Improving British hospital food: why nutrition needs to be part of the cure

As healthcare institutions, hospitals should not simply be places to prevent and cure illnesses and ailments but should be following a more holistic approach to wellness, starting with nutrition and the food they serve to their patients.

According to one survey led by NHS Junior Doctors at a hospital in Oxford, 97% of respondents said they thought hospitals should promote a healthy lifestyle. Despite this fact, these facilities still have work to do to when it comes to food.

Up until now, hospitals in the UK have often had a negative reputation with regards to the food they serve patients and staff. In a UNISON survey from 2019, more than 300 staff across England reported hospital food to be unsuitable for dietary or religious requirements, unhealthy and overall poorly prepared.

Across the UK, hospitals offer a varied selection of meals to their patients ­– but many of them would be considered ‘treats’ rather than food fuelling recovery. Fish and chips, minced beef and onion pie, sausages with mash and gravy, as well as the traditional high calorie all day breakfast, all feature on several hospital menus across the country. Meat-free options regularly include cheese sauce pasta with garlic bread, omelette with chips or potatoes, and cheese and biscuits. Vegan options tend to be the healthiest, sometimes featuring lentil dahl, vegetable or mixed bean chilli and rice, as well as couscous and falafel salads, but these meals aren’t featured on standard menus everywhere, and sometimes need to be requested.

Sweet puddings and desserts are also an everyday option on most menus and can include jelly, chocolate mousse, flavoured sponge cakes, sticky toffee pudding and spotted dick. Fresh fruit salads and yoghurts are often available but are heavily outweighed by options that are high in sugar and fat.

Food safety has also been an extremely pressing issue in hospitals – so much so the Health Secretary Matt Hancock commissioned an Independent Review following an outbreak of listeria in hospital sandwiches which killed six people in NHS Trusts across the country in 2019.

Restauranteur, chef, and Great British Bake-Off presenter Prue Leith DBE led the development of the blueprint as an adviser after she criticised hospital food standards, calling it “unpalatable” in a 2019 statement. She worked alongside NHS Executive Philip Shelley, who chaired the review, and an 18-person panel from a range of governmental health departments, agencies, and charities, including the Food Standards Agency, British Dietetic Association, the Department of Health and Social Care and the Hospital Caterers Association to name a few.

The report came up with eight themes to target to improve hospital food:

1. Catering staff support: Developing a national training certified course for hospital catering staff or NHS catering apprenticeship scheme, improving access to professional development, enhancing recruitment and support for workers in the sector, and encouraging nurses, dietitians, and caterers to have a strong relationship
2. Nutrition and hydration: recognising the clinical value of hospital food, adopting a ‘whole-hospital approach’, making sure food for patients is prepared to the same standard as that for staff and visitors, and ensuring a steering group made up of nurses, dietitians, caterers, speech and language therapists, sustainability leaders, health and wellbeing leads, and patients is used as a “governance structure” in hospitals across the country
3. Food safety: ensuring the implementation of excellent food safety standards
4. Facilities: improve the facilities available for cooking and preparing food for patients, visitors, and staff
5. Technology: developing digital food ordering systems to help staff reduce food waste
6. Enforcing standards: implementing these new standards in the future
7. Sustainability and waste: minding better ways to sustainability and waste
8. Going forward: developing an implementation plan to show progress and changes made over time. Progress would be monitored by the “steering group”

The NHS is the second biggest provider of meals in the UK public sector and spends a large sum of money on food as a result. On average, £634 million was spent on hospital food between 2018 and 2019. NHS Supply Chain, which manages the supply of food products to the NHS and other healthcare organisations is also worth over £600 million. Despite the urgent need to implement changes, it is estimated the national healthcare sector has faced over a decade of underfunding. With this already heavily impacting the level of clinical care it can provide, significant changes to hospital food and drink services have sometimes had to be side-lined, especially when Covid first hit.

“During the height of the pandemic, it was near on impossible to be making those massive changes,” Matt Willis, Co-Head Chef at Clacton Hospital told Food Matters Live. “Thankfully, a lot of the changes that were recommended we’d actioned beforehand, but we weren’t getting the money in over the counter to help us break even much.”

 “We had to scale back on baking and our actual full menu because our suppliers couldn’t supply everything on a regular basis,” he adds. “We had to follow an emergency menu based on what they could provide.”

When the review was published in October 2020, it was seen as a significant step in the right direction that would lead to big changes in hospital foodservice. At the time, Prime Minister, Boris Johnson said the recommendations would help to keep the NHS as “the standard-bearer for healthy choices as it works unstintingly to improve the nation’s well-being” ­– but with the NHS facing the brunt of the coronavirus pandemic, were these recommendations side-lined?

Offering more nutritious food and challenging patients’ habits

While most patient meals are made off-site by private contractors as opposed to on-site, the flavour, appearance and overall experience of food and eating at hospitals has improved significantly, says Willis. “Partially thanks to the review I feel, even when the food has to be pre-made, a dietician has sat down and thought about working this new menu out. There are little tweaks that still need to be made sometimes, but the food overall is much better.”

