The quality of hospital food depends not just on ingredients but on timing, presentation and choice. Jackie Mitchell goes in search of the optimum hospital meal
Thirty-two per cent of hospital patients are unhappy with the quality of the food 25% said that the food was so bad they had to buy their own or ask friends and family to bring food in for them while 67% of staff felt that improvements in hospital food had to be made.
These were just some of the findings in a survey carried out by consumer advocate Which? last December.
It also revealed that 27% of patients found the portions were too small, 34% didn't like the type of food provided, and 38% felt that meal times did not come when they were able, or wanted, to eat.
These findings come almost two years after the Government scrapped the Better Hospital Food programme (BHF). Opinions remain divided on whether it should have been discontinued. Neil Watson-Jones, chairman of the Hospital Caterers Association (HCA), says: "It's a shame it was scrapped, but it has given us a kick-start and helped increase awareness of hospital feeding."
Which? is now focusing on the Health and Social Care Bill 2007/08, currently going through the House of Lords, having had its second reading last month. "We're negotiating to get nutrition mentioned in the text of the bill," says Kate Webb, principal policy adviser for Which?. "The bill needs to recognise the importance of nutrition in hospitals and care-home catering."
The bill, if passed, will create a new regulator, the Care Quality Commission, which will have significant powers. "It will help raise standards and it will be something against which hospitals can be measured," Webb says.
The Which? report acknowledged the efforts made with new guidance from the Food Standards Agency (FSA) and the Improving Nutritional Care action plan from the Department of Health. "There's a lot of guidance out there, but it falls short as it's not something that can be monitored," Webb adds.
The report has been welcomed by Jeff Brades, marketing director for Sodexo Healthcare, "as it provides us with insight into patients' views and enables us to provide a better service".
He adds: "It highlights patients' actual concerns, such as portion size, availability and choice of food. The more we understand patients' concerns, the more opportunity we have to make changes and improvements."
However, according to Watson-Jones, the percentage of patients satisfied with hospital food is higher than the report indicates. "There is obviously room for improvement," he says. "But when the report was issued last December, we did a series of radio and TV interviews, and listeners and viewers were ringing in to say that hospital food had improved. The quality of the food coming out of the kitchen is good the process from leaving the kitchen door to the patient's plate is the problem - it might have to travel as much as half-a-mile."
This is a view echoed by Rosemarie Hoyle, divisional manager for Apetito. "I would like to see more patients having a choice of meal at the point of service, rather than choosing 12 or 24 hours in advance. When someone is ill, their appetite can vary - they just don't know how they're going to feel."
As Hoyle points out, if hospital food is cooked in a prime cooking kitchen at 10.30am, plated up, but then not distributed until 12 noon, the quality of the food will have deteriorated. "Food kept hot over time loses colour," she points out. "Vegetables lose their quality and texture."
Several catering companies, including Apetito, have come up with solutions for this problem. Apetito uses a cook-freeze operation, which means that meals can be regenerated at the point of service (see Derriford Hospital case study). Medirest, part of Compass, has developed the Steamplicity method of steam-cooking food, while Sodexo is trialling another steam-cooking process. Both systems mean that food can be cooked and served on the wards (see page 55).
An added benefit of such systems for caterers would be small kitchens for the end preparation of hospital food, according to Graham Merchant, divisional director for healthcare at Aramark. "We eat with our eyes and presentation counts," he says. "Being able to put the final touches to food close to the patients will make a real difference to the end result."
The Which? report says that caterers don't try hard enough to get feedback from patients. However, Sodexo Healthcare says that it is carrying out surveys more regularly than it used to. "Feedback and action resulting from it are essential if we are to continue to provide a popular service," Brades says.
Similarly, Aramark conducts regular surveys. "We are talking to the people who matter and that's the patients," Merchant says. "They are the ones who are affected, and they should be the people we consult on key areas which need to be improved."
Budgets remain a critical element in supplying adequate meals in hospitals. As Hoyle says: "You have to be realistic - if you had a budget of £10 per patient, it would be a different world."
According to Watson-Jones, the average budget is about £2.60 to £2.80 per patient per day, covering all food and drink. "Another 30p, 40p or 50p would be helpful," he says.
Watson-Jones feels there is a need for more training at ward level - not just catering staff, but nursing staff and healthcare workers. "The onus needs to be taken off the nursing staff," he says. "They don't need to serve the food, just be aware of what the patient is eating. Catering staff are often not involved in serving food - it would help if they were."
Andy Jones, director of catering for ISS Mediclean, involves all the ward staff in food tastings. "It's imperative that staff should taste the food so they can inform patients about it and where it comes from," he says.
