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The proof of the pudding... by Lyn Whitfield

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17 June 2005

Real food is back on the political menu, after TV chef Jamie Oliver shamed the government over junk meals in schools. But despite all the noise, is there enough will and cash to give every school pupil and hospital patient a choice of fresh food? Lyn Whitfield doubts it

The power of modern celebrities seems to be limitless. The media loves them and politicians love the media, so no-one has faster access to Downing Street than a celebrity with a cause. Just look at Jamie Oliver.

Turkey twizzlers became a national topic of conversation thanks to his Channel 4 series, Jamie's School Dinners, which chronicled his work to improve meals in Greenwich. A petition supporting his national Feed Me Better campaign gained 617,000 signatures in six weeks.

Yet before Oliver could even deliver it to Number 10, the government had promised £280m over three years for improvements, including nutritional standards, a minimum spend on ingredients, Ofsted inspections and a school meals trust to advise schools and parents (see below).

Inspired by this success, the British Medical Association's annual junior doctors' conference voted to ask Oliver to sort out hospital food, while another celebrity chef, Paul Rankin, said he'd like to improve food in care homes. However, the BMA resolution shows that there are limits to the power of celebrity after all, since the NHS has had its own celebrity food initiative, the Better Hospital Food programme, fronted by Loyd Grossman, for five years.

There are many similarities between Better Hospital Food and the new school meals package, and its progress, or otherwise, points up many issues that will have to be faced by those attempting to improve school meals, now that Oliver has moved on.

Like the schools initiative, Better Hospital Food was launched on a wave of media and public concern. Reports had shown that a substantial minority of patients went into and came out of hospital malnourished, yet the NHS was wasting food worth £144m a year.

Meanwhile, public dissatisfaction with both the quantity and quality of hospital food came through in a consultation on NHS reform that resulted in the ten-year blueprint for improvement known as the NHS Plan. Its section on 'better hospital food' promised a 24-hour catering service with a main meal in the evening, input from dieticians, new dishes by 'leading chefs', ward housekeepers to make sure food could be eaten and more inspections.

Grossman was initially asked to chair a panel of chefs, including Anton Edelmann of the Savoy and Mark Hix of the Ivy, who visited hospitals and contributed ideas for the new dishes. He became chair of a new Better Hospital Food panel in 2001.

Interestingly, the celebrity element did not go down well. Sun columnist Richard Littlejohn described the chefs as 'the sort of people who spend the whole of Saturday disembowelling a kiwi fruit and using it to garnish a pan-seared penguin's beak in cactus jus'. If they tried serving 'this muck' in Holby City, he added, 'they would get it back in their faces'. Some staff agreed. Newspapers still get letters saying that patients want 'stew', not 'navarin of lamb with couscous and grilled vegetables'.

But Alison McCree, chair of the Hospital Caterers Association, says Better Hospital Food has been important for 'changing mindsets'. 'More trusts now see food as part of the healing process, rather than as a Cinderella service that can be cut when the money gets tight,' she says.

Most hospitals seem to have met the programme's targets, with 94% now serving a main meal in the evening and 84% using the leading chef dishes, although snacks are still thin on the ground. The Department of Health says that assessments by patient environment action teams also show that food standards have improved.

In 2002, on a three-point scale, 118 hospitals (17%) were judged green/good and 554 hospitals (81%) amber/acceptable. In 2004, on a five-point scale, 666 hospitals were judged excellent or good (58%) and 402 acceptable (35%).

As a result, the department's focus seems to be shifting from delivering more and better food to offering patients more choice. For example, it has been working with a major food manufacturer on a 'flexi-menu and meals sourcing project' that lets patients choose from a fixed but broad range of meals, nearer in time to when they will eat them.

Looked at from another angle, though, the figures are not that impressive. The vast majority of hospitals have always been judged good or acceptable, while a stubborn minority 7% in 2004 remains poor or unacceptable.

McCree thinks attention still needs to be paid to getting all trusts up to standard. She suggests that setting minimum standards and a minimum budget for ingredients might help 'because then you could look at trusts that were not very good, and quantify why'.

The NHS spent £563m on catering last year. However, the DoH admits that it can't give sensible averages for trust spend, because of the wide variety of catering arrangements in place.

Meanwhile, waste continues to be a problem. Figures obtained by shadow health secretary Andrew Lansley show that 17 million meals were thrown away last year almost 11% of the total and 2% more than in 2000/01.

