself when using the hob or oven. As a result, he frequently eats cold food, cakes and biscuits instead of a proper meal.

6.3 Functional and cognitive impairment and ability to eat healthier food

Malnutrition has been found to be related to functional impairment in older people. [16] Links are found between several forms of physical or mental impairment such as dementia, depression or other co-morbidities and poor diet and undernutrition. Depression can lead to loss of interest in food. Dementia can affect appetite and food intake. Cognitive impairment is also a significant issue for older people with dementia. For example, they may have difficulty in recognising food and drink and lack the concentration to eat a full meal. [17]

Social isolation can also result in a loss of interest in food. Previous social interaction may have been a positive factor in encouraging healthier eating. However, living alone with no social contact removes the positive link between social interaction and eating.

Other research showed that loss of natural teeth was a risk factor for malnutrition among frail, older people living in the community. [18] In the UK, 58% of adults aged 75 and over have no natural teeth and rely on dentures. These people tend to eat less fruit and vegetables and have lower intakes of some micronutrients such as vitamin C. [19]

Dysphagia (inability to swallow) has been found to be strongly linked with malnutrition. Furthermore, it may be an important predictor of malnutrition progression in older people. [20]

Case study: Mary

Mary, aged 84, is alone, living with depression and has lost interest in food and eating. She is not motivated to cook for herself and often has only one meal per day. She also has an anxiety-related illness, which means she is worried about constipation if she does manage to eat. This leads to food avoidance and only eating very small portions. She is therefore undernourished.

The Wessex Strategic Clinical Network has developed the Wessex Dementia Timeline with local partner organisations as a visual representation of dementia projects in place in Wessex. This resource is for individuals and organisations collaborating to improve dementia care in Wessex. It includes two examples of post-diagnosis projects relating to the importance of nutrition for people with dementia—Does Use of Coloured Crockery Influence Food Consumption of Elderly Patients in an Acute Setting? and Understanding Nutrition and Dementia.

6.4 Food and dietary resilience

Some older people manage to eat well despite the dietary obstacles of old age. It is important to consider how these individuals manage to eat well and whether their personal coping strategies could form part of behavioural interventions to support other people. This concept of dietary resilience needs to be understood when developing policy or designing programmes. [21]

Research into the malnutrition universal screening tool (MUST) states [22]: Four key themes of dietary resilience emerged—prioritising eating well, doing whatever it takes to keep eating well, being able to do it yourself, and getting help when you need it. Personal food resources such as food and nutrition knowledge, cooking skills, good physical health, financial adequacy, and independent transport facilitated the development of adaptive strategies among participants to overcome their nutritional vulnerabilities. The importance of relying on oneself was mentioned frequently: ‘‘I am independent! I don’t want to impose myself on anyone.’’ Participants became aware of services through their social network. For example, ‘‘if ever I was sick and couldn’t cook anymore, I would call Meals on Wheels. Apparently, the meals are very good, nutritious, I don’t know, but others that have used it, talk about it.’’

6.5 Assessment tools to identify malnutrition and the risk of developing malnutrition

Screening for malnutrition and the risk of malnutrition both in hospital and the community forms part of NICE guideline [CG32] on nutrition support. The malnutrition universal screening tool MUST is the most commonly used in UK and is referred to in the NICE guidance on nutrition support.

Outside the UK, the most frequently used tool is the mini nutritional assessment short form (MNA-SF). There is limited research about the comparable efficacy of these screening instruments in community settings although studies have compared them in the hospital environment. [21]

7. Synthesis of research findings and emerging practice

Telephone interviews with older people’s leads from PHE centres, local authorities, local AHSNs and third sector organisations in England were undertaken to discover what examples of emerging practices exist that could be scaled-up and used by others. Practice objectives and outputs were then collated through the completion of a template by project leads, including any evaluation details.

The case studies that follow highlight current challenges and emerging practice.

7.1 Purbeck Malnutrition Taskforce Pilot

The project is based in the Isle of Purbeck, Dorset, a rural setting. The following link gives more details of the Purbeck pilot

Partners: Dorset Clinical Commissioning Group (CCG), Dorset Health Care, Dorset County Council, Tricuro, Dorset Public Health Team, Wessex AHSN, all six GP practices in Purbeck.

Aims and objectives: To establish a collaborative approach across health and social care staff that will reduce the prevalence of malnutrition within the communities of Dorset through the implementation of newly-developed nutritional care pathways and accompanying educational tools that focus on the need for early identification and intervention.

Target audience: Vulnerable adults living independently within the community setting.

Funding: Some funding was provided by Wessex AHSN to support the development and printing of training materials, MUST data collection forms and the purchasing of additional weighing scales. As partner organisations were committed to delivery as members of the Dorset Nutritional Care Strategy Group, other resources were provided to the project in kind, such as staff time to develop, deliver and evaluate the project, IT support and the free use of training venues.

Background: Dorset created a partnership that aims to provide the highest levels of good practice in nutritional care for adults. As a result, the Joint Nutritional Care Strategy for Adults was launched in May 2013. The strategy reflects the joint approach, developed under Dorset’s Better Together programme, that tasks all stakeholders to work together towards a better quality of life across Dorset, Bournemouth and Poole.

Malnutrition is generally treatable. Early identification and intervention is key to addressing malnutrition (MTF, June, 2013). Therefore, the development of care pathways for early identification was an essential aspect of the Dorset strategy.

Evidence shows that malnutrition is most prevalent at home and in the community among those aged over 65 (British Association for Parenteral and Enteral Nutrition (BAPEN) 2011; MTF June 2013). As such, it was decided to pilot care pathways for the home and community setting first, particularly as no community-based screening was taking place outside of district nursing teams at the time.

