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Chairman and Editor: Dr SP Allison

Summary and Recommendations

The Problem
Forty percent of adult hospital patients and 15% of children are malnourished on admission, half of these severely so. The majority who depend on hospital food for all their nutrition, continue to lose weight while in hospital, reflecting the inadequacy of current feeding policies. Between 30 and 50% of hospital food is wasted and average food intakes are less than 75% of that recommended, particularly among the elderly. This impairs clinical outcome and wastes resources.

Cost of Waste
The monetary value of hospital food wasted annually in England alone can be calculated at £45 million. If labour and overheads are included, this cost rises to £144 million. There is also a hidden cost of the extra morbidity associated with malnutrition.

Evidence Base
Recent studies, reviewed in this report, provide strong evidence that measures such as improved staff training, nutritional screening and assessment, and monitoring, combined with better catering practices, can result in most patients' nutritional requirements being met. Fortified meals, between meal snacks and adequate ward staffing have all been shown to contribute to achieving this goal, which leads to better clinical outcome, less waste, shorter hospital stay and a more cost-effective service.

Quality Standards
High standards of nutritional care including hospital food provision should be one of the Quality Standards required of Health Authorities, purchasing groups and Trusts. These authorities should have their own explicit, written nutritional standards and guidelines based on official national standards. Appropriate funding must be made available to attain these standards. Good feeding should also be part of Clinical Governance.

Audit and Accreditation
Achievement of these standards should be monitored and be the subject of regular audit, as well as part of the Audit Commission's assessment, Hospital Accreditation schemes, and Commission for Health Improvement inspections.

Catering Officers
This report is not a criticism of catering officers in the Health Service, who are working under difficult conditions. Most of the shortcomings highlighted are outside the power of catering officers to change and necessitate a combined team effort from all disciplines in the Health Service.

Cost of Food
Better catering and feeding may be slightly more costly, but we consider that this is justified in the interests of the quality of care and a better clinical outcome.

Which Budget?
Consideration should be given to transferring the catering and nutritional care service from the hotel/facilities budget to the clinical support and treatment service budget. Consideration should also be given to a new Nutrition Directorate with overall responsibility for all aspects of nutritional care.

Management of the Service
The Nutrition Directorate should be supervised by a Nutrition Steering Committee responsible for overseeing all aspects of nutrition, including hospital food, oral supplements and artificial nutrition, since these overlap and are interdependent. The committee should have the power, not only of making recommendations, but of implementing change. It should consist of a core group including the chief dietitian, the chief catering officer, a manager from the finance or business section of the hospital, a senior clinician with a special interest in nutrition, a senior nurse, who may be the nutrition nurse specialist, and a pharmacist. Other members may be recruited as appropriate.

Contracting Out
In contracting out or in the development of in-house catering services, the Steering Committee must be involved in contractual arrangements from the beginning. They should be responsible for evaluating the experience of other centres and seeking expert advice. They should also direct subsequent monitoring and audit of the service.

Role of Dietitian
The chief dietitian should have executive not just advisory input into catering services.

Role of Nurses and Other Staff
The primary responsibility for the nutritional care of in-patients rests with the nurses in charge of the ward. Food should be served by nurses,  supported where necessary by other grades of staff trained for this purpose, e.g. ward hostesses, diet technicians/helpers, care assistants, etc. Assistance  with eating must be provided, and special utensils provided where necessary.  Plate or tray collection should be supervised by nursing staff, to enable patients'  food intake to be monitored.

Responsibility of Doctors
Doctors should acknowledge a responsibility for patient nutrition as an important  part of overall management. This falls within the definition of their 'duty of care'.

Nutritional Screening of Patients
Nutritional risk screening should be an integral part of the nursing and medical  admission process. Screening should be linked to a nutritional care plan in  those found to be at risk. All patients should be monitored during their hospital  stay to identify any changes in risk category.

Menus
Menus should be designed to meet the needs of particular patient groups, e.g.  the elderly, children and ethnic minorities. Adequate choice should be available to meet these needs. A range of meals specially fortified in energy and protein  should also be available in every hospital, and snacks and nourishing drinks should be kept on the ward and routinely offered between meals. The timing of meals should be reviewed and made more relevant to patients' customary meal patterns.

Nutritional Requirements
Patients' food intake should meet minimum total energy (30-35 kcal/kg/day),  protein (1 g/kg/day) and micronutrient requirements, as described in the body of  this report. In many cases, none of these are currently being met.

