Analysis

On the hospital menu: memories of comfort food to whet inpatients’ appetites

How a trust wants to make mealtimes more palatable by offering patients food from childhood

How a trust wants to make mealtimes more palatable by offering patients food from childhood


Nursing student Cerys Parfitt serves a meal to patient Jane Barratt  Picture: Tim George

Stimulating the appetites of acute inpatients with food that is appealing, nutritious and affordable is a famously difficult task in the NHS.

But one hospital trust is managing to achieve plaudits for its meals – and in turn, reduce food waste – by employing what looks like a huge dollop of common sense.

60%

of older inpatients experience functional decline during hospital stay

Source: Bapen

Let’s give patients what they want to eat

Staff at Nottingham University Hospitals NHS Trust decided to ask patients directly what dishes they considered to be the comfort food of their childhood. The thinking was simple: if people are offered food that is familiar to them and they have loved most of their lives, they are more likely to eat it.

With this in mind, they set up a consultation to find out what would make people want to eat heartily while in hospital.


Deputy chief nurse, Ann-Marie Riley

‘It is such a simple idea,’ says Ann-Marie Riley, the trust's deputy chief nurse.

‘We just asked the public what they want to eat when they feel poorly, rather than second guess them. But we don’t think anyone else has done it.

‘A lot of the suggestions that came back were things their mum or grandmother had made for them or they had at school.’

Requests included comfort food staples such as cottage pie, beef stew with dumplings, macaroni cheese, and curry; others reflected the community's distinct regional preferences, such as cornflake tart. 

‘It is typical 1990s hospital food, which seems to have slipped off the menu,’ says Chris Neale, assistant head of facilities.

‘When planning menus, we always start with the look and taste, before getting into the nutrition, because if it is doesn’t look appealing, it doesn’t matter how much protein or whatever it has, it doesn’t get eaten’

Nicola Strather, chief dietetic technician, Nottingham University Hospitals NHS Trust

The idea of the trust's 'memory menu' is now fundamental to its approach to its food operation, which provides 1,800 meals three times a day.

The memory menu was introduced in 2018, with a host of new – but old-fashioned – dishes. The trust's menu card offers an overview of the initiative and dishes suggested by patients are marked with an 'm' icon to denote memory dish status.

In reality, some of these meals were already being offered. But now about half of the choices are those patients have suggested.


Deputy ward nurse Sienna Malagad offers patient Peter Spencer a memory menu
Picture: Tim George

Nurturing well-being and boosting nutrition for older inpatients

The consultation was part of the trust’s drive to boost nutrition, which was one element in a plan to combat the decline in general well-being that older people can experience in hospital.

With the support of public and patient representatives, nursing, dietetic and catering staff, there was an enthusiastic response to the meals consultation.

‘We had huge engagement,’ Ms Riley says. ‘Within a week of asking on social media, we had a million impressions on Twitter. For six weeks, my inbox was full of food suggestions.’

Patient representatives and staff embraced the plan and asked at places of worship and in their communities what people would want to see, Ms Riley says.

 


The impact of malnutrition on hospital inpatients

1 in 3

patients admitted to hospital suffer from malnutrition
Source: Bapen

Malnutrition affects more than three million people in the UK at any one time, NHS nutrition guidance states.

Around one in three patients admitted to hospital are, or are at risk of becoming, malnourished. Poor nutrition and hydration not only harm individuals’ health and well-being, they can also reduce ability to recover, leading to increased admissions to hospitals and care homes, says NHS England.

‘We want to make what we offer more appetising so that patients can eat more food. It can be so detrimental if people are not eating when they are with us’

Ann-Marie Riley, deputy chief nurse, Nottingham University Hospitals NHS Trust

Despite recent efforts nationally (see Hospital food review box) the quality of food served up in many hospitals still faces criticism from groups such as the Campaign for Better Hospital Food, and from patients sharing pictures of unappetising hospital food on social media. 

In addition, concerns persist that vulnerable patients do not always get the help they need to eat and drink adequately.

The British Association for Parenteral and Enteral Nutrition (Bapen) says that 70% of patients leave hospital weighing less than when they arrived.

Malnutrition: risk factors and how to spot who is at risk

  • People over the age of 65, particularly if they are living in a care or nursing home or have been admitted to hospital
  • People with long-term conditions, such as diabetes, kidney disease, chronic lung disease, and chronic progressive conditions such as cancer or dementia
  • People who abuse drugs or alcohol
  • Poverty, social isolation and cultural norms, for example, hospitals and care homes may not always provide food that meets particular religious or cultural needs, all increase risk of malnutrition
  • Physical factors can increase the risk. These include painful mouth or teeth, difficulties swallowing or being unable to cook for yourself
  • If an older person is less able to feed themselves and becomes malnourished, this will make them more susceptible to disease, which in turn will make their nutritional state worse and impair recovery

RELATED: How to undertake a nutritional assessment in adults

RELATED: Why unexpected weight loss in older people should not be ignored

Source: Bapen: introduction to malnutrition

 


A menu for patients, designed by patients


Nicola Strather, chief dietetic technician

‘We wanted a menu for patients that was designed by patients,’ says Nicola Strather, chief dietetic technician.

‘Mealtimes matter to patients. We want to treat people as if they are in a hotel or restaurant, although without the budget. People really remember food.

