Health and Social Care (Amendment) (Food Standards) Bill [HL]

Baroness Cumberlege Excerpts

Friday 8th November 2013 Lords Chamber

Moved by

[Baroness Cumberlege]

That the Bill be read a second time.

[Baroness Cumberlege (Con)]

My Lords, I declare my interests, which are in the register. I am the executive director of two companies, Cumberlege Connections Ltd and Cumberlege Eden & Partners Ltd. I thank noble Lords who are taking part in this debate, in particular my noble friend the Minister, who I know is sympathetic to the cause. I hope that I will not be too disappointed. He may be interested to know that many other noble Lords very much wanted to take part in this debate. However, Friday is a difficult day for your Lordships as we are a voluntary Chamber, and many noble Lords have commitments that they fulfil on Friday when the House does not usually sit.

I thank the hospitals I visited, which generously, and perhaps with some courage, allowed me to see and taste the hospital food and to talk to patients. On the whole, I was disappointed. When the food is frozen and has to travel from Wales to hospitals in England and is then reconstructed by steam, is it surprising that fish and chips are soggy and that other food is not quite what you anticipate it will be? Finally, I thank the excellent briefings I have had from the Campaign for Better Hospital Food, whose supporters exceed 5,000 individuals and many other organisations.

At the age of eight I was sent to boarding school, and the most precious item in my trunk was my ration book. School food in post-war Britain was not good. Fish on Fridays was no surprise, because you could smell it at 10 in the morning. Jam was either red or yellow, and made with mangels, and resurrection pudding lived up to its name. After decades of prosperity, however, British food has now changed enormously and beyond all recognition. For instance, whatever happened to gravy? Gravy now masquerades as jus, and leek and potato soup is now vichyssoise.

Virginia Woolf said,

“One cannot think well, love well, sleep well, if one has not dined well”.

When in hospital we do not expect to dine well, but expect to have delicious, appetising and nutritious food—food that aids recovery. In the past 20 years successive Governments have spent more than £50 million of taxpayers’ money issuing guidance to hospitals about how to improve patient meals. When I was a junior Minister I was one of those who tried. I was responsible for food—that was before the Food Standards Agency was established—and introduced the nutrition task force, which in turn set up a hospital catering project team that produced nutrition guidelines for hospital food. Those were launched by the celebrity chef Albert Roux. In the foreword he wrote:

“Food should be regarded as an integral part of hospital service and treatment … Food provides us with the nutrients essential to our existence and general health … In providing comfort, food can also help to make patients feel more at home, reduce stress, and actively contribute to an ambience that can enhance the quality of medical treatment”.

Despite my efforts and those of successive Governments, in many hospitals the food is unappetising, non-nutritious and does nothing to aid recovery. Six out of 10 patients say that they rely on family and friends to bring them food because the food is of such poor quality, and sometimes barely edible. At many hospitals patient meals are viewed as a bureaucratic necessity and not as an integral part of care. Hospital life is boring. When in hospital, patients want three things. They want to go home, they want visitors and they want good nourishing food, because it is food which punctuates the day. That should be something to look forward to, but many patients dread it. The Francis inquiry into Mid-Staffordshire was deeply concerned about the attitude by staff towards meals, mealtimes, nutrition and dehydration. The witnesses’ comments are heartbreaking. I could quote many but will quote only one:

“On examining the food and fluid intake chart, mum had only had half a cup of tea over the last 20 plus hours. Some days nothing was marked as being taken, today there were three cups of fluid on the table, all of which were full. She couldn’t have drunk them if she tried because all three of the cups were placed way outside her reach”.

I do not underestimate how difficult it is to serve meals to large numbers of sick people three times a day. People who choose a meal one day are discharged the next, so that an incoming patient is welcomed by a meal they may detest. Some people may have uncompromising diets or have an appetite which changes from day to day due to the medication they receive. Hospital food is complicated, but there are hospitals where they really think through these issues, have a love of food and organise it well—while in similar hospitals in the same city, of the same size, almost in the same catchment area, the food is simply appalling. I am sure that noble Lords will agree with me, and I know that the majority of people in this country find it unacceptable for hospital food to be unhealthy. However, much of the food served to patients is of a poor nutritional standard.