The age profile of Purbeck’s population is fairly typical of Dorset. More than 22% of people are aged 65 plus, which is significantly higher than the national average of just 16%. Purbeck is predominantly rural with limited access to services. This is highlighted by 41% of the 29 ‘output areas’ (localities as defined by the census) in Purbeck being among the 20% most deprived in England for access to services. Currently, 68% of villages have no general store and, since 2005, three rural post offices and one urban one, together with two rural petrol stations, have closed.

Description and timescales: In November 2013, a decision was made to pilot the new care pathways in Purbeck. The pilot was initially developed to evaluate the process in one GP practice area. The process evaluation demonstrated that MUST screening via community teams was achievable. As such, a one-year pilot was rolled out across Purbeck in winter 2014.

January and February 2014: Training was delivered to more than 100 health and social care staff working for the NHS and local authority teams in Purbeck. The aim was to increase:

• the knowledge and understanding of malnutrition and its associated symptoms and risks
• the confidence and competence levels in delivering nutritional screening using the MUST tool

March 2014: The Isle of Purbeck, Dorset, became a MTF pilot area. An electronic form and data base was developed, accessible by all staff, to record MUST and the subsequent interventions applied.

March 2014 to December 2014: Every patient and service user who was visited at home by health or social care staff was screened with the MUST tool.

November 2014: 140 staff were trained within the following teams: Tricuro reablement service: county council social care staff, Dorset health care community teams, community matrons.

December 2014: The electronic form went live and nutritional screening using the MUST tool took place across the whole of the Purbeck area.

November 2014 to summer 2015: The Tricuro day services and the hospital discharge teams joined the group.

August 2014: The voluntary sector element of the pilot, Help and Care, launched a start-up event called An Appetite for Change in Purbeck.

Short-term outcomes:

• improved monitoring of the prevalence of malnutrition in Purbeck across health and social care that all local agencies are committed to delivering, using the newly-developed shared electronic database
• improved communication between those agencies responsible for the care of vulnerable adults within the community setting
• competencies of community-based staff in supporting the nutritional care of vulnerable adults in Purbeck through the development and delivery of a nutritional screening training package

Long-term outcomes:

• improved quality of care for vulnerable adults across the community setting in Dorset
• an increase in the number of vulnerable adults with a nutritional care plan
• minimisation of the cases of malnutrition in the community setting through early intervention by non-clinical staff

Evaluation: Public Health Dorset is evaluating the one-year pilot. A summary of outcome data for the first 10 months is below:

• 368 people screened (over 10 months)
• 107 at risk of malnutrition (29%) – national average 14%
• 80 people were screened by those who had not carried out screening prior to the intervention
• 27 service users had a decrease in their MUST score
• 39 service users experienced weight gain
• 18 people referred to dietitians
• 128 health and social care staff trained (93% of those working in the locality)
• 83% increased their knowledge of malnutrition
• 98% had a clearer understanding of how their role was important to identifying malnutrition
• 93% were confident to return to their setting and complete MUST
• potential cost avoidance figures have been calculated using national data, which annually equate to approximately £50,000 for health care. As yet there is no national data to enable the team to add the savings from social care.

Next steps: The project is being rolled out in Christchurch, Dorset.

• in June 2015, presentations were made to GPs in the Christchurch area and the Dorset health and wellbeing board
• care pathways were amended to meet the needs of the area
• the electronic form was reviewed and improved for expanding across Dorset
• the project is being demonstrated in other areas of Wessex where there is interest in procuring it
• training of 140 staff in Christchurch began in February 2016. The Christchurch area went live on 1 March 2016
• in February 2016, meetings took place to consider how and when the pilot goes pan Dorset with a business case put forward to stakeholders

Achievements: A collaborative approach across health and social care to reduce the prevalence of malnutrition in older people is considered standard and expected good practice. The implementation of the project was assessed by commissioners. It met the national agenda, including the NHS Five Year Forward View, developing a national strategy for nutrition and the integration of health and social care within the Better Care agenda.

• promotion of true integrated care (health, social care, voluntary sector) through the adoption of integrated nutritional care pathways
• consistent training and materials across teams working in a locality
• raising awareness within the voluntary sector and among carers and older people
• reduction in health and social care needs through a general improvement in the nutritional status of older people
• increased understanding of the benefits of providing good nutritional care, raising its provision up the agenda

Further information: Sue Hawkins, Care Catering Services Manager, Tricuro Catering Services 013 0522 5930, sue.hawkins@tricuro.co.uk

Michelle Smith, Health Programme Advisor, Dorset Public Health. Tel: 0130 522 5703, michelle.smith@dorsetcc.gov.uk

7.2 Older People’s Essential Nutrition (OPEN), Eastleigh

Setting: Initial implementation in Eastleigh, Hampshire. This link gives more details of the Older People’s Essential Nutrition project.

Partners: Hampshire County Council, social workers, occupational therapists, Community Independence Team, Biomedical Research Centre (Nutrition), University of Southampton, GP practices, Southern Health NHS Foundation Trust, Community Nursing, Older People’s Mental Health, pharmacies, voluntary sector, One Community, Age Concern Hampshire and Age Concern Eastleigh.

All staff involved are expected to attend training, complete screening and care planning.

Aim: To develop and evaluate an approach for the provision of good nutritional care for older people greater than 65 years, within the community setting so that other areas across Wessex, and nationally, can learn from the project and either replicate or adopt it in their area/context. The approach builds on an existing pilot in Purbeck (see above), which is part of the Dorset Malnutrition Prevention Programme, one of five national MTF pilots, and part of the portfolio of projects supported by the Wessex AHSN Nutrition Programme.

