It seems a safe assumption that we’d hope our sick friends and relatives in hospital are given good food and enough of it during their stay. However, some hospital patients in Northern Ireland are given meals costing the same to make as prison food while a new published scoring system for hospital food used in England isn’t in place here.
And the fact that the issue of hospital food continues to be raised in Northern Ireland, even after concerns were aired in a 2011 (NI) Patient and Client Council report, suggests that further steps to reassure the public are overdue.
Third-party Freedom of Information requests show that in some instances the same amount has been spent on prison food – around £3 per prisoner per day – as has been spent feeding patients in Belfast City Hospital.
Meanwhile, the Patient and Client Council has confirmed, in a response to an question for this article, that the introduction of a scoring system published online, similar to that used in England, would be also welcome in Northern Ireland: “A constant theme in the Patient and Client Council’s engagement with the public is the lack of information on health and social care. Patients, families and carers have told the Patient and Client Council they require more information to make informed choices about their care.
“The Patient and Client Council would support more information being available about hospital food including the introduction of a published scoring system to help inform patients and their families and carers.”
The Belfast Trust, which is used as an example Trust for this article where specifically stated, also responded in positive terms to an email request about considering new ways to handle feedback: “The Belfast Trust values patient feedback and embrace the opportunity it provides to improve our services and have mechanisms in place to obtain this information. This is in line with Trust values.
“The Trust are willing to consider new tools which will enable us to deliver an excellent service.”
It was also added that The Belfast Trust, and all Trusts in Northern Ireland, are reviewing their actions in response to the 2011 report.
As an aside, it was reported in March last year that the subsidy provided for catering at Stormont totalled almost a quarter of a million pounds.
Hospital food quality in Northern Ireland was in the headlines as recently as November 2015 despite a highly critical report on the subject in 2007, the issue being raised in the Patient and Client Council Survey of 2011 and the publication of (NI) Department of Health guidelines for nutritional standards the same year.
Concentrating on food quality and quantity as opposed to the issue of malnourishment, further FoI requests were made and discussions carried out with a number of people close to the subject. The issue of cost-per-patient appears to be key as opposed to the efforts of those working hard within the resources given to provide the best possible care. It has been pointed out, in some instances and some hospitals, the catering budget can be insufficient to avoid small portions, lack of choice and low quality. Anecdotally, the discussions seemed to support the view of the 2011 report that patient experience can vary from hospital to hospital.
I believe prisoners should, of course, be fed properly however it is difficult to see how the needs of the most unwell in our society can be met at the same cost of £3 per day.
While The Belfast Trust has, understandably, responded to criticism by stating that formal complaints over hospital food are very low it was also explained elsewhere that a patient who has been unable to eat hospital food on offer and has needed to have food brought in by relatives will often fail to make a complaint due to more immediate medical concerns followed by the relief of being home recovering as opposed to wanting to revisit the issue.
It is of note that while the 2011 Patient and Client Council survey stated that between between 51% and 75% of patients responded positively when asked about hospital food. Figures from The Belfast Trust show that it received just six complaints about hospital food in the same year, suggesting that the above theory is correct.
A person with expertise in the subject pointed out that providing hospital food for such a wide range of dietary and nutritional needs can be complex as it is is often focused on nutrition and medical need (such as pureed food) while foods which are weaker in flavour are used as they are acceptable to a wider age range.
In 2011 the deputy chair of the Stormont Health Committee, Michelle O’Neill, responded to the Patient and Client Council report by saying: “These findings are extremely alarming. Providing good, nutritious food and ensuring patients are able to eat it is a basic part of good patient care.
“The PCC was set up as the voice of the patient and if this is what they are telling us is happening then we need to listen.”
The Belfast Trust responded to a request for more information about its monitoring of hospital food quality and quantity by explaining that results of surveys it has carried out “indicate that portion sizes and quality of food is acceptable”.
They added added that: “Dieticians work with Catering to ensure portion sizes are appropriate for patients. Patient choice in terms of portion size is available at the point of service. The Trust have in place a process of monitoring of food waste which includes uneaten meal”.
Although this work is being carried out internally by The Belfast Trust, to provide absolute reassurance that our loved ones will be helped to recover with sufficient good food in every hospital on every occasion a closer look at the the published scoring system seen in England would seem a positive next step for a clear view of where the issue stands in 2016 and where further action is needed.
Concerns over hospital food quality appeared in the media in November 2015 when MLA Barry McElduff raised complaints with the Health Minister that patients at a Belfast hospital had been served portions which were reportedly too small and lacking in nutrition.
