A question of waste
When the Audit Commission produced its Hospital Catering Report in 2001, it said that if the food waste levels of the best-performing hospitals were mirrored across the whole of the NHS, there would be a total saving of £8m a year. That would translate into an additional 25p that could be spent on the daily patient food budget. It is not just in schools that the issue of daily food cost is highly charged.
Hospital caterers were stung by the criticism of their financial management and, by implication, culinary skills. They argued that a certain amount of waste was inevitable because of the obvious fact that hospital patients are ill and often don't have a good appetite.
But there are steps that can be taken to keep food waste to a minimum. Alison McCree, of County Durham & Darlington NHS Trust and current chairman of the Hospital Caterers Association, has been active both nationally and locally in tackling the issue of food waste.
One of the key changes McCree made at Durham was for catering staff rather then nurses to take over the ordering process from patient to kitchen with the help of a ward hostess system.
"The first duty of a nurse is clinical, the first duty of catering staff is food - it's as simple as that," McCree says. "Catering staff get to know each patient. They help in the ordering, talking through the menu and knowing what portion size each patient wants. The reality is that no hospital can afford to be throwing food away."
She adds that catering staff can recognise historical evidence for a particular ward or group of patients, which can help the kitchen forecast menu demand and volume.
Catering staff can also recognise when a patient clearly can't eat anything or very little, such as in a post-operative situation. In the past, when nurses scheduled meal planning for the kitchen, there could be the temptation to order a meal just in case the patient might eat a little.
If the hospital kitchen can react to a sudden need by a patient for something to eat out of normal service time, then this gives nursing staff confidence that a meal is just a phone call away.
So having catering staff on the front line of delivery at ward level is the key to good food waste management, according to McCree.
While bulk food delivery creates more food waste than an individual plated meal system, the difference is not large (see graph), and the bulk delivery method does have its advantages. "Food is served in front of patients. They can see and smell hot food being served. It is so much more appetising than a tray with lidded dishes," McCree says.
Furthermore, Ian Robinson, general manager for catering services at Salisbury NHS Trust, points out that plated service carries a higher labour cost in the kitchen and bulk service at ward level allows serving staff to tailor portion size where a plated service does not.
"A patient might like roast beef so orders a large portion. But that will come with a large portion of roast potatoes and vegetables, which they don't want and will leave," he explains.
So did the changes that McCree made in Durham result in less wasted food? In the late 1990s, food waste was running as high as 25% on some wards. Current food waste level is down to 13% across the Durham Trust and a remarkable 7% in the A&E Darlington site.
The realistic bottom-line food waste level for a multi-service Trust is 10%, McCree says, given the mix of care units and patients all trusts have.
One of the biggest contributors to reducing food waste by patients has been the steady rolling out of protected mealtimes. Traditionally, clinicians have always taken precedence over caterers when it comes to patient attention. If a blood test needs doing, a dressing changed, or a doctor is doing the rounds of wards, then eating has to stop. And it often doesn't re-start because the food has gone cold or the patient has lost all appetite through the disruption.
Protected mealtimes are far from standard in the NHS, but their introduction is spreading. While caterers have welcomed the change of thinking by the NHS, it has not met with universal approval, particularly from doctors and consultants. Their argument against protected mealtimes is that they are stretched to the limit to visit every patient as things are at present. Ring-fencing a ward for 30 minutes while patients eat a meal means their clinical visits might have to be shorter or their working hours even longer.
In any patient satisfaction survey of hospital food, food temperature is likely to be high up the dissatisfaction list. Appetites that are already fragile will wilt at tepid soup and barely warm chips.
Cook-serve, where food is cooked fresh prior to service and taken in insulated transport to the ward might be what some hospital nutritionists would prefer, but it is notoriously difficult to deliver hot food given the time from leaving the kitchen to serving patients in a sprawling A&E site.
Cook-chill and cook-freeze systems are steadily becoming more widespread, and regeneration trolleys for re-heating the food just get smarter and smarter. Some are computer driven for temperature and time and many can hold both chilled foods and food to be reheated in the same trolley. Patients are served either a plated service or from a bulk service at ward level and hot food is always going to taste more appetising and generate less waste.
Robinson says there is no single big cause of food waste in the NHS. "If there were just a single cause we would have found it and eliminated it years ago. The easiest way to cut food waste would be to halve portion sizes, but nobody is going to do that because you'd starve some patients nutritionally and compromise the rest."
Robinson agrees with McCree that good communication between ward staff and kitchen staff is the key to reducing food waste.
BOXTEXT: Key Requirements for Reducing Wastage