Objectives:

• to educate the health and social sector about the implementation of nutritional care pathways based on national guidelines, providing guidance on screening, individualised care plans, co-ordination between relevant workforces and timely care and review
• to reduce the number of older people who are malnourished and the associated health and social care use
• to raise awareness of malnutrition. Training sessions were developed to raise awareness among the public and the health and social care workforce to promote earlier prevention and treatment
• to develop an evaluation framework that will support future commissioning of good nutritional care in Eastleigh and Hampshire as a whole
• to produce a support package. This involves piloting a nutrition package, with training and awareness materials, evaluation tools and nutritional care pathways, that can be adopted in other localities

Target audience: Older people living in the community from all ethnic backgrounds including white British, Asian and Nepalese.

Timescales: The project was set up and pathway design developed from September 2014 to March 2015. Initial training took place in April 2015 and first screening in May 2015. Data collection was planned from May 2015 to April 2016.

Funding: Wessex AHSN funded specific dietitians, data collection and evaluation, training development and delivery.

Background: Malnutrition is estimated to cost (health and social care) Wessex at least £520 million per year (approximately 4% of total UK costs). NICE guidelines and other national guidelines have been around since 2008 but there is very limited implementation of good nutritional care within the community care setting, and there is limited data/research to assess the benefits of such programmes. Local issues included:

• no local pathways currently exist to identify and treat malnutrition. Nutritional care is generally not specifically commissioned or monitored because it is considered part of general care. This tends to remove any specific focus on nutritional care by providers
• a large variety of care providers have responsibility for providing good nutritional care (health, social care, and voluntary sector) with responsibility falling through the gaps without an integrated approach
• care providers are unclear about where to find the information they need to support people with nutritional issues and who to go to for guidance
• other care priorities already fill busy schedules. Limited cost-benefit evidence exists to promote the importance of providing good nutritional care, particularly in the community care setting

It was considered that an integrated, whole-system approach was needed to reach the significant numbers of people living in the community setting.

Evaluation: Data is still being collected and evaluated. Initial figures include:

• 265 people screened (over the first 8 months)
• 32% of screenings were at risk of malnutrition (12% medium risk, 20% high risk)
• 120 professionals trained, plus voluntary sector leads; general public sessions
• evaluating the improvement in nutritional status and in wellbeing

Challenges:

• the large number of organisations, teams and individuals who need to be involved and commit to implementing integrated nutritional care pathways
• the time and effort required should not be underestimated
• initiatives must have local leadership to provide the drive and commitment for delivery
• engagement and commitment is needed at leadership and frontline levels
• specific resources need to be identified to provide training, support for local teams and data collection for the evaluation

Next steps:

• review the project and support the adoption of the approach by county-wide organisations (Southern Health NHS Foundation Trust and Hampshire County Council) and others within the Wessex AHSN remit
• implement solutions to address issues raised during the initial implementation (eg simpler approaches for screening; including MUST information with discharge; electronic data collection and sharing)
• develop and publish a toolkit, including training packages, nutritional care pathways and evaluation framework

Further information: Kathy Wallis, Senior Programme Manager, Wessex AHSN Nutrition Programme, Innovation Centre, Southampton Science Park, 2 Venture Road, Chilworth, Hampshire SO16 7NP. Tel: 079 9000 2108, kathy.wallis@wessexahsn.net

Martine Fullbrook, Public Health Team, Queen Elizabeth II Court, Hampshire County Council, Winchester, Hampshire. martine.fullbrook@hants.gov.uk

7.3 Nutrition and Wellbeing Service, Hertfordshire Independent Living Service (HILS)

HILS provides a meals-on-wheels service on behalf of Hertfordshire County Council. The Nutrition and Wellbeing Service is available to all clients receiving meals from HILS, which includes around 4,000 older and vulnerable people.

Partners: HILS works in partnership with a range of voluntary, community, statutory and private sector organisations. In Hertfordshire, there is a county-wide service called Herts Help that acts as a one-stop shop for referrals to other services and provides information to residents regarding available services. HILS works closely with Herts Help to ensure that referrals are made to other services when required by clients.

Aims: The Nutrition and Wellbeing Service aims to help clients stay well and remain independent by identifying and addressing nutritional, lifestyle and health issues and address malnutrition in the community. In doing so, the project aims to:

• prevent or delay a move into nursing or residential care, or repeat visits to the hospital due to preventable problems such as falls, malnutrition and dehydration
• educate and promote wellbeing among staff and the wider community

Objectives:

• to complete in-house nutrition and wellbeing screening checks for clients, free of charge. The checks involve an assessment for malnutrition using the MUST tool; checking for frailty, social isolation and loneliness using recognised evidence-based tools; determining whether there are any concerns around sight and hearing, risk of falls, mobility, chewing and eating difficulties, mental health, and social wellbeing; adapting the meal service and/or referring issues identified to internal and external services
• to provide one-to-one bespoke advice for those at greatest risk of malnutrition and those with morbid obesity
• to provide nutrition training (including malnutrition and dehydration) for staff, older people living in the community and groups supporting older people
• to develop literature on health and nutrition to raise awareness

Target group: Older and vulnerable people living in the community. This includes frail older people, those with dementia and a range of health issues including diabetes, as well as vulnerable (but not necessarily older) adults with disabilities. The Nutrition and Wellbeing Service is offered free of charge in order to reach those at greatest need. Clients who may be at greater risk of social isolation, frailty, or malnutrition, or have dementia, health, or social concerns, are prioritised for screening. However, the service is available to all clients, who may opt in via self-referral, next of kin or from the initial meals-on-wheels referral. In all, 89% of HILS clients are aged over 65 and 92% of these are over 75 years. Clients are from various ethnic backgrounds. The majority of clients decline to comment but are assumed to be of White British ethnicity. Of the clients, 39% are male and 61% are female.

Timescales: The pilot began in August 2014 with one part-time member of staff. Two full-time staff were employed in July 2015 and the pilot now has three full-time staff.

