Hospital Food

Joan Walley Excerpts

Tuesday 14th June 2011 Commons Chamber

[Joan Walley (Stoke-on-Trent North) (Lab)]

I am very grateful to Mr Speaker for granting me this Adjournment debate on hospital food. As you, Madam Deputy Speaker, and many Members will know, I have long been interested in this issue and have pursued it in Parliament, so when I was fortunate enough for my name to be drawn in the private Members’ Bills ballot at the beginning of this parliamentary Session, I was clear about the Bill I wanted to draft. I wanted it to introduce minimum nutritional, environmental and ethical standards for the food procured by the public sector and served in our hospitals, care homes, armed forces institutions and the rest of the public sector.

The Bill gained widespread support from industry and from more than 60 health and environmental groups, including organisations as diverse as the caterer Sodexo, the women’s institute, the Chartered Institute of Environmental Health, and the Royal College of Paediatrics and Child Health. These organisations have witnessed years of failed attempts to improve public sector food through voluntary initiatives, and have seen first hand the damage caused by bad food in our public institutions, and they are united in the belief that the only way to improve public sector food is to ensure that all public bodies buy food according to national minimum standards. Despite that, the archaic parliamentary procedure that applies to private Members’ Bills means my Bill has still not received its Second Reading debate, and without Government support it is very unlikely to proceed.The Procedure Committee is conducting an inquiry into parliamentary sitting hours, and I hope it takes seriously the inadequate procedure relating to private Members’ Bills and proposes reforms that allow MPs the opportunity to introduce a Bill and proper parliamentary time for the consideration of its merits. My experiences in that regard have led me to seek an Adjournment debate to address this general issue from the perspective of health and the procurement of sustainable food in so far as that affects the Department of Health.

The procurement of sustainable food by the public sector is a cross-cutting issue. The Department for Environment, Food and Rural Affairs has lead responsibility for cross-cutting sustainable development issues, and I expected it to have been more decisive and to have taken an effective initiative in exploring how progress can be made. I wish to bring to the attention of the House a letter from the DEFRA Minister with responsibility for food, which basically said there was an ongoing review and he hoped to have the opportunity to report to the House by March, but we still have not had that opportunity.

Tonight’s debate arises at a timely moment given today’s announcement on the Health and Social Care Bill, and I want to link the issue of sustainable food and procurement with health and healthy food in hospitals. If, indeed, the stated aim of our NHS is to have excellent care for all, we need to address the issue of hospital food, so I am very grateful for the opportunity to raise the issue of the procurement of sustainable food in hospitals as well as the equally important issue of the quality of hospital food—

--- Later in debate ---

[Madam Deputy Speaker (Dawn Primarolo)]

I am sorry for the interruption, but the procedure caught up with us. Please, continue.

[Joan Walley]

I am most grateful for the explanation, Madam Deputy Speaker. I was confused by the fact that this Adjournment debate started before 10 o’clock. That might explain some of my slight nervousness, as I was unsure about whether I was speaking in order with the proceedings of the House. I am grateful.

Sustainable food procurement links to health and to hospital food, too. I want the Government to set out the role that food plays in patient pathways and the priority I believe that hospitals should give to ensuring that, where required, patients are assisted to eat the food that is served. We have heard too many shocking accounts of malnutrition and dehydration as well as the plain criticism that hospital food is bad and unappetising. We should be doing something about that.

At the core of this debate is a central contradiction. The Government are happy to rail against regulation and boast about their bonfire of red tape, but they are equally proud—and rightly so—of their standards for the procurement of sustainable food for the Olympics and of their intentions for there to be a Government buying standard for food. They promote their localism agenda aggressively, leaving choice to those at a local level, but the net effect, I believe, is that no overall quality standard applies to the food served in hospitals. I do not see how such a postcode lottery can be justified and I want to consider that in more detail.

