03 Jul 2020
Dietitians, like other health and care professionals, have really stepped up as part of the response to the COVID-19 pandemic. Through this process, the BDA Wales Board have noted several important points we wish to raise with the committee:
- Critical Care dietitians have responded well to significant challenge of COVID-19, playing a vital role in acute settings to support people hospitalised with the disease. Nutrition is a vital to supporting someone as they fight the infection and then helping them regain strength and function as they recover, both in hospital and the community.
- Where possible dietitians have worked hard, utilising technology to support people living with other health conditions who can no longer access secondary, primary or community services in the normal way.
- We anticipate a significant increase in demand for dietetic services as the lockdown due to an increase in demand from COVID-19 patients, those living with chronic conditions who have not accessed support and those whose health has been impacted by months of lockdown.
- Malnutrition amongst the elderly and those with existing health conditions is almost certain to have increased, which will place extra demand on dietetic services and the care system.
- COVID-19 has highlighted the importance of a comprehensive approach to obesity, diabetes and other conditions, which have all been identified as risk factors for the disease. Dietitians have a central role to play in the services designed to support people with these conditions.
- Food insecurity has been exacerbated significantly by COVID-19. Urgent action is needed to address this.
- The pandemic has highlighted the importance and impact of prevention and strong public health policies. We must learn lessons from this for the future and adopt a prevention-first approach to health. Conditions such as malnutrition and obesity, which exacerbate COVID-19, are best dealt with before they develop.
At the very frontline, dietitians have been playing an important role in critical care and ICU. Any patients that have been ventilated and/or sedated as part of their treatment for COVID-19 will have also required specialised nutrition support through enteral or parenteral feeding (via feeding tubes or intravenously). This is an essential role in critical care and analysis from the International Nutrition Survey continually shows that there is a direct correlation between the total number of funded dietitians in intensive care and improved patient care. Dietitians have been closely involved as a core part of the MDT, in the planning and creation of the network of field hospitals created to increase capacity in response to the pandemic.
Despite the fantastic job that dietitians have been doing, we know that we do not currently meet even baseline staffing levels in critical care before the crisis. With the surge in demand other dietetic services have had to release significant numbers of staff to support critical care, with obvious knock-on impacts. Things have been further complicated by uncertainty over guidance on Aerosol Generating Procedures, in particular in relation to the placing of Naso-gastric and Naso-jejunal tubes.
Of course, the need for support does not end when the person leaves hospital. From what we know of COVID-19, patients may experience poor appetite, dysphagia, muscle loss, frailty, malnutrition, PTSD and global weakness from ICU. To address all of these potential issues, an MDT approach is required. Dietitians must form a part of this MDT. Welsh Government’s Rehabilitation: a framework for continuity and recovery 2020 to 2021 makes clear that rehabilitation will be “everyone’s business”, and that nutrition and diet are a core part of this.
Discharge documentation needs to clearly state the rehabilitation requirements for each patient and an MDT service needs to be there to support these requirements in the community. This is in line with guidance from the British Society of Rehabilitation Medicine. A clear triage system outlining who is responsible for each stage is required. A significant concern here would be that patients are rapidly discharged without sufficient follow-up and support, only to present at their GP practice/out of hours later with ongoing issues relating to frailty/malnutrition.
Dietitians in Wales provide support to people living with a wide range of conditions, such as diabetes, malnutrition, obesity, allergies and eating disorders in the community, primary care and secondary care. This includes conditions which require ongoing support and will have been more difficult to manage during lockdown and with reduced access to the usual range of foods.
We know that patients haven’t accessed healthcare in a timely manner due to the need for self-isolation or concern about COVID-19. This will most likely have resulted in an increase in chronic conditions such as diabetes and obesity and an increased requirement for dietetic services. Although dietitians have made good use of technological solutions to maintain clinics and provide support, this has not and cannot fully replace face to face clinics and programmes.
It is therefore almost certain that there will be a significant spike in demand for services as we begin to see a return to face to face clinics and services. This demand will come from those who have had COVID-19, those who have deconditioned as a result of lack of access to care, those that have not sought care when they should have done and those that are directly impacted by the effects of lockdown itself. We welcome the commitment made by the Chief Allied Health Professions Officer Ruth Crowder and her colleagues on May 15th, but we will need to build on that.
It is essential that we retain the staff that have come back onto the HCPC register in response to COVID-19. This will require appropriate support and compensation. Equally, government should look at how it can rapidly expand the health and social care workforce to make up for many years of significant under investment.
Specifically, in relation to diet and nutrition, the small dietetic workforce will need to work to train and support others to provide services to those that need them on top of an increased workload from COVID-19 patients requiring nutrition support in both the acute and community setting. Fortunately, we have an existing all Wales nutrition education programme Nutrition Skills for Life, that with increased capacity can support wider health and social care nutrition education.Upskilling and freeing dietitians and other AHPs to play a bigger role will improve patient outcomes, reduce pressure on other services. We would in particular like to see a wider range of professionals, including dietitians, given the ability to train as independent prescribers. We recognise this is a matter that has to be decided at a UK level, but hope Welsh Government can support such a change.