Funding: Funding was provided by North Hertfordshire District Council (grant funding in 2015/2016) and Hertfordshire Healthy Homes Local Initiative (grant funding in 2015/2016). Additional funding will be sought to continue the project.

Background: The service was developed primarily to provide a nutrition service for HILS. Independent adults in the community who are well supported are more likely and more able to visit their GP if they have nutritional concerns. They could be referred to a dietetic community clinic provided by the NHS. HILS works primarily with isolated vulnerable older adults, often living alone with limited mobility, limited support and limited independence. This is a growing sector within the community. The service was developed in order to meet the needs of this very vulnerable group who may slip through the net. HILS also works with older adults who are more socially active and who attend lunch clubs by equipping them with the skills to support their continued independence and prevent issues such as malnutrition and dehydration.

Outcomes: The HILS team is working with the University of Hertfordshire, supporting a variety of undergraduate projects investigating the relationships between health variables that have not been considered previously within a similar community setting, as well as providing valuable nutritional analysis to help develop the meals service further.

Screening of new clients entering the service to date has revealed that around 30% require additional nutritional or wellbeing-related support, including nutrition boosts. Re-screening is underway to provide impact measurement progress. A full range of booklets have been produced to support clients, their families, and professionals working with older people, and feedback on these tools has been excellent.

Evaluation: Evidence to show the impact of the service was being gathered with a view to completing an evaluation in 2016. This will include a range of qualitative and quantitative data.

Staff training: 15 training sessions were held for over 150 members of staff, each receiving 3.5 hours of nutrition education. All sessions were well received. Staff reported that the education benefited their clients and helped them do a better job. They had also applied the knowledge in their personal lives.

Training for older people: nine shorter sessions, each lasting 30 minutes, were delivered to older people and their support networks, with over 90 people attending to date. Feedback has been extremely positive. People said they had more knowledge and had enjoyed the practical nature of the training.

Training for referrers: six sessions were delivered, each lasting 3.5 hours, to help 56 people understand more about nutritional issues and provide useful tips, including advice about when to refer to a health professional. Regular training is still being provided to extend knowledge across Hertfordshire.

Challenges:

• setting up the infrastructure to support and promote a novel service has been challenging. A very small team covers all aspects of the service including writing policy and procedures, setting up databases for accurate recording and reporting, undertaking marketing and networking and providing training and assessments. The team works closely with other parts of the business to ensure the smooth running of new services that focus on health
• clients can be wary about engaging with a new service. However, once information was provided, users were receptive and gave positive feedback about training and wellbeing checks
• involving GP practice staff and public health earlier would have been beneficial, although it would have delayed the start of the project by several months. In the initial stages, when developing the service, discussions were held with relevant health professionals and experts in malnutrition and nutrition

Next steps: Further evaluation and dissemination of the service will be shared with CCGs, public health, the University of Hertfordshire and interested parties. It is anticipated that postgraduate students will support the service and undertake research to add to the evidence base. With financial backing, the service could potentially be extended to:

• provide community malnutrition clinics to all those being prescribed oral nutritional supplements, to educate people to meet their energy needs without the need for expensive supplements that may not address the root cause
• provide drop-in information and advice sessions at lunch clubs and day centres, including those that specialise in dementia
• increase numbers of training sessions offered to referrers and support groups
• provide a home visit wellbeing and nutrition check to people beyond the HILS client base, and refer, as required, to support services that promote independence and wellbeing
• provide education, training, clinics, and nutrition and wellbeing checks outside Hertfordshire
• support other organisations to replicate this holistic service outside Hertfordshire
• further work with the University of Hertfordshire’s nutrition and dietetic degree programmes

Feedback from external training sessions:

The most useful part of the training: “Understanding how easy it is to become dehydrated.”

“Activities – very enjoyable and a good learning tool. The training was very good and kept my attention all the way through,” a community care officer.

Feedback from sessions with older people:

“I enjoyed the activity about fluids in foods the most.”

HILS staff training: “Very informative, not only for work but for my own family.”

“The sessions were just about perfect, a good mix of activities and listening.”

Verbal feedback from clients following the nutrition and wellbeing screening check: The HILS water jug is a useful guide to help ensure they drink enough fluid each day. The service is a great idea—it is nice to know that they were being supported and looked after. It is pleasing to hear about the variety of useful and free support services offered in Hertfordshire, for example, mobile optician, free welfare/finances check. This highlighted the need to raise awareness and continue to work in partnership with others.

Further information: Michelle Dewar, Team Leader, Nutrition & Wellbeing, Registered Dietitian, Hertfordshire Independent Living Service, Nutrition & Wellbeing Service, 16 Green Lane One, Blackhorse Road, Letchworth, Herts SG6 1HB. Tel: 033 0200 0103, mobile: 074 3261 4970, nutrition@hertsindependentliving.org

7.4 Vitality for Life, Kensington and Chelsea

The project in Kensington and Chelsea, London, is described in detail here

Partners: Royal Borough of Kensington and Chelsea, public health and fuel poverty representatives, Open Age, Age UK Kensington and Chelsea, Central London Community Healthcare (CLCH), NHS Nutrition and Dietetics team, People First website, Hammersmith and Fulham Council and the City of Westminster Council.

Rationale:

• prevention of malnutrition will reduce frailty though improvement in symptoms of dementia, mental wellbeing, prevention of sarcoma, sarcopenia and reduction in risk of falls
• there is a strong correlation between malnutrition and isolation—those with malnutrition undertake less physical and social activity. There are some resources in place to support both and an increased awareness of malnutrition also supports improved use of leisure and community services
• similarly, through undertaking shopping trips, food through exercise programmes, social meet and eat groups and food and friends, this supports improved mental health, reduces social isolation, leads to active citizenship, community engagement and community resilience
• all these interventions help to reduce the burden on hospital and NHS community services as well as social care services such as community care packages and costly residential care placements

Aim: To improve independence in older age by empowering older people to live healthier lives for longer.

