Health and Social Care (Amendment) (Food Standards) Bill [HL]
(11 years ago)
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Baroness Cumberlege (Con)
My Lords, I declare my interests, which are in the register. I am the executive director of two companies, Cumberlege Connections Ltd and Cumberlege Eden & Partners Ltd. I thank noble Lords who are taking part in this debate, in particular my noble friend the Minister, who I know is sympathetic to the cause. I hope that I will not be too disappointed. He may be interested to know that many other noble Lords very much wanted to take part in this debate. However, Friday is a difficult day for your Lordships as we are a voluntary Chamber, and many noble Lords have commitments that they fulfil on Friday when the House does not usually sit.
I thank the hospitals I visited, which generously, and perhaps with some courage, allowed me to see and taste the hospital food and to talk to patients. On the whole, I was disappointed. When the food is frozen and has to travel from Wales to hospitals in England and is then reconstructed by steam, is it surprising that fish and chips are soggy and that other food is not quite what you anticipate it will be? Finally, I thank the excellent briefings I have had from the Campaign for Better Hospital Food, whose supporters exceed 5,000 individuals and many other organisations.
At the age of eight I was sent to boarding school, and the most precious item in my trunk was my ration book. School food in post-war Britain was not good. Fish on Fridays was no surprise, because you could smell it at 10 in the morning. Jam was either red or yellow, and made with mangels, and resurrection pudding lived up to its name. After decades of prosperity, however, British food has now changed enormously and beyond all recognition. For instance, whatever happened to gravy? Gravy now masquerades as jus, and leek and potato soup is now vichyssoise.
Virginia Woolf said,
“One cannot think well, love well, sleep well, if one has not dined well”.
When in hospital we do not expect to dine well, but expect to have delicious, appetising and nutritious food—food that aids recovery. In the past 20 years successive Governments have spent more than £50 million of taxpayers’ money issuing guidance to hospitals about how to improve patient meals. When I was a junior Minister I was one of those who tried. I was responsible for food—that was before the Food Standards Agency was established—and introduced the nutrition task force, which in turn set up a hospital catering project team that produced nutrition guidelines for hospital food. Those were launched by the celebrity chef Albert Roux. In the foreword he wrote:
“Food should be regarded as an integral part of hospital service and treatment … Food provides us with the nutrients essential to our existence and general health … In providing comfort, food can also help to make patients feel more at home, reduce stress, and actively contribute to an ambience that can enhance the quality of medical treatment”.
Despite my efforts and those of successive Governments, in many hospitals the food is unappetising, non-nutritious and does nothing to aid recovery. Six out of 10 patients say that they rely on family and friends to bring them food because the food is of such poor quality, and sometimes barely edible. At many hospitals patient meals are viewed as a bureaucratic necessity and not as an integral part of care. Hospital life is boring. When in hospital, patients want three things. They want to go home, they want visitors and they want good nourishing food, because it is food which punctuates the day. That should be something to look forward to, but many patients dread it. The Francis inquiry into Mid-Staffordshire was deeply concerned about the attitude by staff towards meals, mealtimes, nutrition and dehydration. The witnesses’ comments are heartbreaking. I could quote many but will quote only one:
“On examining the food and fluid intake chart, mum had only had half a cup of tea over the last 20 plus hours. Some days nothing was marked as being taken, today there were three cups of fluid on the table, all of which were full. She couldn’t have drunk them if she tried because all three of the cups were placed way outside her reach”.
I do not underestimate how difficult it is to serve meals to large numbers of sick people three times a day. People who choose a meal one day are discharged the next, so that an incoming patient is welcomed by a meal they may detest. Some people may have uncompromising diets or have an appetite which changes from day to day due to the medication they receive. Hospital food is complicated, but there are hospitals where they really think through these issues, have a love of food and organise it well—while in similar hospitals in the same city, of the same size, almost in the same catchment area, the food is simply appalling. I am sure that noble Lords will agree with me, and I know that the majority of people in this country find it unacceptable for hospital food to be unhealthy. However, much of the food served to patients is of a poor nutritional standard.
In 2012, a nutritional analysis of commonly served hospital meals showed that they often contain more saturated fat and salt than meals served at fast-food restaurants, including McDonald’s and Burger King. Hospital food which is high in fat, sugar and salt, is not helping to nourish patients, and much of it is wasted. Government figures suggest that as many as 50,000 people a year could be dying with malnutrition in NHS hospitals in England, and at least one in every 10 meals is thrown into the bin uneaten.
The British Association for Parenteral and Enteral Nutrition estimates that three out of four patients are not eating enough during their hospital stay, and that the majority of them lose weight while in hospital. This problem is particularly rife among elderly patients. Only today, the Campaign for Better Hospital Food published new data showing that hospitals in England spend more on nutritional supplements for patients than on the meals served to them during their stay. While of course I recognise that nutritional supplements are vital in the cases of some patients, should they have become the routine prescription given to patients who are unwilling to eat hospital meals, or failing to gain nourishment from them? Patients should be nourished with enjoyable food rather than by nutrient and vitamin pills administered as medicine.
We look forward to hearing later in this debate from my noble friend Lady Miller of Chilthorne Dormer, who has expertise in this area and chairs the All-Party Parliamentary Food and Health Forum, the noble Lord, Lord Rea, the previous chairman, and other noble Lords who have experience or knowledge of this issue. I suspect that my noble friend might be tempted to address in his reply the subject of foundation trusts in the context of mandatory standards for hospital food, which is the purpose of this Bill. Both Scotland and Wales now benefit from mandatory standards for hospital food.
The Government have given hospital trusts greater control over how they manage and care for patients and have given them the opportunity to influence the shape and direction of the NHS. That is absolutely right, and I strongly support it. However, it is no less important to have a safety net to ensure that the NHS does not fall below acceptable levels and that standards of care are regularly monitored and enforced. Standards are not goals; they do not restrict a hospital’s freedom. They provide basic levels of assurance for organisations commissioned to provide healthcare. So we are not setting a precedent; there is an abundance of standards already in place in the NHS, which reflects the important role that they play, including employment standards; care standards for patients with specific ailments, such as diabetes; and standards for financial auditing, to name but a few. Standards for hospital food should be no exception.