Let me turn first to malnutrition. It is not just a matter of having appetising food for patients; this can literally be a matter of life and death. In its 2009 report submitted to the Department of Health, the Nutrition Action Plan Delivery Board showed that in the region of 47,800 people had died with malnutrition while in English hospitals in 2007. Of those, 239 patients died directly because of malnutrition—that is an important distinction to make. In the report, the delivery board recommended as a key priority that the Government should clarify nutrition

“standards and strengthen inspection and regulation”

to address this problem. The issue is being flagged up.

In its recent report, “Still Hungry to be Heard”, Age UK found that the number of people leaving hospital malnourished is on the increase. A recent answer to a parliamentary question from my hon. Friend the Member for Islington South and Finsbury (Emily Thornberry), placed in the Library of the House of Commons, acknowledged that from 2006-07 to 2009-10, instances of malnutrition increased in total from 2,581 to 3,773 and, as regards discharged episodes, from 2,883 to 4,412. That inevitably leads to further serious consequences, including longer stays in hospital, the need to take more medication and an increased risk of infection and even death.

To put it in purely financial terms, the estimated cost of malnutrition to the NHS in 2006 was £7.3 billion a year. Although we do not have an accurate figure for how much it costs the NHS today, given the fact that malnutrition is on the increase it is likely to be higher still. I believe that the Department of Health should have up-to-date figures on the cost of malnutrition, and I urge the Minister to look into the matter and give us an indication of what the costs are.

Dealing with malnutrition in hospitals is not simply about making food taste better. Even if we could do that, a whole range of other issues must be addressed. First, hospital staff must be aware of what food patients can and cannot eat. They need to be able to identify which patients need help with eating their meals and to be willing and able to provide that help or, if they cannot provide it, to have a robust system of volunteers to assist. Age UK has produced a seven-step guide to eradicating malnutrition in hospitals, to which I urge the Minister to give his attention. There is also an issue with dehydration and it is important to make sure that patients in hospital have proper access to water. That simply cannot be taken for granted.

It is not only nutrition and malnutrition that need to be addressed. There must be recognition by Government of the role that healthy food plays in healthy lives. The Government estimate that 70,000 preventable deaths each year in the UK are caused by diet-related ill health. One simple thing that the Government could do to tackle that problem is to ensure that the food served to patients in hospital is nutritious. That sounds simple but the issue is how it will be done. It is also important that the Government prioritise the role of public health.

I also want to mention the dignity and nutrition reports—[Interruption.] I am most grateful. Talking of dehydration, it is important that I refer to the dignity and nutrition reports recently published by the Care Quality Commission.

[Madam Deputy Speaker (Dawn Primarolo)]

Order. If the hon. Member wishes to take a seat and take some more water so as not to strain her voice, I am sure that the Chamber will not mind waiting a few seconds more.

[Joan Walley]

I am most grateful Madam Deputy Speaker.

The first tranche of what will be 100 dignity and nutrition reports into individual hospitals found that in four of the 10 hospitals investigated, the nutritional needs of patients were not being met. The reports also stated that the quality of hospital food remains a long-standing concern. This highlights both the extent of the problem and the importance of the Care Quality Commission’s role in monitoring and reporting on hospital performance in relation to nutrition. I believe that its resources should be increased so that it can carry out more such checks and fulfil the delivery board’s recommendation of strengthening inspection and regulation. I also believe that the CQC should be made fully accountable for how that work is done.

I want to discuss regulation because that is ultimately the best means of improving hospital food. It is remarkable that there are still absolutely no legal standards governing the quality of the 330 million meals served in the NHS each year. In its report, “Yet more hospital food failure”, published earlier this year, Sustain’s “Good Food for Our Money” campaign surveyed dozens of Government-backed initiatives to improve the quality of hospital food. Alas, it found that those initiatives have cost at least £54 million of taxpayers money and have achieved improvements in only very few isolated cases. The reason is simple: they have all been voluntary, so except in those few isolated cases they have been largely ignored. Let us contrast that with the successful attempts to improve the food served in schools, where meals have to meet legal nutritional standards. A survey by Consensus Action on Salt and Health—CASH—in October 2010 showed that most meals served to children in hospital could not legally be served in a school because they contained too high a level of salt and saturated fat. The reason for the success in schools is simple: minimum nutritional standards in schools are legally binding, but in hospitals they are purely voluntary.