Objectives: With the growing strain on acute hospitals, the main objectives of this project are to:

• raise awareness of malnutrition and food poverty and their impact on health and wellbeing
• create a user-friendly malnutrition risk estimation tool aligned with the fuel poverty estimation tool
• create a tool that is in line with the ‘making every contact count’ model. This would include, but not limited to, engaging third sector stakeholders, health and local authority staff, contracted providers (eg meals on wheels and care providers) and private sector such as pharmacists and chiropodists in malnutrition awareness
• raise awareness of services to enable older people to improve food access
• develop a simple reference resource of local services

Target group: Older adults in the community in Kensington and Chelsea, that is, adults greater than 65 years old, especially frail adults at risk of malnutrition because of food/nutrition insecurity. All ethnicities are included. The project was not gender specific. In terms of health inequalities, it also targets food insecurity, fuel poverty, education, unemployment and low income.

Background: The project started in May 2014 and is ongoing. It is funded by NHS Central London Community Healthcare. The working group was set up to look at what could be done about social Isolation, fuel poverty and food poverty. The group applied for one year of funding to research the issue, provide education, raise awareness and design a resource but did not get funded at this time. The local NHS provided a small amount of funding for a slimmed down version of the project to take place from 2014. A short leaflet or ‘trigger tool’ was produced with two or three questions and signposting information, supported by a website developer from People First

Outcomes: The tool, in the form of a leaflet, was finalised in October 2015. It provides clues to indicate whether someone is at risk of not getting enough food and what can be done about it. The tool is circulated to professionals in Kensington and Chelsea in conjunction with malnutrition awareness training, for example, GP practice staff, community-based health professionals, carers and Age UK staff. The working group agreed to disseminate the tool this way so as to take the opportunity to train local professionals about malnutrition awareness too.

Evaluation: Feedback on the leaflet was provided by a range of people. North London Cares impact evaluation can be found here

The Winter Wellbeing project of 2014/15 mobilised young people to help their older neighbours in Camden and Islington to stay warm, active, healthy and connected during the most isolating time of the year. The report can be found here

Challenges:

• it would have been better to have included more stakeholders from the other two London boroughs, as all three boroughs were not evenly represented
• it was overly ambitious to aim to work across three boroughs. This wasted time and resources
• it might have been better to attempt to pilot the tool in a small area initially, such as Kensington & Chelsea, or part of it
• collaborating with external partners offered a greater range of expertise and scope of experience, but it was a challenge working on a project in separate organisations and offices
• staff turnover was high in CLCH during the project, requiring the involvement of numerous different people and affecting the continuity of input. This difficulty was hard to mitigate
• greater importance should have been placed on project evaluation. A suitable evaluation tool could have been established as part of the project planning and development
• feedback of the tool was received from focus groups of various backgrounds, however, there wasn’t any consultation with older adults in the community due to time constraints

Next steps: The Food for Vitality leaflet/toolkit is on the People First Kensington and Chelsea website. The messages it contains are being built into training. The tools are starting to be disseminated across the community, for example to GP surgeries.

Feedback from professionals and volunteers who were introduced to the tool though training sessions:

“I thought losing weight was a normal part of ageing. This is a great tool to help me identify if someone might not be as nourished as they should be.”

“The questions aren’t invasive. If you ask a person, they won’t think you are doing a serious medical evaluation – so I think people will respond well to this tool, especially as it has community-based, sign-posting information.”

“A great resource to highlight the growing issue of malnutrition.”

“We need to look after our older people and this is a great way to make sure more people see the simple signs of malnutrition.”

“All the leaflets out there are to do with 5-a-day and obesity. It’s good to see another key issue being raised with a user-friendly tool, and not just advice and information.”

Further information: D McCarthy, Project Lead, Age UK, 1 Thorpe Close, London W10 5XL. Tel: 020 3181 0002, dmccarthy@aukc.org.uk

7.5 Paperweight armbands and raising awareness of malnutrition among older people, Salford

The work done in Salford, Greater Manchester, is described here.

Partners: Age UK Salford, Salford Royal NHS Foundation Trust, Salford Commissioning Care Group (CCG), Salford City Council, Greater Manchester West, Salford Integrated Care Programme (ICP) and older people in Salford.

Aims:

• raise awareness across the community
• develop Sally Ford Standards for nutritional care (Salford ICP has created a fictional older woman, Sally Ford, whose needs will be taken into account as they work to tailor solutions to malnutrition)
• ensure good nutrition and dysphagia education
• work with primary care regarding prescribing of oral nutritional supplements and sip feeds and raising awareness of the signs of malnutrition for staff and patients

Target group: People older than 65 years.

Timescale: The project was launched in May 2014 at an event organised by the Age UK Salford team, with over 80 people attending from across Salford healthcare. Knowledge was shared and views on areas where improvements could be made.

Funding: The Department of Health (DH) and NHS change management for one year.

Background: Salford has 35,000 people over 65 years of age, based on demographics from the report, Integrated Care for Older People in Salford 2013. The BAPEN commissioning toolkit suggests 14% of this age group may be at risk of malnutrition. This is almost 5,000 people in Salford. The document further states that in excess of £100 million per annum of health and social care expenditure in Salford relates to older people, which will increase substantially as the population becomes older. The number of older people is forecast to rise by 28% by 2030, from 35,000 to 43,300.

The pilot quickly gained support from the Salford ICP, an organisation designed to improve health and care for older people, which has access to various multi-agency partnerships and workstreams across the city and strong links with the third and private sectors.

Malnutrition in Later Life: Prevention and Early Intervention - A Local Community Approach is the MTF guide that was used as a ‘starting point’ for the Salford community approach.

