Previous attempts at overhauling hospital food have failed to improve quality, sustainability and standards. Can Prue Leith’s review succeed where others have failed? Nick Hughes reports.
“When the members of the panel agreed to take part in this review, there was a degree of cynicism whether it could lead to positive change.” The comment, made in their foreword by chair Philip Shelley and independent advisor Prue Leith, doesn’t immediately inspire optimism over the impact their independent review is likely to have on hospital food standards.
Shelley and Leith note that “previous efforts to improve the quality of the food for patients in hospitals, usually led by high-profile chefs, started well but as money dried up or government ministers’ priorities changed, they ran into the sand”.
Indeed, failure to bring about lasting improvement in hospital food pre-dates this and many previous governments. As far back as 2009, the food and farming alliance Sustain reported that £50m had been spent by governments over the previous 10 years on reviews, task forces, action plans, and voluntary measures. Although well-intentioned, each failed because “they lacked firm action, legislative change, money and the enforcement needed to do so”, recalls Sustain’s chief executive, Kath Dalmeny, who co-founded the original Campaign for Better Hospital Food.
Shelley and Leith write that they “truly believe” this time is different, citing the support of both the prime minister Boris Johnson and the health secretary Matt Hancock. But is their optimism well founded? And how are they proposing to improve the quality, safety and sustainability of hospital food?
Published in October, the “root and branch” review was commissioned by Hancock following an outbreak of listeriosis in the summer of 2019 in which seven patients tragically died after eating contaminated hospital sandwiches. It begins by setting out the scale of NHS catering provision and, by implication, its potential to be a force for public good. In 2018 to 2019, the NHS spent £634m on hospital food, representing approximately 6.7% of the total cost of running the NHS estate. It is the second biggest provider of meals in the UK public sector behind schools, serving 141 million inpatient meals last year.
Publication of the review was postponed due to covid-19, but rather than kick food down the list of hospital priorities, the review states that the pandemic has “shone a light on the importance of good food and proper nutrition, including both the effects of food insecurity, malnutrition and the effects of obesity”, which has been identified as a key risk factor for covid-19. “If we are serious about improving the nation’s health and tackling health inequalities, we must be serious about food,” the reviewers stress.
Hospital caterers are already required to meet a range of standards concerning nutrition, hydration and procurement that are included in NHS contracts. These standards are in the process of being reviewed by the government, however Shelley, Leith and their team conclude that the penalties for non-compliance are not working: they want hospital food standards enshrined in law – as is the case with school food standards – and inspected by the Care Quality Commission.
The reviewers do a fine job explaining the challenges and complexities involved in hospital food provision: the wide range of patient needs that must be met, poor catering infrastructure and different operational models whereby some hospitals produce all their food onsite for immediate service while others outsource to commercial providers who deliver pre-prepared chilled or frozen meals for reheating. They are careful not to dismiss “food that comes out of a factory” as inherently “bad”, stating that “the thing that matters is that food must start with good fresh ingredients, and be prepared by well-trained chefs using traditional processes and minimal additives”.
Indeed, a recurring theme of the review is its reluctance to suggest a “one size fits all” solution for NHS trusts, preferring instead to identify shared characteristics of the best hospital food providers and from these draw out a series of more specific recommendations.
Those trusts that do hospital food well are found to adopt a “whole hospital approach” to food where the restaurant is the hub of the hospital for staff and visitors alike, with food considered a key part of patient care and treatment.
They have chief executives who understand the value of food and see it as an investment into the health of the whole hospital community rather than another budget to be cut.
They focus on serving good, nutritious food in an attractive environment – including a preference for ceramic over single-use tableware – and encourage multi-disciplinary working where catering, dietetics and nursing come together to help improve nutritional outcomes for patients.
There appears little to argue with here. But as ever with an independent review the proof of its impact will be in the adoption (or otherwise) of its recommendations – arranged under eight headings, from “going green” to “food as medicine”.
One standout recommendation is that directors of nursing should have accountability for food services as part of their remit over the nutritional care of patients. Because catering usually falls under the estates and facilities budget, the reviewers say it is often a target for cuts rather than prioritised as an area for investment in patient care. “In the best examples we have seen, menu planning for patients is a joint responsibility between nursing and estates,” they note before recommending that responsibility for the hospital’s food and drink strategy should straddle nursing, dietetics, catering, speech and language therapists, sustainability, staff and well-being leads, as well as patients.
Trusts are urged to see food safety as everyone’s responsibility, not just that of the catering team, and establish appropriate governance structures to ensure concerns are acted upon swiftly.
On sustainability, the reviewers paint a picture of good intentions that often don’t translate into good practice. They recommend trusts use Defra’s balanced scorecard for public food procurement where cost is balanced against other considerations such as nutrition and sustainability. In practice, they suggest a good menu design should cover “seasonal and local produce with sound provenance, sustainable fish, less and better meat, as well as supporting agroecological farming”.
The balanced scorecard approach is mandatory for central government departments and can also be used by the wider public sector, although experts believe it is currently underutilised. Rob Percival, head of food policy at the Soil Association, which certifies hospital trusts with its “food for life served here” award, told an EFRA Committee hearing on public sector food procurement last week that if the government was to implement the balanced scorecard approach across the entire public sector there would be clear benefits for British farmers and an increase in environment and animal welfare standards. “[But] it needs to stop being a secret and become a mandated tool,” he said.
Waste is another focus for the review. NHS data shows that 14 million kilograms of unserved meals were thrown away in 2018 to 2019. That figure could be “significantly higher” because only around one in four trusts record food waste data. The reviewers want trusts to agree a common method of recording and monitoring food waste and to roll out food waste minimisation plans with a package of supporting materials to raise awareness. They also believe that by moving to a digital meal ordering system by 2022, hospitals can reduce waste while tailoring menus to patients’ dietary needs and personal preferences.
Catering skills also come under scrutiny – the reviewers cite a lack of “real chefs” in certain hospitals. They recommend developing a national training certificated course for hospital caterers as a practical measure to improve skills. More philosophically they urge hospital chefs to see themselves as part of the broader catering profession. “The core skills that are required of them are the same as if they were cooking in a restaurant,” they point out.
Inadequate infrastructure, including a lack of ward kitchens, is identified as a major barrier to serving high quality food 24 hours a day (many hospital restaurants close overnight and at weekends). The reviewers want to see funding provided to upgrade existing hospital kitchens and for all new healthcare buildings to provide “health-enhancing, fresh and sustainable food to patients, staff and visitors, while maximising local job opportunities by ensuring 21st-century catering facilities”.
Craig Smith, chair of the Hospital Caterers Association, welcomes the “excellent” recommendations but notes that there does not appear to be any new money allocated to help hospitals enact them. “We simply can’t move forward without capital investment in our hospital catering operations, and we urge the government to release details of funding plans to support these initiatives,” Smith says.
The conclusion of the reviewers that “bad food is likely to lead to future ill health and therefore more cost to the taxpayer” is cleverly framed to appeal to the bean counters in Whitehall. But with ministers and health officials still in the grip of coronavirus it remains to be seen whether this review will buck the trend of 20-plus years of false dawns.
The government has announced it will establish an expert group of NHS caterers, dietitians and nurses to take forward the recommendations made in the report and decide on next steps. “This pandemic has demonstrated more than ever the importance of good food and proper nutrition,” said Hancock at the time of its launch.
Seasoned campaigners are unlikely to be won over by warm words alone. Like Smith, Dalmeny believes Leith and her panel of experts have set out some “excellent” recommendations. “It is now over to the government and its regulators to commit legislative muscle and funding required to see them through,” she says.