To date, successive Governments have failed to send a clear message to hospital caterers that the quality of their food is critical to patient health and the sustainability of our food system. It is not asking for the impossible. For many years, the Royal Brompton hospital in Chelsea has practised a progressive approach to its food procurement, providing nutritious and appetising meals prepared from fresh ingredients, which enables patients to recover faster.

Unfortunately, the Government’s ideological commitment not to introduce more regulation, regardless of its merit, is a serious block to improving hospital food. I return to Government buying standards. The coalition Government have at least recognised that voluntary initiatives have limited effect; they do not work across the board and over time. As a result, they will introduce Government buying standards that set compulsory minimum standards for food served in central Government institutions. I hope it will be soon, as the standards were promised for March 2011, and we have waited for more than a year. They were promised by the Conservative party pre-election; they were welcomed by the coalition Government and were the subject of a great deal of Department for Environment, Food and Rural Affairs civil servant attention throughout 2010. The work also involved the Department of Health to integrate badly needed health standards for food served in central Government institutions. The integration of health and sustainability standards for food bought with public money was an innovative and much needed approach, and should act as an inspiration for the wider catering sector to follow suit. Tackling health, ethical and environmental issues together should save the country money and be of great benefit to food producers and the environment.

The real issue for me is that even when the Cabinet Office home affairs committee signs off the Government buying standards, they will not apply to hospitals and hospital food. That is the heart of the concern. On the day the Government are revising the Health and Social Care Bill and recommitting it to further scrutiny, should the Health Minister not be exploring with colleagues at DEFRA and in the Cabinet how the long-promised Government buying standards can be extended to hospital food? If that is ruled out, surely there should be urgent discussions with the NHS Future Forum, the National Audit Office and expert groups, such as Age Concern and Sustain, which have a track record on this matter, with a view to tabling amendments to the Bill so that we have minimum standards for nutrition in hospital food.

[Tessa Munt (Wells) (LD)]

There is another part to the equation. I have worked in further education colleges and it would seem logical that when we train chefs they should take a module on the specifics of nutrition for people in hospital. That is a different element. Does the hon. Lady think we could focus on that to improve standards?

[Joan Walley]

I am glad to take that intervention. It is an extremely important point. Basic minimum standards should be applied to schools and in future to hospitals, but that will not happen by accident. It will happen only if we put in place all the necessary education, training and skills. Whoever is responsible for providing the food needs to be trained. I agree that that is a third dimension to the issue.

I apologise to the House for having lost my voice because of my cold. In conclusion, surely there is no other institution where it is more vital to serve healthy, wholesome food than in our hospitals. That is important in so many ways—for the recovery of patients, staff morale, and the atmosphere that fills the wards. When hospitals serve good nutritious food, everyone benefits. I therefore call on the Government to introduce minimum nutritional, environmental and ethical standards for hospital food that will radically improve the quality of food served, reduce costs to the NHS and improve the health of the nation.

[The Minister of State, Department of Health (Mr Simon Burns)]

I congratulate the hon. Member for Stoke-on-Trent North (Joan Walley) on securing this debate on hospital food. I hope she gets better swiftly. I have considerable sympathy with her as she was clearly suffering through no fault of her own, and I wish her a speedy recovery.

I know that food and nutrition is a subject dear to the hon. Lady’s heart, and that she has done a considerable amount of work in her constituency, bringing together schools, primary care trusts, the city council and others, Prue Leith not least among them, to see what can be done locally to improve the diet of her constituents. I pay tribute also to the many NHS staff who have worked so hard to push nutritional care up the agenda, and who continue to make it their priority.

Good food—nutritionally balanced, clinically appropriate meals that taste good— are right up there with good hygiene and good clinical care when it comes to a patient’s experience of the NHS. They are all things that we should be able to take for granted while being cared for by the NHS. Good food contributes directly to recovery from illness and it adds structure to a day that can be all too long and featureless. Although I agree with much of what the hon. Lady said, there are some details on which we may not have such close proximity of views.