The Bill requires the Secretary of State to appoint a body of experts to draft hospital food standards and make it mandatory for all patient meals to meet those standards. The Care Quality Commission and the Chief Inspector of Hospitals will be required to check that the standards have been adopted and are met. If they are not, it gives the CQC power to act, ultimately by withdrawing a hospital’s registration. The CQC is working hard to increase the regularity and effectiveness of its monitoring exercises, and is ensuring that patients participate in them. The CQC already evaluates patient satisfaction with meals, so this Bill would require only that monitoring is carried out to assess adherence to more specific standards. This solution does not in any way necessitate burdensome regulation, and does not require the Government to take greater administrative control over the provision of hospital meals. In fact, patients themselves are likely to take a leading role in monitoring hospital food, as more and more of them sign up to join inspection teams, as encouraged by the Care Quality Commission’s new Chief Inspector of Hospitals, Professor Sir Mike Richards.
Finally, I address the issue of cost. At the moment, taxpayers are being doubly charged for poor hospital food. Not only are they paying for the cost of patient meals but they are funding the associated costs that bad hospital food incurs, such as food waste, malnutrition and longer recovery times. I frequently hear people say that good hospital food is expensive and costs too much for hospitals to afford, but the facts do not bear this out. It has been shown that there is no correlation between the cost of patient food and its popularity with patients. Many of those hospitals serving the best food, produced and prepared to very high standards, are actually paying less for it than are hospitals where patients are dissatisfied with what they are being served and where food is wasted. For example, according to data from NHS Estates, Ipswich Hospital NHS Trust spent an average of £13.59 on food for each patient per day in 2012, yet less than half of patients at the hospital surveyed by the Care Quality Commission rated the food as good. In contrast, the Royal Marsden NHS Foundation Trust in London spent £5 on food for each patient per day in the same period, and more than seven out of 10 patients surveyed by the Care Quality Commission described the food as good. So those public sector organisations that have set standards for their food have done so without incurring extra cost.
In 2010, the Department for Environment, Food and Rural Affairs carried out an extensive evaluation of the costs of introducing government buying standards for food served in central government, including prisons and government departments. The standards mandate was that organisations buy more organic food, more fresh fruit and vegetables, and sustainable fish. The evaluation concluded that the organisations would not pay more—and, indeed, they do not now pay more—for higher quality food. If patient meals contain high-quality ingredients and are cooked by highly skilled caterers, they are more popular with patients, more likely to be eaten and therefore less likely to be wasted.
In conclusion, this Bill has widespread support from the public and from 97 national organisations, including Age UK, the British Heart Foundation, the Hospital Caterers Association, the Royal College of Physicians and thousands of members of the public. I contend that hospital food standards must be made mandatory if all patient meals are to be of a sufficient high quality, are to be nutritious and made to minimum standards of production.
This is a modest but sensible Bill with widespread support, and I urge my fellow Peers, as well as my noble friend as the Minister responsible on behalf of the Government, to support it. I look forward to my noble friend’s sympathetic response. I beg to move.
Baroness Gibson of Market Rasen (Lab)
My Lords, first, I thank and congratulate the noble Baroness, Lady Cumberlege, on claiming this spot in a very busy parliamentary calendar to raise a subject that is very important to so many people. Her work in and knowledge of the National Health Service, its triumphs and drawbacks, make her the perfect person to raise the issue of hospital food. I am not an expert in this area, but I have over recent years been a patient.
People are taken into hospital at one of the most vulnerable times of their lives. They become patients in a second, and face the illness itself, the shock of hospitalisation, disorientation and the feeling of being alone to face sudden and apparently insurmountable problems. For many of us, it is a traumatic and frightening experience, even for those of us who are usually confident and sure of what we are about and how to react to what is happening around us. At such a time, we need comfort; food should be part of that comfort and something to look forward to—but, alas, too often it is not.
I am pleased to say that I have not spent much time in my life in hospital. I had been reasonably lucky with my health over the years until about three years ago, when I was diagnosed with leukaemia. For the first period of my illness, I had to remain in hospital in a room set aside from the main ward, because I was very vulnerable to germs and needed a sterile environment. The medical care that I received was second to none; I am still receiving it, and it is wonderful. The problem arose when I was confronted with what I can describe only as “food from hell”. I did not expect cordon bleu cookery, but I expected to eat nutritional food and some thought being given to which foods patients may fancy—especially as medicines can affect appetite and change taste buds.
The food in my hospital was brought in each day by the catering company employed and reheated on the premises. It looked, smelled and tasted awful. There was a choice of food, but not an appetising one. The soup was more water than soup powder; the main courses bore little resemblance to what they were supposed to be; and the sweets were just that—sickly sweet beyond belief. On one occasion, the Irish stew, as it was described, was so awful that, had I been Irish, I would have been tempted to sue the hospital on the grounds of the insult to the Irish nation. When I first went into hospital, there was a choice of cheese and biscuits, but it was quickly removed on the grounds of cost. There was no fresh fruit offered, and the vegetables were cooked to a uniform standard of what I can describe only as grey mush.
Since 1992, successive Governments have introduced more than 20 initiatives, which have all failed to improve hospital food in England, costing the taxpayer more than £54 million. Such initiatives have relied on hospitals to adopt voluntary food standards rather than such standards being mandatory. The result is that one in every 10 meals served to patients is returned to the kitchen uneaten. A BBC programme in 2008 that investigated the unhealthy state of hospital food revealed that £1 million worth of food each year is wasted.
Among eminent people who have attempted to improve hospital food have been Simon Rimmer, who sought to revamp food in Liverpool hospitals, and Jamie Oliver, the latter stating that the failure to provide the nutrients that could help the healing process seemed completely crazy to him. It does to me also.
The Soil Association has drawn public attention to the sorry state of hospital food, saying it was more likely to contribute to a disease service than a health service. This is a cause for national concern and yet it need not be so. This was proved when James Martin, a well known and respected TV chef, recorded a programme about Scarborough General Hospital, where he undertook to improve the food in both nutritional value and presentation. He first won over a very sceptical workforce in the hospital kitchens. He then explained and taught about nutritional requirements for vulnerable patients and, finally, produced menus that were practical and popular.
This Bill is not asking for the moon. Most food served in our public sector institutions has to meet mandatory standards, including that served in hospitals in Scotland and Wales. All the Bill asks for is the same standards in our English hospitals, together with a body of experts to specify hospital food standards, and the CQC to ensure compliance with those standards. I hope that the Minister agrees with that.
