Analysis

Hospital food: the trusts yet to reach nutrition standards

Providers in England making good progress on the five standards, but there is still work to be done

Providers in England making good progress on the five standards, but there is still work to be done


A light meal at East Lancashire Hospitals Trust, where nursing staff work with 
caterers to devise appetising menus and reduce waste. Picture: John Houlihan

Around a quarter of NHS trusts in England may not be meeting hospital food standards – three years after they became legally binding.

Chief among the nutrition standards for England’s hospitals is the requirement to demonstrate the Council of Europe’s ten key characteristics of good nutrition and hydration care. These range from screening all patients for malnutrition on admission to taking account of an individual’s nutritional and hydration needs in their care plan, and protected mealtimes.

The Council of Europe also calls for a multidisciplinary approach in which staff including nurses, dietitians and nutritionists, doctors, and caterers contribute to their trust’s nutrition strategy.

Nursing Standard submitted Freedom of Information (FoI) requests to all acute UK providers and responses suggest that while most meet the food standards – the figure was 50% in 2016, according to a panel of experts – there is still work to be done. 

Failure to comply with all five standards, introduced in England in 2015, does not mean NHS providers are failing to meet patients' most basic nutritional needs. Care Quality Commission (CQC) inspectors check hospitals give patients enough to eat and drink to meet their specific requirements.

The standards were established by the independent Hospital Food Standards Panel, which was commissioned by the Department of Health and Social Care (DH). NHS providers in Scotland, Wales and Northern Ireland have their own non-legally binding standards.

Hospital food standards at a glance

The five hospital food standards for trusts in England

  • Standard 1 Meet the ten key characteristics of good nutrition and hydration care as set out by the Council of Europe, including screening all patients for malnutrition and ensuring protected mealtimes
  • Standard 2 Meet the British Dietetic Association guidance, which includes health staff leading on the development and monitoring of nutrition policies
  • Standard 3 Adopt the Malnutrition Universal Screening Tool (MUST), which sets out the steps nurses and other clinicians should follow, including measuring body mass index and unplanned weight loss to check inpatients for malnutrition on admission
  • Standard 4 Adopt Public Health England's principles of healthy and sustainable food for staff and visitors. This includes encouraging on-site retailers to promote healthy food
  • Standard 5 Follow government's sustainability guidance

£9.08

The average cost of food per inpatient per day in 2016-17, up from £6.89 in 2015-16

Source: Nursing Standard FoI request

Epsom and St Helier University Hospitals NHS Trust in Surrey meets four of the standards, but admits mealtimes are not consistently protected. 

Royal Liverpool and Broadgreen University Hospitals NHS Trust is still working to reach all five standards. It has created three steering groups that include nurses, dietitians and others, which report their progress to senior management and the board.

Patchy implementation

Age UK head of health influencing Lesley Carter says some hospitals are inconsistent in how they meet patients’ nutritional needs.

‘Many have not got it right yet because they have not joined up the work being done by all their different departments’

Lesley Carter, Age UK

Ms Carter, who is a nurse, was a member of the hospital food panel and is project lead for the Malnutrition Task Force, an independent group of experts working to prevent malnutrition in older people in England.

She says: ‘Awareness of hydration and nutrition in hospitals has increased significantly. However, there are still many that have not got it right yet because they have not joined up the work being done by all their different departments.’

The success of simple measures


Nurse Bindu Mathew with patient Doren Lockley at Royal Blackburn Hospital.
Picture: John Houlihan

Proactive nursing staff at East Lancashire Hospitals Trust have formed a group to help plan menus and make recommendations aimed at improving the food options at its sites.

Nurses and healthcare assistants (HCAs) have had regular meetings with the trust’s catering manager Tim Radcliffe, who was appointed 18 months ago.

Since then, the cost of providing meals has fallen from £11.55 per patient per day in 2015-16 to £8.28 in 2016-17.

Their efforts have also meant that last year only 0.725% of the 2,100 meals cooked fresh on site each day for patients at the trust’s five hospital sites were returned uneaten.