One reason might be that patients do not like what is on offer, or have to order so far in advance that they don't feel like it when it arrives the rationale behind flexi-menus. But another might be that food is still not well presented and patients are still not being given 'protected meal times' and help to eat.

McCree says that although there are ward housekeepers, trusts have given them a variety of responsibilities, not all of which relate to food.

Neil Porter, chair of the Local Authority Caterers Association, says standards are not a panacea. 'We welcome the School Food Trust and we welcome the fact that there will be mandatory standards,' he says. 'However, those standards must be more than a piece of software that you can throw recipes into and come out with a good result. If [the nutritional values] assume children will eat peas, but there is a choice and they choose baked beans instead, that might throw them out.'

In other words, as in so many other areas of public policy, there is a tension between the government's desire to mandate standards and to give consumers choice.

Porter highlights another tension. Although the government has said it wants a minimum spend on ingredients, it has also promised to give more autonomy to schools. 'It may be difficult to get the money to where it is actually intended,' he says.

These tensions could become even more stark if Better Hospital Food and the new school meals package are put into a broader policy context.

Jamie's School Dinners made much of getting fresh food into Greenwich's schools and improving the cooking skills of staff. This has not been the main focus of Better Hospital Food and is obviously not the focus of the flexi-menu project.

Yet sustainability lobby groups and unions argue that local procurement not only delivers fresher, less additive-filled food, but other benefits such as reduced road transport and pollution and a boost to local economies. The Department for Environment, Food and Rural Affairs has been trying to drive this 'sustainability' agenda across government through its public sector procurement initiative, and this has been picked up by the NHS Purchasing and Supply Agency and NHS Estates.

But local and sustainable procurement is not easy. Karen Jochelson, a fellow at the King's Fund who has been conducting a study on sustainable food for the Better Hospital Food programme, says European Union rules mean 'the public sector cannot simply discriminate in favour of local suppliers'. It has to do other things, such as introduce seasonal and traditional dishes, 'which can lead to contracts for fresh and local food' or specify that food is to be produced according to recognised welfare standards.

Some trusts have worked hard on this agenda. McCree's own trust in Darlington was the first in the country to introduce organic milk, as a result of looking for a local supplier and she says patients 'have noticed and commented on the difference'.

But NHS agencies can only do so much to encourage trusts or catering companies to follow suit, given the government's stated desire to 'devolve' more autonomy to the front line.

Meanwhile, Sir Peter Gershon's review of public sector efficiency calls for savings of £21.5bn to be made across the public sector by 2007/08, with £7.17m coming from procurement.

Sustainability groups are worried that this could push public bodies back to procuring solely on price, concerns that Defra seems to share. One of its ministers, Lord Whitty, has warned that cuts should not be made without considering their wider impact.

Porter says that Defra's sustainability agenda has had 'some impact' on schools, although they face the same issues as hospitals when navigating EU procurement rules. But he says the Gershon agenda is a concern because 'potentially, you are looking at one agenda to promote the local economy and another that stops you doing that'. The government, he says, 'needs to be a lot clearer about what it wants'.

Another problem for the sustainability lobby is that many hospital trusts have contracted their catering out. The DoH recognises that Private Finance Initiative deals have driven this trend, and, indeed, left some hospitals without kitchens, although, in another response to Lansley, it admits it cannot put precise figures on either.

The PFI is a big issue when it comes to school meals. Shortly after the government announced its school meals package, a pressure group in Merton, south London, claimed that its schools were locked into a 25-year PFI deal that would make it impossible to get rid of junk food.

However, a spokesman for the council disputed this, saying: 'We do not believe the contract prevents us from changing food standards, and we are working with Scolarest [a catering company] on doing that.'

But the better meals issue has wider repercussions beyond schools and hospitals, notably in the care sector. John Beer, treasurer of the Association of Directors of Social Services, said he had been both horrified and impressed by Jamie's School Dinners. 'What he found was horrendous, but it was encouraging to see that with that amount of drive, it was possible to get a lot of change quite quickly,' he said.

Beer, who is also executive director of health and social care at Southampton City Council, has taken a close interest in food services in the city. 'I asked to see menus and asked what food was being served in the children's homes that we managed, and I was quite pleased,' he says. 'In one local authority I worked for, it was chips, chips and more chips, but we're not doing that.'

Beer predicts different trends in catering in homes for elderly people and meals on wheels.

