Following the deaths of six people linked to an outbreak of listeria in contaminated food earlier in 2019 the Government has launched the Hospital Food Review (Department of Health and Social Care (DHSC), 2019), with a clear ambition to deliver high-quality and safe food to patients and members of the public who use the NHS to improve public confidence.
Background
One of my earliest memories as a student nurse in the late 1960s was helping to serve lunch to patients on an orthopaedic ward. The dinner trolley always arrived from the hospital kitchen at 12 noon. The ward sister duly portioned the food on to plates ready for delivery to patients by the student nurses or cadet nurses who would help patients who were too frail to eat themselves. The food had been freshly prepared in the hospital kitchen, although from memory there was little choice and no vegetarian option.
In addition to the hospital kitchens, each Nightingale ward had it own fully functioning kitchen, where food could be freshly prepared. For example, it was the role of the night nurses to prepare the following morning's patient breakfasts. At around 5am, the student nurses undertaking their 12-week stint of night duty would butter several loaves of sliced bread and cover these with a damp tea towel to keep them fresh. Breakfast would be distributed to patients before the day shift commenced, accompanied by lashings of tea served from one-gallon enamelled teapots.
It should be stressed that patient acuity in hospital wards in the 1960s and for much of the 1970s was much lower than that seen in contemporary health care. In the case of orthopaedic patients, for example, bed rest was long and continuous. Patients with a fracture of the femur, for example, would typically languish in bed with their fractured leg in a Thomas splint for 12 weeks or more, even though many were fit for discharge.
Many patients, from the perspective of contemporary health care, were kept in hospital for excessive periods of time. Hamill and Hill (2016) reported the case of 6-year-old child in 1906 who remained in bed for 3 weeks after an operation to remove an inflamed appendix. The key point is that, after the early days of an illness or operation, patients begin to feel better and to enjoy their food more. The old adage of feeding a cold and starving a fever will be familiar to any nurse who has ever been infected by influenza, where the idea of eating a full normal meal is an anathema and a small bowl of porridge is all they desire.
Many acutely ill or debilitated patients have little interest in standard hospital food because their appetites may be substantially diminished. This is especially true of sick children whose parents worry when they will not eat and who will try everything to get them to eat or drink anything, including so-called junk foods.
Why has hospital food deteriorated?
Although patient acuity has increased substantially in present-day health care, with fewer hospital inpatient bed days and earlier discharge, changes to hospital governance attributed to the introduction of the internal market in the 1980s saw many services, including cleaning and catering, being contracted out. The competitive tendering processes that led to the outsourcing of these services has proved controversial, not least because, although the outsourcing is associated with lower costs, it has also been linked with a greater volume of complaints (Glasper, 2019).
Over the intervening years complaints about hospital food have grown exponentially, so much so that in 2012 the then health secretary Jeremy Hunt announced the publication of new standards for hospital food, accompanied by a set of basic principles covering food quality, nutritional content and patient choice (Glasper, 2012). Publication of these standards followed a critical Care Quality Commission (CQC) (2011) report that inspected dignity and nutrition in 100 NHS trusts. This focused on outcome five of the standards' mandatory essential care needs (ie meeting nutritional needs) and identified five problems associated with nutrition for patients in hospital:
The CQC report found that 11% of hospitals had insufficient staff to adequately support patients who needed help during mealtimes, which often clashed with medication rounds. Although senior nurses had implemented red-tray systems in many trusts, the CQC (2011) report indicated that junior staff were unaware of this initiative. Furthermore, 13% of hospitals inspected had problems in identifying patients at risk of poor nutrition.
In context, the red-tray initiative was a simple innovation that focused attention on patient nutrition in clinical settings. Bradley and Rees (2003) described a study conducted in a hospital in Wales where red trays were used as a visible indicator of vulnerable patients who needed help from staff with eating and drinking. This initiative is now used in many hospital wards caring for patients at risk of malnutrition, such as acute medical units. However, the use of coloured trays and water jugs is not without risk and a reported incident where a patient died after drinking cleaning fluid from a green jug underscores this (Javed, 2018). In the subsequent inquiry the Brighton hospital's use of different types of water jugs was criticised because few of the staff who were questioned had fully understood the system.
