Catering for patients A follow-up report
Prepared for the Auditor General for Scotland November 2006 Auditor General for Scotland The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds.
He is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management.
He is independent and not subject to the control of any member of the Scottish Executive or the Parliament.
The Auditor General is responsible for securing the audit of the Scottish Executive and most other public sector bodies except local authorities and fire and police boards.
The following bodies fall within the remit of the Auditor General:
• departments of the Scottish Executive eg, the Health Department • executive agencies eg, the Prison Service, Historic Scotland • NHS boards • further education colleges • Scottish Water • NDPBs and others eg, Scottish Enterprise.
Acknowledgements Audit Scotland gratefully acknowledges the time and effort given by the NHS boards and special health boards participating in this review. We are particularly grateful to the catering managers and finance managers who provided most of the information used in this report.
We would also like to thank members of the study advisory group (listed in Appendix 2) who provided valuable advice and feedback throughout the study.
Roddy Ferguson managed the project with support from Kenny Reilly and Geoff Lees, under the general direction of Tricia Meldrum.
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Executive and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds. 1 Contents
Part 1. Summary Part 3. Financial management Part 5. Summary of recommendations Setting the scene Key findings Page 26
Why hospital catering is important Hospital catering costs have risen Appendix 1. Boards and hospitals more slowly than other followed up from baseline Key findings operating costs Page 27
About the study There remains wide variation in the Appendix 2. Study advisory group Page 3 amount spent on catering services Page 28 Page 13 Part 2. Meeting patients’ needs and preferences Catering staff costs have risen more quickly than the costs of food Key findings and beverages
Patients are not routinely screened Catering services for NHS staff and for risk of undernutrition on visitors are not breaking even admission to hospital Page 15 Page 5 Boards have reduced wastage due Not all boards have fully developed to unserved meals systems for ensuring the nutritional balance of patient meals Recommendations Page 17 Progress is being made but patients’ nutritional care is not yet consistently Part 4. Strategic management prioritised at ward level Page 6 Key findings
All boards have systems in place to Catering services are becoming offer patients choice and to cater for more of a strategic priority at patients with special dietary needs board level Page 20 Catering services are offering an improved level of choice to patients Catering staff vacancy rates and Page 9 sickness absence rates remain high
Boards have some processes in Implementation of Agenda for place to seek patients’ views on Change varies among boards catering services Page 21
Recommendations A fully functioning national Page 11 eProcurement system for catering is not yet in place across the NHS in Scotland
Boards have the required food safety and hygiene control systems in place Page 24
Recommendations Page 25 2 Part 1. Summary
Catering services are offering patients an improved level of choice but boards still need to do more to ensure patients’ nutritional care. Part 1. Setting the scene 3
Setting the scene Key findings About the study
1. This review of hospital catering • Catering services are offering 5. The overall aim of this study was follows up the issues from our an improved level of choice to assess progress against the baseline report which was published to patients, including giving recommendations reported in the in November 2003.1 The baseline patients the opportunity to 2003 baseline report. In particular, report provided detailed findings order meals less far in advance, the study examined whether: and recommendations on nutrition, offering a range of portion sizes processes are in place to provide quality, patient satisfaction, costs and ensuring that snacks are quality nutritional care to patients; and the management of the available to patients outside patients are receiving a good quality catering service. This follow-up normal mealtimes. catering service; catering services study assesses the progress have improved their control of costs made in implementing those • Boards still need to do more and wastage; boards have strategies recommendations and improving to ensure the nutritional care for catering services and are hospital catering services. of patients. All patients are monitoring progress against not yet screened for risk of these strategies. Why hospital catering is important undernutrition and many hospitals do not have systems 6. Our baseline report investigated 2. Nutritional care is key in helping in place to ensure a nutritional the key areas of the catering the recovery of patients in hospital balance in the meals provided. service in 2003 and made 31 and hospital catering has an recommendations for improvement. important role to play in this.2 3 The • Not all boards are carrying out The key findings of that report are quality of hospital food is a very quarterly patient satisfaction summarised below: important part of ensuring that the surveys. However, many patient’s experience in hospital is boards are developing improved • Nutritional care needed to be positive. Regular mealtimes perform ways to get patients’ views given a higher priority by all a significant social role which can on catering and use these to staff through measures such promote the general well-being of improve the services provided. as nutritional screening, using patients and assist in their recovery. standardised recipes and • Catering costs have risen by nutritional analysis of menus. 3. Food safety and hygiene are a third since the baseline. essential and need to be rigorously Catering staff costs have • Patient satisfaction with monitored to minimise the risk of risen due in part to the low catering services was high but infection and ensure high-quality pay agreement, whereas the improvements were needed in patient care. costs of food and beverages the amount of choice available per patient day have remained to patients and in the ways that 4. The scale of the costs involved stable. patients’ views were gathered in catering for patients, staff and and used. hospital visitors is also significant. • Non-patient catering services are In 2004/05, hospital catering cost still being subsidised but boards • Food wastage at ward level the NHS in Scotland £73 million, are improving their management needed to reduce. We equivalent to just under one per information systems to allow recommended that regular cent of the total spend on the NHS.4 them to manage this. monitoring of wastage levels Catering is also a large employer should be introduced with the with 3,272 staff involved in producing • Boards have reduced the aim of reducing waste to a target and serving over 17 million meals amount of food wasted due to level of ten per cent. each year.5 6 unserved meals.
