The sticky subject of hospital food is back in the headlines. So, why is this still an ongoing issue, and what can be done to improve the offering? Rosalind Mullen spoke to the operators to find out the problems they face
We don't need to dwell on why hospital food is under fire as being unhealthy and unpalatable. The media is full of it, from Channel 4's Dispatches programme, to reports from cardiologist Dr Aseem Malhotra in The Guardian, to a recent report commissioned by the Soil Association.
The report, First Aid for Hospital Food, not only warns that the NHS is wasting millions of pounds by failing to source fresh produce from local suppliers, it also slates the quality of food, revealing that more than two-thirds of the 1,000 people surveyed took their own food into the wards, more than half would not be happy serving it to a child, and over 33% thought hospital meals were "unacceptable".
More depressingly, it noted that every survey since 1963 found hospital meals were unhealthy and barely edible. Elsewhere, we hear that more than 10,000 patients are malnourished when they leave hospital and most of the 175,000 that arrive malnourished will leave in that condition.
a complex operation
So, what's going on? Without doubt, hospital catering is complex. This is a 24/7 year-round job. Each trust has dietitians who ensure that the menus are nutritionally balanced, but caterers still have to meet different religious, clinical and personal requirements - particularly difficult with long-stay patients. In some hospitals up to 2,000 patients have to be fed in a one-hour window. Not least, the logistics of getting food from a remote kitchen to the wards and ensuring it is served hot and in prime condition is a major challenge.
But that's only part of it, as Simon Scrivens, managing director of Healthcare at Sodexo, explains: "The budgets tend to be £2-£3 per person per day. Some hospitals want to reduce patient feeding costs - but we've got the patients at the other end. We're caught between a rock and a hard place.
"Some hospitals want cook-chill and some want us to cook fresh on site. The fundamental issue is not where it is prepared - let's face it, cook-chill is good enough for consumers who shop in Tesco. The fundamental issue is how much [the trusts] pay."
Consultant Andrew Etherington, from Andrew Etherington Associates, an executive member of Foodservice Consultants Society International and a specialist in NHS catering issues, agrees that hospitals don't allocate enough funds for food. He cites Mike Duckett at Royal Brompton NHS Trust whose freshly cooked, seasonal meals attract a 20% higher patient satisfaction rate than in most hospitals and are upheld as an example of how good hospital catering could be. That's partly because Duckett is lucky enough to work for a trust that allows him the freedom and the budget - £3.50-£4 per person per day - to buy what he wants. He also has full working kitchens that allow him to cook on site, unlike most hospitals.
In reality, it's difficult to unravel who's doing what. "Each trust accounts differently, so it's almost impossible to really know the food costs or to benchmark them," explains Etherington.
Perhaps controversially, Etherington claims hospital food is not nearly as bad as it is made out to be. "The Dispatches programme showed an old-fashioned service where the food is prepared in a central kitchen, plated, covered and transported to the ward, during which time it sits and goes nasty. More modern systems allow the food to be either cook-chill or cook-freeze and reheated on the ward either in a trolley or in a microwave."
That said, he concedes there is room for improvement. For instance, while it is important to give patients a choice, he believes the quality of food suffers when too much choice is offered because this incurs wastage - around 30% in many hospitals. Etherington argues the savings made by cutting waste could be spent on better ingredients.
Many cutting-edge trusts already achieve this by sourcing from local suppliers. Nottingham City Hospital, for example, saved £6m last year by buying produce locally instead of from expensive multinationals, while on a smaller scale, Sussex Partnership NHS Foundation Trust gets yogurt from a local supplier at two-thirds of the price of the nationally approved supplier.
At Royal Cornwall Hospitals Trust, head of hotel services Mike Pearson has a budget of £3 per person per day and spends 80% of it with local suppliers. All the cook-freeze dishes are prepared from scratch in state-of-the art kitchens at its Cornwall Food Production Unit.
The partnership with local suppliers means the trust allows them the flexibility to provide what is plentiful and affordable. For instance, if they need white fish they will take ling, haddock, cod - or whatever "is in glut". And by cooking from fresh without using processed mixes, the team believe the meals taste better so there is less waste.
