- Collaborative working in food service delivery
- Food procurement
- Food costs
- Dietetic considerations when purchasing food
- Food service systems
- Food safety
- Food service delivery – the ‘Last Nine Yards’
- Food waste
Food is a precious and expensive commodity; we need to be careful how we use it and minimise waste. All food service systems have positives and negatives - the most important thing is that the chosen system delivers a quality and safe food service.
Dietitians, catering and nursing colleagues have campaigned for many years on the importance of working together to improve nutritional outcomes for patients. Where we see exemplar food services, the collaboration is more than this ‘Power of 3’. It is a whole organisation working together in partnership, sharing skills, passion and inspiration to deliver the best possible food service.
Food procurement is the process of sourcing, acquiring and paying for food. This may be carried out by several different members of the wider hospital team including the Trust catering team, a specialist Trust procurement team or via a contract caterer. Food can be bought from a range of suppliers including the NHS supply chain, manufacturers and wholesalers as well as smaller, local independent grocers, butchers, dairies and bakeries. Catering contractors will have their own approved food and drink suppliers who they work closely with to provide their catering solution. In this situation the hospital is ‘contracted to use’ the catering contractors’ suppliers (see Chapter 7 for more information).
In England, all food and drink procurement by the NHS should comply with the Government Buying Standard (GBS) for food and catering services (1) with an exception to patient food and drink (2). The devolved nations have similar documents including Scotland: Scottish Government Procurement Strategy (2017-2019) (3) and Catering for Change: buying food sustainably in the public sector (4), Wales: Buying Food Fit for the Future (5) and Northern Ireland: Northern Ireland Food Strategy framework: Food at the Heart of our Society - A Prospectus for Change Public Consultation Document (6). For more on national food legislation and standards see Chapters 3 and 5.
The cost and supply of food is complex. The UK produces approximately 60–80% of the food we consume (7) which means that we rely on food supplies from the rest of the world for approximately 20-40% of our food. Many factors impact the supply and therefore cost of food. These include (7), but are not limited to:
- Weather e.g., arable crop yields which, in turn, is affected by the climate and global warning.
- Politics - through food policy and the need to eat more sustainably and produce less carbon emissions e.g., the UK Government was one of the first in the world to set net zero (carbon emission) by 2050 targets into domestic legislation via an amendment to the Climate Change Act 2008 (8).
- Agricultural disease outbreaks such as avian influenza (bird flu) 2022/23 (9).
- Trade barriers with the rest of the world. Brexit has altered the relationship of Britain with Europe for the import and export of food impacting transport and supply chains.
- COVID-19 pandemic e.g., movement restrictions affecting trade, spacing in factories meaning that fewer products can be produced, panic buying, shortage of workers due to infections.
- International war e.g., the Ukraine-Russian conflict has impacted the supply and price of wheat, with approximately 30% of the world's wheat coming from Ukraine and Russia. It has also had an impact on availability of other products, including animal feed, fish, vegetable oils and fuel supplies (10).
Dietitians should be aware that food is getting more expensive and that this is likely to continue.
It is important that all hospitals obtain good nutritional ‘value for money’ when procuring food for patients, staff and visitors with the promotion of quality food and adequate hydration to support a patient's nutritional care as part of their recovery and staff and visitor wellbeing.
Cost is not the only factor that needs to be considered; dietitians have a crucial role to play in the procurement process and should be actively involved with colleagues in advising on the range of products for standard menus, 24/7 solutions (including healthier eating options for staff) and emergency menus (such as in the COVID-19 pandemic or a major incident). Considerations include:
- Checking the nutritional composition of food and drink purchased against standards in this document (see Chapters 10 and 12). Nutritional specifications for foods can be obtained from manufacturers/suppliers to compare their nutritional composition (macronutrients) with standards (see Chapter 8)
- Checking the allergens contained within food and drink products, thinking about where they may be required and whether suitable for patient, staff and visitor catering
- Checking the nutritional specifications and allergens of food and drink bought when there are supply issues and products are substituted due to food safety concerns, delists and/or short-term lack of availability
- When choosing a suitable alternative, think about ingredients, cost, method of supply (i.e., ambient or frozen), cooking or preparation method and whether the substitute product is suitable for the food system or equipment.
