Tuesday 22 February 2011

Hospital Food CAN Improve - Here's How

So last night's Dispatches was an undercover expose of hospital food. *Sigh* Another one.

Tonight, I believe we are to be treated to Heston Blumenthal's treatment of the subject. *Sigh*

Back in 2000 the famous-chef-person was Lloyd Grossman. The exposes found - you'll never believe it - that you wouldn't feed hospital food to your dog.

No doubt back in the 50s, someone tried to enlist Fanny Cradock to improve standards after some clipped-voice BBC reporter got served gruel for a few weeks as an in-patient suffering from rickets or something.

How many exposes do there need to be? Why do we never listen? More to the point, why don't politicians and hospital managers see why it matters?

:Last night's programme pointed out that this was part of wider failings in patient care. The same ward that leaves a patient lying in their own filth for hours on end is unlikely to hold a fork or cup to make sure a patient gets to eat. The same hospital that covers up the failings of an incompetent surgeon is unlikely to care whether or not the custard is hot.

Oh, I remember all too well the "beef crumble" and "grey-gristle pie" (unidentified meat) of the mid 90s! Who's ever eaten beef crumble for goodness sake? Many patient's are elderly and it goes without saying that all are ill - appetites are unlikely to be huge and often patients are too frail to feed themselves. Did you know that it uses calories to be ill too? Infections munch up calories like an hour in the gym  and post surgically, a patient can literally need thousands of extra calories just to not lose weight as the body goes into overdrive to heal itself.

But there is hope!! It can change and change very effectively. My hospital, Addenbrookes really embraced the 2000 food revolution. It took a few years, but eventually, the effects filtered onto the wards. The food is now somewhere on the spectrum between good - excellent and this is how they did it :

1) In the 90s, hospital catering was largely outsourced and quality had been endlessly squeezed to make room for profit. What's more, food was often prepared elsewhere and simply re-heated on site. Addenbrookes fired up the dormant kitchens, and bought it back in-house.

2) Real Menus  - Every patient gets a glossy menu at the beginning of their stay with 3 or 4 daily choices at each meal. Every morning, the patient chooses what they'd like for the next day, cutting down on waste. The options come up on heated trolleys and there is always room to change your order or even go back for seconds.

3) Quality of ingredients - A "vegetable" had previously only ever been soggy and pre-frozen, now they're the right colour - carrots are buttery with a little parsley, beans crunchy and sprouts fresh. Salads sprang into life and are always available as a side dish. Meat turned into real meat and you could find plenty of it lurking under a crispy puff pastry pie crust or fluffy dumpling. Mashed potato is made from potatoes (a little lumpy, but "real" at least) Deserts are yummy - fluffy sponge puddings and homely apple pie.
There is always a cold option that can't spoil if you need to wait a while to eat it - maybe smoked mackerel or cold meats. My personal favourite is cold poached salmon with a fresh cucumber and coriander salsa.

4) 24 Hour menus - This is the most important innovation of all. If you found yourself a long term in-patient, you used to miss meals all the time. Most days you are wheeled off for a scan or procedure and by the time you get back you've missed lunch and maybe even dinner too. You might have been nil-by-mouth the night before and could very often go 24 hours or more without getting a thing to eat. It's not hard to see how after a week or two of this malnutrition started to beckon.
Now, Addenbrookes always has sandwiches, cheese and biscuits or soup available on the ward out of mealtimes and they introduced a 24 hour menu, always available if a patient feels a bit peckish. You simply ask the nurse and within half an hour or so a hot or cold meal option is sent up from the kitchens.

5) Snacks and encouragement - patients are now offered a little treat with the tea rounds - maybe a muffin or a jam tart. Biscuits are always offered and the staff serving the food are helpful and concerned. They encourage and cajole, they tempt patients to munch on a calorie or two wherever possible. They notice which patients aren't eating and support them as much as they can.

6) Special menus - All special diets are catered for - diabetic, low fibre for bowel disease, low fat for weight loss, high calorie for weight gain. Patient's with special dietary needs get a separate menu that simply goes in with all the other orders.

7) Protected meal times - Lunch and dinner times are now protected. In practise this doesn't always work, but there is at least an attempt to keep doctors rounds or visitors away. Staff are a little more able to find time to help weak patients feed themselves and meals don't congeal uneaten as endless phlebotomists and physios interrupt them.

8) Finally, it must have taken real commitment. Financial, sure, but also at every level of patient care. There must have been excellent training to ensure that all staff realised the importance of nutrition to patient care. From the catering staff to the medical staff to the managers, all must have been brought on board and inspired to change attitudes. That is the part that is hardest to achieve and Addenbrookes appear to have achieved it very successfully. Asking for a cup of tea or a slice of toast no longer feels like you are being demanding - in fact it's encouraged - the most important distinction of all.

The BIG question is, did it cost money? I imagine not. The improvement to patient moral and nutrition would have shortened hospital stays, reduced re-admissions from malnutrition and infection and reduced waste. I've always been convinced that spending a little more on food would save tens of thousands elsewhere. Even if it did cost a few pence more per patient, it was a few pence well spent if the health of patients benefited - surely that's what the NHS is there to do?

