Scottish Government Consultation on Proposed Options to Improve and Assure the Nutritional Standard of Food in NHSScotland Hospitals

Food in Hospitals Background and Rationale

Setting the scene

Our ambition is for all patients being cared for in NHS Scotland hospitals to receive food that reflects their nutritional needs and meets established nutritional standards. Although we have made progress in driving up the standard of food in hospitals, concerns continue to be voiced that, on occasion, the quality of food provided to patients in hospitals still falls short of acceptable standards. On 17 November 2014, the then Cabinet Secretary for Health and Wellbeing, Alex Neil MSP, announced that the Scottish Government would consult on whether nutritional standards for food in hospitals should be placed on a statutory footing. The Scottish Government's Programme for Government 2014-15 'One Scotland' reiterated this commitment: 'We will take forward a consultation on whether nutritional and catering standards in hospital should be placed on a statutory footing'.

This commitment forms part of the Scottish Government's wider 2020 Vision for Health and Social Care in Scotland. Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. As part of this the Scottish Government's 'Healthcare Quality Strategy for NHSScotland' (2010)^[1] set out our drive to have a 'person-centred' approach which includes the ambition to have "mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values which demonstrate compassion, continuity, clear communication and shared decision-making." It is this approach and ambition that is driving our aim to further improve the nutritional standard of food to patients in NHS hospitals.

Actions to further improve hospital food are being taken forward in the context of the Scottish Government's wider overarching national food and drink policy, Scotland's 'National Food and Drink Policy; Becoming a Good Food Nation'. This policy states that Scotland should become a Good Food Nation, a Land of Food and Drink not only in what we as a nation produce but also in what we buy, serve and eat. The Scottish Government wants food to be a key part of what makes the people of Scotland proud of their country - food which is both tasty to eat and nutritious, fresh and environmentally sustainable. It sets out a 2025 vision for what we as a country should be aiming to achieve in which food served in hospitals, schools and elsewhere is seen as a high priority.

If nutritional standards for food in hospitals were to be put on a statutory footing it would reflect similar efforts by the Scottish Government to improve the health and wellbeing of the nation by providing more nutritious food for children in schools as part of the Schools (Health Promotion and Nutrition)(Scotland) Act 2007.^[2] This Act ensured that nutritional standards were developed for school meals.

The Importance of High Quality Nutrition and Food Provision in Hospitals

It has been increasingly recognised that the provision of food of high nutritional quality to patients in hospitals constitutes an important aspect of clinical care. Significant proportions of the hospital population are likely to be undernourished on admission. Maintaining the nutritional health of patients is further impacted by the fact that patients who are ill in hospital may have reduced appetites or an impaired ability to eat.^[3]

Published in February 2014, a British Association for Parenteral and Enteral Nutrition (BAPEN) report revealed that overall, malnutrition affected 24% of adults on admission to hospital in Scotland. While this was lower than the UK as a whole (29%) and lower than any of the other nations of the UK, it provided an indication of the prevalence of the problem. The report was based on amalgamated data from hospitals in Scotland that participated in four Nutrition Screening Week Surveys (NSWs) undertaken between 2007 and 2011^[4].

There is also evidence that the treatment of malnutrition imposes significant annual costs on the NHS. BAPEN estimated that, in 2007, public expenditure on malnutrition in the UK was £13 billion. The National Institute for Clinical Excellence (NICE) also estimated that better nutritional care represented the fourth largest potential cost saving to the NHS in England and Wales^[5].

NHS Scotland is also in a unique position to positively influence healthy eating practices in wider society. Given hospital patients may not always follow healthy eating principles in the home or community setting, it is important for hospitals in Scotland to be exemplars of high quality nutrition. The ambition would be that patients could then sustain their healthy eating experiences when they leave hospital. However, depending on an individual's nutritional status, it may be necessary for hospitals to offer meals which may appear to contravene healthy eating guidance. For example, some patients, based on clinical needs or nutritional assessment, require a high calorie diet as part of their recovery which is why NHS Boards make high energy meals available to patients. Menu options that follow healthy eating principles should be available for other patients.

The Scottish Dietary Goals describe, in nutritional terms, the diet that will improve and support the health of the Scottish population. They are also intended as a strategic reference point for organisations and stakeholders whose actions can influence Scotland's national diet. As a key public sector institution, NHS Scotland has a role to play to support people to eat healthier^[6]. 'Recipe for Success: Scotland's National Food and Drink Policy' also identifies the NHS as having enormous symbolic importance for society's wider expectations when it comes to food. The NHS should therefore be ambitious in providing affordable access to good nutrition^[7].