Food Preparation and Serving
All methods of food preparation, e.g. in-house cook-serve or bought in cook- chill (with ward kitchen regeneration) have proved successful, but each is highly dependent on the method of distribution and serving. With proper management,  a bulk trolley bedside service best serves patients' needs and is the method recommended by this working party.

Near Ward Kitchens
Consideration should be given to the use of a few near ward kitchens, strategically sited to serve the needs of particularly vulnerable patients, identified as having nutritional needs, not readily met by a centralised catering service.

Interference with Meals
Interruption of patients' meal times by ward rounds and procedures should be  minimised, and each ward should have a clear policy in this respect. The  environment at meal times should be made as conducive to eating as possible.

Proprietary Oral Supplements
Proprietary oral supplements and artificial nutrition techniques should not be a  substitute for the adequate provision of normal food. Where clinically indicated,  however, they can be extremely effective means of achieving nutritional goals  and improving clinical outcome.

Effect of Drugs
The use of drugs with side effects of anorexia, nausea and gastrointestinal  symptoms should be minimised by careful review of drug charts, particularly in  the case of elderly patients.

Monitoring and Audit
Regular monitoring and audit of nutritional care should be undertaken at the  point of consumption, to measure patient satisfaction, nutritional content of the  menu and food intake and wastage. Other measures such as weight change  during  hospital admission, length of stay and clinical outcome criteria may also  be assessed in relation to the adequacy of patients' nutritional intake.

Education and Training
Fundamental to the success of any catering or nutritional care policy is a  programme of education and training for all staff, who should feel a sense of ownership of and responsibility for the service. There should be clear channels of communication by which all staff can influence policy and contribute to improved standards of care.


Summary

In 1859 Florence Nightingale said "thousands of patients are annually starved in the midst of plenty from want of attention to the ways which make it possible for them to take food. I say to the nurse, have a rule of thought about your patient's diet." In recent years there has been an increasing concern about the high prevalence of malnutrition among hospital patients. In response to concerns, this report, from a clinical perspective, looks at current inadequacies in hospital food provision and the ways that this might be improved.

The problem of malnutrition is unfortunately widespread in the UK. Studies have shown that up to 40% of adult and 15% of child admissions to hospital have some signs of malnutrition. The consequences of malnutrition for patients are impaired mental and physical function, increased mortality and increased surgical complication rates. It has been demonstrated that a malnourished person has a prolonged hospital stay and in the USA treating malnutrition has been estimated to save the average hospital $1 million.

Malnutrition of people before admission to hospital is largely disease-related and associated with reduced appetite or ability to swallow and digest food as the result of their clinical condition. A patient's malnutrition may continue in hospital because of the types of treatment, the drugs that are administered and the tests which are undergone. A major contribution to worsening nutritional status during admission and stay for many patients is the inadequacy of current catering and feeding practices which are modelled on institutional catering for the healthy rather than being targeted to the needs of the sick.

The consequences
The clinical consequences of malnutrition have been demonstrated many times and include impaired mental and physical function, increased mortality and increased complication rates post-surgery. In some patients, malnutrition may be the main condition that precipitates admission.

The economic consequences of undernutrition have been underestimated. Recent reports demonstrate a relationship between undernutrition and an increased length of stay on wards.

The Solution
The solution is food as treatment. Although the special techniques of enteral and parenteral nutrition support a minority of patients with failure of swallowing or gastrointestinal function, the majority of patients are dependent on hospital food to sustain them during illness. The provision of food suitable for the sick is not just a hotel function, it is treatment.

Why don't people eat in hospital?
There are a number of factors that prevent people from eating in hospital:

  • Problems in ordering food. For instance, some people may need help in ordering due to language, disabilities or illiteracy. There are also inefficient ordering systems.
  • Menu choice does not take into account cultural differences or special needs and is rarely guided by adequate patient surveys to determine preferences.
  • Often the general appearance and presentation of food is poor and the preparation, transportation and serving methods do not ensure the preservation of nutrient content and palatability.
  • Meal times are disrupted for some patients due to ward rounds, investigations and procedures which means that some patients miss meal times.
  • Patients who require special help are not identified on wards and busy nurses do not have time to help patients eat.
  • Factors in the ward environment, for example other patients medical conditions, can often put patients off eating.
  • There is a breakdown in communication between nursing, catering and dietetic staff on the wards.
  • Health managers have failed to design protocols setting standards and policies.
  • Surveys have shown that there is a low nutritional knowledge among medical and nursing staff.

