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Food service: Under the knife

20 April 2006

Next week, NHS catering managers from up and down the country will be gathering in Birmingham for hospital food's annual check-up - the Hospital Caterers Association (HCA) national conference.

Expectation surrounding this year's conference will be high. The single biggest initiative to improve the state of food in our hospitals in recent years - the Better Hospital Food (BHF) programme - is, incredibly, five years old, and while for many it has been something to celebrate, its fifth anniversary comes at a particularly crucial watershed in its development.

First, responsibility for food in hospitals has been passed from the now-defunct NHS Estates to the National Patient Safety Agency (NPSA), which has a new person in charge of delivering Government policy on food - Evelyn Ogilvie. She will be speaking at next week's conference and the HCA will be keen to hear what she has to say, not least because the assessment of food quality in hospitals has now widened to include the overall catering service, as much covering how the food is served at ward level as how well it's cooked. Caterers will be anxious to hear what the new focus means for reaching standards.

More acute But the development most likely to affect, and possibly threaten, the continued success of the BHF programme is the current climate of budget cuts and spending freezes in the NHS. According to Kevin Bailey, facilities manager for Poole Hospital's catering services, the situation is "more acute than at any time in the past five years".

Bailey has been given CRES targets (Cash Releasing Efficiency Savings) requiring him to reduce spend by 2.5%, a figure that will be common to many other trusts. On top of these current targets, however, the National Audit Office (NAO) last month published a report, Smarter Food Procurement in the Public Sector, which called for further savings to be made on public sector food procurement - to the tune of an extra £224m by 2010.

Under such financial pressure, the BHF programme's mission to serve better food looks a tough one: quite simply, can the quality of food be improved while still cutting its cost? The aim of the NAO's report is to prove that reconciling these two seemingly contradictory agendas is not impossible. What it does warn is that "to successfully combine them places considerable demands on the skills and capacity of those responsible for actually delivering food procurement".

Improve further That particular piece of condescension aside, there's much in the report that NHS managers will read with interest. Individuals on the front line as well as organisations such as the Purchasing and Supply Agency (PASA) have been working to improve procurement, and the report gives an idea where they will be expected to improve things further.

Are the recommendations fair? Charles Abolins, director of facilities and capital development at Northampton Hospital, is one who accepts the call for more savings, saying there is "certainly general scope for improvement". Bailey agrees, saying: "We have to keep services competitively priced and make sure targets are maintained."

Rather than roll their eyes, whinge and declare future cuts impossible, NHS catering managers, it seems, are up for the challenge.

However, there are elements of the report that could confuse, in particular the tension between centralised procurement and creating local supply networks. In the NAO's report, the Government's bean-counters call for the public sector to save money by joining forces to create more purchasing power. This makes economic sense, except that, as well as BHF, the Government's other major project for hospital food in the past five years has been the Public Sector Food Procurement Initiative (PSFPI). Rather than promote centralised procurement, the PSFPI has spent the past four years looking at exactly the opposite: more local supply networks supporting more sustainable procurement.

The NAO responds by saying that the report is not recommending one route over the other, just that caterers need to improve efficiency overall - be it from local supplies or national contracts.

"There are real efficiencies to be made from centralised buying if trusts club together," it says. "But there is a balance to be struck. We think sustainability can also be improved. Not everyone needs to move to local supply chains, but there is scope to use local suppliers. We are not being prescriptive; the market needs to be able to see what it can support."

Different chains That sounds reasonable, except that elsewhere the report also questions why there are such discrepancies between the prices of, say, a pint of milk - which is anything from 17p to 44p, according to the NAO's research. As a spokesperson for PASA explains, the answer to their question is precisely because there are different supply chains. "Using national contracts is not mandatory, as was highlighted by the NAO report, so choices can be made locally, resulting in the variations found in the report," the spokesperson says.

You have to feel sorry for PASA. It exists to help set up a more centralised and modern approach to procurement in the NHS - exactly what the report says is missing.

Although the NAO says it is not criticising PASA, just encouraging it to do more, the inherent contradictions between more efficient procurement and the PSFPI certainly make its life hard. But because individual trusts can choose either to embrace the PSFPI or not, PASA, as an organisation, must be congratulated for also exploring the improvement of local supply chains, through the Collaborative Procurement Hubs, as well as the modernisation of centralised buying, through e-tendering and e-auctions.

However, despite the inherent contradictions, there are examples to show that you can have the best of both worlds. John Hughes, catering manager at Nottingham City Hospital, says he was sceptical about the PFSPI ever working. "If you had asked me 18 months ago, I would have said it couldn't work," he says. "But then we had a crack at it, and the more we did it the easier it became."