Standards governing nutritional care

Standards governing the provision of food, fluid and nutrition in hospitals have existed in Scotland since October 2002, when NHS Quality Improvement Scotland (QIS) published 'Clinical Standards for Food, Fluid and Nutritional Care'. The need for standards was identified following the publication of audit data on malnutrition in hospitals. It was recognised that improvements were necessary in the recognition of malnutrition, in the quality of hospital catering, and in the implementation of a strategic and coordinated approach to food, fluid and nutritional care within NHS Boards. QIS revised these standards in September 2003^[8]. In 2013, the Scottish Government commissioned Healthcare Improvement Scotland (HIS) (formerly QIS) to refresh these standards to make sure they reflected up to date evidence and guidance. HIS published the updated 'Food, Fluid and Nutritional Care Standards' in October 2014.

The scope of the HIS standards extend to both community and acute hospitals, and standard 3 ('Planning and delivery of food and fluid in hospital') and standard 4 ('Provision of food and fluid to patients in hospital') apply specifically in this setting^[9].

In December 2015, HIS also published 'Complex Nutritional Care Standards' which are designed to complement the existing 'Food, Fluid and Nutritional Care Standards'. These standards were developed to cover individuals with particular nutritional requirements. The nutritional requirements of some people cannot be met by the usual oral route, even with extra help at mealtimes or by the prescription of simple oral nutritional supplements. Under these circumstances additional help is sometimes required, either by feeding by a tube into the gut, or through a line placed into a vein. Techniques that involve tubes or lines constitute 'complex nutritional care'^[10].

Standards governing hospital food

It was recognised that NHS Boards required some support to implement standards for food, fluid and nutritional care, and in 2008 Scotland became the first nation in the UK to publish standards for nutrient and food provision for patients in hospital. 'Food in Hospitals: National Catering and Nutrition Specification for Food and Fluid Provision in Hospitals in Scotland' (2008), produced by Health Facilities Scotland (HFS), sets nutrient, food-based and menu planning guidance for food in hospitals. It also provides practical guidance and suggestions on how these standards can be met. These specifications were developed to support NHS Boards in implementing the HIS 'Food, Fluid and Nutritional Care Standards'. Specifically, HIS standards 3, 4 and 5 that encompass planning and delivery of food and fluid in hospital, provision of food and fluid to patients in hospital, and patient information and communication about their food, fluid and nutritional care.

At the request of the Scottish Government, HFS has recently refreshed its 'Food in Hospitals' guidance to reflect the most current scientific and international based evidence available. Published on 22 March 2016, the document provides 'essential criteria' for the provision of nutrients to hospitalised adults. These criteria differ in the recommendations they make for 'nutritionally well' and 'nutritionally vulnerable' hospital patients. 'Nutritionally well' patients are defined as patients with dietary needs in line with those of the general healthy population. 'Nutritionally vulnerable' patients are defined as patients who:

• are admitted to hospital undernourished
• have preceding, unexplained or unintentional weight loss
• have physical difficulty eating and/or drinking
• have acute or chronic illness affecting appetite and food intake
• have cognitive or communication difficulties
• have increased nutritional requirements
• require the texture of food and/or fluid to be modified
• have an increased length of stay.

The full 'essential criteria' for the provision of nutrients are available in Annex A of this document.

This consultation will ask whether minimum legal standards should be set that require NHS Boards in Scotland to have to achieve standards of the nutritional content of the food served to NHS hospital patients based on guidance set out in the refreshed 'Food in Hospitals' . This would be similar in approach to requirements currently set for nutrition in schools. The Schools (Health Promotion and Nutrition) (Scotland) Act 2007 imposes duties on education authorities and managers of grant-aided schools to ensure that all food and drink provided in schools complies with nutritional requirements specified by Scottish Ministers in regulations. Furthermore, there is additional guidance set out in 'Healthy Eating in Schools' which assists schools with food and menu preparation.^[11]

Children's Hospitals

The nutrition provided to children in hospital has to be tailored to age-specific needs, as well as any special dietary requirements. Provision of adequate food choice as well as the provision of food which is familiar are additional important considerations. Children have the capacity to become nutritionally compromised more quickly than adults, which can result in decreased immune function and an associated susceptibility to infections. This has the potential to result in increased length of hospital stay.^[12]

However, notwithstanding this, the mean length of hospital stay for children is two days. This differs from the adult population, who on average are admitted for a longer period. Children-specific hospital menus can, for the most part, therefore follow general healthy eating principles. However, menus also have to be sympathetic to the dietary needs for longer term admissions and those children who are subject to repeat admissions.

