Can England’s A&E units spot the malnourished? Mark’s story revisited

Can England’s A&E units spot the malnourished? Mark’s story revisited
Mark Bothwell, who's on jobseeker's allowance. He says he hasn't been eating properly for years.
Mark Bothwell, who’s on jobseeker’s allowance (JSA). He says he hasn’t been eating properly for years.

Mark Bothwell (above) came into the London food bank today. He’s had a painful problem with his shoulder for some time that leaves him unable to accept many types of physical work, and he also has depression. He’s been waiting for months for his claim for employment and support allowance (ESA) to be processed. Not that this 29-year-old is likely to be better off financially by transferring over from JSA, but he would at least be relieved of  some stress. He says: ‘It’s a job-stopping illness, so the positive thing (about changing benefits) is not having to worry about job hunting.’

Last week, he described two recent trips to the accident and emergency (A&E) unit at the local hospital – the Queen Elizabeth in Woolwich. He says that terrible chest pain drove him to seek help, and that a viral infection causing inflammation of the outer lining of the heart was suspected. Mark, who is already on strong medication prescribed by his GP for his shoulder pain, had an adverse reaction to one of the medications given at the A&E. It upset his stomach and caused ‘a lot more pain’. This extra pain meant he had to make a second visit to A&E later that week. While the doctors took a family history during his visits to cover heart issues, and did blood tests, an ECG and X rays, he says the doctors didn’t ask about his circumstances. ‘They didn’t ask if I’d been eating properly for the last few months. Actually, I’ve not been eating properly on and off for years. Money has come and gone for years since I moved out of the house at 21. I was homeless for 18 months. Although I’ve had the foodbank vouchers, which has been good – it’s not been enough to cover the last four months. Even during this time (when he’s had some help from food vouchers) there have been a couple of days when I’ve not been able to take my pills because I haven’t had enough food.’ He says that recently, when he hasn’t had enough food, ‘shoplifting has crossed my mind, and this is how desperate people can get’.

Why didn’t  the doctors in A&E ask him about his circumstances, which may have flagged up the effect poor nutrition for many years could be having on his health? Could it be because the A&E unit, like many in the NHS in England, is understaffed and generally in crisis? The hospital is part of the Lewisham and Greenwich NHS trust, and this week health inspectors the Care Quality Commission published a report that was highly critical of many aspects of services at the trust, which it says requires improvement. The A &E unit at the Queen Elizabeth is deemed to be inadequate, and ‘not fit for purpose’. The inspectors, who visited the hospital in February, have serious concerns about the safety of A&E services there . They note a shortage of beds for admission to the hospital, causing a block in the system, particularly for patients in A&E. Ambulance personnel told inspectors there were regular delays in booking patients in and patients often had to be treated in the back of ambulances. They also pointed to the low staffing levels in A&E, with 29 full-time equivalent nurse vacancies and vacancies for four consultants and six junior doctors. The report also says that since the closure of the accident department at the nearby Queen Mary’s Hospital  in 2012, attendances had risen from around 300 to over 450 a day. Because of a lack of space, patients who ‘would have benefited from being able to lie on a trolley or bed were having their treatment on a chair in full view of other people’. Against this background, do the A&E staff  have the time to take detailed enough case histories?

Mark’s  food budget of about £2 a day and spells without eating adequately over many years must be impacting on his health, yet none of the doctors treating him in hospital asked him about his nutrition.  Is the NHS really capturing the facts about how many people are becoming ill, or having their health conditions made worse because of malnutrition and food poverty? The steep upward trend in the number of people being driven to use food banks indicates a rise in the number of individuals and families struggling to eat well. But as the Faculty of Public Health so clearly points out, actual food bank numbers are ‘an inadequate indicator of need, because many households only ask for emergency food help as a last resort’. So the true scale of food poverty remains hidden.