Aramark introduced ward hostesses in June 2005 to help serve food to patients, and they also act as conduits between the patients and the caterer. "Patients can provide feedback to the hostess and the patient gets the time and attention needed," Merchant says.
The timing of hospital meals was criticised in the Which? report, and this is something that Aramark is addressing. "One of the things we're doing is offering patients more choice and increased flexibility on meal times, to deliver a more patient-friendly service," Merchant adds.
A movement for protected meal times has been taken up by most NHS hospitals. This is where wards can be shut down for periods of 45 minutes to one hour for food service. Watson-Jones says that this is improving across the NHS. "It provides a calm period for patients to eat food," he says.
Protected meal times have also been successful at hospitals where Aramark supplies catering services. "They are agreed in advance with each ward, so that ward staff can assist the catering team," Merchant says. "The speed and quality of meal times has increased, and patients who need assistance with eating have benefited hugely."
Several catering companies have introduced steam-cooking technology, which means that hospital meals can be prepared quickly and easily at on the ward.
Medirest, part of Compass, has introduced its Steamplicity method of cooking at 16 of the 21 hospitals where it provides catering services.
Meals using fresh ingredients are assembled at Compass's Cuisine Centre and then delivered to hospital sites. The food is steam-cooked using a valve inserted in the packaging. These valves are activated when the meal is cooked in a microwave oven, and the food cooks in three to five minutes. This means patients can choose a meal an hour before it is served, and meals can be available to patients 24 hours a day.
The meal options are created with input from hospital dietitians. Examples of dishes include braised beef casserole with mashed potatoes, carrots and garden peas roast chicken with stuffing, roast potatoes, cauliflower and broccoli and mushroom and bean stroganoff with rice.
Sodexo is trialling a steamed food concept from Tillery Valley Foods at Hillingdon Hospital NHS Trust in Uxbridge.
Jeff Brades, marketing director of Sodexo Healthcare, says that, in initial trials, there has been positive feedback. "The patient is able to choose their meal just a few hours before receiving it," he says, "and those serving the food are able to prepare the meal from frozen using the steam-valve technology in less than three-and-a-half minutes."
Case study: Derriford Hospital, Plymouth
On two occasions recently Derriford Hospital in Plymouth gave members of the public an opportunity to taste its food.
Last year, at the hospital's AGM at the city's Guildhall, it was decided to demonstrate live regeneration of food and invite members of the public to taste it.
This experiment was so well received that the hospital decided to repeat it for a second day by setting up a regeneration station in the main reception area.
"The general perception is that hospital food is rubbish, and we wanted to show people that it isn't," says Liz McGuffog, head of site and commercial services at the hospital. "We received brilliant comments. It was very positive, so we may do this on an annual basis."
Since 2001, Derriford Hospital has been using Apetito's cook-freeze system. The now-defunct Better Hospital Food programme (BHF) was introduced at the same time, "which gave us added impetus to change suppliers," McGuffog says. "We were looking for dishes with better nutritional content and smaller packs, to reduce the wastage element."
Derriford Hospital has 900 patients and the food cost per patient per day, including ingredients and labour, is £6.95. Apetito's cook-freeze system means that meals can be chosen and regenerated at the point of service, and the patient's meal will be piping hot. The food is prepared centrally at Apetito's own factory to standard recipes, so all meals are consistent. Nutritional information is listed on every pack.
The cooked food is blast-frozen immediately to retain freshness and nutritional content, and is delivered to the hospital, where it is stored. It is regenerated in special trolleys that transport the food around the ward, where it is plated up by ward housekeepers. At each meal time, the trolley service is started at a different part of the ward, so it's not always the same patient who gets served first.
Rosemarie Hoyle, Apetito's divisional director, says: "This works well because, if a patient doesn't get their first choice at lunchtime, they will get it at supper time, as the service will start at a different part of the ward."
Apetito supplies almost 2,000 hot meals per day to the hospital. There is a seven-day menu offering a choice of three hot meals or two cold meals for lunch, and two hot meals or two cold meals for supper. Traditional roast dinners are popular, as are classic desserts such as sticky toffee pudding, rhubarb crumble and bread-and-butter pudding.
"The menu is constantly under review," McGuffog says. "We survey patients on a regular basis using questionnaires. We look at the comments and, if a dish is unpopular, we look to replace it."
Apetito provides food in multi-packs and mini-packs, which allows the hospital to avoid wastage. "For example," McGuffog says, "if we have a request for 10 portions of a dish, we can send up one pack of eight and a mini-pack of two - instead of two multi-packs of eight."
By Jackie Mitchell