Outcomes:

The PaperWeight Armband: A paper armband was created that can determine whether someone is at risk of malnutrition, depending on how freely the armband can move up and down the upper arm. This is a simple and innovative way of identifying malnutrition.

Raising awareness among older people: Awareness of malnutrition was raised through postcards and fridge magnets that were shared with older people in the Salford community. The postcards and fridge magnets carried simple messages about malnutrition, such as symptoms and tips to combat malnutrition. The Salford team arranged for a local café to provide free cake and coffee when an older person presented the postcard. Altogether, 1,000 postcards and fridge magnets were produced and distributed to older people and GP surgeries in Salford. In addition, colourful information displays and posters were displayed in GP practices with information about natural alternatives to prescribed supplements.

Supermarket tours: Age UK Salford and dietetic assistants took older people on shopping tours of supermarkets in Swinton and Eccles. Floorplans of the supermarkets and aisle information were given to older people. Age UK Salford is continuing to run the shopping trips on an individual basis.

Diet sheets: New diet sheets, written by older adults, dietitians and speech and language therapists are available for hospital and community use on the Salford Royal NHS Foundation Trust website.

Evaluation: A localised version of a malnutrition leaflet has been produced with feedback from older people. The PaperWeight Armband was tested by patients in ‘after care’ and their feedback was captured in case studies. Age UK intends to evaluate further with other partner organisations, such as local housing associations. The University of Chester was appointed to do the evaluation, which will follow in due course.

Challenges:

• the pilot brought together a range of people and organisations who would not otherwise have worked together. Collaboration was essential. It provided opportunities for the work to be successful
• it was important, initially, to get senior representatives from all adult social care services together and to link priorities in an action plan so that people could be held to account
• it is necessary to use all avenues to get the message out and to keep the momentum going

Next Steps: The work is continuing to be shared through the MTF website

The PaperWeight Armband handbook, An Appetite for Change, contains two case studies. It is available in the PaperWeight starter pack together with 100 PaperWeight Armbands, a staff poster and 10 booklets called ‘How to improve your food and drink if you have a poor appetite’.

A customised option allows different areas and organisations to use their own branding on the PaperWeight Armband. Details are available from Age UK Salford

Age UK is in discussion with the Wessex AHSN about taking forward the PaperWeight Armband work.

Further information: Jean Rollinson, Director of Service Development, Age UK Salford, 108 Church Street, Eccles, Salford M30 0LH. Tel: 016 1788 7300

7.6 Staffordshire Eat Well programme

Partners: Age UK South Staffordshire; Staffordshire County Council; Staffordshire and Stoke-on-Trent Partnership Trust; Community Council of Staffordshire; Carers Association South Staffordshire and Age UK (national).

Aims: To address the need for more sustainable ‘food first’ community approaches to malnutrition in the older population to prevent an escalation of the risk of malnutrition.

Target audience: The more active older population who enjoy better health and wellbeing.

Timescale: April 2013 to 2016.

Funding: A partnership pilot funded by DH.

Background: Data gathered by BAPEN, applied to the demographic in Staffordshire, led to recognition that malnutrition is a significant and growing issue in older people. With most malnutrition cases in the UK (93%) residing in the community, coupled with many patients at increased risk of malnutrition being discharged from hospital into their own homes, there is a need for more sustainable ‘food first’ community approaches to malnutrition, with an active older population, enjoying better health and wellbeing. The Staffordshire Eat Well pilot was set up to address this gap and prevent escalation of risk.

Description: Volunteers are trained to screen for individuals at risk of malnutrition and provide advice (in line with current Staffordshire Nutrition Support Guidelines) and provide community support to address presenting risk factors (such as isolation, menu planning and cooking skills, exercise interventions) and signpost to clinical support as required.

Outcomes:

• co-ordinated partnership action, through the stakeholder group
• raised profile of malnutrition, with hundreds of community talks/food demonstrations delivered
• increased specialist skilled volunteer base to deliver evidence-based interventions, with 109 volunteers trained
• improved health and wellbeing among volunteers. Benefits include transferrable skills, feeling valued and reduced isolation
• better identification of community malnutrition. Some 293 beneficiaries were supported; 49% aged over 80 years; 67% with mobility issues or at risk of falls, and 15% living with dementia
• improved health and wellbeing of beneficiaries, with 30% reducing their malnutrition risk, 3% increasing it and 67% maintaining their risk
• improved risk factors for malnutrition as a result of social contacts, cooking ability, and access to aligned services
• return on investment was £5 for every £1 spent, by delaying the potential escalation of care needs through secondary care and reduced oral nutritional supplement usage
• resources produced included volunteer and commissioner models

Evaluation: The project was evaluated by the University of Chester. It will result in commissioner and provider toolkits being developed. This approach is adaptable to a reablement care model, whereby non-governmental organisations (NGOs) would be directly interfacing with social care and NHS professionals post discharge. The following methods were used:

• qualitative interviews with volunteers and beneficiaries
• wellbeing survey scores (WEMWBS) and life satisfaction scale for volunteers and beneficiaries
• nutritional risk improvement measures (eg pre/post malnutrition risk MUST scores) for beneficiaries
• training evaluation for volunteers and professionals
• evaluation surveys of community awareness activities for beneficiaries
• output indicators, including numbers of volunteers recruited and trained; NGOs and paid professionals who have been trained through the programme; beneficiaries who have received information and support, and referrals made to GPs, dietitians and other health and social care services
• development of a final evidence-based model to be used by organisations and commissioners in other parts of the UK within community settings

An independent evaluation by Staffordshire University was also undertaken to strengthen the validity of the results.