Baroness Miller of Chilthorne Domer (LD)
My Lords, I start by paying tribute to my noble friend Lady Cumberlege not only for her excellent presentation of the Bill, but for all the work that she has done in preparing for today’s debate and in pursuing this matter over the years.
I also pay tribute to the Sustain organisation, which plays an important part in the Campaign for Better Hospital Food and has provided us with a lot of information and briefings. That organisation deals with every aspect of food from growing and procurement to sourcing local food. The campaign to make us healthier and keep us healthy through eating healthier food is one element of what that body does.
Amid all the gloom about the failure of voluntary initiatives in this area over decades, there are a few shining examples of good practice. I first came across one of them when I was a Somerset county councillor and the council was looking at food procurement. The Royal Cornwall Hospital took a very different approach by procuring its food locally, thereby ensuring that it was fresh and that it contributed to the local economy. It also commissioned a completely different approach to hospital kitchens by putting catering staff at the heart of making people better. As a result, the hospital’s food became much more appetising and the amount of waste went down. Food waste is still a tremendous issue. I think that that hub now supplies three other hospitals in Cornwall. It is an amazing example of what can be done when the will is there and the leadership of the hospital makes that effort. However, voluntary initiatives are not always sufficient, given that the Royal Cornwall Hospital initiative was introduced back in the early years of this century and if other hospitals had wanted to follow that example they would have done so by now. That is why I think the Bill is very important because unless we have mandatory standards nothing will happen. The Campaign for Better Hospital Food summarised the history of the past two decades as one in which every year a high-profile initiative is introduced by either a Minister or a celebrity chef, but one, two or three years later it bites the dust.
The people to whom I have spoken about the Bill have found it jaw dropping that there are no mandatory standards for hospital food. They find that incredible. As the noble Baroness, Lady Cumberlege, mentioned, I have the privilege of chairing the Food and Health Forum. Back in January 2012, we listened to presentations on this subject and I was struck by two points in particular. One of the presentations was given by members of the Royal College of Nursing, who forcefully made the point that hospital food contains too many harmful elements—salt, sugar and saturated fat have been mentioned in the debate—and far too few of the elements that provide good nutrition. For example, the noble Baroness, Lady Gibson, mentioned the lack of fresh fruit. We listened to another presentation from the charity Heart of Mersey, which seeks to combat heart disease. That charity has campaigned very hard to improve hospital food because diet is very much implicated in hospital admissions for people with heart disease. How on earth are they meant to get better if hospital food exacerbates their health problems?
Clause 3(b) of the Bill is very important. The Government may say that it is too onerous to impose requirements relating to good procurement and other issues. However, the clause asks only that account is taken of the food chain, animal welfare, fair trade and food waste. Those are all very important elements. The example of good practice I cited at the Royal Cornwall Hospital proves that these issues can be addressed.
The status of catering staff is a key issue. All too often they are seen as being at the bottom of the food chain, if noble Lords will excuse the pun. However, they play a key role in ensuring that patients recover. When I was talking to my husband about this debate, he reminded me that he is one of the closest living relatives of Florence Nightingale. She ensured that one of the key elements in her nursing regime was to give soldiers hot food every day instead of the old, putrid food they had received hitherto. That was a key element in improving the mortality rate in the relevant hospitals.
This small, modest Bill is absolutely key in this area. I hope that the Minister will welcome it as the efforts of medical staff are often undermined by the poor hospital food being given to their patients.
Lord Rea (Lab)
My Lords, not only the Members of your Lordships’ House but the whole country should be grateful to the noble Baroness for securing this debate.
For too long the topic of hospital food has been a running sore. It has a reputation for being of poor quality and indifferently served, as borne out so clearly by my noble friend Lady Gibson. Often too little help is given to those who have difficulty feeding themselves. This is not to say that nothing has been done about it. As all the previous speakers have said, a large number of initiatives have been launched over the years at considerable cost but with, by and large, disappointing results. Governments of both political persuasions have launched initiatives and guidelines but these have all been on a voluntary basis with no sanctions for non-compliance. Although there have been a number of successes where good standards have been reached, as has been mentioned, many more remain far from satisfactory. Many of us are grateful for the briefing provided by Alex Jackson of Sustain, co-ordinator of the Campaign for Better Hospital Food, which has been referred to. He has drawn up details of no fewer than 21 voluntary initiatives since 1992 which have come to nothing after initial fanfare, as the noble Baroness, Lady Miller, said.
At least four celebrity chefs have been called in to advise the Department of Health. Sadly, their hard work has not had a lasting effect. Albert Roux, for example—to continue the quotation given by the noble Baroness, Lady Cumberlege—said:
“If we have learned anything from the last 20 years it is that meetings, speeches and gimmicks do not work—what we need now is change to the whole hospital food system, starting with the introduction of food standards for every patient meal”.
This lack of progress is shameful when the results of a number of studies demonstrate that good nutrition has a beneficial effect on patients, thereby speeding recovery from infections and other diseases as well as from surgery.
Good, enjoyable food, as has been pointed out, boosts morale, which in itself has healing qualities. A surprisingly high proportion of NHS in-patients have some signs of malnutrition—around 40% by several estimates; an amazingly high number—which delays recovery and lengthens hospital admissions. There is evidence that this has improved little over the years. Good nutrition is likely to save the NHS a lot of money. A recent international study published in the Lancet has shown that faulty or inadequate nutrition plays a part in 40% of deaths world wide. That applies not only to the developing world but to our main problem—chronic, non-communicable disease, which is also very much diet-related.
Another important possible benefit from good nutrition in hospital is that it could act as an example of good practice, or a beacon—an overused word—demonstrating the principles and practice of providing a nutritionally sound diet. In other words, good nutrition could play an educational role in helping patients and their carers to improve their diet after they are discharged. This would be an appropriate task for any institution looking after the nation’s health.