Food Wastage
The food intake of hospital patients is inadequate and wastage rates high. One study performed by the Worshipful Company of Cooks Centre for Culinary Research at Bournemouth University found food wastage varied between 17% and 67% on nine hospital wards. In a Nottingham hospital on the medicine, surgery, healthcare of the elderly and orthopaedics wards, 40% of the food was wasted at an annual cost of £110,000. The estimated value of food wasted is £144 million in England alone.

Reduced nutrient consumption
With the high food wastage, patients are not gaining the necessary nutrient and energy intake. Studies have found that patients are only getting between 30% and 75% of the recommended energy intake level and up to 70% of the recommended protein levels.

Co-ordination of the service
This report is not a criticism of catering officers, who are working in isolation under difficult circumstances. Medical, nursing, dietetic and managerial staff all have an important responsibility. Consideration should be given to detaching catering from the hotel service and bringing it under a multidisciplinary nutrition directorate or similar structure, responsible for all aspects of the nutritional care of patients from normal food to supplements and artificial feeding. There should also be a co-ordinating group consisting of catering officers, management, medical, nursing, dietetic and pharmacy staff. Fundamental to this approach is a new management policy, putting nutrition in the forefront of the quality of care criteria.

The food chain
This term is used to describe the entire process of nutrition care using hospital food. The chain is as strong as its weakest links. For instance, if the food quality is poor it will not be eaten despite the efforts of ward staff.

There are several key areas in the food chain where improvements can be made.

Screening, assessment and monitoring of patients
Key to any system is to ensure that every patient's nutritional status, requirements and preferences are taken into account on admission to a hospital ward. Without screening and monitoring, nutritional care is likely to be random, ill directed and ineffective. As well as being implemented at ward level, awareness of nutritional issues needs to be supported by training and audit.

Improving distribution and service
To maintain nutrient content, temperature and palatability of food, it should be served as quickly as possible after preparation or regeneration. Catering staff should recognise the importance of their task in relation to patient care. Timing of food production and delivery needs to be agreed between nursing and catering staff and monitored regularly. In serving and distributing food, good results can be achieved with a well designed cook-chill and cook-freeze preparation on or off site, provided that these are combined with a bulk trolley service on the ward.

The nutritional requirements of patients
'Healthy eating' diets, low in fat and sugar may be appropriate for some hospital patients with coronary heart disease or obesity, but a large proportion of hospital patients such as the acutely ill or undernourished require diets with increased energy or nutrient levels by the addition of extra fat, protein and micronutrients, and that people at risk of vitamin deficiency are identified.

Menu planning must take account of age and cultural factors and take information from patient surveys. Snacks between meals should be available for people who find establishing regular feeding patterns difficult. Finally proprietary supplements and tube feeding should be available where appropriate but not used as a substitute for normal food.

Improved staffing
High wastage and low food intake is due partly to poor training and organisation of ward staff. In addition, changes in modern healthcare means that nurses have demands on their time. The appointment of additional ward staff grades to support and help the nurse (ie. ward hostesses, diet technicians or nutrition care assistants) can improve outcome and quality of care as well as reduce the length of hospital stay. A formal review of the role of nurses and supporting staff would be helpful in view of the lack of published studies of the value of employing other grades of staff.

Staff training and education
Greater emphasis needs to be placed on nutrition in the undergraduate training of doctors and nurses, and a continual process of in-service and postgraduate training in the field needs to be implemented. Several studies have shown for example, that compliance with nutrition screening and quality of nutritional care on wards is highly related to in-service training and is greatly improved by a system of link nurses, with at least one nurse on each ward with a special interest in this field.

Monitoring standards through audit
Food is key to maintaining patient health and should be submitted to the same critical analysis as other forms of care and treatment. Any institution should begin with an assessment of its current practice before embarking on any changes. Standards of nutritional screening and assessment of nutritional care should be the main criteria for hospital audits. Accreditation and audits should be maintained to ensure continuing high standards.

Costs
The budget for hospital food varies between NHS Trusts but ranges from £1.60 to £2.40 per person per day which is less than other countries such as Denmark, which spends £3.00. If consumption of hospital food is increased it could lead to the use of less expensive feeding and methods, better clinical outcome and shorter hospital stay.

Conclusion
The estimated cost of food wastage to the NHS is £144 million each year in England alone. The report shows that there is room for improvement at all points in the Food Chain - from the nutritional screening of patients on admission to appropriate menus and ways of serving food. It will take a co-ordinated approach between management, catering dietetic, medical, nursing and other staff. We have yet to fulfil the recommendations of Florence Nightingale, written in 1859.

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