'When planning menus, we always start with the look and taste of the meal, before getting into the nutrition, because if it is doesn’t look appealing and tasty, it doesn’t matter how much protein or whatever it has, it doesn’t get eaten.’

The project complemented the trust’s policy of encouraging inpatients to be dressed and as active as possible during the day while in hospital, to keep stays to a minimum and reduce risk of deconditioning. 

The #endPJparalysis campaign says 60% of older people experience functional decline following a hospital stay, including reduced mobility, loss of strength and independence.

Patient feedback and responsiveness to complaints


Patient representative Trish Cargill, assistant head of facilities Chris Neale and
nurse Sienna Malagad  Picture: Tim George

Feedback from patients is good, the Nottingham team says. When they hear complaints about dishes, they have tastings to consider possible improvements. ‘If we get negative or constructive feedback, we take that into consideration every time, Mr Neale says.

70%

of patients leave hospital weighing less than on admission
Source: Bapen

Food-related complaints through the Friends and Family Test have also reduced. A qualitative patient survey on the menu elicited positive feedback.

The memory menu is also believed to have benefits for inpatients who have dementia, a group making up about one in four.

‘If they hear about something they had when they were younger, it can evoke memories of food that made them feel better,’ Ms Riley says. ‘If it is something you have had as a child, it can be more appetising. And that is what it is all about, we want to make what we offer more appetising so that patients can eat more food. It can be so detrimental if people are not eating when they are with us.’

When the trust was carrying out the initial public consultation the deputy chief nurse heard on Twitter from a woman who said she had struggled to persuade her mother, who had dementia, to eat. However, when she tried meals people had suggested for the memory menu, the woman's mother began to regain appetite because the dishes reminded her of when she was younger. ‘It had influence outside the hospital, which was lovely,’ Ms Riley says.

Issues to consider when catering for patients’ meal requests

Nutritional limitations 

There were some suggested that would not have survived the cooking process or simply didn’t meet current food standards. One such was bread and dripping, but that would not be provided on a modern hospital menu for nutritional reasons.

Practical and budgetary questions

Another suggestion was toad in the hole, but testing revealed it could not stand up to the on-ward reheating process. Overall, the memory menu does not cost the trust more money, Mr Neale says. The meals vary considerably in price, from 56p per portion for the cheapest to £1.47 for the popular braised steak dish, but overall the dishes are not more expensive than previously.

Reduced waste 

The level of waste has fallen from 10-12% to 2% since the memory menu and same-day food ordering for patients on a tablet computer was introduced. ‘It is a massive difference,’ Mr Neale says, and a saving that allows the trust to spend more on ingredients.

 

The importance of exercising choice at mealtimes

Sarah Davis, now a shared governance educator, but who was until a few months ago a cardiology ward staff nurse, says she and colleagues have noticed patients tend to eat more now that the memory menu is in place. Part of the success is due to the wide choice,' she believes.

‘If I was a patient I would like to have the choice of a meal I know I am going to enjoy. That will be something different for each person – choice is really important. One of the most important kinds of feedback we get is after patients have eaten a meal and say they really enjoyed it, and had the food they wanted.’

It is good to see patients eat their food with pleasure, as nutrition is so important for recovery, Ms Davis says. ‘We see patients clear their plates,’ she says.

The trust is also trialling a device that makes scrambled eggs in 15 seconds. The portable Scraegg machine is being used on two wards at Nottingham City Hospital and is taken around the wards during breakfast service.


Patient Peter Spencer weighs up his
meal choices  Picture: Tim George

Notions of what is comfort food will change over time, so the menus will need to evolve

Ms Riley says the memory menu project will have to evolve, as what people consider ‘comfort food’ will change over time, and they plan to review the menu choices every year.

She would encourage other hospitals to consider trying a similar approach, seeing what local delicacies are popular and what local communities really want to eat when unwell.

‘It is not complicated, and it is something every trust can try. We are quite lucky in that we have inhouse food production, and can respond quickly, but an external provider could also do the same thing,’ she says.

Read more about patient nutrition 

Hospital food review


Prue Leith

In 2019, nine patients in eight hospitals in England developed listeriosis linked to pre-packed sandwiches and salads. Six of the patients died.

In response to the scandal, health and social care secretary Matt Hancock ordered a review of hospital food last August.

The review, which includes input from chef, food writer and Great British Bake Off judge Prue Leith, is focusing on:

  • New ways of monitoring food safety and quality, including looking at how NHS boards are held to account
  • How food can help aid faster recovery, taking into account the unique needs of vulnerable groups
  • Turning the NHS into a 'standard-bearer' for healthier choices for patients, staff and visitors. A 2019 Unison survey of more than 350 hospital staff in England found that more than half wouldn’t eat food served to patients because it’s unhealthy and of poor quality
  • How to make more healthy food available for NHS staff, particularly night shift staff 
  • Ways to increase the number of hospitals with their own kitchens and in-house cooks

Ms Leith has been a vocal critic of poor hospital food choices, and has called on hospitals to provide nutritious meals that aid recovery, and that dishes be tailored to the patient's individual needs.

She told a national newspaper in October: ‘The biggest complaint about the NHS is about the food, and the biggest complaint about the food is about the lack of toast. There is no toast or the toast is like pipe lagging or cold. This is so easy to fix.’

In addition, new national standards for healthcare food for patients, staff and visitors are being developed by NHS England, NHS Improvement and Public Health England


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