In Wales, hundreds of patients have been diagnosed with malnutrition in the past few years. New figures from a Freedom of Information Act request show 1,229 patients have been diagnosed since 2007/08. In England, primary and secondary diagnoses of malnutrition in hospitals rose from 3,161 in 2008/09 to 5,499 last year, according to figures released by health minister Norman Lamb. In November 2013 an early-day motion in the House of Commons from MP George Galloway noted a ‘doubling of the diagnoses of primary and secondary malnutrition in Bradford Teaching Hospitals NHS Foundation Trust in the years 2010 to 2013 compared to 2008 to 2010’.

Are all cases of malnutrition as a primary or secondary diagnosis being clearly identified, given the levels of understaffing and the workloads in some A&E units?  What information is being gathered by GPs? These are issues the All=Party Parliamentary Group on Hunger and Food Poverty may want to start examining closely during its inquiry.

The outlook for Mark this weekend is more positive, and he didn’t need a food voucher this week. His MRI results show a frozen shoulder, and he’ll be referred for physiotherapy by his GP.  Mark is relieved that he doesn’t need surgery, and he’s been told he should receive a letter within 10 days telling him when he’ll start receiving ESA payments. He’s finally got an appointment to access  group pain management talking therapy, which will take place once a week for 10 weeks. The depression is still there, but is ‘starting to feel a lot better’.

London foodbank life: Surreal at times, but dangerous too

London foodbank life: Surreal at times, but dangerous too
Ben Adou hasn’t received jobseeker’s allowance since early March. He came into the foodbank hungry.

I’m pondering the brutal absurdities of day-to-day life for a growing number of the people I come across at this London Trussell Trust foodbank. Sarah (not her real name), wants a job. She’s a gentle and intelligent 28-year-old law graduate with Borderline Personality Disorder (BPD). A month ago she was nearly made homeless when the hostel told her they were going to evict her. The housing association running the hostel changed its mind at the last minute, but tragically she’s considering escort work as a possible way to clear debts, including a Wonga loan at extortionate rates. What does the future hold for her after she finally worked up the courage to escape a violent home situation? Will Mark, who’s trying to battle both depression and a debilitating shoulder injury, ever get his claim for employment and support allowance (ESA) processed? It’s been more than 10 weeks now, and he’s still no clearer about when he’ll get his money. Meanwhile his health is deteriorating fast, with other worrying symptoms now developing, which have driven him to the local hospital’s accident and emergency unit.

While they struggle on, Ben Adou (pictured above) came into the foodbank to share his story. Last week I mentioned that he brought along a foodbank voucher – his third. He couldn’t have survived without them, as he hasn’t received any jobseeker’s allowance (JSA) since March 7. This has plunged Ben – a widower of 56 whose wife died of cancer in 2012 – into a financial crisis. He claims housing benefit, has no savings and has nothing to fall back on. There is no safety net here. He came into the foodbank at what he somewhat ironically called lunchtime – hungry because he hadn’t been able to eat that morning. At least he was able to get some tea and a spare sandwich, and leave with his emergency pack of long-life food and some bread that had been donated that day. ‘You have brought me happiness by giving me food’, he said.

The problems started when Ben, who mostly works as a labourer, was offered a job through the controversial Universal Jobmatch scheme at the beginning of March. It turned out to be just two days of work, which he said had ‘completely messed up my JSA claim’. It’s also impacted on his ability to pay a contribution towards his rent, pay his council tax and to meet other household and phone bills. It has made it almost impossible for him to get to interviews. Crucially, of course, he can’t buy food. Any sort of a social life is totally out of the question, of course. With his JSA on hold, he now has no idea exactly when his benefit payments will resume. He called into the jobcentre to try to get to the bottom of things: ‘They said I was overpaid JSA during spells when I was working, and I disagree. They’ve put in writing that they know they owe me £431.60, but they’re saying that I owe them about £286.00 – and that this was a possible overpayment to me.’