A recent Action for Sick Children Scotland (ASCS) survey examined parent and carer experiences of mealtimes and children's food in hospital. It also looked at NHS Boards' catering and dietetic procedures and policies governing the provision of food for children in hospital. The survey, while recognising many areas of good practice across the majority of NHS Board areas, found areas of children's food provision where there was room for improvement.

In particular, the ASCS survey reported some dissatisfaction with the presentation of the food, and with the lack of adequate support for special diets, age-specific nutrition and appropriate food choice.^[13]

HFS' refreshed Food in Hospitals specification includes specific guidelines for children's food. This includes nutrition criteria for particular age groups, and guidance on appropriate portion sizes and kitchenware. The criteria were produced using input from experts in the field of diet and nutrition.

Private Hospitals Providing NHS Treatments

At present Private Hospitals funded to provide NHS treatments on behalf of the NHSScotland do not provide audit and monitoring reports to HFS on the nutritional standards of hospital food and are not covered by the existing 'Food in Hospitals' guidance. At this time this consultation is not seeking to include Private Hospitals under the current options. However, Question 5 does seek to find out whether respondents consider that Private Hospitals providing NHS Treatment should be incorporated in any outcome of this consultation.

Current monitoring arrangements

Monitoring of food in hospitals guidance

Since 2009, NHS Boards have self-assessed their adherence to 'Food in Hospitals' and report their findings to HFS who publish 6 monthly reports on the Boards' abilities to comply with the guidance. There is currently no independent inspection process in place to scrutinise NHS Boards' compliance with the 'Food in Hospitals' guidance. The last published audit based on self-assessments returned by NHS Boards, January to June 2015, revealed 96.5% compliance to the guidance across Scotland. In comparison, compliance in January to June 2010 was 90.5%.

Health Facilities Scotland is currently reviewing how NHS Boards assess themselves against the guidance and whether any additional processes, such as peer and/or public review, are needed to best assure compliance, as it has been suggested that an independent means of inspection would be more advantageous. This will include aspects on menu planning, delivery, service and patient mealtime experience. As part of this process NHS Boards will be required to provide more robust evidence to support their returns. The revised framework will be developed in the context of wider work to monitor and assure the quality of food, fluid and nutritional care of patients in hospitals.

Monitoring of wider nutritional care

Since February 2012, the HIS 'Food, fluid and nutritional care' standards have been inspected against as part of the Care of Older People in Acute Hospitals (OPAH) inspection programme. HIS review NHS boards against a range of standards, best practice statements and other national documents relevant to the care of older people in acute hospitals. This includes appropriate nutritional care and hydration, and the OPAH inspectors make reference to the 'Food in Hospitals' guidance in their reports. When HIS inspectors identify concerns, they require Boards to produce and urgently implement an action plan to assure any issues are addressed.

However, it is important to emphasise that the HIS OPAH inspections scrutinise nutritional care rather than the provision of nutritious food. This involves aspects of patient care such as nutritional screening to determine a patient's risk of malnutrition, and nutritional assessment to record any special dietary requirements, food allergies or any assistance the patient needs. The nutritional content of food provided to older people in acute hospitals is not reviewed as part of the OPAH inspections.

Wider work

'Food in Hospitals' and the 'Food, Fluid and Nutritional Care Standards' are not the only programmes being undertaken to improve food provision in NHS Scotland's hospitals. Instead, they form an important component of a wider approach to improving nutrition and nutritional care.

Part of this wider approach is providing a key focus on preventing malnutrition. That is why the Scottish Government arranged a Malnutrition Summit in May 2015, which reiterated the importance of food in community health and social care. The event produced several recommendations on addressing malnutrition in the community, including that Integrated Joint Boards understand and build on existing infrastructures to tackle local needs.^[14]

The Health Promoting Health Service (HPHS) is the national programme for health improvement action in hospital settings across NHS Scotland. HPHS aims to create hospital settings that enable and promote good health through a range of actions that influence the physical hospital environment, enhance the clinical care of patients and support NHS staff health and wellbeing. HPHS also recognises that every healthcare contact is a health improvement opportunity.

