My Lords, I begin by congratulating my noble friend on securing the introduction of this Bill, which seeks to set standards for healthy and sustainable food in hospitals. The Government warmly welcome the role that my noble friend’s Bill has played in bringing this important issue to the attention of your Lordships’ House. Few subjects matter more than food and drink. Poor diet can cause serious illness and even increase the risk of early death. My noble friend has a supporter here when she talks about high standards. We both want nutritious food that meets the recovery needs of patients and the health needs of staff and visitors, and sustainable food that supports our farmers and accounts for the needs of our livestock. Above all, we want tasty food that that looks good and is available whenever it is needed. My noble friend and I are at one on this.
We agree that more needs to be done to be certain that hospitals comply with high standards. We are proposing a series of measures that include instruction, incentives and inspection—the three Is. These build on the work announced last year by my right honourable friend the Secretary of State for Health and will raise awareness and increase transparency so that there can be no excuse for poor food.
The cornerstone of this approach will be our hospital food standards panel, under the chairmanship of Dianne Jeffrey, chairman of Age UK. The panel, which I can tell my noble friend Lady Miller includes Sustain as well as patient representatives and others, will start with the needs of patients, especially older people. It will look at nutritional quality, mealtime experience and the help given to patients to eat. It will check the evidence on food production systems to understand how a meal can leave the kitchen as an attractive, tasty dish, but arrive at the patient cold and unappetising. Noble Lords who share my own frustration when struggling with a sachet of sauce or pat of butter, will be pleased to hear that the panel will not let such small details escape their scrutiny.
The panel will also consider sustainability. This year, around 80% of food commodities purchased through NHS Supply Chain will be UK-produced, but the panel will look at how we can further reduce our environmental impact, including waste from food and food packaging. The panel will also consider animal welfare.
In this way, we address my noble friend’s main concerns. However, our ambitions go further. We have asked Dianne Jeffrey to consider food served to staff and visitors, including food sold in vending machines. Noble Lords may be surprised to learn that less than half of the food served in hospital is eaten by patients. The majority goes to staff and visitors. We must not neglect their needs.
We have a serious obesity problem in this country and so have a responsibility to help people make healthier choices. That does not have to mean banning chips and fizzy drinks, but should certainly mean delivering healthier options to make it easier for people to choose healthily as well as simple to understand information and labelling on food—using the calorie labelling and front-of-pack schemes increasingly evident on our high street and in supermarkets.
This is not about undermining personal autonomy. What freedom exists in choosing between two meals if both are high in saturated fats and salt? Where is the freedom in choosing between a standard chocolate bar and a king-sized one? We are asking the panel to examine how the NHS can increase choice, not reduce it, and enable informed choice.
Twenty-one trusts have committed to measures for encouraging healthier restaurants, vending outlets and buffets under the responsibility deal’s pledge on healthier staff restaurants. We want more to do the same. How will we make all these things happen? Like my noble friend, we have been frustrated to see continued variation in food standards across our NHS. That is not because hospitals do not know what good food looks and tastes like. Good guidance and standards already exist, and the best hospitals are using them. For instance, government buying standards for food and catering were introduced in 2011, covering nutrition, sustainability and animal welfare. We have the British Dietetic Association’s guidance on nutritional content of patient meals, and we have our own guidance on healthy eating. So rather than produce new standards or guidance, our panel will identify which existing guidance should apply as a matter of routine, which should be aspired to as best practice and which should be left for local determination.
Standards are important but compulsion, in our view, is not. There is no evidence that making standards mandatory in Scotland or Wales has led to food that is any better than in England. Indeed, patient satisfaction ratings with hospital food in Scotland have actually gone down in recent years. Nor should standards relate to whether food is prepared in-house or not. Each NHS provider must decide for itself how to deliver its food services. What matters is not who provides the meals or how but that they are of high quality and meet the needs of patients. We are unaware of any clear relationship between the quality of food and whether it is cooked on-site or delivered frozen or chilled and regenerated. I agreed with the noble Lord, Lord Rea, on that point. There are many ways to produce food in hospitals. All can deliver good food.
We are determined to make sure that this happens. However, this Government have committed to creating new regulation only as a last resort, as the noble Baroness, Lady Thornton, observed. Because of that,
we have identified other, highly transparent ways of delivering the change that my noble friend wants to see. Of course, legislation has a role. All healthcare organisations must register with the Care Quality Commission, whose powers are enshrined in law. The department is updating the CQC’s registration requirements to include new fundamental standards of care that all providers have to meet, and the CQC is developing compliance guidance. We will ensure that the work of the panel aligns with that.
Crucially, we have asked NHS England to amend the NHS standard contract so that it helps to deliver improvement. In the new contract, due out next month, hospitals will be required to have regard to guidance on the provision of catering services, including government buying standards for food and catering. We will work with NHS England to ensure that the panel’s work is appropriately highlighted in later contracts and technical guidance. Commissioners of NHS-funded services have the power to require remedial action to be taken where there is clear evidence that providers are failing to meet the terms of the standard NHS contract.
There are also incentives for excellence. Under the system of commissioning for quality and innovation, which we call CQUIN, commissioners can reward providers for delivering high food standards. For instance, providers might be rewarded for improving food quality, or meeting external standards such as those of the Soil Association’s Food for Life Partnership.