This debate is never more relevant than now. "Efficiency savings" will always start with catering and coalition plans to outsource and privatise almost everything in the NHS mean that old profit-demon will start to munch away at quality all over again. It's not too late for hospitals like Addenbrookes to roll out a national scheme using their experiences to get things right - but it will be soon.


  1. In order to change the food in kitchens there has to be a desire to change - and there is none. Until enough people complain nothing will happen, but because the majority of service users are elderly, there is a trend to accept the unacceptable.

    How sad that we treat people this way

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  2. Until our public sector comprehends food is part of the health equation there will be little mass change.

    Would it not be sensible for all our medical students to undertake significant nutritionist training?

    Maybe our cabinet should then be fed the food from a hospital of my choice for a month just to see the health implications?

  3. One of the things that helped improve food quality at my local hospital was when staff canteen kitchens and menus were the same for patients. If you had Doctors and nurses grumbling the kitchen staff whether in house or outsourced took notice.

  4. It is astonishing that people get iller and even die from poor food and hygiene in our hospitals. These are elemental basics of care you would think got sorted out in the Victorian Age. But the astonishing thing is it does happen, especially with the elderly. Thanks for raising this important issue further.

  5. As a vegan (who has been pretty lucky in avoiding hospitals so far, touch wood), I have often heard that some hospitals are much better than others at catering for particular requirements. Some sound great.

    Others, well, did you see the episode of "Come Dine with Me" where there was a guest with gluten intolerance who was just told to "eat round" the offending items? The host or hostess just made no effort at all. And there is no guarantee that fools like that would be denied a job in catering.

    One of my family members is a chef (and a meat eater) and he takes great pride in his inability to be phased by herbivores or diabetic Muslims or gluten-free orthodox Jews or, well, he can cater for pretty much anyone. For him, it is very much a matter of professional pride.

  6. I want your hospital!

    Last time I was in overnight I was in surgery through lunch and dinner. I arrived back in the ward just as the remnants of dinner were being taken away. I was desperately hungry, but the staff couldn't find anything for me to eat. Eventually they found me a sandwich. I had no choice of filling as they only had one, and it was about a third of what I actually needed to eat.

    I am a diabetic, and needless to say, I had a hypo in the night. I had hypoglycaemia, in a hospital bed, and all they could find me was some cornflakes and a "fruit pot." They couldn't even make me some toast like they could a few years ago.

    That was a most unpleasant experience.

  7. A few points
    1) nursing and medical staff already have plenty of training around the importance of good nutrition etc...problem is with the supply chain. we cannot give what is not there and believe me, its not true lack of complaining. Culture in the NHS is to ignore comments from clinical staff as we are just a bunch of slackers.
    2) Lots of hospitals that were modernised during the 1980s no longer have kitchens
    3) few clinical staff have the time (or the money) to eat in the staff canteen. At my trust a hot meal for lunch and dinner (14 hour shift) even if I had the time, would cost me £10 a day. Sandwiches are not much cheaper. I bring food from home and heat in in the microwave- then let it go cold as I rarely have the time to eat it.
    4) I'm not sure how Addenbrookes improved so much, as I have never worked there. At a trust not far from me, the food improved drastically when they started cooking on-site again. However this co-incided with a "vacancy control" policy on HCA and housekeeper/portering posts. They also closed 2 wards...coincidence? I think not.
    5)Although the film was informative, I felt it was misleading in some parts...the tea party in sisters office and the rehab unit for stroke patients....nice to see in action but this would never be possible on an acute ward...enough staff nurses and HCAs plus a SALT and dietician around at mealtimes???? Certainly not on any acute ward I have dealings with.
    6) Obviously there are links between poor nutrition and poor healing, infection etc etc...this has been known for a very long time. Problem with socialised medicine is that the amount of money is finite...we already have a situation where patients are ending up in the ICU due to lack of nurses on the wards, at a cost of thousands per day....if this is being ignored then I doubt that anyone will listen to similar stories about nutrition.
    7) Most hospitals budget for around £2-50 per patient per day for three meals. In the US this is around £10 and in Germany around £12...the difference? Food is not free in these countries.
    I could go on, but its just too depressing. A friend recently had elective surgery in a private hospital...the NHS paid as she was over the 18 week target. She asked for a copy of the bill...food was charged at £25 per day.

  8. You might get that at Addenbrooks: at the Royal Free in Hampstead it's this:


    and you should see some of the pictures I've taken... I've yet to get anyone to identify what the meals were supposed to be!

  9. My experience has been of being in an NHS ward, unable to move and the meal time 'food train' has passed me by. I know they didn't do it on purpose, but when I could move I went to the security station and asked if they could order me a takeaway. He went one better and opened the canteen for me to make sure I had anything I wanted and more to eat.

    He could have lost his job for that, but I didn't want to complain about the lack of food, the staff had saved my life and I was grateful. A bit of hunger was the least of my worries really.

    Great article Sue and I've bookmarked you, will follow this blog from now on.


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