As the hon. Lady mentioned in the course of her comments, we will shortly publish the Government buying standards for food. Developed by DEFRA and the Department of Health, they will support and encourage public bodies to provide a healthy balanced diet for public sector workers. They will also help to reduce the environmental impact of food and catering in the public sector. However, as the hon. Lady said, within the NHS, these standards will be voluntary, not mandatory. Government buying standards are already promoted through the NHS operating framework for 2011-12 and through the Boorman review of health and well-being on the NHS, now being implemented by NHS Employers. We will promote the Government buying standards through training and materials developed to help NHS organisations to procure more sustainably.

The Government believe in giving far greater responsibility and control locally to NHS providers. NHS trusts must be allowed to determine their own procurement policy. Hospitals need to find out the wants and needs of their local population and then work out how to meet them efficiently. Government’s role is to set the direction and the policy, but it is for local experts to deliver the food locally. This is not to say that the NHS is on its own. There are a number of resources available, including guidance on reducing food waste, sustainable procurement and developing menus and food services.

No health care catering manager need feel unsupported. If hospitals wish to increase the proportion of locally-sourced food, there is guidance to help them do that. If they have a problem with food waste, there are resources that can help them to tackle it. This is the way we should tackle problems—with assistance and support, not restrictive legislation and diktat. It is wrong for Government to meddle in the detail and to attempt to micro-manage the NHS from on high. Our job is to create the right environment, to set standards and to lead, and that is what we are doing.

[Joan Walley]

Is not there a contradiction in having minimum standards in schools but not having minimum standards that would apply in the same way to patients in hospitals?

[Mr Burns]

No, I do not think so, for the reasons that I have already given and because of our ethos that the modernised NHS should respond through local decision-making rather than top-down diktat from Whitehall or Westminster. However, as I have outlined, we are prepared to, and we have and we will, provide the guidance to enable local deliverers to seek advice and take decisions based on the best needs of their patients.

We should also bear in mind that the food needs of patients are already regulated and checked by the Care Quality Commission, through the choice of suitable food, the food and nutrition to meet reasonable needs and the support to enable patients to eat and drink—a subject that I will come on to because I feel very much, as the hon. Lady did, that that is an essential part of the care of patients in a hospital setting.

I share the hon. Lady’s concerns about poor standards of nutritional care. In too many cases, food has slipped off the menu of some NHS providers, and that is not good enough. Of course, proper nutritional care is a multidisciplinary affair. There are many links in the chain from field to fork. Food must be well sourced and properly cooked by well-trained catering staff, delivered efficiently by the porters, and properly presented on the ward. The chain is a long one, and if any single link breaks, the good work that went before it is undone. Of course, the best food is of no value if it is not eaten, and many people, particularly older patients, will need help, and they must have it. Stories of food left out of reach, or taken away before a patient has had the chance to eat it are shocking and, sadly, too common, as are stories of those unable to feed themselves left without the assistance they require.

The latest in-patient survey found that less than two thirds—64%—of patients always got the help they needed to eat. But that sadly meant that 36% did not always get the help, which, frankly, is unacceptable. That is something that hospitals must concentrate on to ensure that we quickly and dramatically raise those figures. In a civilised society, in this day and age, that is unacceptable as part of patient care, particularly for elderly people.

That is why we asked the CQC to inspect 100 hospitals, focusing on issues of dignity and nutrition. The CQC has begun to publish reports on individual hospitals, and we expect a final report in September. In most cases so far, the care was every bit as good as one would expect. There were many examples of high-quality nursing and of people enjoying healthy, nutritious meals. Indeed, in a number of cases, the quality of food was actually complimented. But the inspections also identified a number of hospitals that were failing to provide the nutritional care their patients need. In one damning example, a doctor was forced to prescribe water on a patient's medicine chart to ensure they got enough to drink. That, again, is unacceptable, and something that one would find hard to believe if it had not shown up in the inspection. Where there are deficiencies, the CQC has demanded that improvements are made. Progress against these demands will be followed up and, like everyone in this House, I expect such follow-up to be rigorous and complete.