This notwithstanding, Wilson (2012) was critical of red-tray-type systems for patients at risk of malnutrition and dehydration, arguing that they conceal more significant problems associated with patient nutrition, such as the lack of managerial support for high-quality nursing care. Crucially, the introduction of nutritional screening on admission has helped identify patients at risk.
Screening tools
For adult patients, the Malnutrition Universal Screening Tool (MUST) was developed by the Malnutrition Advisory Group (BAPEN, 2016). Developed in 2003, it has been championed by, among others, the Royal College of Nursing. In 2013, the National Institute for Health and Care Excellence (NICE) recommended using MUST for staff working in hospitals, primary care and care homes to aid implementation of the new Nutritional Support in Adults quality standard (NICE, 2012).
Similarly, a child's nutritional status can be assessed using the screening tool STAMP (Central Manchester and Manchester Children's University Hospitals NHS Trust, 2008). Sick children's nutritional status is known to deteriorate after admission, with an increased susceptibility to a variety of infections. Additionally, hospital-acquired malnutrition can precipitate adverse clinical events, leading to avoidable prolonged admissions. Because children admitted to hospital are at risk of malnutrition, screening should become part of the routine admission assessment process.
Scale of the problem
Frank et al (2015) asserted that malnutrition affects more than 3 million people in the UK, with associated health costs estimated at more than £13 billion a year. Malnutrition in hospital patients has been associated with additional morbidity complication rates, length of hospital stay and higher readmission rates.
Running alongside the latest government initiative is the Campaign for Better Hospital Food, launched in 2001. Although this has not been entirely successful, it continues to advocate higher standards for hospital food. It is now part of Sustain, an alliance for better food and farming, which liaises with the Soil Association and a number of hospital trusts. For example, a partnership between Cornish NHS trusts and the Soil Association led to positive changes in the food served to patients in the county's hospitals (Russell et al, 2007). The partnership used locally produced organic food, including fresh fish, eggs and cheese, with the initiative being well received by staff and patients.
Despite the 2012 hospital food standards, it was only after strategic lobbying by the Campaign for Better Hospital Food and others that NHS England introduced national targets in 2016 to reduce poor quality food and improve the availability of healthier options in hospitals. The campaign wants hospitals to use higher quality food ingredients, deliver healthier food for staff and visitors, as well as patients, and reduce the use of vending machines.
Quest to improve hospital food
Although there have been clear improvements in certain aspects of hospital food, the latest listeria outbreak has precipitated further action by the Government, which now intends to work with the NHS to improve food quality in hospitals (DHSC, 2019). As part of the latest initiative, the Government has recruited celebrity chef Prue Leith, who suggests that millions of pounds of public money is being wasted on ‘unpalatable’ hospital food. In an article entitled ‘Hospital food is a recipe for disaster’ (Leith, 2015), she stated that hospital meals are made miles away in factories from the cheapest ingredients, delivered frozen, regenerated in the hospital and kept warm in a trolley, concluding that it is little wonder that the meals subsequently served are disgusting.
As part of the Hospital Food Review, the panel will seek ways of increasing the number of hospitals with their own kitchens and their own chefs to produce and cook suitable menus for patients, to aid faster recovery, taking into account the unique needs of vulnerable groups such as elderly people. Additionally, the review will consider how to make the NHS a leader for healthier choices for patients, staff and visitors.
The chair of the Hospital Food Review, Phil Shelley, intends to meet with catering managers at trusts across the country, examining beacons of best practice from trusts that are leaders on food quality and innovation. The review panel aims to ensure that nutrition and food safety are the top priority. It will seek to establish national quality standards for food served in the NHS to ensure that both staff and patients have access to high-quality food and drink.