Barry Elduff was stated as saying that he had been contacted by patients, including a cancer patient, who had raised concerns: “Good and healthy food helps you on the road to recovery so I felt I had to bring this to the attention of Simon Hamilton.
“They said the portions were very small and that the food wasn’t very nutritious. I am not saying anything about the doctors or nurses, who I know do a fantastic job under a lot of pressure, and I’m not saying that this happens all the time.”
In an FoI response for this article, The Belfast Trust responded that – for its hospitals – complaints about hospital food amounted to just eight in 2015, a typically small number compared to previous years.
However, on the Patient and Client Council website a blog entry about hospital food from September 2014 has the following comments added by the public:
15 Sep 2014 12:06
“With this Promoted Strategy in place since 2011, please can anyone explain why the food in our Hospitals is so poor? Over the past 6 months I have been with a relative who had terminal cancer and saw the poor standard of food on the wards. When he politely declined it-none of the nurses paid any attention!”
12 Sep 2014 20:55
“I think the food in hospitals is simply disgusting. My husband was in and out of hospital and was terminally ill and a stay in hospital done nothing for him because of the food . On one occasion I said we go to canteen and try something there . I left the meal as I was actually heaving after one bit of it . A lot of improvement needed for sure.”
12 Sep 2014 17:17
“If the nurses were properly trained they would know all about nutrition. Gone are the days when the Sister was able to ask the kitchen for something light for a patient who was feeling off colour and the food brought to the ward was unsuitable. Not all patients are fit to eat what is on the menu. It was so much better when the nurse in charge plated the meals at ward level.”
A former Mater Hospital pneumonia patient I spoke to, Etain O’Kane from Belfast (a vegetarian), supplied photos and details of meals she received during a stay in December last year.
Her photo diary of the food provided includes details of main meals she found inedible, occasions when food had to be brought in by relatives and ‘no meal provided’ sections where an apparent communication issue between staff led to no vegetarian meal being ordered.
Etain stated that, although she had been hungry after meals, she did not complain due to lack of energy caused by her medical condition. She said those who were not vegetarian seemed to be given high-fat, heavily-processed food such as sausage rolls, curry and chips.
However, The Belfast Trust provided a sample ‘core menu’ for this article showing a wide range of (non-vegetarian) food served and added that “special diets and cultural preferences are addressed on an individual basis”.
Elsewhere, a person close to the issue explained that those involved in providing meals will often go beyond the call of duty to make sure a patient with special requirements is provided with a suitable meal and that provision of meals is a “very difficult” issue as hospital food is designed for the sick and therefore made to be easily eaten and accommodate all age groups. She added that therapeutic diets such as low salt and unusual textures of food such as puree provided for medical reasons can taste so different from food at home that it can lead to caterers being criticised by the patient.
A nurse I spoke to explained that, in terms of hospital food in general, there can be a lack of variety in the meals given, especially for vegetarian patients. She added that she has heard patients complaining of being hungry, portion sizes being small, that she has been told that she was not allowed bring meals from the canteen for hungry patients and that hospital meals, overall, can at times be stodgy and poorly presented.
She also pointed out that, despite this, patients may not get around to formally complaining due to more immediate medical concerns and the stress of being in a hospital environment.
The Belfast Trust website states that visitors should not bring perishable food (such as meat and dairy) for patients.
The Trust also provided further clarification for this article, saying: “Nurses cannot bring canteen food to patients as this is in breach of PHA Guidelines.
“Relatives are advised not to bring in high risk food to relatives again to ensure patient safety. This is also to adhere to PHA Guidelines.”
This piece and the complaints above focus on the quality and quantity of hospital food. Much of the work in Northern Ireland on hospital food in the last ten years – especially more recent efforts – appears to focus on the issue of malnutrition and care arrangements such as meal-times and supervision.
However, there have been a number of important developments:
– November 2007, new hospital food “nursing care” standards launched: Department of Health reports that only 18% of patients are satisfied with the food served and between 30% – 50% is wasted as new guidelines are launched.
– March 2011, Patient and Client council survey: States that the majority (51% – 75%) of those surveyed commented positively about hospital meals however attention to portion size and further work on special dietary needs was needed. The report revealed that the biggest number of concerns were around food being too cold and that comments on the menu were ‘mostly’ positive (70% or over). Some patients surveyed (see report for further details) suggested that improvement in quality and menu were needed while one person is quoted as commenting “put patient first, not budget”. Up to to half (26% to 50%) called for ‘less curry and chips’, more healthy choices and optional portion sizes.
The conclusion section of the document states that food should be served at an acceptable temperature, come in an appropriate portion size, be of good quality and contain fresh fruit and vegetables.