- Ensuring that foods purchased do not adversely impact the environment and are ‘sustainable’ (see Chapter 4).
Packaging for single portioned food and drink products that are patient or individual facing should be designed to be accessible and easy to open e.g., butter portions, sandwiches, juice cuplets. More detail can be found on the Hospital Caterers Association (HCA) website (11).
There are requirements under the Patient Lead Assessment of the Care Environment (PLACE) for healthcare organisations to review their purchasing decisions in relation to packaged foods for provision to patients. PLACE 2022 (12) stipulates that Trusts must specify at the time of food procurement that products comply with ISO 17480 Packaging Accessible design – Ease of opening standard.
With growing public concern about the environment and sustainability (13), the procurement of food and drink products is now influenced by the type of packaging of the product. Decisions may also be affected by whether the packaging is recyclable and the sheer amount of packaging a product has (2). At the time of printing, the planned legislation for October 2023, is set to ban single-use plastic plates, trays, bowls, cutlery, balloon sticks, and certain types of polystyrene cups and food containers (14).
A food service system can be defined as the methods by which a food service operation procures, stores, prepares and serves food.
The main food service systems which are usually identified by the food distribution method and include (15):
- Cook fresh (serve) - Traditional
- Central production (on site) - Cook-Chill or Cook-Freeze
- Delivered In (off site) - Cook-Chill or Cook-Freeze
Each system is covered in more detail in the sections below. They all have their own benefits and challenges. The overall goal is to ensure that the food supplied is safe, appropriate and is of good quality. All healthcare settings should identify which system is most suitable for their organisation considering:
- Menu planning for the speciality and patient group (see Chapter 9)
- Size, layout and space of both the hospital and the main kitchen
- Training and skill levels of staff
- Hygiene of the premises and food safety considerations
- Storage, preparation and service equipment both in the kitchen and at ward level
- Waste management practices and procedures used
- Systems of cost control and the budget available
- Environmentally sustainable practices.
Services that cater or provide food service are also known as catering services.
The main classifications of food service systems in healthcare settings
A cook fresh or ‘traditional cook (and serve)’ catering service is where food is prepared in a main hospital kitchen on the premises where the food is to be served. Ingredients are assembled, food is prepared and cooked on site and distributed as soon as possible and at the appropriate temperature (either hot or cold) to the wards (or adjacent service area such as a main hospital restaurant).
A cook fresh system can be either:
- Centralised – Individual patient orders are assembled and set up close to the production area. Trays are then distributed to the wards and served to patients. Sometimes a tray line/belt in the main kitchen is used for the plating of orders onto plates on the individual trays.
- Decentralised – Food is delivered to the ward in bulk (or restaurant servery) where it is served into individual portions on to the plate for the patient (or customer).
A central production catering service is when food is prepared well in advance of the time it is required for service. It is produced onsite in the main hospital kitchen, then either quickly blast chilled or frozen. It is stored at a controlled temperature and is then regenerated and served to patients at a later date. Hazard Analysis Critical Control Point (HACCP) procedures must be followed in food handling and hygiene procedures to ensure the food safety of the products (16).
A delivered in catering service is when fully prepared meals are purchased in either a bulk/multiportion (several servings) format (such as separate entrees, carbohydrates, vegetables and desserts) or as an individual plated main meal format.
Meals are produced off-site by a commercial food manufacturer or a Central Production Unit (CPU). A CPU can refer to an NHS organisation when a hospital with a large kitchen produces food for a number of smaller community units or other local hospitals. Food can be either chilled or frozen. It is delivered to the hospital in a suitable chilled or frozen vehicle and stored at appropriate temperature in a kitchen hub (distribution point) until required for usage. Food is then ‘picked and packed’ into a ward trolley for regeneration (or regenerated in the kitchen) and subsequent service.