Hughes has successfully introduced milk from a local dairy, which costs him only £3,000 more than the £60,000 he was spending through the national contract. To offset the increase of 5%, Hughes upped the price he sold it at.

But the exercise had further, unexpected results. Once the team began to look at how much milk they were sending to wards, he discovered that hospital staff were using the patients' milk. "Now staff might expect to get free milk, but it should not come out of the patient feeding budget," he says. "It means we are using only a pint a day per patient as opposed to a pint-and-a-half. Trying to implement the PSFPI has been hard work, but it has also forced us to look at ourselves."

The background to his initiatives has been increased revenue from the hospital's branded coffee shops, called Coffee City. The first outlet is even opening outside the trust in Nottingham's city centre. Once subsidised, the business now delivers £200,000 profit for the trust. It's a model he plans to share with other trusts. "I don't believe anyone can't do it," he says. "I may have to make 15% more savings, but in two or three years' time we could also be talking about 15% more profit."

What does rankle with Hughes in the NAO's report is the call to improve infrastructure. It states that better infrastructure would improve sustainability and improve cost saving in the long term, something no catering manager would argue with. Unfortunately, says Hughes, the Central Production Units built before were either never used, or were sold off, knocked down or used by contractors. "New trusts are now being built without kitchens," he says. "We should specify that they have to have kitchens. Of course, if they don't have kitchens, it lowers capital investment in the short term, but in the longer term it gets more expensive."

He also argues that, for the BHF programme and the PFSPI to work, even in the face of cuts, the NHS must take ownership of its facilities and food provision. "The report mentions transparency of costs," he says. "Well, all the nonsense I hear about firms quoting inflated costs, it makes me wonder whether we have got anything to learn from the big catering firms at all."

For Abolins, enough has already been achieved through the BHF programme to safeguard its momentum. "The important thing to remember is that the key elements of the BHF programme are in place," he says.

Certainly, one legacy can already be detected: hospital food is now taken far more seriously by the NHS. The National Institute for Clinical Excellence draws attention to the need to improve delivery of food in its reports, while nutrition has found its way into the pages of the nursing guidelines, Essences of Care. The British Association for Parenteral and Enteral Nutrition (BAPEN) also reported last December that malnutrition costs the NHS some £7.3b every year in longer recovery times - a figure that puts NAO's £224m cost-cutting drive to shame.

Greater attention "Nutrition generally has never had the focus it should have had, but 2006 does seem to be the year when greater attention is given to it," says Rhonda Smith from BAPEN.

For NHS catering managers going to Birmingham, that makes all the cuts easier to stomach. "Catering used to be very much seen as support services," says Bailey, "but in recent times there's an increasing emphasis on making every part of the hospital as efficient as possible, including clinical care. We don't feel singled out."

Ahead of next week's speech, Ogilvie is also keen to stress the value which is now attached to food delivery. New developments from the NPSA reflecting that value will include nutritional assessments of patients and the promotion of food as a clinical treatment. She says: "I will be highlighting the need for the NPSA to work with hospital caterers to embed the delivery of nutritional requirements as an important part of safer patient care."

The conference will certainly provide a forum for sharing good practice and solutions. It will also provide encouragement. "People have got to get off their arses and have a crack at it," says Hughes. "Implementing the PSFPI and improving food while making savings are completely reconcilable. It's time for more of a have-a-go culture."

Buy local, buy cheap John Hughes has managed to make savings, even while shopping locally. Tony Goodger from the Meat & Livestock Commission (MLC) told him about a pig farmer nearby, explaining about that it would be much cheaper to use a different cut of pork - boned and rolled shoulder instead of leg - because no one else wanted it. "This has saved us quite a bit of money and allowed us to invest more in beef," Hughes says.

Similarly, he has taken the offcuts from the leeks which a local farmer has to cut to a specific size for supermarkets - very cheap, not uniform, but very good for soups. "Doing things like that has always been shied away from because of worry about ‘risk'," Hughes says. "But what is risk? It's all food, and we are food professionals. We can't pass on responsibility all the time. We should manage that risk. That is what we are paid to do."

Hughes also sits on the East Midlands Food and Drink Forum, alongside Kevin McKay from the Local Authority Caterers Association (LACA). "We're beginning to talk about joint purchasing and sourcing food - but at a local level," says Hughes.

It's the type of balance between joint purchasing and sustainable sources that would have the boys at the NAO beaming.

For more information on sourcing locally, or links to getting in touch with local suppliers in your area, try these websites:

HCA National Conference

  • 27-28 April, Hilton Birmingham Metropole, Birmingham
  • For more information and the conference programme, visit www.hospitalcaterers.org
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