One major improvement some hospitals have implemented recently is a variety in meal offerings, making sure there is a choice of food that suits different nationalities as well as people with any dietary requirements, disabilities or cognitive disorders like dementia or Alzheimer’s.

Contract catering company Sodexo is one of many external providers of hospital food in the country. It offers translated menus to people “who don’t have English as their first language,” says Dr Simone Lester, Medical Director at Sodexo Healthcare UK&I. “The translations are agreed in partnership with the Trust and are based on the demographics of the hospital. We also work with the Trusts and use their translator services, should we require them, to assist when patients choose their meals.”

“To support those patients with cognitive impairments, our ward hosts read menus to patients,” she adds. “We also provide pictorial menus either as a separate menu or ward hosts can access photographs of dishes to show patients what something looks like.” The catering company has also developed braille menus in some hospitals.

Meals are also being improved for patients who may struggle to eat (if they have experienced a stroke for instance.) Over the years, efforts have been made to involve speech language therapists in the development of meals, says Willis, which has resulted in small changes that have bettered the patient’s eating experience. “It’s the little things that can make things appear more appetising to the patients. Moulds are used now to turn the food into specific shapes which can sometimes help patients”, he says. “It’s a big improvement from what it was – when I first started, you literally served a splat of food on a plate.”

When it comes to developments around staff food, East Lancashire NHS Hospital Trust has “developed free meal bags in A&E, opened the staff restaurant until 10pm and developed an app which allows colleagues to order and pay online, then collect their order at a time that suits them”, says Tim Radcliffe, who works closely with the Great Food Good Health Programme and also sits on the Expert Panel of NHS Caterers.

Despite the many positive changes, it is quite often the least healthy meals that remain the most popular. This comes down to costs and external caterers needing to produce what sells, according to Dr Shireen Kassam, Consultant at King’s University Hospital and Co-Founder of Plant-Based Health Professionals. She has campaigned regularly to reduce red meat consumption in these spaces. She says, “There are various challenges which come with having private providers who ultimately prioritise optimising revenue and minimising waste – which is obviously important – but ultimately the decision will be based off sales, regardless of our requests for better or healthier, more sustainable menus.”

This makes bringing in more nutritious options such as plant-based meals more difficult. “At King’s we had a completely plant-based day on Earth Day, and during May we had Meatless Monday,” says Dr Kassam. “But I just had a meeting with our catering manager and they said sales were 50% down on a Monday in May. People wanted to have their cooked breakfast especially, and if it wasn’t there they would walk out. Even though there were some meat alternatives, I guess if people aren’t familiar eating them they’re not going to suddenly decide to spend their money on them.”

The popularity of different dishes also depends on where hospitals are located and whether they’re general, paediatric, or geriatric. “Just because a food is popular in a certain part of the country, doesn’t mean it’s going to be popular everywhere,” says Willis. “In the North of England, a lot of people often would love a curry. Down here in Essex, not so much. They’d mostly likely want a cottage pie or bangers and mash. They want all the hearty meals that they had growing up because this is a geriatric hospital.”

It is wrong to assume that no nutritious meals are available. The problem is that many still see them as alternatives to unhealthy meals that they would rather have, says Dr Kassam. “There are healthier options and you can make healthy choices, I think it really does come down to behavioural change and supporting people to make better choices. The food environment really dictates how we make those choices.”

Improving chef training

Since the review, efforts have been made to train kitchen staff to develop more nutritional meals through the NHS Chef’s Academy – a series of free training events, which first launched in 2020. Led by Nick Vadis, Chef Ambassador to NHS Supply Chain and Stephen England, Culinary Specialist, the Academy aims to upskill the NHS Chef workforce, training them to develop healthy, tasty and balanced meals that suit all dietary requirements. The meals must also be suitable for vulnerable patients as well as staff and visitors.

Vadis describes the Academy as: “an amazing opportunity for NHS Chefs to learn new skills and develop their culinary knowledge on insight driven food. It also provides them with a platform for mixing with their peer group and learning together.”

During their training, chefs have also been able to speak to dietitians and nutritionists, to learn how meals on menus are designed, their calorie content, and what makes a meal nutritionally balanced. The chefs also receive a bank of under 600 calorie recipes which contain a full nutritional analysis for them to make in their own hospital kitchens.

Despite these successful training events, with most food being prepared by external contract caterers, the positive changes arising from these programmes will probably not be seen in most hospitals across the country. “Not very much food is prepared fully on site anymore and as a result, you sort of have to cater for the worst-case scenario,” Dr Shireen Kassam. “Dishes often need to meet the requirements for somebody who might be lacking in calories or who might be needing more protein, so they don’t miss out. Whereas anyone else, even if you didn’t have that issue, you’ll often be fine consuming that dish too.”

Food safety

Following the 2019 listeria outbreak, food safety can no longer be an afterthought, and most hospitals require an annual review, says Matt Willis. “It has to be renewed because sometimes things change, and that’s for the benefit of yourself and of the people you’re serving, be it patients, visitors or staff.”