NHS Scotland hospitals are in a unique position to give patients - who may not practice healthy eating principles outside the hospital environment - the opportunity to experience and eat nutritious, healthy food. The ambition would be that this encourages the continuation of healthy eating practices into the community.

Under the Health Promoting Health Service initiative, the Scottish Government has recently launched the Healthcare Retail Standard - a set of criteria that retailers operating in healthcare buildings are required to follow to ensure that 50% of the food and 70% of the drinks for sale are healthier. Retailers have until 31 March 2017 or when their contract is renegotiated to make the changes.

At the same time, caterers in healthcare buildings are also required to adhere to the Healthy Living Award Plus criteria. The Healthy Living Award is a national award applicable to the food sector in Scotland. The award criteria are based on the general principles of a healthy balanced diet, and have been developed to be consistent with Scottish Government dietary goals. The goals describe, in nutritional terms, the diet that will improve and support the health of the Scottish population^[15].

Legislative Background

Food safety in Scotland is governed by laws and guidance, such as the Food Safety Act 1990, that cover a broad range of areas including food production, processing, packaging and labelling.^[16] Details on legislation covering food safety can be found in Annex D.

Should the consultation outcome support placing nutritional standards for food in hospitals on a statutory footing, it is likely that an enabling power would need to be provided for first, in primary legislation, under which regulations could then be made. Any such proposal would be subject to the scrutiny and approval of the Scottish Parliament before it could take effect.

Catering Standards

The Scottish Government is seeking views on whether to develop catering standards for the NHS in Scotland. 'Food in Hospitals' establishes menu planning and food based guidance to assist hospitals achieve the nutrient criteria identified in Annex C. The menu planning guidance establishes minimum expectations in terms of the provision of adequate choice of meals in hospitals, as well as some necessary characteristics of those meal. The food based guidance establishes minimum expectations in terms of the provision of foods known to contribute to a diet of good nutritional quality. Full details of both the menu planning and food based guidance are included in Annex B and Annex C. 'Food in Hospitals' also takes account of therapeutic diet provision for individuals with particular dietary requirements.

Criteria for the following diets is provided:

• Higher energy and nutrient-dense
• 'Healthier Eating'
• Allergen-free
• Gluten-free
• Texture modified
• Diets for renal disease
• Diet suitable for people with neutropenia
• Monoamine Oxidase Inhibitors (MAOI) diet

Provision is also given for special and personal diets, including for religious and cultural reasons.

The Scottish Inpatient Patient Experience Survey 2014 indicated that the majority of hospital patients, a total of 68%, were happy with the food they received and an even greater proportion with the drinks provided. That said, a substantial percentage of hospital patients reported a negative experience of the food served (20% were not happy with the food they had received). If the food presented to patients appears unappetising then it is likely to preclude full enjoyment of the meal, and have an associated negative effect on intakes and nutrient provision. However, there was considerable variation between NHS Boards in terms of this response. Across all Boards, patients reported a positive response rate of between 53% and 89% to the question 'I was happy with the food/meals I received'.^[17]

HFS is currently leading a Scottish Government funded review of hospital catering and publication of a catering production strategy is expected later this year. This aims to improve both the efficiency and productivity of the NHS catering service, and the strategy will include best practice and principles of different food production systems and the associated meal delivery systems and service to patients. The development of the strategy will be supported by further engagement with NHS Board representatives and public partners, and is due to report in 2016.

Work is also on-going to develop a checklist that will record patients' overall experience of their food - including patients' views on how their food looks - with a view to using this feedback to make improvements to the service. In addition, NHS Greater Glasgow & Clyde and NHS Lanarkshire are piloting a Bedside Electronic Patient Meal Ordering System which is designed to enable NHS boards to reduce food wastage.

While it is not possible to regulate for the taste and presentation of hospital food, 'Food in Hospitals' recommends that caterers should be conscious of how a particular meal looks on a plate. It also recommends that portion sizes must look appealing on the plate and look appealing in relation to other components of the whole proportionate meal^[18]. The refreshed 'Food in Hospitals' criteria includes a suggestion that the presentation of final dishes served to patients be monitored every two months. This consultation seeks views on whether enhanced scrutiny arrangements should monitor the presentation of food provided to patients.