Challenges:

• ensuring sufficient support from accredited healthcare professionals and implementing integrated supervision arrangements for accredited healthcare professionals working in the voluntary, community and social enterprise (VCSE) sector
• capturing of data by a volunteer workforce for evaluation
• continued funding of new initiatives/models of care when budgets are under pressure
• choosing appropriate research methodology in community prevention interventions to demonstrate impact and academic rigour

Serious consideration must be given to embed the VCSE into local health care systems. No formal mechanisms are currently in place to champion new models of care between the VCSE and healthcare. Currently, these rely strongly on good will and the championing of individuals.

Next steps:

• working with commissioners to demonstrate the value of embedding the VCSE into local health and social care systems
• find opportunities to co-design services, providing a holistic preventative approach to reduce the likelihood of older people and others with long-term conditions requiring further intensive interventions from health and social care

Comments from clients:

“The information has been invaluable and the service great for people like me living alone.”

“I am now much more aware of what I should eat and I’m now eating better.”

Comments from partners:

“This is a partnership where the whole is greater than the sum of its parts. When people are aligned and there is something in it for everybody, and it is ultimately driven by the service users, and people can see the differences we are making, then everybody is happy.”

“The training sessions that we run are for a variety of people across the community, not just the elderly. The people that attend the sessions are very interactive and put a lot of questions to the Age UK volunteers. They learn what the problems are and the signs to look out for, this is helpful for people who have elderly neighbours and older relatives, they are the eyes and ears out in the community.”

From staff:

“As families disperse they are further afield so clients can end up quite isolated and then it is the support and signposting that is important. So we now have a lot to do with community matrons, the NHS, occupational therapists, falls teams, and mental health teams.”

Further information:

Kings Fund

NHS England nutrition and hydration guidance

Contacts: Nicola Day, Public Health Commissioning Lead, Physical Activity and Nutrition, Staffordshire County Council. Tel: 017 8527 7859, nicola.day@staffordshire.gov.uk

Robert Bruce, Wellbeing and Prevention Manager, Age UK South Staffordshire. Tel: 017 8578 8496, robert.bruce@ageuksouthstaffs.org.uk

Wendy Anderson, Professional Lead for Dietetics, Staffordshire and Stoke-on-Trent Partnership Trust. Mobile: 079 7126 2692, wendy.anderson@ssotp.nhs.uk

7.7 Casserole Club, Staffordshire

More details can be found here.

Partners: VAST, a charity providing creative services and business support to community groups in Staffordshire. Disclosure and Barring Service (DBS) checks. FutureGov, Specialist Cloud Services, including deployment, software support and helpdesk. Staffordshire County Council, Contact Centre, matchmaking team and telephone queries.

Rationale: In 2011, FutureGov created a new kind of community project to connect people who like to cook with their older neighbours who are not always able to cook for themselves. They started with just one person, a mobile phone and a spreadsheet to see if they could bring neighbours and communities together over meals. They felt that the Casserole Club could be a positive and human way to tackle some of the health and social care challenges we face today. More than four years later, there are Casserole Clubs across England and Australia. More than 7,000 people have signed up to take part in the project to share thousands of tasty, home-cooked meals with their neighbours.

Aim: To achieve the target of 400 registered diners.

Objectives:

• support individuals to remain living independently in their own homes
• help socially isolated people to improve their health and wellbeing and quality of life
• provide individuals with choice and give them more control over their health and wellbeing
• improve nutritional understanding and intake
• support the prevention agenda so that vulnerable people avoid the need to prematurely access social care and health support
• reduce loneliness and social isolation
• help individuals to access local activities as appropriate and to engage with their local community
• provide opportunities for volunteering and training and development opportunities for volunteers

Target group: Older people living alone. Promotion is targeted and focused in areas where volunteer cooks are heavily populated, in order to match the vetted cooks waiting for local diners to register.

Timescale: Complete by the end of the 2016/17 contract period.

Description: Casserole Club is a project that connects people who like to cook and are happy to share an extra portion of a home-cooked meal with an older neighbour living close by who could really benefit from a meal and a friendly chat.

Like a local, community-led take-away, Casserole Club members serve up tasty, home-cooked food to their neighbours, getting more people eating and cooking fresh meals while strengthening local neighbourhood relationships. Cooks are required to sign up to the website and undertake a short safeguarding process before they can search and contact local diners. The Casserole team works with local organisations to help reach diners and take direct referrals from friends and relatives.

Casserole Club works because it takes something volunteers are already doing – cooking meals at home – and transforms it into a scheme that strengthens local communities. Since there are few requirements about how and when extra portions of food are shared, the cooks and diners are able to choose the meal sharing experiences that work for them. Through sharing food, we’ve seen new friendships and connections develop that make us smile every day. Whether our cooks and diners have been sharing for years or just a few months, nearly everyone who takes part in Casserole Club is happier for having done so.

Outcomes:

1. Support individuals to remain living independently in their own homes. By early March 2016, 117 diners had registered county-wide. Of these, there are currently 67 pair-ups of diners (and a number of meals shared). The number of pair-ups has slightly decreased due to relocation, deterioration in health or circumstances around employment, but friendships have been maintained where possible.

2. Help socially isolated people to improve their health and wellbeing and their quality of life. The Casserole Club website has recorded 195 meal-shares by Staffordshire cooks. The qualitative feedback from diners is positive, which suggests that the project does have some impact to the health, wellbeing and quality of life of socially isolated people in Staffordshire.

3. Provide individuals with choice and give them more control over their health and wellbeing. The indicator is the ‘proportion of active and physically inactive adults’. Examples collected suggest improved access to physical activity.

4. Improve nutritional understanding and intake. By providing the opportunity to receive a freshly prepared meal, usually on a weekly basis, the club has an impact on the diet and weight of diners and may influence eating habits too. Qualitative data indicates some improvements in diet and reductions in excess weight.