In 2012, a nutritional analysis of commonly served hospital meals showed that they often contain more saturated fat and salt than meals served at fast-food restaurants, including McDonald’s and Burger King. Hospital food which is high in fat, sugar and salt, is not helping to nourish patients, and much of it is wasted. Government figures suggest that as many as 50,000 people a year could be dying with malnutrition in NHS hospitals in England, and at least one in every 10 meals is thrown into the bin uneaten.

The British Association for Parenteral and Enteral Nutrition estimates that three out of four patients are not eating enough during their hospital stay, and that the majority of them lose weight while in hospital. This problem is particularly rife among elderly patients. Only today, the Campaign for Better Hospital Food published new data showing that hospitals in England spend more on nutritional supplements for patients than on the meals served to them during their stay. While of course I recognise that nutritional supplements are vital in the cases of some patients, should they have become the routine prescription given to patients who are unwilling to eat hospital meals, or failing to gain nourishment from them? Patients should be nourished with enjoyable food rather than by nutrient and vitamin pills administered as medicine.

We look forward to hearing later in this debate from my noble friend Lady Miller of Chilthorne Dormer, who has expertise in this area and chairs the All-Party Parliamentary Food and Health Forum, the noble Lord, Lord Rea, the previous chairman, and other noble Lords who have experience or knowledge of this issue. I suspect that my noble friend might be tempted to address in his reply the subject of foundation trusts in the context of mandatory standards for hospital food, which is the purpose of this Bill. Both Scotland and Wales now benefit from mandatory standards for hospital food.

The Government have given hospital trusts greater control over how they manage and care for patients and have given them the opportunity to influence the shape and direction of the NHS. That is absolutely right, and I strongly support it. However, it is no less important to have a safety net to ensure that the NHS does not fall below acceptable levels and that standards of care are regularly monitored and enforced. Standards are not goals; they do not restrict a hospital’s freedom. They provide basic levels of assurance for organisations commissioned to provide healthcare. So we are not setting a precedent; there is an abundance of standards already in place in the NHS, which reflects the important role that they play, including employment standards; care standards for patients with specific ailments, such as diabetes; and standards for financial auditing, to name but a few. Standards for hospital food should be no exception.

The Bill requires the Secretary of State to appoint a body of experts to draft hospital food standards and make it mandatory for all patient meals to meet those standards. The Care Quality Commission and the Chief Inspector of Hospitals will be required to check that the standards have been adopted and are met. If they are not, it gives the CQC power to act, ultimately by withdrawing a hospital’s registration. The CQC is working hard to increase the regularity and effectiveness of its monitoring exercises, and is ensuring that patients participate in them. The CQC already evaluates patient satisfaction with meals, so this Bill would require only that monitoring is carried out to assess adherence to more specific standards. This solution does not in any way necessitate burdensome regulation, and does not require the Government to take greater administrative control over the provision of hospital meals. In fact, patients themselves are likely to take a leading role in monitoring hospital food, as more and more of them sign up to join inspection teams, as encouraged by the Care Quality Commission’s new Chief Inspector of Hospitals, Professor Sir Mike Richards.

Finally, I address the issue of cost. At the moment, taxpayers are being doubly charged for poor hospital food. Not only are they paying for the cost of patient meals but they are funding the associated costs that bad hospital food incurs, such as food waste, malnutrition and longer recovery times. I frequently hear people say that good hospital food is expensive and costs too much for hospitals to afford, but the facts do not bear this out. It has been shown that there is no correlation between the cost of patient food and its popularity with patients. Many of those hospitals serving the best food, produced and prepared to very high standards, are actually paying less for it than are hospitals where patients are dissatisfied with what they are being served and where food is wasted. For example, according to data from NHS Estates, Ipswich Hospital NHS Trust spent an average of £13.59 on food for each patient per day in 2012, yet less than half of patients at the hospital surveyed by the Care Quality Commission rated the food as good. In contrast, the Royal Marsden NHS Foundation Trust in London spent £5 on food for each patient per day in the same period, and more than seven out of 10 patients surveyed by the Care Quality Commission described the food as good. So those public sector organisations that have set standards for their food have done so without incurring extra cost.