The Patient and Client Council responded to a question for this article asking if any further evaluation had been carried out as a follow-up to the 2011 survey by stating that no further specific work on the 2011 document has been undertaken. The Patient and Client Council does, however, take part in a Regional Nutritional Steering Group, has carried out work looking at malnutrition reported by carers and has produced, as well as promoted, an online tool to support the Promoting Good Nutrition document (see below).
– February 2013, horse meat found: Media report that burgers containing horse meat from a supplier in the Republic of Ireland had been supplied to hospitals in Northern Ireland.
– September 2014, new standards in England: Patient and Client Council blog that ‘similar’ standards to new guidelines in England exist in Northern Ireland by way of the Promoting Good Nutrition document. The English guidelines recommend that NHS hospitals develop a food and drink strategy to include the nutritional needs of all patients, healthier eating for the entire hospital community and sustainable procurement.
POLICY IN NORTHERN IRELAND
In Northern Ireland, the Patient and Client Council represents patients on a Regional Nutrition Steering Group.
The steering group works to implement ’10 Key Characteristics’ of the Promotion of Good Nutrition guidelines, including one (Characteristic 3) calling for the care provider to “provide specific guidance on food and beverage services and nutritional care in its service delivery and accountability arrangements”. Characteristic 4 states that “people using care services are involved in the planning and monitoring arrangements for food service and beverage/ drinks provision”.
The Belfast Trust confirmed, in an email response for this article, that for their part “people using care services are involved in the planning and monitoring arrangements for food service and beverage/drinks provision”.
The report also promotes the use of the the Eatwell Plate to avoid malnutrition and states that “providing good nutritional care needs to be everyone’s business”.
Along with additional information about care arrangements for hospital patients at mealtimes, in response to a request for this article the Belfast Trust explained that their work following the 2011 report has included established a Multidisciplinary Food & Nutrition Steering Group “responsible for ensuring the nutritional needs of our patients are addressed”.
“Trust menus are approved by Trust Dieticians and follow the BDA guidelines for all patient diets including portion size and the use of fresh fruit and vegetables.
“Dieticians liaise with Nursing staff re special dietary requirements. Quality of food is audited by Environmental health officers on a regular basis to ensure the Trust are adhering to all relevant food safety legislation.”
The Belfast Trust added that it has been “working to ensure that the ‘Promoting Good Nutrition – A Strategy for Good Nutritional Care for Adults in all Care Settings in Northern Ireland’ is implemented” and said “it is reviewing the actions taken to date as are all Trusts across Northern Ireland”.
It was pointed out that “in some areas within BHSCT patients and carers are involved in a stakeholder forum/s where they can directly influence their mealtime experience” and that a “a draft policy on Prioritising the Mealtime Experience is currently out for consultation within BHSCT”.
ENGLAND: NEW MEASURES
Government action to improve hospital food in England has come about in an environment of severe criticism in the media, such as claims that 67% of hospital staff would not want to eat the food given to patients, which is “often worse than prison food”, and that one in four meals are thrown away with some costing as little as 69p to make.
It had been claimed that “the government has spent 60 million of taxpayer’s money on trying to make food better and none of it has worked” and that (excuse the source) ’fry-ups’ were served to heart attack patients.
With a long-running and high-profile campaign in place (reports section here), a report by Hospital Food Standards Panel led to new government guidelines for England (also here and here) being announced in August 2014. These were described as inadequate and difficult to enforce by campaigners.
The report, led by an Age UK representative for the the Hospital Food Standards Panel which in turn was set up by a Parliamentary Under Secretary of State for Health, crucially also brought about the announcement of online scoring of hospital food through NHS Choices.
While the scoring system can, of course, only show the symptoms of poor quality food, and not the cure, it has allowed ease-of-access to the information for all patients through an online map of the data.
Looking further at how the scoring system is designed and how effective it has been is beyond the scope of this piece. Clearly the devil is in the detail or – in this case – in the methodology. However, the extent of the action taken in England and the apparent clarity of the data produced suggests that considering similar steps here would at least give reassurance and data to patients as well as clearly and usefully inform the debate the next time the issue arises locally.
Over 1,500 years ago Hippocrates said “Let food be thy medicine…”. That principle is not new thinking.
The introduction of the single, centralised scoring system used in England does, however, potentially bring something new to the hospital food debate in Northern Ireland. The idea of using a similar system locally has been welcomed by our own Patient and Client Council.
It would seen, then, that properly-executed published scoring could only bring more reassurance to each of us that, when we walk away after visiting time, the funding and standards are there to ensure our loved ones are always being given the good food, and enough of it, they need to recover.