Mr Radcliffe says: ‘There is nothing ground-breaking here, just simple things that anyone can do. We encouraged wards to stop over-ordering meals from the kitchen. In just eight weeks we saw a reduction in meal requests of around 76%.’

Mr Radcliffe says: ‘The nutrition group tell me what patients like, what they are eating less of, and we adjust accordingly.

‘Our staff make and deliver the meals to the ward door, but it is nurses and HCAs who actually serve it to the patients. All the evidence shows this is the best way to ensure patients get the nutrition they need.’

 

Nursing Standard requested information from all 135 acute hospital trusts in England, of which 115 responded.

It also requested information from the 14 local health boards in Scotland, all seven in Wales, and the five health and social care trusts of Northern Ireland.

All providers in Wales, 12 in Scotland and four in Northern Ireland said they meet all the standards set out by their devolved administrations.

50%

Of hospital trusts in London met all five hospital food standards in 2016
Source: Taking the Pulse of Hospital Food – report by the Campaign for Better Hospital Food

The picture in England has been complicated by the transfer of responsibility for overseeing hospital food from the DH to NHS Improvement in 2017. The authority is yet to issue guidance to trusts.

Independent monitoring

There is an argument that the CQC should be empowered to cover food standards in its hospital inspections.

The Soil Association runs a programme called Food for Life, which is designed to ensure proper access to healthy, sustainable food at public institutions – sustainability is one of the five standards.

Susannah McWilliam is the programme manager for the association’s Hospital Leaders initiative, which supports trusts in devising nutrition and hydration strategies. 

Dr McWilliam, also an expert adviser to the Hospital Food Standards Panel, says: ‘I very much agree with having an independent monitoring group in place to oversee the standards, as well as seeing the CQC make the standards part of their inspection procedure.

‘I have seen progress made, but it was always going to be a big task to bring together patient nutrition, staff health and well-being, and sustainability in one set of standards’

Susannah McWilliam, programme manager, Hospital Leaders initiative, Soil Association 

‘Our association provides an award to hospitals that cook food fresh on site, which has to be renewed annually, therefore providing a measure of ongoing monitoring of standards.'

The accreditation has so far been won by 46 trusts, which between them prepare 42,000 meals a day.

‘Trusts need to be encouraged’

‘The biggest problem is that there is no clear mechanism in place from the government to check how robust strategies are – or if trusts even have one yet. No one is encouraging trusts to make positive change,’ Dr McWilliam says.

‘I have seen progress made, but it was always going to be a big task to bring together patient nutrition, staff health and well-being, and sustainability in one set of standards.’

NHS Improvement’s executive director of nursing Ruth May says she is encouraged that 75% of trusts are complying with all five standards.

70%

Of trusts in England prepare fresh food – at least hot soup and sandwiches – for patients on site

Source: Nursing Standard FoI requests

‘We are continuing to help trusts ensure patients receive good nutrition and hydration,' she says.

‘This includes a review of the healthcare food standards and commission, and our nutrition collaborative to improve the accuracy of nutritional screening.’ 

The nutrition collaborative involves 25 providers working together to improve the accuracy of nutritional screening and suggest appropriate interventions.

While it remains to be seen whether ensuring adherence to the food standards will require intervention,  it appears more work is needed to make the standards a routine part of inpatient care everywhere.

What nurses can do

  • Be observant when walking around the ward. Note whether a glass of water is within easy reach of the patient, or a tray of food has been left untouched, advises Age UK’s head of health influencing Lesley Carter
  • Share best practice by setting up a forum to highlight challenges and solutions, says the Soil Association’s Hospital Leaders programme manager Susannah McWilliam
  • Share what you know about the tastes of individual patients. RCN professional lead for acute and critical care Suman Shrestha says: ‘Patients’ tastes can be affected considerably when they are in hospital. This can be due to the condition they have, or even because of the treatment they are receiving. This needs to be factored in when planning the right nutrition for patients.'
  • Recommend that your organisation employs specialist nutritional nurses. Mr Shrestha says his hospital, Frimley Park, in Surrey, has specialist nutritional nurses who carry out full assessments on malnutrition risk. They run roadshows to explain their work to staff, and invite staff to taste the food themselves

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