In 2010, the Department for Environment, Food and Rural Affairs carried out an extensive evaluation of the costs of introducing government buying standards for food served in central government, including prisons and government departments. The standards mandate was that organisations buy more organic food, more fresh fruit and vegetables, and sustainable fish. The evaluation concluded that the organisations would not pay more—and, indeed, they do not now pay more—for higher quality food. If patient meals contain high-quality ingredients and are cooked by highly skilled caterers, they are more popular with patients, more likely to be eaten and therefore less likely to be wasted.

In conclusion, this Bill has widespread support from the public and from 97 national organisations, including Age UK, the British Heart Foundation, the Hospital Caterers Association, the Royal College of Physicians and thousands of members of the public. I contend that hospital food standards must be made mandatory if all patient meals are to be of a sufficient high quality, are to be nutritious and made to minimum standards of production.

This is a modest but sensible Bill with widespread support, and I urge my fellow Peers, as well as my noble friend as the Minister responsible on behalf of the Government, to support it. I look forward to my noble friend’s sympathetic response. I beg to move.

--- Later in debate ---

[Baroness Cumberlege]

My Lords, I thank my noble friend Lord Howe for his comprehensive reply. What the Government are doing is extremely encouraging, but I am still not convinced that all this voluntary work and the emphasis on guidelines will achieve what we want. We will need to press for some mandatory standards. I want briefly to comment on some of the very knowledgeable contributions that have been made by noble Lords.

The noble Baroness, Lady Gibson of Market Rasen, started by saying that she is not an expert, but in her contribution she showed real clarity about her expertise as an expert patient. There is nothing more compelling than personal testimony. She did say that this is not asking for the moon, and I agree with that. It is a simple Bill and, indeed, a modest one.

It has been clear throughout the debate that noble Lords have been diligent about reading their briefing, and pretty well everyone described the 21 initiatives that Governments have put in place over 20 years as being extraordinary. In no way do I underestimate the concern and commitment of successive Governments, and we have heard about that again today. All Governments want to improve hospital food, but it is a question of how that is done: how do we make it happen? We know that the NHS is very good on policy, on discussions and on—what do they say?—paralysis by analysis, but it is the implementation that it is weak on, and that is what particularly concerns me about hospital food. I have a quote from one of those years: “It is good food, not fine words, that keeps me alive”.

My noble friend Lady Miller and the noble Baroness, Lady Thornton, gave us some shining examples of the good food being produced in hospitals. I am pleased to see that because it is very good for patients, and I would bet that it raises the morale of the staff as well. The Royal Cornwall Hospital was highlighted. I have not had time to visit that hospital, but I know that my noble friend Lady Jolly speaks of it often. I understand also that the Royal Brompton Hospital and others are good. However, my noble friend Lady Miller said that what really makes a difference within a hospital is the will to do well and good leadership; that is very important. Today, I am asking the Government for a bit of strong will and the leadership to bring in this legislation.

Catering staff are, of course, key to this. One of the things I have noticed when visiting hospitals is that different institutions approach this differently. That is great and I am all for them using their initiative and seeking their own ways of doing things. Some places have integrated nursing and catering staff, while in others there are dedicated catering staff who have an absolute love of food, and you can see the difference. There are merits in each of the different ways of approaching this, and that is right. Having talked to nurses and to catering staff, I am interested in the following question: where are the doctors? I am delighted that the doctors are here today and I thank them both, the noble Lords, Lord Rea and Lord Turnberg, for their contributions.