A hybrid catering service is where any of the above systems are combined to create a mixed system that usually retains elements of the cook fresh system.
Menus use a combination of raw ingredients, frozen and chilled products and pre-made ingredients (soups and sauces etc). These are prepared, cooked and/or regenerated onsite before being delivered to wards. For example, salads, sandwiches, vegetables and soups are prepared from fresh ingredients on site, but main course meals, carbohydrates and desserts are delivered in.
The benefits and challenges are similar to those described above. This system is usually in place where you have some labour, can be less skilled and minimal cooking equipment or space but want to retain an element of fresh preparation/cook. It could result in a higher food cost as there is a potential for more waste due to the running of two systems e.g., preparation waste plus delivered in meals waste.
The National standards for healthcare food and drink (2) highlight that NHS Trusts must be aware of their legal obligations as food business operators and must ensure that they are compliant with food safety legislation. Whilst everybody involved in the food service system has a responsibility to ensure that the food served is safe, it is expected that all Trusts have a nominated food safety specialist (2).
Hazard Analysis Critical Control Points (HACCP)
All caterers are legally required to carry out a HACCP (17) (similar to a risk assessment) of their food operation, and to put in a Food Safety Management System to reduce food safety risks, including allergen contamination.
All points of potential risk from the selection of suppliers and product specification, through to preparation, cooking, storage and delivery of food to the patient, must be assessed.
What is possible to do in one hospital might not be safe to do in another, due to space, available equipment and the food service system. Team members must be trained on the controls that they need to implement which have been detailed in the HACCP or Food Safety Management System.
Food must be kept at a safe temperature to prevent bacterial growth and food borne infections. Therefore, any member of the ward team (clinical or catering) should avoid further processing food (e.g., blending or reheating) once it’s been served without first speaking with the caterer who has originally produced or regenerated the food.
Food safety concerns not only include food borne infections and food allergy (covered below) but also the risk of the patient being provided with food that is inappropriate for them (e.g., an unsafe texture). All three of these risks must be considered in food safety management systems.
In 2019, there was an outbreak of listeriosis in the UK, which caused the tragic death of seven patients after they ate pre-prepared sandwiches contaminated with Listeria Monocytogenes (18).
Listeriosis is a significant risk in healthcare settings where individuals are more vulnerable such as older adults, immunosuppressed patients, or pregnant women (18). It is linked (19) with chilled ready to eat (RTE) food in hospitals such as cooked sliced meats and pre-prepared sandwiches. It is important that organisations ensure the safety of RTE products through the supply chain, effective procurement and food hygiene controls (19). For example, having strict time controls for high-risk foods left out of temperature control and the need for patient trays to be cleared in a timely manner.
Anyone involved in handling food must receive appropriate food safety training. The level of training required depends on the team member’s role. In addition, allergen training must be provided to all staff involved in the preparation, handling and serving of food. The training should include the potential effects of allergens in the body, the key 14 allergens and the allergen controls that they must implement.
Depending on the level of risk, food safety training and allergen training can either be delivered at a local level, or by a course accredited by an organisation such as the Chartered Institute of Environmental Health (CIEH) or Royal Society of Public Health (RSPH).
For sites that produce food that is prepacked for direct sale (PPDS) (20), where the food is packaged before the food is ordered and served packaged, training must be provided to the relevant team members on the requirements of what is commonly known as Natasha’s Law.
Organisations must have a policy in place that outlines how food allergies are managed. The food service and clinical teams need to have knowledge of any processes for the delivery of safe food to a patient with a food allergy. See Chapter 12 for further information on catering to patients with food allergies.
