Practical nutritional support: working together to make it happen.

The national nutritional agenda is changing and feeding patients appropriately in hospital has now been identified as an area of concern (Department of Health, 2000a,b). Clinical governance is also a political imperative and NHS Chief Executive Officers are now personally responsible for local implementation (Department of Health, 1999). It is a fact that a significant number of patients are undernourished on admission to hospital (McWhirter & Pennington, 1994; Corish et al. 2000; Edington et al. 2000; Kelly et al. 2000) and that some patients may continue to lose weight during their hospital stay. Furthermore, many clinical staff are unaware of the benefits of nutritional intervention to the extent that patients are not weighed on admission (Lennard-Jones et al. 1995), that weight is generally considered to be unimportant (Rasmussen et al. 1999) and that referrals to the dietetic service are not made (McWhirter & Pennington, 1994; Kelly et al. 2000). Many benefits accrue from feeding patients adequately while they are in hospital, and these benefits are both clinical and financial (Tucker & Miguel, 1996; Green, 1999; Ochoa et al. 2000). However, food provision is a complex process, demanding coordinated input from many different services. There have been many recommendations highlighting inadequacies in the current arrangements and suggesting how these may be managed (Allison, 1999; Maryon-Davis & Bristow, 1999). One approach is to consider nutritional intervention as a continuum (Fig. 1) in which different professionals have differing roles at different times. It follows that individual patient needs can then be best met by a clinical nutrition support team working within the structure of a nutrition steering committee (Fig. 2; Silk, 1994). Clinical governance is defined as ‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’ (Department of Health, 1999). A range of activities have been identified as importantly contributing to this process (Fig. 3). The establishment of an effective clinical nutrition support team can help to deliver the requirements of clinical governance at local level, thereby attracting support from Trust Boards and Health Authorities. Setting up such a team needs to be carefully planned and managed (Howard, 2001). There are five stages each of which incorporates aspects of clinical governance. Getting started is the greatest challenge and demands clarification of roles and responsibilities to ensure there is clear accountability within the team. At the same time it will be helpful to identify key stakeholders and allies, thereby ensuring that the team is aware of the organisational ‘agenda’ and that they are alerted to any impending changes in service provision. Team-building activities, e.g. sharing tasks and discussing working practices, are an essential part of developing good communication. Making the case, whether for recognition or resources, is when the team must have good knowledge of the evidence