The Government’s Universal Jobmatch website  – managed independently by private recruiter Monster – has come under much criticism. MP Frank Field said in a Guardian article, that it is ‘bedevilled with fraud’ and ‘out of control’.The Department for Work and Pensions (DWP) revealed in a letter to Field that more than 350,000 job adverts might breach the website’s terms and conditions , which specify that employers must advertise a real job, not use premium rate numbers, pay at least the minimum wage and not cost the applicant any money to start.

In the meantime, Universal Jobmatch keep on sending him texts calling him to jobs he can’t take up and job interviews he can’t attend – because he has absolutely no money to get there. A few weeks ago he passed two interviews for some work in central London, but couldn’t get the money together to travel up to the job. The day before he had been offered work starting yesterday in Morden, ‘but I had to say no because I couldn’t afford to travel there’. He has no money, so needs a job. He can’t get a properly paid job, because he has no money to get there. A week previously he had been called for a first interview for a commission-based job, then was offered an induction. It was only at that point that he found out he would have to use an Oyster card and put money on it himself to enable him to travel around London to sell products door-to-door. Needless to say, ‘this wasn’t explained at the team meeting’.

He explained to JobcentrePlus that he needed some money, but doesn’t seem to have been told that he could have been given money directly by them. There’s a fund for that sort of thing, you see. But no-one seems to be told about it. Every year in April, JobcentrePlus offices are given a budget to pay for Budgeting Loans.These are interest free loans for people on JSA and other benefits. Travelling expenses within the UK are included in the needs covered by such loans. This money comes out of the JobcentrePlus Social Fund budget.

Ben, like many of the people I meet, is dealing with this ghastly situation with tremendous resilience. But there’s only so long he can cope without long-term damage to his health and wellbeing. He is diabetic and he also has a heart problem. Kafkaesque doesn’t even begin to describe the ridiculous, complex hassles faced daily by a growing number of our most vulnerable citizens. This week we found out that committed campaigner and journalist Mike Sivier’s battle to get information on deceased former sickness benefits claimants released that is clearly in the public interest has been unsuccessful – so far. He wants an update on the number of sickness benefit claimants who have died, but a tribunal has upheld the Information Commissioner’s decision that his Freedom of Information request was ‘vexatious’. But the judge criticised both the information Commissioner and the DWP for the other reasons they put forward to prevent the death figures from being made public. From what seems to be emerging here in London, do we also now need to look more closely at the equivalent figures for people on JSA?

Tight budgets, poor diets, judgmental callers

Mark Bothwell, who's still waiting for his ESA claim to be processed.
Mark Bothwell, who’s still waiting for his ESA claim to be processed.

A discussion programme on the Nicky Campbell Radio 5 Live Breakfast show this week on whether a tight budget means a poor diet  prompted quite a few callers to make comments including, ‘it’s all down to organising yourself’ or ‘it’s due to a lack of education’. Here at the London food bank, the majority of the people who come here for help know exactly what they should be eating.  They know what a healthy diet looks like. They’re just desperate and hungry, and can’t often afford to buy items such as meat or many fresh vegetables. Or anything much at all. That’s why they’ve been given a voucher for the food bank by a frontline care professional such as a GP.

People on low in-work incomes  – for example those working two zero-hours contracts paid below the Living Wage and often at the National Minimum Wage to make ends meet – don’t have the money to buy much meat protein. They have to focus on keeping a roof over their heads, and trying to ensure they have the electricity or gas to cook with. Neither do they often have the luxury of  time or the mental and physical energy to plan, shop for, cook and serve nutritionally balanced meals. In London, they probably can’t afford to run a car – which makes doing a bulk shop  – very handy when you’re time poor – really hard. They might live on a large estate, without the great  range of shops on their doorsteps that would allow them to make easy price comparisons. There would probably be a chip shop though, that would at least feed their family cheaply. Once they do get some food in, many can’t spend a lot of time preparing it. Those who are short of money often prioritize feeding their kids rather than themselves.