"All budgets are under scrutiny. We make sure we order the right amount of food and have little waste so our recipes are better value," explains director of Cornwall Food, James Mills.
So what about nutrition? Kevan Wallace, chairman of the Hospital Caterers Association, reckons that the "fixed and enforceable nutritional standards" called for by Malhotra are not viable.
"These would be difficult to apply in a hospital environment where you have the need to cater for all age groups, a wide ethnic mix and the extensive dietary requirements of patients depending on their medical condition. There are already strict guidelines and standards in place."
Long-stay patients are a separate issue, but Scrivens shares the view of many caterers when he says it's more important to offer short-stay patients what they want to eat. "An 18-year-old may want a pizza. It's not healthy, but he isn't going to eat a plate of food he doesn't recognise."
In fact, many caterers argue that the food that leaves the kitchen is of good quality, but by the time it has reached the patient it has degenerated. Steven Cenci, managing director of healthcare with Medirest at Compass, reckons its use of Steamplicity (see below), which cooks food at the point of service, has improved meals for patients.
"With some catering offers, particularly cook-chill and cook-freeze, meals may be reheated up to three times before reaching the patient - in the factory, in the hospital's kitchens, and on the trolleys going to the wards. Frequently, these meals are only nutritionally analysed at the stage of cooking," says Censi.
Other more practical steps can be taken to ensure food is actually eaten by the patients. "Investing in training catering staff and increasing on-ward catering supervision are vital elements in the provision of appetising, well-presented meals for patients. Raising awareness of the importance of food to the recovery process among healthcare professionals can ensure mealtimes get the focus they require," says Rosemarie Hoyle, healthcare divisional manager for apetito.
Bureaucracy is partly to blame. Loyd Grossman, who spearheaded the now-disbanded Better Hospital Food Programme in 2002/3, highlighted this on the Dispatches programme when he said consistency is difficult to achieve with the high turnover of health ministers and special interest groups.
Despite those hurdles, some observers reckon that hospital food needs a national programme and a champion - like Jamie Oliver for school meals. But that brings us back to the fact that any proposals need to be workable across a variety of hospitals.
â- Dishes must conform to strict standards set by the Care Quality Commission
â- The Royal College of Nursing's Principles for Nutrition and Hydration mean nurses have to ensure patients receive their food and are able to eat it
Top initiatives to improve nutritional standards
â- Better communication between clinical and catering teams to ensure patients don't receive tepid food or the wrong meals, or that meals aren't delivered when the patient is having treatment
â- A red tray system to highlight any patients who may need help eating or who have special diets
â- Ward hosts who liaise between nurses and caterers and ensure that when food arrives on the ward, the patients receive it hot and that any problems are reported
â- Regenerate food on the ward either by microwave or trolley - the closer to a patient that the food is reheated the better
â- Source food from local suppliers and cook dishes from scratch to reduce waste and increase quality
steamplicity: leading the way to healthier eating
Medirest, the healthcare arm of Compass, has introduced Steamplicity, a system that cooks food at the point of service. Instead of meals being reheated or defrosted, they are steam-cooked in minutes from fresh, locking in essential nutrients and retaining flavour, form and colour.
Patients decide on the day what they would like to eat from a choice of more than 25 hot and cold dishes, incorporating healthy options, higher energy dishes, softer meals that are easier to chew, and vegetarian meals as well as gluten-free and lower sodium choices.
"The fact that patients can order their food close to mealtimes means not only do they eat more, but also that waste is minimised. Meals can also be timed to be cooked and hot when staff are able to assist patients with eating," says Steven Cenci, managing director of Medirest Healthcare.
"We regularly see just 3-5% food waste, compared with the 20-40% waste for bulk-plated, cook-chill or cook-freeze systems. Research carried out by Bournemouth University shows around 36% more food is consumed by patients because they order exactly what they feel like eating that day. This is great news as post-operative recovery times are undoubtedly linked to food and calorific intake."
Cenci admits that food costs have increased, but he says the benefit of simpler logistics, reduced labour and wastage brings the balance within budget. He also adds that the PEAT report recorded that 85% of patients are satisfied or very satisfied.