Of course, providing for large numbers of patients in an average-sized hospital on a limited budget is not easy; the logistics of the operation can be formidable. Quality tends to be inversely proportional to the size of the hospital. However, there are examples of good systems in large units that work. Earlier this year I spent a week in UCLH having a knee-joint replacement, and it was clear that thought had been applied to the catering on offer. For one thing there was a choice of menu, although you had to decide on this a day in advance. The food was unexciting and rather too substantial for my post-operative appetite, but was of fairly good quality, courteously served and adequately hot, having been reheated on the ward. A healthcare assistant was on hand to help those with a problem feeding themselves. I am not too sure of the food’s nutritional credentials, however. I found that the halal choice was the most attractively presented and tasty, though a bit too spicy for a westerner. But the experience of friends and relatives in NHS hospitals has not been so good, as my noble friend Lady Gibson most graphically pointed out.
The ward kitchen has an important role. While it is mostly not used for the actual preparation of meals, it is important in their presentation to patients. Its role could perhaps be expanded to include the preparation of simple meals such as a boiled egg or piece of toast for those unable to eat the main meal provided. Perhaps ambulant patient should be able to use the kitchen, when convenient, with the help of their visitors, relatives and friends. They could make a cup of tea, for instance, when they felt like having one.
Sadly, poor nutritional standards are still to be found in some hospital food, as has been graphically pointed out. Recently, as the noble Baroness, Lady Cumberlege, mentioned, one hospital meal was found to have a higher fat and salt content than a Big Mac. As we all know, the diet of many people in England is far from optimal and contains too much sugar, saturated fat and salt, and too few of the vitamins and trace elements found in fresh vegetables, fruit, fish, lean meat and eggs. Dietary intake is more often than we realise too low in many older people. In hospital there is a captive audience, an ideal population on whom to demonstrate how well cooked good food can be attractive, delicious and not too expensive. The food will taste better and may have better nutrient value if it comes from sustainable sources with good animal welfare standards. I am glad that there is provision for that in the Bill.
Why have so many initiatives failed? My guess is that hospital food is of low priority on the agenda of hard-pressed managers who are often struggling to meet targets and stay within budgets. The effects of poor diet do not show up in most hospital statistics, whereas mortality rates or waiting times can easily be measured, and executives and clinicians held to account. The considerable benefit that good nutrition can have is not fully appreciated. Poor ward diets are often complacently tolerated by management because their quality and acceptability is often not monitored. The introduction of mandatory standards with strong sanctions for non-compliance would eliminate any complacency because the relevant manager would be held to account. As the noble Baroness, Lady Cumberlege, said, other public sector institutions and schools are now required to conform to and have adopted mandatory nutritional standards, as has the National Health Service in Wales and Scotland. Interestingly, Compass, probably the largest catering firm in the country, has said that it supports mandatory standards because they level the playing field among suppliers and caterers while maintaining a high standard.
I am puzzled as to why the Government have been so reluctant to adopt mandatory standards for hospital food. A response to Sustain’s hospital food standards campaign was published by the Department of Health in September this year. It does not directly give the reasons for the Government’s reluctance, given that mandatory standards have been widely adopted elsewhere in the public sector. However, I hope the noble Earl can report that the Government are coming round to the idea and will agree to support the Bill.
Before sitting down, I have one question for the noble Baroness, Lady Cumberlege. Clause 1(6) states that the Bill,
“applies to … food provided to patients at a hospital”.
Does this apply to a private hospital as well as an NHS one?
Baroness Masham of Ilton (CB)
My Lords, I thank the noble Baroness, Lady Cumberlege, for bringing to your Lordships’ House this Bill to:
“Make provision for the regulation of food standards in hospitals”.
I feel that the least solution is to have a minimum standard.
I must declare an interest. I have had to spend some time in hospital at various times and can say from first- hand experience that if it had not been for high-protein drinks and blood transfusions, I would have spent much longer recovering. The hospital was Stoke Mandeville; it gives excellent care but is let down by the food, which is so unappetising and tasteless that it is often discarded. I am not surprised that around 30 million hospital meals in England are not eaten each year.
On one occasion when I was doing my visit as a member of the board of visitors of a young offender institution, the inmates were complaining about the food, which happened to be a rather good-smelling macaroni cheese. I said to them, “You should spend a week in the hospital I have just been in and then you would have something to complain about”. There was silence.
This Bill is long overdue. There is a desperate need for regulation of food standards across the country as there is so much variation in hospitals. I am sure that your Lordships will agree with this statement:
“It is crucial that patients receive tasty, nutritious food as part of their care. Although the NHS is spending more on patient meals, there is still too much variation across the country”.
The Government say that the NHS should be a patient-centred health service. Accepting this Bill would help to demonstrate their sincerity and prove that it is not just a matter of words.
Katherine Murphy, chief executive of the Patients Association, of which I am a member, said that the huge disparity between low and high spending on food in hospitals could not be justified and that the best patient meals are often those that are freshly cooked in a hospital’s own kitchen. Patient meals cooked in this way are often also the cheapest to make because they give hospital cooks the option to find the best deals from local suppliers. I am told that the Royal Brompton Hospital falls into this category.
There should be flexibility in hospitals over the availability of food and the giving of medication. This is necessary for people with Parkinson’s disease, when medication should be taken before meals, and patients with diabetes, who should not go without food for long periods. Nurses should learn how important food is for the health of patients.
One of my nephews spent a month in Glenfield Hospital in Leicester after a heart operation and he praised the food. I have not heard such sentiments about the food at Stoke Mandeville Hospital. There, the patients’ food is pre-cooked in Wales and brought to the hospital, where it is reheated and served up to patients in an unappetising and tasteless state, which does nothing for their morale and recovery. An example of that concerns one of our spinal injury members who was very ill. A few days before he died, he telephoned a friend asking for some decent food which he could eat. His friend could not get there but arranged for one of the doctors, who was sympathetic, to bring him something he could eat and enjoy. I dedicate my contribution today to Stephen and all ill patients who need good, nourishing hospital food.
Yesterday, one of your Lordships told me about the time when his mother was in hospital. It was a teaching hospital here in London. When her food was brought in, it was put down and left, but she needed help to eat it. So concerned was her son that he arranged to come in at meal times so that he could help her, but some people do not have friends or relatives who can do this. On one occasion, my husband was in the local hospital, which had just changed over to a housekeeping service. The housekeepers brought the food to the patients. I told the housekeeper who brought my husband’s lunch that he had a problem with swallowing and I explained his condition. She was very interested and told me that nobody had ever told her anything. She wanted to help.