The Report of the Independent Review of NHS hospital food (15) outlines the 'Last Nine Yards' initiative, which aims to improve catering at ward level. The ‘Last Nine Yards’ specifically refers to what happens after the food has arrived at the ward and the processes of getting it to the patient. Food that is not eaten has no nutritional value, so it is vital that the care taken in the presentation of the food is given equal value at service time, ensuring the meal is a positive experience for every patient, every time (21). Therefore consider:
The type of food packaging given to patients and whether this is easy to access (as described above in the section on packaging)
Which condiments or garnishes would provide an increase the palatability of the meal
Which crockery, cutlery, water jugs and glasses are easy for patients to see and lift (or where adapted crockery or cutlery is needed)
Which menus and foods are available for different patient group e.g. Finger foods, ‘little & often’ approach and snack choices
24/7 availability of appropriate food and drink
Promotion of the mealtimes matters/assisted mealtimes approach – involvement and engagement from the wider clinical team at mealtimes to support patients requiring help i.e., sitting up and preparing for meal services, washing hands, removing bedpans and encouraging or assisting patients who require it.
Food waste refers to food or drinks that are procured, prepared, delivered and intended to be eaten but end up being thrown away.
The Waste and Resources Action Programme (WRAP) (22) outlines that ‘producing food requires significant resources including land, energy and water’. Food waste from households and businesses is still around 9.5 million tonnes (Mt), 70% of which was intended to be consumed by people (30% being the ‘inedible' parts). This had a value of over £19 billion a year and would be associated with more than 25 Mt of GHG emissions. For more detail on environmental sustainability see Chapter 4.
All food waste has both a negative environmental impact and a monetary cost – it concerns everyone.
There are four main types of food waste shown in table 6.1.
Table 6.1 The four main types of food waste
Food that is thrown away during the preparation and cooking process. For example, vegetable off cuts (e.g., tomato cores, carrot tops, celery leaves), seeds, peel, rinds, eggshells and carcass trimmings including bones.
Food that is damaged or out of date, such as rotten vegetables, bruised apples or bananas, mouldy bread and out of date yoghurts or sandwiches.
Food that is ready to serve but is in surplus. This may be due to over production in the kitchen; extra, unrequired portions remaining in bulk packs or excess food ordered to a ward.
Food that is left uneaten on the plate after the meal is served such as garnishes, sauces, skin off a jacket potato, salad or any food that is simply not eaten and left on the plate.
For dietitians and other clinicians, plate waste has health implications that can occur because of unmet nutritional requirements, the consequences of which are described in Chapter 1. Understanding the reasons for food waste on the ward is critical to understanding patients’ food consumption.
Effective monitoring of food waste is equally vital to the catering team because of the cost implications. Waste is an issue at all levels and should be carefully considered in any food service operation. Table 6.2 summarises the potential reasons for food waste.
Table 6.2 – Potential reasons for food waste
Reasons for un-served waste
Reasons for plate waste or reduced food consumption
Monitor, manage and reduce food waste
Hospitals must assess their level of food waste, set reduction targets and develop plans to minimise waste using the approach outlined by WRAP (23, 24). For further information and support, see section 4 of the National standards for healthcare food and drink, ‘Improving sustainable procurement and reducing food waste’ (2) and the following guides in England (25) and in Scotland (26).
Actions that organisations can take to manage food waste include:
- Documenting all food waste, at all stages of the food chain so it is known where the greatest waste occurs
- Monitor waste across ward types
- Implement changes to the food service to address key causes of food waste, e.g., adjusting the breakfast meal time on a mental health unit, as service users issue would often sleep through the meal service. Or decreasing portion sizes and implementing a grazing style menu on a dementia ward.
- Develop practices and policies such as ‘Mealtime matters’ to create an atmosphere for patients that is more conducive to enjoying meals
- Consider all aspects of the meal service including timings and environment e.g., is there a dining room on the ward that can be utilised to enhance the dining experience?
- Ensure that meals served reflect patients’ cultural, personal or special diet needs
- Instigate amends in meal and/or additional snack provision, which is evidenced on an individual’s food and drink record chart
- Audit waste of a certain type of menu item e.g., maternity wards – lots of soup wasted, children’s wards more vegetables wasted and adjust menu structure accordingly
- Audit portion sizes
- Implement a digital meal ordering system (2). It is acknowledged that this could have a positive impact on waste, as it means meals are not sent for those who are nil by mouth or who have been discharged and enables patients to choose their meal much closer to the time they will eat as the data can be immediately sent to the kitchen. Patients are less likely to change their mind leading to less waste (16).