It is now well established that diet related conditions such as type 2 diabetes, CVD and obesity are risk factors for COVID-19, with a disproportionate number of those dying from the disease having one or more of those conditions. It is equally well established that diet plays a big - if not the biggest - role in someone’s risk of developing many of these conditions. The Welsh Government has a 10-year plan in the form of Healthy Weight, Healthy Wales that if fully implemented would have a significant impact. However, that should not mean that steps are not taken urgently to implement the changes that will lead to that long-term change. This should include all the actions outlined in the Obesity Alliance Cymru call to action. Many of these ideas have been adopted in HW:HW, but not all, and all need to be acted upon with urgency.
Malnutrition is a prevalent but often unrecognised issue, especially amongst those aged over 65. We think it is worthy of specific attention in relation to COVID-19. Malnutrition can be caused by physical impairment, loneliness, lack of appetite, other health conditions, such as cancer or dementia, or poverty. In 2016, the cost of malnutrition in Wales was estimated by to be more than £1.4 billion per annum.
COVID-19 will have exacerbated all of these issues, as people are more isolated, less easily able to access food and lack support for other healthcare conditions. It is vital that a comprehensive approach to screening for and addressing malnutrition in the community is put in place, bringing together dietitians, other AHPs, community nursing teams, carers and others. A positive development has been the adoption of All Wales adult nutrition screening tools for both inpatients and community care, but more work is needed to ensure this screening is spread to all healthcare settings and utilised by all health care staff.
It is well established that malnutrition and dehydration increases risk of infection, and people with malnutrition will have longer hospital stays and recover more slowly from illness. It also increases risk of other issues such as falls and frailty. However, with appropriate support, it can be prevented. In future, we must take a much more proactive, preventative approach to tackling malnutrition. Too often malnutrition is only identified at the point someone enters hospital or the care system. Prevention is discussed in further detail below.
The Food Foundation estimate that there are 638,885 adults living in Wales with very low, low or marginal food security during the pandemic. They report a 250% increase in food insecurity amongst the UK population as a whole compared to before the pandemic. These individuals and families are likely to be more vulnerable for other reasons, such as loneliness, comorbidities, poor housing etc. This is a matter of serious concern.
Of course, COVID-19 has simply exacerbated pre-existing problems of food poverty and food inequality in Wales and the rest of the UK. It is already well established that people facing financial pressures have poorer quality diets and are more likely to experience food access issues such as living within a “food desert”. The Trussell Trust reported a 15% increase in food bank usage in Wales in 2018-19, with over 113,000 emergency parcels handed out over the year. This only tells part of the story, as we know many others will have gone hungry or been undernourished rather than receiving food parcels. Dietitians and the public health programmes that they run can have an impact on these issues, but these services lack funding and support, with significant differences in resources between Welsh Health Board areas. Food insecurity should be a matter or priority regardless, but during and post-COVID it should be particularly important.We have already seen from PHE reporting that there is significant inequality in the way that COVID-19 has impacted on different parts of the community. Sadly, we know that health inequalities were already existent and growing in Wales even prior to the pandemic. Poverty and food inequality will have been a key part of this, alongside much wider issue such as housing, access to care and employment. It is vital that a comprehensive approach is taken to all these issues.
It has been widely recognised that public health and prevention have been absolutely central to the response to COVID-19, and it is important that health leaders learn from this and place much greater emphasis on prevention and public health in future. At the moment the NHS spends less than 5% of its budget on prevention.
Nutrition should be an area of particular focus. Many of the diet-related conditions that place such pressure on the NHS and which have been linked to worse outcomes from COVID-19 are preventable with support. Dietetic-led and award-winning programmes such as Nutrition Skills for Life have been proven to be effective, and could have an even greater impact with more investment in capacity
The Welsh Government has recognised the importance of a prevention-based approach in their Healthy Weight, Healthy Wales strategy, but we must make this a reality. To date we are not aware that promised funding for health boards to implement the All Wales Obesity Pathway and increase access to clinical services, particularly for overweight children have not yet been issued. We know that funding that has been made available has not been used to bolster dietetic services, despite their vital role in managing and preventing obesity.
Dietitians and dietetic teams have responded quickly and effectively to the pandemic in both acute and community settings. They have redesigned their services, utilised new technology and overcome significant challenges, including understaffing.
However, there remain serious concerns about the short- and long-term impact of the pandemic on the nutritional health and wellbeing of the people of Wales. Rehabilitation will be key, and services need investment and support to meet a surge in demand from those recovering from COVID-19 and those affected by lockdown. The pandemic has also made it clear that we need to act more quickly on issues such as obesity, malnutrition and food insecurity.