I am sure that the arrangements for feeding patients who need help should be much better organised. Kind, responsible people may be better than nurses, who very often seem too busy to help. There should be a foolproof system so that all patients get fed with care and compassion. Maybe there should be an amendment to the Bill in Committee so that there is a foolproof system for patients who need help with feeding and drinking.
I wish the Bill a speedy and successful journey through Parliament.
Lord Turnberg (Lab)
My Lords, I, too, am extremely grateful to the noble Baroness for bringing forward this Bill. There are many people out there who believe that she deserves a medal, and I would certainly subscribe to one for her for having introduced the Bill.
Ever since I started working as a young doctor in the NHS in the 1950s and 1960s, 50 or 60 years ago, hospital food has been something of a joke—a joke that is not particularly funny for patients, many of whom either refuse to eat it because it looks so unappetising or, having tasted it, can eat very little of it. No one who listened to my noble friend Lady Gibson and the noble Baroness, Lady Masham, could possibly doubt that. It is hardly surprising to find that many patients lose weight in hospital and that there is enormous waste as so much has to be thrown away. I fear that it is becoming pretty obvious that I, too, have read the excellent briefing that has been placed before us.
However, that is not for want of trying to improve matters. According to the report by the Campaign for Better Hospital Food entitled Twenty Years of Hospital Food Failure, there have been numerous government initiatives, over many years, urging hospitals to pay attention to the standards of their food. There have been no fewer than 21 different initiatives in 20 years, which is more than one a year and two for each of the 11 Secretaries of State for Health who have held office during that time.
Each of those initiatives has urged a voluntary improvement by hospital trusts but these seem to have fallen on deaf ears. We are just as bad as ever, according to reports from Age Concern and the Royal College of Nursing. And it is not just the appearance and attractiveness of meals that are wanting; the nutritional value is even more problematic. Insufficient fresh fruit, vegetables and fish, and too much fat and salt, as we have heard, are far too commonplace. It is hardly surprising that patients often rely on family and friends to bring in food for them, and this is all happening despite efforts to enlist the help of a number of celebrity chefs. Sending now for Jamie Oliver without some form of regulation or legislation will simply not work.
It is the case that fewer than half the meals are cooked on site and that only a minority are made from British produce. There is of course an additional problem which is not tackled in the Bill and that is the complaint made, in too many places, of either food and drink being placed out of the reach of infirm patients at the end of their beds where they can see it but not reach it, or perhaps the food is within their reach but they need help to cut it up and spoon it into their mouths. Age Concern found that over 40% of patients needing this sort of help actually got it. That problem has to be solved by better training and the culture change that we keep banging on about in this House.
So far as the Bill of the noble Baroness, Lady Cumberlege, is concerned, there seems little doubt that voluntary initiatives have not worked and that we desperately need something more. We need to mandate better food and catering, and it is clear that this will not cost any more. We also need a proper inspection system. It is interesting to note that food standards are mandated in prisons and schools but not in our hospitals. It is even more interesting that there are mandatory standards for hospitals in Scotland and Wales, and that much of the food offered in English hospitals would not meet their standards. We need also a robust inspection regime, although perhaps not too robust. Perhaps the CQC in its regular inspections could simply sit down to lunch or dinner with the patients and make an assessment. That should not impose too much bureaucracy. It might cause some nausea.
I am strongly in favour of the Bill. We have spent far too long on voluntary initiatives. They just do not work. We must do more to correct this dangerous and seemingly everlasting problem. As my friend, the noble Lord, Lord Willis, who I met when coming in this morning, said, “It is a no-brainer”.
Baroness Thornton (Lab)
My Lords, I thank the noble Baroness, Lady Cumberlege, for this comprehensive Private Member’s Bill and I commend all speakers in this knowledgeable debate. Clearly, despite many initiatives and endeavour over a long period of time—it has to be said that there has been some improvement in the quality and nutritional value of hospital food because of the focus of the previous Government and this—this Bill and this debate show that there is still a great need for improvement. The Library note about the Bill was immensely helpful, as was the publication, Twenty Years of Hospital Food Failure, in February 2013 by the campaign group Sustain, an alliance of organisations. It outlined government hospital food initiatives since 1992. As my noble friend Lord Turnberg mentioned, an enormous number of initiatives have been taken.
I read with interest the Government’s guarded response to that report. The report said that,
“public spending on government voluntary initiatives has failed”,
and called on the Government to set mandatory health and sustainability standards for hospital food in England. The Department of Health issued a response to Sustain’s hospital food standards campaign, which states:
“The government’s preferred approach remains to encourage the adoption of Food GBS”—
government buying standards—
“within the NHS through incentives, signposting and assessments”.
That does not sound to me to be consistent with the noble Baroness’s Private Member’s Bill and the tone of this debate.
I volunteered to speak on this issue, partly because when I was appointed to a ministerial job in January 2008 as the health Whip, my first question in your Lordships’ House concerned nourishment and nutrition in hospitals. I can still recall my nervousness at the time but the House was kind to their new Front-Bencher and I survived. We all know that the noble Baroness, Lady Knight, is very concerned with these issues and she asked the Government:
“How they will respond to the recent reports about the levels of malnourishment of patients in NHS hospitals”.
At the time, I spoke about the fact that the then Government had published in October 2007 Improving Nutritional Care: A Joint Action Plan to outline how nutritional care and hydration should be improved in NHS hospitals and had introduced protected mealtimes and focused on nutritional screening. I concluded:
“There are three strong mechanisms for assessing the quality of food and nutritional care: the Healthcare Commission’s annual health check, in-patient services, and the annual Patient Environment Action Team inspections. These show how seriously the Government are taking the issue”.—[Official Report, 30/1/08; col. 619.]
I wonder whether the Minister is about to say something along the same lines in his response to this debate.
I was very struck by the huge list of initiatives over 20 years that have tried to raise the standards and quality of hospital food. My noble friend Lady Gibson told us a sorry and miserable story. Her example of Scarborough Hospital was most heart-warming. Recently, I met the head of catering for a hospital who explained to me how it produces high-quality meals, how it uses hotel nutritional and food standards, how much of its food is locally sourced and how much as it could possibly manage was freshly prepared.