- Department for Environment, Food and Rural Affairs. The Government Buying Standard for food and catering services. https://www.gov.uk/government/publications/sustainable-procurement-the-gbs-for-food-and-catering-services [Accessed 20th March 2023]
- NHS England. National standards for healthcare food and drink. https://www.england.nhs.uk/publication/national-standards-for-healthcare-food-and-drink/ [Accessed 20th March 2023]
- The Scottish Government. Scottish Government Procurement Strategy (2017-2019). https://www.gov.scot/publications/scottish-government-procurement-strategy-2017-2019/documents/ [Accessed 11th February 2023]
- The Scottish Government. Catering for Change: buying food sustainably in the public sector. https://www.gov.scot/publications/catering-change-buying-food-sustainably-public-sector/documents/ [Accessed 11th February 2023]
- Welsh Government. Buying Food Fit for the Future. https://indd.adobe.com/view/f76f7fee-3fd6-4e39-933e-7c564aa6393a [Accessed 20th March 2023]
- Department of Agriculture, Environment and Rural Affairs. Northern Ireland Food Strategy framework: Food at the Heart of our Society - A Prospectus for Change. https://consultations2.nidirect.gov.uk/daera/food-at-the-heart-of-our-society-a-prospectus/supporting_documents/21.22.076%20NI%20Food%20Strategy%20Framework%20Consultation.PDF [Accessed 20th March 2023]
- Chatham House. Implications of COVID-19 for UK food supply resilience. https://www.chathamhouse.org/2021/12/implications-covid-19-uk-food-supply-resilience/05-pressures-uk-food-and-nutrition-security [Accessed 11th February 2023]
- Legislation.gov.uk. Climate Change Act 2008. https://www.legislation.gov.uk/ukpga/2008/27/contents [Accessed 11th February 2023]
- Department for Environment, Food and Rural Affairs et al. Bird flu (avian influenza): latest situation in England https://www.gov.uk/government/news/bird-flu-avian-influenza-latest-situation-in-england [Accessed 11th February 2023]
- BBC. Meierhans J. Farmers warn Ukraine war will hit UK food prices. https://www.bbc.co.uk/news/business-60691116 [Accessed 11th February 2023]
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- NHS Digital. Patient-Led Assessments of the Care Environment (PLACE): 2022 Assessment Food. https://digital.nhs.uk/data-and-information/areas-of-interest/estates-and-facilities/patient-led-assessments-of-the-care-environment-place [Accessed 20th March 2023]
- NHS England et al. Delivering a ‘Net Zero’ National Health Service. https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf [Accessed 20th March 2023]
- Department for Environment, Food and Rural Affairs. Far-reaching ban on single-use plastics in England. https://www.gov.uk/government/news/far-reaching-ban-on-single-use-plastics-in-england [Accessed 20th March 2023]
- Department of Health and Social Care. Report of the Independent Review of NHS Hospital Food. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/929234/independent-review-of-nhs-hospital-food-report.pdf [Accessed 20th March 2023]
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- Food Standards Agency. Hazard Analysis and Critical Control Point (HACCP). https://www.food.gov.uk/business-guidance/hazard-analysis-and-critical-control-point-haccp [Accessed 15th February 2023]
- Public Health England. Investigation into an outbreak of Listeria monocytogenes infections associated with hospital-provided pre-prepared sandwiches, UK May to July 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/937907/2019-05-Listeria-CC8-Outbreak-Report.pdf [Accessed 15th February 2023]
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- Food Standards Agency. Introduction to allergen labelling for PPDS food. https://www.food.gov.uk/business-guidance/introduction-to-allergen-labelling-changes-ppds [Accessed 15th February 2023]
- Hospital Caterers Association. Last Nine Yards – Improving hospital catering at ward level. http://www.hospitalcaterers.org/service-excellence/last-9-yards/ [Accessed 11th February 2023]
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