5. Support the prevention agenda so that vulnerable people avoid the need to prematurely access social care and health support. Indicators for this outcome are smoking prevalence (in adults over 18 years), recorded diabetes, mortality caused from causes considered preventable and mortality from cardiovascular disease. No impact on these indicators has been reported or recorded to date.

6. Reduce loneliness and social isolation. The indicator is ‘the number of people who use services and report they have adequate social contact.’ The number of diners currently receiving meals across Staffordshire is 67, which is a fraction and not a true representation of our growing older population. Of those diners, however, positive comments suggest that the club has provided cooks and diners with increased social contact.

7. Help individuals to access local activities as appropriate and to engage with their local community. Evidence from feedback indicates that Staffordshire diners appreciate the social aspect of the scheme as much (if not more) than the meals that are shared. The Casserole Club evaluation (from 2014), reported that 7 out of 10 diners describe cooks as their friend and 6 out of 10 said that the club has affected their social life, suggesting that diners feel more socially connected as a result.

8. Provide opportunities for volunteering and to provide training and development opportunities for volunteers. Some 560 cooks have completed their Casserole Club profile to become fully-vetted Casserole Cooks. Of the 560, 121 are fully vetted and either sharing meals with a diner or waiting for a local person to register as a diner. A further number of registered cooks have completed their online disclosure and barring service (DBS) check and are waiting for clearance so that they can find local diners to pair with.

Challenges:

• not having control of the Casserole Club website platform, this was owned by Future Gov
• difficulty initially to source an organisation to process DBS checks
• the minimum age for diners was 55, we would have liked this to be open to younger volunteers
• Staffordshire is a large, diverse county. This made it difficult to recruit cooks in some areas, due to the size of the county. It was also difficult to capture a representative diner audience
• recruitment and the retention of cooks, exit process needed
• pairing of cooks and diners could be difficult
• mixed level of engagement from district councils to support and promote the initiative

Evaluation:

• Contact Centre, monthly dashboard reports
• Casserole Club service review with cooks and diners, and also non volunteers, using phone interviews, face-to-face interviews, focus groups and questionnaires
• procurement mid-term review
• communications team promotions of Casserole Club, including feedback and case studies plus a number of video recordings taken for BBC news and an international documentary

Next steps:

Staffordshire County Council intends to continue provision of the scheme in 2016/17.

Councillor Mark Sutton, cabinet support member for social and health care at Staffordshire County Council, said:

Cooks simply prepare a meal in their own home, popping a portion in a container and dropping it round later that day to an older neighbour we’ve matched them with. Often our cooks stay for a cup of tea and a chat after bringing the meal around. It’s a great, simple way of getting to know neighbours, sharing delicious and nutritious meals and encouraging lasting friendships within the local community. We want people in Staffordshire to be healthier and happier, which is one of our key priorities, and schemes such as Casserole Club can help us achieve this.

Clare Bradford, aged 39, was one of the first cooks to sign up in Staffordshire. Clare said:

I think Casserole Club is a great project and it’s such a simple idea. I only signed up a couple of months ago and was delighted to be matched up with Janet who only lives round the corner from me. Spending a little time with her when I drop off her meal is most enjoyable and I know it makes a big difference to her to. There are lots of lonely older people out there, especially over Christmas and Casserole Club could make a real difference to them.

Further information: The Staffordshire Matchmaking Team, which sits within Staffordshire County Council’s Contact Centre Service. Tel: 030 0111 8006, wellbeing.services@staffordshire.gov.uk

7.8 One to One Nutritional Support, Kent

Setting: Faversham day centre, Kent.

Funding: DH.

Project description: People attending the Age UK Faversham day centre were provided one-to-one support to increase their nutritional intake. The project focused on older people who were living in the community and already in touch with a local Age UK service, the day centre. Many of the older people were living alone and suffering with co-morbidities and/or frailty. The project was part of a larger pilot prevention programme, funded by DH, that sought to bring together the whole health community across different settings to help address and tackle malnutrition for older people in Kent.

Rationale: 1 in 10 older people suffer from malnutrition or are at risk of malnutrition. Some 93% of malnourished people live in the community and often have little or no support around eating and drinking. Good nutritional care is not prioritised by the older people themselves and health professionals.

People with malnutrition see their GP twice as often, have three times the number of hospital admissions and stay in hospital more than three days longer than those who are well nourished. There is also a huge impact on those caring for older people who are under nourished. Carers UK found that 60% of carers worry about the nutrition of the person they care for. One is six carers is looking after someone at real risk of malnutrition but do not have nutritional support of any kind.

Challenges:

• addressing malnutrition in the community is challenging, if older people do not have any contact with community services it is almost impossible to find those at risk of becoming malnourished, especially as there is a lack of awareness around malnutrition in later life
• another challenge was access to services. It is often very difficult to get a referral to a dietician or other specialist help. When referrals are made there are often very long waiting lists

Further information: Laura Pearce, Commissioning Officer, Social Care, Health and Wellbeing, Kent County Council, 3rd Floor, Invicta House, County Hall, Maidstone, Kent ME14 1XX. Tel: 030 0041 5447, mobile: 078 5029 9717, laura.pearce@kent.gov.uk

Age UK, Faversham, paula@ageukfaversham.org.uk

Rachel Wilkinson, Malnutrition Task Force, Age UK, rachel.wilkinson@ageuk.org.uk

8. Conclusions

Given the current evidence and the information provided by the case studies we would suggest that those commissioning future services in the community for older people (greater than 65 years old) consider in particular the following four aspects:

• access to healthier food and drink options and food poverty
• ability to prepare healthier food
• functional and cognitive impairment and ability to eat healthier food including poor oral health
• food and dietary resilience

The synthesis of research findings and emerging practice shows how many areas have developed innovative programmes of work aimed at tackling malnutrition among older people.

9. References

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9. The Association of UK Dietitians
10. Age UK
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