My noble friend Lord Rea spoke about changing the whole hospital food system and he is right. We know that those beacons of good practice exist and that it is entirely possible to achieve a satisfactory outcome for patients and their families. My most recent experience of hospital food was when my daughter had a short stay following the birth of our first grandchild. I suppose that, because there are lots of relatives on maternity wards who bring food, cakes and all sorts of things, there might not be quite the same problem. However, I was very impressed by two things. First, there was access to the kitchen on the ward for patients and their families to make toast, warm drinks and so on. Secondly, the food was very plentiful and nourishing, and a lot of fruit was available. I am referring to a very large London teaching hospital. If large teaching hospitals can achieve that, I cannot see why any other hospital cannot do so.
My noble friend Lord Turnberg pointed to the problem of the voluntary approach so far. We know that voluntary approaches can work but they will work only if management and hospitals have the will to make them work. The issue that we face with this Private Member’s Bill is whether we have reached the end of the road of the voluntary approach on this matter.
I can understand why the noble Baroness exempts outlets in hospitals that sell food, including cafes, shops and such like. I wonder whether we might find ourselves in a similar position to that of Jamie Oliver when he introduced nutritional standards to school meals and stopped children from going out to buy their lunches. We then saw parents pushing burgers and pizzas through the railings of the school.
I have a serious question to ask the noble Baroness, Lady Cumberlege, and the Minister. Is this Private Member’s Bill and its proposal consistent with this Government’s resistance to statutory regulation, the setting of standards and the administration and monitoring of those standards in other areas of the NHS? I draw the attention of the noble Baroness and the Minister to the Government’s resistance to statutory regulation of healthcare assistants, which we believe would have a beneficial effect for patient care in the NHS. Will they explore the consistency of their arguments in this matter?
Finally, why is this Private Member’s Bill about only hospitals? Why is it not inclusive of the other areas, such as care homes, under the aegis of the CQC? I ask that question particularly given the campaigns of organisations such as Age UK on the nourishment of older people, people with mental health problems and such like in places of residential care.
On these Benches, we welcome the Bill. We believe that we have to keep pushing on this issue until we have it cracked and sorted. I hope that the noble Baroness will have some words of encouragement from the Minister in his response to her Private Member’s Bill.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by congratulating my noble friend on securing the introduction of this Bill, which seeks to set standards for healthy and sustainable food in hospitals. The Government warmly welcome the role that my noble friend’s Bill has played in bringing this important issue to the attention of your Lordships’ House. Few subjects matter more than food and drink. Poor diet can cause serious illness and even increase the risk of early death. My noble friend has a supporter here when she talks about high standards. We both want nutritious food that meets the recovery needs of patients and the health needs of staff and visitors, and sustainable food that supports our farmers and accounts for the needs of our livestock. Above all, we want tasty food that that looks good and is available whenever it is needed. My noble friend and I are at one on this.
We agree that more needs to be done to be certain that hospitals comply with high standards. We are proposing a series of measures that include instruction, incentives and inspection—the three Is. These build on the work announced last year by my right honourable friend the Secretary of State for Health and will raise awareness and increase transparency so that there can be no excuse for poor food.
The cornerstone of this approach will be our hospital food standards panel, under the chairmanship of Dianne Jeffrey, chairman of Age UK. The panel, which I can tell my noble friend Lady Miller includes Sustain as well as patient representatives and others, will start with the needs of patients, especially older people. It will look at nutritional quality, mealtime experience and the help given to patients to eat. It will check the evidence on food production systems to understand how a meal can leave the kitchen as an attractive, tasty dish, but arrive at the patient cold and unappetising. Noble Lords who share my own frustration when struggling with a sachet of sauce or pat of butter, will be pleased to hear that the panel will not let such small details escape its scrutiny.
The panel will also consider sustainability. This year, around 80% of food commodities purchased through NHS Supply Chain will be UK-produced, but the panel will look at how we can further reduce our environmental impact, including waste from food and food packaging. The panel will also consider animal welfare.
In this way, we address my noble friend’s main concerns. However, our ambitions go further. We have asked Dianne Jeffrey to consider food served to staff and visitors, including food sold in vending machines. Noble Lords may be surprised to learn that less than half of the food served in hospital is eaten by patients. The majority goes to staff and visitors. We must not neglect their needs.
We have a serious obesity problem in this country and so have a responsibility to help people make healthier choices. That does not have to mean banning chips and fizzy drinks, but should certainly mean delivering healthier options to make it easier for people to choose healthily as well as simple to understand information and labelling on food—using the calorie labelling and front-of-pack schemes increasingly evident on our high street and in supermarkets.
This is not about undermining personal autonomy. What freedom exists in choosing between two meals if both are high in saturated fats and salt? Where is the freedom in choosing between a standard chocolate bar and a king-sized one? We are asking the panel to examine how the NHS can increase choice, not reduce it, and enable informed choice.
Twenty-one trusts have committed to measures for encouraging healthier restaurants, vending outlets and buffets under the responsibility deal’s pledge on healthier staff restaurants. We want more to do the same. How will we make all these things happen? Like my noble friend, we have been frustrated to see continued variation in food standards across our NHS. That is not because hospitals do not know what good food looks and tastes like. Good guidance and standards already exist, and the best hospitals are using them. For instance, government buying standards for food and catering were introduced in 2011, covering nutrition, sustainability and animal welfare. We have the British Dietetic Association’s guidance on nutritional content of patient meals, and we have our own guidance on healthy eating. So rather than produce new standards or guidance, our panel will identify which existing guidance should apply as a matter of routine, which should be aspired to as best practice and which should be left for local determination.
Standards are important but compulsion, in our view, is not. There is no evidence that making standards mandatory in Scotland or Wales has led to food that is any better than in England. Indeed, patient satisfaction ratings with hospital food in Scotland have actually gone down in recent years. Nor should standards relate to whether food is prepared in-house or not. Each NHS provider must decide for itself how to deliver its food services. What matters is not who provides the meals or how but that they are of high quality and meet the needs of patients. We are unaware of any clear relationship between the quality of food and whether it is cooked on-site or delivered frozen or chilled and regenerated. I agreed with the noble Lord, Lord Rea, on that point. There are many ways to produce food in hospitals. All can deliver good food.
We are determined to make sure that this happens. However, this Government have committed to creating new regulation only as a last resort, as the noble Baroness, Lady Thornton, observed. Because of that, we have identified other, highly transparent ways of delivering the change that my noble friend wants to see. Of course, legislation has a role. All healthcare organisations must register with the Care Quality Commission, whose powers are enshrined in law. The department is updating the CQC’s registration requirements to include new fundamental standards of care that all providers have to meet, and the CQC is developing compliance guidance. We will ensure that the work of the panel aligns with that.
