The NHS food review has seen big changes on tiny budgets

It may not be the glamorous face of hospitality, but Phil Shelley, chair of the Independent Review of NHS Hospital Food and NHS senior operational and policy manager, stresses that it is a sector full of innovation and creativity, far removed from the prevailing image of hospital dining that has long been the butt of jokes.

Following the publication of the Independent Review of NHS Hospital Food in 2021 there has been a concerted effort to recognise the mammoth task undertaken by chefs working in the sector, introduce new standards and drive innovation across all NHS trusts.

The commissioning of the review followed a 2019 outbreak of listeriosis, in which seven patients died after eating sandwiches supplied across five hospital trusts contaminated with Listeria monocytogenes. The report covered hygiene and safety as well as nutrition, chef training, equipment provision, investment and standards across patient, visitor and staff meals.

It was by no means the first attempt to improve standards in the sector, following campaigns by high-profile chefs including Albert Roux, Loyd Grossman and James Martin. But Shelley was clear from the outset that this time, meaningful change had to be seen for patients as well as staff working in hospitals and those visiting loved ones.

He says: "There's that feeling of déjà vu for some people, that they've been around and seen this before. We had many discussions before we really got into the work to make sure that this would be different. My view was that there were two things we had to prioritise: first, building a small expert group that over a three-year period could help to push the review recommendations out there. That group would support [NHS] trusts and individuals, and it had to include not just caterers, but clinicians and dieticians – if you have a successful meal service in the NHS, it is because those three groups work well together.

"The second thing was that we needed mandatory food standards. We have had food standards for some time, but because they're not mandatory, people are not always committed to follow them."

Two years on from the report's publication there are now eight mandatory food standards, that all NHS trusts must adhere to, which, Shelley says, will set the standard for being "not just a fantastic organisation, but a safe one too".

The new standards include that trusts must have a board director responsible for food (nutrition and safety), a food and drink strategy, access to appropriate catering dietetic advice and a nominated food safety specialist.

Recognising the importance of catering teams is vital to Shelley and the standards also include a requirement to invest in a high-calibre workforce and recognise the complex knowledge and skills required by chefs and foodservice teams. Trusts or their partners must also be able to demonstrate they have a learning and development programme in place for all staff involved in healthcare food and drink services.

Meals for millions

In 2019 more than 6,000 catering staff working across the NHS served some 141 million inpatient meals across 963 sites before staff and visitor meals are considered, making the NHS the second biggest provider of meals in the public sector, at a cost of some £634m.

However, the review found that while some contracted caterers and hospitals offered excellent training it was not the norm, with many hospital chefs learning their trade on the job. The report's independent advisor, chef and broadcaster Prue Leith, drew particular attention to the need to raise the self-esteem and public standing of hospital chefs to encourage positive change and entice younger people into the profession. After all, patient surveys demonstrate the reality is not as poor as public perception may have it, with 22% of patients surveyed in 2019 rating the food very good and 36% as good.

To this end the review set out an ambition to bring the workforce into closer contact with the wider hospitality industry and deliver continuous professional development and the sharing of good practice.

Key to meeting this objective has been Nick Vadis, culinary director of Compass Group and winner of the Outstanding Contribution Award at the 2022 Foodservice Cateys, who created the NHS Chef's Academy on behalf of NHS Supply Chain to offer training courses to develop skills and culinary knowledge, while providing an opportunity for chefs to feel a sense of community and pride. Vadis says: "Having gone out to visit trusts in the breaks between lockdowns we came up with this initiative called the NHS Chef's Academy. The idea was to give an opportunity for NHS chefs to come away from that trust for one day and have culinary interaction with chefs from other trusts and with us, while learning new skills, new recipes and ideas that can be taken back to their workplaces."

The courses initially focused on staff and visitor meals, exploring themed days and ways to inject excitement into lunch, but have since progressed into patient meals. The NHS Chef's Academy has produced seven books of recipes on various themes so trusts can choose what their teams are trained in. There is also a dietician and nutritionist on hand for every course to explain how meals have been designed to be nutritionally balanced. At the end of the sessions chefs receive a certificate and credits that count towards apprenticeships and other training courses as well as a bank of nutritionally-balanced recipes to take back to their kitchens. So far 200 chefs have taken part in one-day courses, some returning multiple times.

Talent show

Recognition of the talent in the hospital sector also saw the creation of the annual NHS Chef Competition. Shelley says: "We had eight teams compete over six days of finals. We tested them on many different areas around things like religious and lifestyle meals, dietary restraints, on things like cooking venison, on plant-based food. Prue said it was the only competition she's been involved in where the chefs have been tested over so many areas of cooking. It showed they are very, very capable."