It is very interesting to look at the obesity plan that the Royal College of Physicians has produced; hospital food does not seem to enter into it. Bariatric surgery does, and the need for more nurses to be trained in bariatric surgery—all those things—but surely doctors should be looking much more closely at the whole condition of their patients, what they are receiving and how they are getting better.

The noble Lord, Lord Rea, said that sanctions are missing and the lack of progress has been shameful—I so agree. This is an opportunity to improve, as he was saying, not only the quantity and quality of food in hospitals but the education so that people can better understand food in general. I was asked whether the Bill includes private hospitals. No, it does not; it applies to the NHS.

I thank the noble Baroness, Lady Masham, very much. I know that Stoke Mandeville is seared on her heart. I am very pleased that I have escaped on my visits there but she certainly told us a great deal about how disappointing the food is. I was interested in what she said about having kitchens on the wards and in hospitals generally, and not food brought from Wales. The noble Lord, Lord Turnberg, also made that point.

There is a very nice quote from Elizabeth David, that great pioneer of good cooking:

“Good food is always a trouble and its preparation should be regarded as a labour of love”.

When the food is produced on an assembly line in Wales, frozen and then reheated on the ward, how can the people who are producing that food love it? They never see a patient. Whereas if hospitals have their own kitchens, you see chefs going round and asking the patients what they like, what they do not want, what size of portion they want—all the rest of it. That is the labour of love.

I was very distressed to hear the noble Lord, Lord Turnberg, say that many patients lose weight in hospital. He also went on to say that celebrity chefs are not the answer. I agree: that is another thing we have tried and tried and it does not work.

I was interested to think about how patients can use their power to improve hospital food. We have tried and tried. Age UK tried the “Hungry to be Heard” campaign, which was all about food in hospital. As nothing happened, it revamped it as “Still Hungry to be Heard”. I really do not think that across the country the food has improved that much, despite some of the good examples we have been given. It is interesting that two-thirds of staff would not eat the food given to patients. That says everything, as far as I am concerned.

I thank the noble Baroness, Lady Thornton, for volunteering for this debate. I had no idea she had such a long-standing interest in this subject. Her contribution was outstanding. I agree with her: I am afraid we have reached the end of the road on volunteering and now we need to really grip this subject. She asked me about the consistency of government policy. I fear it is not consistent and I fear that will be our struggle. I am trying to think of other ways in which we can perhaps introduce something if this Bill does not get through the House of Commons. The noble Baroness also mentioned care homes. I was very conscious that in the NHS you really need to focus on the subject to get it done and I thought that if we went much more widely, we would certainly fail.

Finally, I am delighted that I and my noble friend the Minister are at one in that we want to support high standards and we agree that more needs to be done. The Government are certainly not inactive and I have been impressed by the response he has given us today, starting with this new panel he has set up. It has a huge task ahead. He highlighted the remit of the panel and what it will do. It looks very ambitious. I hope it succeeds. When will it report? How can we monitor progress? We need to see that this is not the 22nd initiative that the Government have produced in 20 years. We really want it to succeed.

On the question of staff and visitor food, I appreciate that less than half the food in hospital is served to patients: it goes to visitors and staff. I visited a hospital and asked to see the kitchens. They said, “Why do you want to see the kitchens? The food is brought in from miles away”. I said, “I still want to see how you are going to regenerate it”. As I went into the kitchen area, I met two chefs. One chef was cooking for private patients. I thought, “That’s fine, they’re paying for it; fair enough”. The other chef was cooking for the staff. I went into the staff restaurant, which was superb. You could have chosen anything; the food looked lovely. Then I tasted the hospital food given to patients—I say no more.

It has been a very interesting debate. Again, I thank my noble friend for his summing up. I understand that there are a lot of initiatives; it is how they work in practice that concerns me. I will certainly keep an eye on this Bill. I am not totally persuaded. I want to continue. I commend the Bill to the House.

Bill read a second time and committed to a Committee of the Whole House.