Crucially, we have asked NHS England to amend the NHS standard contract so that it helps to deliver improvement. In the new contract, due out next month, hospitals will be required to have regard to guidance on the provision of catering services, including government buying standards for food and catering. We will work with NHS England to ensure that the panel’s work is appropriately highlighted in later contracts and technical guidance. Commissioners of NHS-funded services have the power to require remedial action to be taken where there is clear evidence that providers are failing to meet the terms of the standard NHS contract.
There are also incentives for excellence. Under the system of commissioning for quality and innovation, which we call CQUIN, commissioners can reward providers for delivering high food standards. For instance, providers might be rewarded for improving food quality, or meeting external standards such as those of the Soil Association’s Food for Life Partnership.
My noble friend also calls for a new inspection regime. We can respond to her call in the following way. The CQC has appointed Professor Sir Mike Richards as Chief Inspector of Hospitals and he is establishing a robust system of registration, regulation and inspection. The programme is not a rigid one-size-fits-all process, but a more measured, risk-based approach. This requirement has all the power of the Health and Social Care Act 2008—we do not need further legislation.
The Care Quality Commission has pledged to start rating NHS acute trusts and foundation trusts from December this year and aims to complete this process before the end of 2015. It will introduce a more specialised inspection model with a greater focus on culture and leadership and teams that include clinical and other experts and people with experience of care. It will use information and evidence in a more focused and open way, including listening better to people’s views and experiences of care in order to predict and respond more quickly to services that are falling short.
However, we need strong monitoring. We now review the food served in every single NHS hospital via annual patient-led assessments of the care environment —we call them PLACE inspections. This year, a small army of more than 5,000 patient assessors, including a patient who is a member of our panel, took part in PLACE assessments, including tasting the food on offer. If the vegetables were overcooked, or the gravy was cold, they reported it. If the custard was lumpy or the sandwiches dry, they reported that too. Their feedback directly helps hospitals to improve. As my noble friend said, there is no evidence of a direct link between cost and the quality of food. We are looking further into this to see if we can establish any link. Our PLACE inspections have given us detailed information directly from patients, which will help us understand how good food can best be produced without wasting money.
We also use PLACE to record whether hospitals comply with recommended guidance. We already ask about the government buying standard for food, and next year we will ask about the Soil Association’s Food for Life catering marks. Once the panel has reported, we will include a question about other recommended standards. Commissioners and providers together can use this information to improve services.
We know that this approach can work. In 2011, government buying standards for food and catering services were launched. They were compulsory for central government departments, but voluntary within the NHS. Yet already around half of all hospitals comply, with another quarter pursuing compliance. My colleagues at Defra are reviewing these standards, and members of the panel are involved in that.
My noble friend also asked for action where hospitals fail to comply with standards. The CQC already has these powers and can take action through civil enforcement or under the criminal law. As I said, commissioners can also act where the standard contract terms are breached by requiring providers to take remedial action and, in the case of serious failures, they can escalate that action. However, it is not just about punishment. What my noble friend wants, quite rightly, is improvement. Our approach is designed to achieve this, which is why PLACE requires hospitals to publish an action plan to show how they will address any problems. This has already started. In Sheffield, hospitals already score well on food but plan to increase menu choice with a £7 million capital development of their catering infrastructure. East Lancashire Hospitals NHS Trust plans to review ordering systems and improve service delivery by opening a second food production belt. It is also reviewing its vending machines. These are tangible improvements, identified by patients and planned and delivered locally. They are evidence of success.
The noble Lord, Lord Turnberg, spoke about the sourcing of food, a subject I mentioned a moment ago. He may like to know that some 60% of the food ingredients supplied to the NHS is procured under contracts negotiated at a national level by the NHS Supply Chain. It requires suppliers to provide information on product quality and provenance and to have a verification process in place. It is working with its contracted food suppliers to identify products that meet the food GBS and make the information available through its website. However, it is important to remember that, under public sector procurement rules, the NHS cannot promote or appear to promote a buy-British policy.
My noble friend Lady Cumberlege referred to the use and cost of nutritional supplements. It is always better if patients can get the nutrients they need from proper food rather than supplements—there is no argument about that—but some patients cannot digest normal food, or need extra calories, and they need supplements. The cost of £320 million that noble Lords may have read about is actually related to spend in the community, not in hospitals. It also includes the provision of real food such as gluten-free bread or low-protein biscuits. I would not want noble Lords to be misled by any press reports they may have seen on that score.
Malnutrition has many causes, a theme that was taken up to the noble Lord, Lord Rea, but it is most often seen in conjunction with other illnesses. The British Association for Parenteral and Enteral Nutrition estimated the cost in 2007 at more than £13 billion, but it did acknowledge that some of these costs may be unavoidable. This is because serious illness and injury will always result in loss of appetite associated with changes in the body’s metabolism, which in turn results in tissue breakdown and muscle loss. These costs are linked to malnutrition rather than being direct costs, so they cannot be assumed to translate into potential savings in the cost of care.
The noble Lord, Lord Rea, and my noble friend Lady Cumberlege referred to unhealthy foods being served to patients, such as foods that are high in fat and salt. The best food does no good if it is uneaten. For very ill patients who cannot eat large amounts, it may be better for them to eat high-calorie, higher-fat food. Our panel will work hard to strike the right balance between long-term health needs and the short-term requirement for high-calorie food. The noble Baroness, Lady Masham, and the noble Lord, Lord Turnberg, referred to the problem we hear about so often of food being left out of reach and patients not being given the help they need. It is unacceptable for food to be left out of reach. Where a patient is at risk of malnutrition, specific plans of care are introduced such as serving food on a red tray, which signals to the team that extra support is required. We support the notion of protected mealtimes whereby all non-essential clinical practices are avoided during those periods. Family members and volunteers who have had additional training are often invited to help patients with their meals.
Success is what we want. This Government want food that boosts health and recovery, that tastes good and impacts lightly on our environment. Our approach rests on what I referred to earlier as the three Is: instruction, incentives and inspection. Instruction is provided through registration standards and the NHS standard contract, incentives via the CQUIN scheme and inspection by PLACE and the CQC. These, we believe, are the way to success.