It is hoped that improving the visibility of talent in the sector will also boost recruitment. During the pandemic there was an influx in chefs joining the NHS and Shelley says that many have stayed thanks to the more sociable working hours and the benefits offered to NHS employees. However, as Leith recognised, there remains a need to entice young people into the industry and Shelley and his team have been visiting colleges to speak about the opportunities a career in the NHS can offer.

The importance of this well-trained workforce is obvious when you look at the challenges of food provision across the NHS. On the ward, teams face a myriad of challenges to prepare enticing and nourishing meals to people who often lack appetite, need help to eat and who will have a list of dietary requirements and intolerances that would have any restaurant chef cowering under the pass. Food must also be delivered from a kitchen that could be a substantial distance from the ward and is likely to need investment. On top of this, hospital teams must ensure NHS employees – highlighted by the report as a particularly underserved group - have access to nutritional food 24 hours a day, seven days a week and deliver an enticing retail offer to visitors.

It's no wonder then that classic crowd-pleasers have remained a staple of hospital menus, but Shelley says many trusts are starting to step out of this well-trodden furrow, particularly when it comes to their retail offerings. He explains: "You do often have a basic menu, because 60% to 70% of patients are elderly and generally quite traditional, so you will have roast, battered fish, poached fish, shepherd's pie and lasagne, but curries and spicier dishes are now very much a staple part of NHS menus and there is also the retail offering.

"We have some fantastic retail outlets within the NHS. Ashford and St Peter's [Hospitals NHS Foundation Trust in north Surrey] creates great food, doubling the uptake of retail meals during the Covid-19 pandemic, when everyone else was shutting down [see panel]. Staff couldn't travel very far and needed to be looked after, so it gave the opportunity to be innovative on menus and start to think well, actually, let's treat this like the high street."

It's not just in the kitchen where rigorous training is needed to help patients get the nutrition to aid their recovery, so recommendations extend to those working front of house delivering food to hospital wards.

Shelley adds: "If we're serving food and drink to our patients it needs to empower recovery and service is really important in that. If someone says ‘I don't like anything on the menu, just give me a bit of mashed potato and gravy', that's where you need somebody to say, ‘well, why don't you try a little bit of this with it' to help get nutrients into the body."

Delivering change across an organisation as large and strained as the NHS was always going to be a challenge, but Shelley, his team and partner organisations have put a lot in place in a short amount of time and will be monitoring trusts to ensure the new mandatory standards are acted upon.

He says: "We've given trusts six months to get themselves in gear, then we're sending out surveys and reports to check progress and see where we can offer support when needed.

The NHS is under pressure all the time, and this is our time now, to up the standards of food served in NHS

"There is that consideration of the NHS being under pressure, but actually the NHS is under pressure all the time, and this is our time now, to up the standards of food served in NHS, through the workforce and through ward level. Food is such an important part of the day for our patients. We need them to feel as if it's a social occasion and should be celebrated."

After all, as the report says: "Crisp toast for breakfast, a delicious lunch with a friendly word, a cup of tea willingly served in the middle of the night can do wonders. Food is a form of medicine."

Measuring food waste

Food waste is estimated to cost the UK healthcare sector £230m a year. Reducing this figure was a key area of focus for the report and presented a real challenge, with accurate records unavailable across the NHS.

Working with Wrap and its Guardians and Grub tool, a pilot is being run across 15 sites, which will see all food waste weighed to provide accurate figures for the first time. From April, this will be extended across NHS trusts who will have 12 months to ensure food waste is being accurately monitored.

Shelley said: "We know it's going to be high, because it's never been measured like this before and it is likely to have been underestimated."

Once an accurate snapshot is produced, the focus will move to reducing food waste. The report found that many trusts had already taken action by donating unopened dry goods to local organisations or providing cooked and chilled foods to soup kitchens, or to staff working night shifts.

Shelley adds: "We have a responsibility in the NHS not to waste food and finance, to reinvest money so that we can reduce waste across our services. That's our target and I'm really proud that catering managers are taking this on board and have realised, now's the time to do it."

What are the new NHS food standards?

Last year the NHS introduced new mandatory standards on the advice of the review panel:

1. Organisations must have a designated board director responsible for food (nutrition and safety) and report on compliance with the Healthcare Food and Drink Standards at board level as a standing agenda item.

2. Organisations must have a food and drink strategy.

3. Organisations must ensure that they have access to appropriate catering dietetic advice and support.

4. Organisations must have a nominated food safety specialist.

5. Organisations must invest in a high-calibre workforce, improved staffing and recognise the complex knowledge and skills required by chefs and foodservice teams in the provision of safe food and drink services.

6. Organisations must be able to demonstrate that they have an established training matrix and a learning and development programme for all staff involved in healthcare food and drink services.

7. Organisations must put steps into place to monitor their food waste, manage any waste produced and take action to reduce the food waste produce for plate waste, production waste and unserved food.

8. Organisations must have suitable food and drink solutions for all staff over a 24/7 service period.