Jeremy Hunt’s announcement that minimum standards for NHS hospital food will be introduced in England is about time. Whereas the NHS in Wales, Scotland and Northern Ireland have had food standards for a number of years, England lagged behind.
Hospital food has been widely derided for decades and in general, the public has had very low expectations. Yet good nutrition has never been seen to be more important. Do these new standards go far enough? Who will monitor them? What will the end result be and, importantly, will it really change our view of hospital food?
Let food by thy medicine
So, how is hospital food currently prepared and delivered? Getting food to patients is a complex affair, involving catering for a significant number of underweight and obese people, older patients with no appetite, and special dietary requirements.
Despite Hippocrates’ adage that “let food be thy medicine and medicine thy food”, in the NHS many hospitals have changed their catering arrangements to save money. Few now cook food in a way we would recognise. Many in-house kitchens have been replaced by various systems based around reheating food brought in frozen or chilled. This in part relates to the size of hospitals, where safe and hot food served at ward level may be prepared in a distant part of the hospital site.
This means that the way many people cook food at home or even on television or in restaurants would not work in a hospital system. It is also the reason why textures and the appearance of food, if recipes are not adequately tested, can be disappointing when served.
The importance of food in hospitals has not been seen as an equivalent clinical priority to other aspects of care. This was partly challenged by the report on the Mid-Staffordshire hospitals scandal, where along with many serious failings, inadequate provision of nutrition and hydration were found as significant issues. So along with providing nutritionally adequate food that the patient will eat, it’s important that they are also supported to be able to eat. More than a third of inpatients surveyed by the Care Quality Commission in 2013 said they required assistance with eating, but this didn’t always happen.
The double burden
Good nutrition within a hospital is more difficult to achieve that might appear. Hospitals provide food to a wide range of groups with differing needs, from very young to very old patients, visitors and staff. The new standards state that adequate provision needs to be made for everyone.
Hospitals have what is called the double burden, because more than one in five patients is undernourished but a similar number are obese. This is same level of obesity found in healthcare staff and the public. For an institutional caterer such as a hospital, providing “healthy options” may lead to the underweight patients and those with a poor appetite losing even more weight. This is also complicated by the 24-hour nature of hospitals, with people needing food outside of a typical breakfast, mid-day and evening meal pattern.
These issues in combination with the contracting out of food provision has led to a number of fast-food outlets and vending machines in hospitals which don’t necessarily provide healthy options. The new standards will follow the government’s Responsibility Deal and Public Health England’s recommendations for healthy food. Hopefully this will improve healthy choices for visitors and staff.
Role of dietitians
The new standards also say that menus should be approved by a registered dietitian. As someone who trains dietitians, this is potentially very exciting; in practice however, it could be delivered very differently.
If it merely involves a dietitian checking with a contractor that they meet the new standards, this would be far from ideal. But if every hospital has a dedicated dietitian, whose role includes working with catering staff to design and check menus, monitor satisfaction and food waste, support and train ward staff, feed patients and tailor individual nutrition plans focused on foods rather than supplement drinks then this would be a huge step forward. This could potentially also prove cost effective across health communities and save the NHS money, by reducing the need to prescribe expensive nutritional supplements.
Recommendations have been made for minimum nursing levels, might there be a similar idea for dietitians based on hospital size or meals served?
There have been recommendations for patients to be screened for malnutrition on admission for nearly a decade,to record weights and heights along with food intake, to improve nutritional care but this has been patchy across the NHS. This is now the opportunity to better monitor this, and improve overall care. It should not be acceptable for a patient to leave hospital in a worse nutritional state than they came in.
Better menu design
The need to provide healthy options alongside appetising energy (calorie) and protein dense meals (which ordinarily would not be considered healthy) is perhaps the key challenge. Ultimately, this won’t be solved by standards; it needs motivated catering managers and chefs to work with dietitians with interests in catering. To make this happen they would also need access to appropriate kitchens to develop cost effective menus to meet the range of needs presented by a dynamic population of hospital diners.
In addition to catering for the diversity of the nutritional requirements, hospital food needs to generally promote at least five portions of fruit and vegetables, decreased salt intake and reducing energy (calories) by reducing fat and sugar. However, this needs to be balanced by a need for flexibility in providing for patients who may have increased nutrition needs.
Hospital food is never likely to be Michelin starred, but it should always be tasty and well presented. Expectations of hospital food need to be challenged, as can be seen in some of the many examples of excellent hospital catering – yes, they are out there. Food is more than nutrition, food needs to be enjoyed and so wherever possible we need to give this importance.
Food to many people is part of their identity, it is something often shared with others and can be a source of comfort. Hospitals can take away many of our basic comforts like sleeping in our own bed or our daily routine. It should be a goal when interpreting the new food standards. Perhaps we could take a lesson from Sweden where taste and pleasure are balanced with nutrition, sustainability and safety, and catering systems are integrated from beginning to end of the process. It means the best food possible is served.
Standards for food are just a start. This is an opportunity to rethink how we provide food in our hospitals and empowered caters, chefs and dietitians to work with patients to develop menus people want to eat. At the end of the day, food left on the plate has no nutritional value to the patient.