Baroness Cumberlege
My Lords, I thank my noble friend Lord Howe for his comprehensive reply. What the Government are doing is extremely encouraging, but I am still not convinced that all this voluntary work and the emphasis on guidelines will achieve what we want. We will need to press for some mandatory standards. I want briefly to comment on some of the very knowledgeable contributions that have been made by noble Lords.
The noble Baroness, Lady Gibson of Market Rasen, started by saying that she is not an expert, but in her contribution she showed real clarity about her expertise as an expert patient. There is nothing more compelling than personal testimony. She did say that this is not asking for the moon, and I agree with that. It is a simple Bill and, indeed, a modest one.
It has been clear throughout the debate that noble Lords have been diligent about reading their briefing, and pretty well everyone described the 21 initiatives that Governments have put in place over 20 years as being extraordinary. In no way do I underestimate the concern and commitment of successive Governments, and we have heard about that again today. All Governments want to improve hospital food, but it is a question of how that is done: how do we make it happen? We know that the NHS is very good on policy, on discussions and on—what do they say?—paralysis by analysis, but it is the implementation that it is weak on, and that is what particularly concerns me about hospital food. I have a quote from one of those years: “It is good food, not fine words, that keeps me alive”.
My noble friend Lady Miller and the noble Baroness, Lady Thornton, gave us some shining examples of the good food being produced in hospitals. I am pleased to see that because it is very good for patients, and I would bet that it raises the morale of the staff as well. The Royal Cornwall Hospital was highlighted. I have not had time to visit that hospital, but I know that my noble friend Lady Jolly speaks of it often. I understand also that the Royal Brompton Hospital and others are good. However, my noble friend Lady Miller said that what really makes a difference within a hospital is the will to do well and good leadership; that is very important. Today, I am asking the Government for a bit of strong will and the leadership to bring in this legislation.
Catering staff are, of course, key to this. One of the things I have noticed when visiting hospitals is that different institutions approach this differently. That is great and I am all for them using their initiative and seeking their own ways of doing things. Some places have integrated nursing and catering staff, while in others there are dedicated catering staff who have an absolute love of food, and you can see the difference. There are merits in each of the different ways of approaching this, and that is right. Having talked to nurses and to catering staff, I am interested in the following question: where are the doctors? I am delighted that the doctors are here today and I thank them both, the noble Lords, Lord Rea and Lord Turnberg, for their contributions.
It is very interesting to look at the obesity plan that the Royal College of Physicians has produced; hospital food does not seem to enter into it. Bariatric surgery does, and the need for more nurses to be trained in bariatric surgery—all those things—but surely doctors should be looking much more closely at the whole condition of their patients, what they are receiving and how they are getting better.
The noble Lord, Lord Rea, said that sanctions are missing and the lack of progress has been shameful—I so agree. This is an opportunity to improve, as he was saying, not only the quantity and quality of food in hospitals but the education so that people can better understand food in general. I was asked whether the Bill includes private hospitals. No, it does not; it applies to the NHS.
I thank the noble Baroness, Lady Masham, very much. I know that Stoke Mandeville is seared on her heart. I am very pleased that I have escaped on my visits there but she certainly told us a great deal about how disappointing the food is. I was interested in what she said about having kitchens on the wards and in hospitals generally, and not food brought from Wales. The noble Lord, Lord Turnberg, also made that point.
There is a very nice quote from Elizabeth David, that great pioneer of good cooking:
“Good food is always a trouble and its preparation should be regarded as a labour of love”.
When the food is produced on an assembly line in Wales, frozen and then reheated on the ward, how can the people who are producing that food love it? They never see a patient. Whereas if hospitals have their own kitchens, you see chefs going round and asking the patients what they like, what they do not want, what size of portion they want—all the rest of it. That is the labour of love.
I was very distressed to hear the noble Lord, Lord Turnberg, say that many patients lose weight in hospital. He also went on to say that celebrity chefs are not the answer. I agree: that is another thing we have tried and tried and it does not work.
I was interested to think about how patients can use their power to improve hospital food. We have tried and tried. Age UK tried the “Hungry to be Heard” campaign, which was all about food in hospital. As nothing happened, it revamped it as “Still Hungry to be Heard”. I really do not think that across the country the food has improved that much, despite some of the good examples we have been given. It is interesting that two-thirds of staff would not eat the food given to patients. That says everything, as far as I am concerned.
I thank the noble Baroness, Lady Thornton, for volunteering for this debate. I had no idea she had such a long-standing interest in this subject. Her contribution was outstanding. I agree with her: I am afraid we have reached the end of the road on volunteering and now we need to really grip this subject. She asked me about the consistency of government policy. I fear it is not consistent and I fear that will be our struggle. I am trying to think of other ways in which we can perhaps introduce something if this Bill does not get through the House of Commons. The noble Baroness also mentioned care homes. I was very conscious that in the NHS you really need to focus on the subject to get it done and I thought that if we went much more widely, we would certainly fail.
Finally, I am delighted that I and my noble friend the Minister are at one in that we want to support high standards and we agree that more needs to be done. The Government are certainly not inactive and I have been impressed by the response he has given us today, starting with this new panel he has set up. It has a huge task ahead. He highlighted the remit of the panel and what it will do. It looks very ambitious. I hope it succeeds. When will it report? How can we monitor progress? We need to see that this is not the 22nd initiative that the Government have produced in 20 years. We really want it to succeed.
On the question of staff and visitor food, I appreciate that less than half the food in hospital is served to patients: it goes to visitors and staff. I visited a hospital and asked to see the kitchens. They said, “Why do you want to see the kitchens? The food is brought in from miles away”. I said, “I still want to see how you are going to regenerate it”. As I went into the kitchen area, I met two chefs. One chef was cooking for private patients. I thought, “That’s fine, they’re paying for it; fair enough”. The other chef was cooking for the staff. I went into the staff restaurant, which was superb. You could have chosen anything; the food looked lovely. Then I tasted the hospital food given to patients—I say no more.
It has been a very interesting debate. Again, I thank my noble friend for his summing up. I understand that there are a lot of initiatives; it is how they work in practice that concerns me. I will certainly keep an eye on this Bill. I am not totally persuaded. I want to continue. I commend the Bill to the House.