Improving the food safety knowledge of staff has been key at East Lancashire Hospitals Trust, says Tim Radcliffe. “All staff are now trained on allergens on a yearly basis as part of their core mandatory training. More management training has also been introduced, so they’re qualified to a higher level on food safety compared to what they were previously.”

Alongside the recommendation for excellent food safety standards in the Independent Review, the implementation of Natasha’s Law from October 2021 also meant all pre-packaged for direct sale goods required a label with a full ingredients list including the 14 allergens. According to Willis, many workers in the hospital catering team “were just not ready for it in terms of how serious it was. We were doing all the things like making sure the dates and names of allergens were on things, but some people just weren’t mentally prepared. We need to train ourselves to look at our ingredients lists because that’s one of one of the biggest things that could save a life.”

Reducing food waste

Another pressing challenge hospitals have been tackling since the review is food waste. According to a WRAP study from 2019 up to 18% of food in hospitals is wasted, which costs the healthcare sector about £230 million every year. Most of the time, this waste comes from unfinished patients’ meals. This can be due to a multitude of factors such as the meals being the wrong portion size, patients not having an appetite, or the food simply not being visually appetising.

With it being an urgent issue to address even before the pandemic, several hospitals have actively been tackling food waste on a regular basis. At Clacton Hospital, the issue has been addressed since the pandemic started, says Matt Willis. “We didn’t have a budget to waste food anymore. Portion control was a big part of it, making sure that the staff dishing up are fully aware of how much to give per patient per meal. And if we need more, to make sure they have selected the larger portion on their menu card.”

For Sodexo, addressing food waste in hospitals became a priority nearly a decade ago through its food waste prevention programme. In the UK, it has set up a data-driven reduction programme called WasteWatch in NHS and Nuffield Health hospitals, which has reduced the retail food waste by nearly half, according to the company, and won the category of ‘Best Waste Prevention Project’ at the 2021 Waste2Zero Awards.

“Since Sodexo launched WasteWatch, it has cut down on CO2 emissions and preventing over 280 tonnes of food waste in the UK,” says Dr Simone Lester. “WasteWatch rapidly captures food waste data and gives clear insights into what is being wasted and why. Teams can then bring in operational and behavioural changes to help end avoidable food waste, whether generated in the kitchen or by consumers.” It is also estimated that within Sodexo’s 28 healthcare sites collectively, over 500,000 bathtubs of water and nearly 21,000 kg of food waste has been saved, amounting to over 37,000 meals.

One recommendation the Independent Review gave was to digitise patient food menus. It was predicted digital menus would allow hospital staff to use their time more effectively, increase patients’ satisfaction with food as they would be able to order closer to the time, and reduce paper waste, and potentially food waste too. The University Hospitals of Morecambe Bay NHS Foundation Trusts, for example, uses The Patient Meal Choices App which integrates with Electronic Patient Record (EPR) and Bed Management, to allow a patient’s location to be tracked during their stay, making sure meals aren’t wasted. Previously, if a patient was discharged or transferred to a different ward, the food they ordered would be thrown away due to the orders being taken the day before.

Another popular digital meal ordering service is Saffron Bedside, which is used by more than 275 hospitals globally. Sodexo have introduced the digital menu technology in several facilities they’re partnered with, which has significantly reduced the amount of wasted food.

As Phil Jones, Managing Director of the catering managing software explains, the technology “has dramatically reduced the number of ‘just in case’ scenarios where a meal was delivered to a patients’ bed, but the food has ended up going to waste because the patient’s appetite may have changed, they may have gone for surgery or even been discharged.

“Before Saffron Bedside was introduced, figures showed that staff served 18,650 lunch meals and 19,181 supper meals each month. Just one month after implementation, monthly figures reduced to 15,512 at lunch and 15,826 at supper – a 17% reduction across each mealtime and a significant reduction in food waste.”

A new feature has also been introduced more recently to the software, which allows catering providers to calculate and note the CO2 values for the food they prepare and their menus, says Jones.

Room for improvement

While hospital food in the UK is on its way towards changing for the better, there is a lot of work still to do – especially when it comes to providing nutritious food.

Despite healthier meals being on offer, many still choose not to eat healthily at hospitals when presented with unhealthy alternatives. Part of this is due to the lack of communication between dietitians and patients, who aren’t required to see patients unless it’s for a particular issue. Regular advice or counselling could prevent people from having to come back to hospital for something more serious in the future, says Dr Kassam. “Given that virtually all the chronic conditions that people are in hospital for could be improved through a dietary approach, everyone should see a dietician after a heart attack, when you diagnose diabetes, or when you’ve had bowel cancer.

“More than 50% of cases of cancer are preventable, and most people wouldn’t know that factors such eating more fruits and vegetables, fibre, not drinking alcohol, and carrying less weight, can help prevent it.”

Nearly two years after the publication of the Independent Review, progress is steady, but needs to be regularly observed if any change is to remain in place. “The gap between the Trusts that are very good and the not so good is very wide and we have to try to get everybody to a certain level nationally”, says Tim Radcliffe. “We all just have to keep up the momentum, and Trusts should be monitored to provide assurances that if they’ve been recommended to do something that they will be doing it.”