As for those on UK benefit levels that have been described by the European Committee of Social Rights as ‘manifestly inadequate’ , the chances of them being able to avoid food poverty are patently not reflected by the facts.  This food bank is part of the  Trussell Trust network of 420 UK food banks, which fed 913.138 people in 2013-14. But using research by Eoin Clarke, the Trussell Trust represents under half the estimated emergency food providers in the UK. He has listed 960 emergency providers, including food banks. Why so many  – an exponential growth – if a poor diet is down to poor education or disorganised individuals?

What about those who are among the increasing numbers who simply are not getting even these internationally criticised levels of benefits through on time  – either because of  delays or sanctions? Mark, whose case has been covered before here, has a serious shoulder problem and is in terrible pain. His arm is in a sling. He’s on jobseeker’s allowance (JSA) of £72.40 a week, and has applied for employment and support allowance (ESA). He put his claim for to this higher (but not that much higher) level of support about 10 weeks ago. He’s still waiting for his claim to be processed. Meanwhile, he’s trying to eke out what he describes as an existence.  Yes, most of the time he sees it as an existence rather than a fulfilling life. He told me: ‘The other day I was so bored I walked to Dartford and back. It took me nearly three hours each way – stopping every so often to rest. It was just to get me out of the flat.’

Unexpected bills  throw him off his budget, and this is what forced him to call into the food bank for a cup of tea and to see if we had any fresh food (sometimes people donate food that has to be given out on the day, or there’s some tinned food that is still in date but that can’t be included in the packs given out to those with vouchers). A direct debit he didn’t have quite enough funds for was returned twice to his bank, and the bank charged him £8 each time. This loss of £16 would have been the money he spent on food. Mark, who has to ensure he eats when he takes his strong painkillers a couple of times each day, said he had an appointment with his GP the next day, who would hopefully gave him a food bank voucher. So he would have to go to the only food bank open on a Saturday, and haul the bags home using his one good arm. He wouldn’t have got the bus, because he can’t afford it.

I’m coming across more and more people at the food bank who are even worse off than Mark if that’s possible. One client – Ben – a widower of 58 who came into the food bank hungry yesterday, is actually destitute . This is because his JSA was put on hold in early March, around the time the work he was offered through the controversial Universal Jobmatch system finished after two days – and he’s received nothing from the Department for Work and Pensions (DWP) since then. I’ll be detailing his case next.

Welcome to the UK in 2014. We should be proud of the way we treat our most vulnerable. The President of the UK Faculty of Public Health Professor John Ashton has written – along with John Middleton and Tim Lang – an open letter to Prime Minister David Cameron on food poverty in the UK. In the letter to the Lancet on behalf of 170 signatories, he mentions the ‘worrying gap in health circumstances and outcomes between rich and poor people in the UK.’ He says UK food prices have ‘risen by 12 per cent in real terms since 2007, returning the cost of food relative to other goods to that in the 1990s’. He notes that in the same period, UK workers have suffered a 7.6 per cent fall in real wages.  He adds: ‘It therefore seems likely that increasing numbers of people on low wages are not earning enough money to meet their most basic nutritional needs to maintain a healthy diet. We should not accept this situation in the UK, the world’s sixth largest economy and the third largest in Europe.’ He says that during the past five years, ‘food has been one of the three top factors in price inflation, sufficient to worry even higher-income consumers’. This inflation, he continues, ‘ has translated into families cutting back on fresh fruit and vegetables and buying cheap, sweet, fatty, salty, or processed foods that need little cooking’. A ‘vicious circle’ is set in motion, with poorer people ‘having worse diets and contributing to the worrying rise in obesity, diabetes and other dietary-related diseases’.

As Professor Ashton states so clearly to the Prime Minister, even the higher-income consumers are seeing the effects of  inflation on their food budgets. There’s obviously an impact there, and it’s right that this aspect is highlighted. But are we fighting hard enough for people such as Ben, who spent yesterday morning hungry and don’t currently have any budget for food? Or for anything….