The CQC's inspection programme is just one example of how we are shining a light on all aspects of the performance of NHS providers—in this case on hospital food. There are also the annual patient environment action team inspections, the CQC's in-patient survey and patient feedback through NHS Choices, along with any local surveys that trusts choose to undertake. This information is crucial if patients are to make informed choices about their care and if pressure is to be brought to bear upon providers to improve.

Improving the patient experience of care is vital to drive up standards. Providers need to listen to patients’ complaints and suggestions and to change and improve in response. This will be one of the main ways in which the NHS will improve in coming years. Our information revolution will mean that patients are better placed to understand and influence the NHS, and we expect to see standards increase as performance becomes more transparent.

When it comes to hospital food, people know what they want. They expect good-quality, wholesome meals that are attractively served, arrive on time and taste good. They want to receive the food they ordered, not what is left over. They want to be able to eat it in comfort, they want sufficient fluids to drink, and they want the help they need when they need it. That is hardly asking the earth, so we owe it to them to be clear about what they can expect in their local hospital, however good or bad it may be.

I understand the hon. Lady’s concerns about hospitals that are built without kitchens. However, there are many ways to provide food in hospitals. Excellent meals can be delivered ready-made, either chilled or frozen, and poor-quality food is not an inevitable consequence of being made off-site. Although the quality of the food at the University Hospital of North Staffordshire has been rated as among the poorest 20% in the country, that is not simply because it is not made in a hospital kitchen. Other hospitals, such as those in Papworth Hospital NHS Foundation Trust and Dorset County Hospital NHS Foundation Trust, also have meals brought in and maintain in-patient survey scores that are among the highest in the country. In fact, for a small hospital, delivered meals can combine a wider choice of food and more accommodating meal times, with economies of scale and greater flexibility.

Delivered meals can also help hospitals to meet high sustainability standards, because although on-site kitchens might at first seem more likely to be sustainable, that is not necessarily the case. Larger off-site kitchens are often more efficient because, by utilising economies of scale, they can reduce the amount of energy they use. What is important is the quality of the finished product and whether it meets the specific needs of patients, not where or by whom the food is produced or prepared. If the best solution for a particular hospital is to do that on site, that is what should happen. However, the service should be contracted out if that is in the best interests of the individual hospital and its patients. We should reject any knee-jerk reaction that says doing it in one way will automatically be a disaster, or vice versa. With food, as with all aspects of NHS care, it is the outcomes that are important to patients, not the process. We need to remember that whoever provides the food, the trust management retains the responsibility for its quality. If the provider does not meet the standards that the trust has set, it must take action.

Of course, efficiency and value for money are also important. We have to find ways of producing excellent food at manageable cost. For some hospitals, that will certainly mean looking at delivered meals. This is sensible and prudent management, but it need not and should not mean poor quality. As long ago as 2002, the Audit Commission found no relationship between the amount of money spent on meals and their quality, and the Department of Health’s more recent internal analysis backs this up. Across the country there are trusts that provide great meals at low cost, which is precisely what all providers should aspire to. The Queen Victoria hospital NHS foundation trust is in the top 10% of NHS organisations rated by patients for having good food, but in the lowest 5% for production costs.

As ever, improving patient experience is central to the Government’s vision of the NHS. Good food is not only a vital element of that experience, but vital for improving clinical outcomes. However, I do not accept that the answer to these problems is to impose ever more controls that would prove expensive to administer, undermine local accountability and stifle the innovation and flexibility that hospitals need to tailor improvements to their specific local needs and constraints. Where food services are not as good as they should be, we should highlight the fact in order to improve care for patients. I do not pretend that making improvements will be easy or fast. Although there is much to do, I am confident that we now have the right approach and that the real winners in all of this will be patients.

Question put and agreed to.