My noble friend also calls for a new inspection regime. We can respond to her call in the following way. The CQC has appointed Professor Sir Mike Richards as Chief Inspector of Hospitals and he is establishing a robust system of registration, regulation and inspection. The programme is not a rigid one-size-fits-all process, but a more measured, risk-based approach. This requirement has all the power of the Health and Social Care Act 2008—we do not need further legislation.
The Care Quality Commission has pledged to start rating NHS acute trusts and foundation trusts from December this year and aims to complete this process before the end of 2015. It will introduce a more specialised inspection model with a greater focus on culture and leadership and teams that include clinical and other experts and people with experience of care. It will use information and evidence in a more focused and open way, including listening better to people’s views and experiences of care in order to predict and respond more quickly to services that are falling short.
However, we need strong monitoring. We now review the food served in every single NHS hospital via annual patient-led assessments of the care environment —we call them PLACE inspections. This year, a small army of more than 5,000 patient assessors, including a patient who is a member of our panel, took part in PLACE assessments, including tasting the food on offer. If the vegetables were overcooked, or the gravy was cold, they reported it. If the custard was lumpy or the sandwiches dry, they reported that too. Their feedback directly helps hospitals to improve. As my noble friend said, there is no evidence of a direct link between cost and the quality of food. We are looking further into this to see if we can establish any link. Our PLACE inspections have given us detailed information
directly from patients, which will help us understand how good food can best be produced without wasting money.
We also use PLACE to record whether hospitals comply with recommended guidance. We already ask about the government buying standard for food, and next year we will ask about the Soil Association’s Food for Life catering marks. Once the panel has reported, we will include a question about other recommended standards. Commissioners and providers together can use this information to improve services.
We know that this approach can work. In 2011, government buying standards for food and catering services were launched. They were compulsory for central government departments, but voluntary within the NHS. Yet already around half of all hospitals comply, with another quarter pursuing compliance. My colleagues at Defra are reviewing these standards, and members of the panel are involved in that.
My noble friend also asked for action where hospitals fail to comply with standards. The CQC already has these powers and can take action through civil enforcement or under the criminal law. As I said, commissioners can also act where the standard contract terms are breached by requiring providers to take remedial action and, in the case of serious failures, they can escalate that action. However, it is not just about punishment. What my noble friend wants, quite rightly, is improvement. Our approach is designed to achieve this, which is why PLACE requires hospitals to publish an action plan to show how they will address any problems. This has already started. In Sheffield, hospitals already score well on food but plan to increase menu choice with a £7 million capital development of their catering infrastructure. East Lancashire Hospitals NHS Trust plans to review ordering systems and improve service delivery by opening a second food production belt. It is also reviewing its vending machines. These are tangible improvements, identified by patients and planned and delivered locally. They are evidence of success.
The noble Lord, Lord Turnberg, spoke about the sourcing of food, a subject I mentioned a moment ago. He may like to know that some 60% of the food ingredients supplied to the NHS is procured under contracts negotiated at a national level by the NHS Supply Chain. It requires suppliers to provide information on product quality and provenance and to have a verification process in place. It is working with its contracted food suppliers to identify products that meet the food GBS and make the information available through its website. However, it is important to remember that, under public sector procurement rules, the NHS cannot promote or appear to promote a buy-British policy.
My noble friend Lady Cumberlege referred to the use and cost of nutritional supplements. It is always better if patients can get the nutrients they need from proper food rather than supplements—there is no argument about that—but some patients cannot digest normal food, or need extra calories, and they need supplements. The cost of £320 million that noble Lords may have read about is actually related to spend in the community, not in hospitals. It also includes the provision of real food such as gluten-free bread or
low-protein biscuits. I would not want noble Lords to be misled by any press reports they may have seen on that score.
Malnutrition has many causes, a theme that was taken up to the noble Lord, Lord Rea, but it is most often seen in conjunction with other illnesses. The British Association for Parenteral and Enteral Nutrition estimated the cost in 2007 at more than £13 billion, but it did acknowledge that some of these costs may be unavoidable. This is because serious illness and injury will always result in loss of appetite associated with changes in the body’s metabolism, which in turn results in tissue breakdown and muscle loss. These costs are linked to malnutrition rather than being direct costs, so they cannot be assumed to translate into potential savings in the cost of care.
The noble Lord, Lord Rea, and my noble friend Lady Cumberlege referred to unhealthy foods being served to patients, such as foods that are high in fat and salt. The best food does no good if it is uneaten. For very ill patients who cannot eat large amounts, it may be better for them to eat high-calorie, higher-fat food. Our panel will work hard to strike the right balance between long-term health needs and the short-term requirement for high-calorie food. The noble Baroness, Lady Masham, and the noble Lord, Lord Turnberg, referred to the problem we hear about so often of food being left out of reach and patients not being given the help they need. It is unacceptable for food to be left out of reach. Where a patient is at risk of malnutrition, specific plans of care are introduced such as serving food on a red tray, which signals to the team that extra support is required. We support the notion of protected mealtimes whereby all non-essential clinical practices are avoided during those periods. Family members and volunteers who have had additional training are often invited to help patients with their meals.
Success is what we want. This Government want food that boosts health and recovery, that tastes good and impacts lightly on our environment. Our approach rests on what I referred to earlier as the three Is: instruction, incentives and inspection. Instruction is provided through registration standards and the NHS standard contract, incentives via the CQUIN scheme and inspection by PLACE and the CQC. These, we believe, are the way to success.
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