He says care homes tend to serve 'meat and two veg' rather than fried or processed food, since that is what their elderly residents tend to want. Meals on wheels, he says, are using more and more frozen food, which is then reheated. Although he admits there are 'issues in terms of diet and nutrition', the big factor is offering more choice particularly for an ethnically diverse population.

The future direction of the Better Hospital Food programme is somewhat uncertain, since NHS Estates is being abolished and most responsibility for food has passed to the chief nursing officer and the National Patient Safety Agency.

In a statement, the NPSA said it would be focusing on nutrition and ensuring patients could 'ingest' the food they needed, while also ensuring that they are given 'a wide range of tempting foods' and encouraging innovation in preparation and delivery.

However, Better Hospital Food shows initiatives of this kind operate in a complex and contradictory environment, one that a celebrity chef or two can do only so much to resolve. It also suggests that the big issue facing the School Food Trust might be whether to try to make improvements in an essentially commercial service, or to go for a more fundamental shift in attitudes.

The Scottish Executive has introduced nutritional standards that are widely thought to have improved food standards and led to the introduction of more fresh food in schools. It has found £63m for its programme and defended it as a 'social justice' measure, designed to help all children get the most from their education.

Porter says that one English council, Hull, has decided to make its meals free to pupils 'because it values children eating more than it values the cash element' and another is following suit. 'The question is: are meals a commercial venture, or are they a service?' he says. 'We have tried the commercial route. Perhaps there are signs we are starting to go back the other way.'

Small beginnings

Defra and the King's Fund have been funding a two-year project by London Food Link, which is part of Sustain, and the Soil Association, to introduce more local and organic food into four hospitals in the capital.

The project has successfully trialled supplies of fruit from Kent and Sussex, tomatoes from West Sussex, mushrooms grown under the North Circular Road in Newham and organic milk and beef from Hampshire.

However, Emma Brockridge from Sustain admits this has been a 'long, slow process'.

'Milk, for example, was very hard,' she says. 'We initially found a little co-operative in Sussex and worked with them on an audit [against NHS standards].

'It found the material used on the barn roofs didn't comply, so we worked with them to change it. Then they were bought out by a large diary, and we had to start all over again.'

At the other end of the supply chain, the project found hospitals were geared up to receiving milk in three-gallon containers, while small suppliers wanted to deliver it in smaller ones.

It also found hospitals often store milk in fridges provided by their existing suppliers, so switching contracts could require new fridges.

The project's major findings, however, have been that hospitals are often unable or unwilling to move away from existing suppliers, not least because budgets are often too tight.

Suppliers, meanwhile, have found it difficult to make the small contracts on offer pay and to organise transport into London.

As a result, the project is now focusing on getting small producers into existing supply chains 'to cut the number of small vans coming into London' and reduce invoicing costs.

School meals pledges and progress

  • An expert panel to draw up 'tough minimum nutritional standards' for school mealsThe School Meals Review Panel started work in May and is chaired by Suzi Leather, former deputy chair of the Food Standards Authority. It includes dieticians, nutritionists and representatives from education and the catering industry. Its remit is to 'strongly consider' introducing nutrient-based standards, while bearing in mind 'issues of cost and implementation'. It will also consider 'whether there are grounds for restricting choice' and for banning particular foodstuffs. It will further advise on 'the costs and benefits of specifying fresh/unprocessed food'.
  • £60m, some of it from the National Lottery, to create a School Food TrustLeather has also become chair of the interim School Food Trust, which is due to become fully operational this summer. She is supported by chef and food consultant Rob Rees and a head teacher, Chris Dean. Like the panel, the trust will draw together a wide range of interests and advise and support local education authorities, schools and parents who want to improve the quality of school meals. It will also 'work with key agencies to develop a ladder of qualifications for kitchen staff'.
  • £220m to be distributed to local authorities to increase spending on ingredients, and to increase training and hours for school staffThe government has said that 50p per meal should be spent on ingredients in primary schools, and 60p in secondaries.
  • Education watchdog Ofsted to review the quality of meals as part of its routine inspection of schools

NHS Plan food commitments

  • A 24-hour catering service, delivering continental breakfast, light lunch, two-course dinner, plus cold drinks and snacks twice a day
  • Dieticians to advise on nutritional values in food and leading chefs to design new dishes
  • 'Ward housekeepers' to ensure that 'the quality and presentation' of meals meet patient needs and that patients 'are able to eat the meals on offer'
  • Patient views to be measured as part of a new NHS performance assessment framework

PFjun2005

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