1 Catering for patients, Audit Scotland, November 2003. A copy of the baseline report is available to download at www.audit-scotland.gov.uk. 2 Malnutrition within an Ageing Population: A Call to Action, European Nutrition for Health Alliance, August 2005. 3 Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition, National Collaborating Centre for Acute Care, London, February 2006. 4 Scottish Health Services Costs, year ended 31 March 2005, Information Services Division (ISD). 5 Scottish Health Statistics workforce data, year ended 31 March 2005, ISD. 6 Audit Scotland survey, June-August 2006. 4
• Spending on catering services • reviewing supporting evidence 11. The rest of this report is organised varied significantly and services supplied by boards and hospitals into three parts. Part 2 reports on to staff and visitors were being progress in meeting the needs subsidised. We recommended • observing mealtime practice and preferences of patients. Part 3 that this could be better in a sample of ten wards to reviews how costs and wastage are controlled by introducing pricing understand the context in which being managed. And Part 4 looks policies, income generation catering is delivered at what improvements have been targets and policies on the level made in the strategic management and cost of subsidisation. • using existing documents and of catering services. findings from other sources 7. NHS Quality Improvement (including NHS QIS and the Scotland (NHS QIS) has produced Health Facilities Scotland standards for food, fluid and Catering Group).9 nutritional care in the NHS in Scotland and has recently reviewed 9. Fourteen NHS boards, the State and reported progress against three Hospital and the Golden Jubilee of the six standards.7 8 Audit Scotland National Hospital were included has worked closely with NHS in our study.10 We surveyed 149 QIS to provide a comprehensive hospitals that provide meals to picture of work in this area. The patients, visitors or staff and also complementary approach adopted carried out more detailed follow-up by both organisations has led to NHS work in a sample of 33 hospitals QIS focusing on the nutritional care which we had reviewed in the of patients, while our review has baseline study.11 These sample focused on the delivery of catering hospitals are listed in Appendix 1 services. We have drawn on findings and are referred to in certain exhibits from the NHS QIS review as part of throughout the report where we this follow-up report. show the level of progress that has been achieved. 8. In our study we reviewed progress made at board and hospital level by: 10. Throughout the report we provide data for the 149 hospitals that • surveying all NHS boards, two provide catering services. Where special boards and 149 hospitals we have reviewed progress at the that provide catering to patients, sample hospitals included in the staff or visitors baseline study, we make this clear in the text of the report. Where it was • interviewing catering and possible to compare progress we finance managers at a sample have given the results for 2003 and of boards to follow-up on the 2006. However, it was not possible recommendations from the to directly report on progress at trust baseline study (Appendix 1) level since between 2003 and 2006 the NHS in Scotland restructured from trusts to boards.
7 Food, Fluid and Nutritional Care in Hospitals – Clinical Standards, NHS QIS, September 2003. 8 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006. 9 Health Facilities Scotland is a division of National Services Scotland providing operational guidance to NHSScotland healthcare bodies on non-clinical topics. 10 Our survey was undertaken between June and August 2006. NHS Argyll and Clyde was dissolved in April 2006 but is included in the analysis of information received prior to that date. 11 The baseline report reviewed a sample of 41 hospitals. The follow-up report reviewed 33 of these to monitor progress. 5 Part 2. Meeting patients’ needs and preferences
Key findings Patients are not routinely screened hospital, it concluded that no boards for risk of undernutrition on were complying with the standard of • Patients are not routinely admission to hospital recording all of the required nutritional screened for risk of information within one day of undernutrition on admission 2003 Recommendation: Boards admission for all of their patients. to hospital. should ensure that patients are screened on admission for risk of 14. NHS QIS also reported that • Not all boards have fully undernutrition. boards have not yet fully developed developed systems for processes for nutritionally assessing, ensuring the nutritional balance 2003 Recommendation: Boards screening and care planning of patient meals. should use a validated screening for patients. Once developed, tool and ensure that staff have these processes need to be fully • Acute hospitals with long-stay been trained in the use of implemented across all hospitals. beds operate at least a three- this tool. This is an essential step in week menu cycle to maintain ensuring appropriate nutritional variety in the meal options for 12. In this section of the report care for patients and NHS QIS has these patients. we use findings from the recent recommended that this is a priority NHS QIS review of food, fluid and for all boards. • Ninety-seven per cent of nutritional care in hospitals.12 NHS hospitals offer at least two QIS reviewed this area of patient 15. The NHS QIS review also found meal choices at both lunch care under standard two of its that most boards were not yet using and dinner. clinical standards for food, fluid and validated screening tools in all ward nutritional care in hospitals. areas. Only five boards had started • Catering services are using to develop a nutrition awareness, flexible approaches which 13. Although NHS QIS found evidence education and training programme allow patients to order their of progress in screening patients for which would cover training in the use food nearer to mealtimes and risk of undernutrition on admission to of validated screening tools.13 ensure snacks are available outside mealtimes.
12 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006. 13 NHS Fife, NHS Forth Valley, Golden Jubilee National Hospital, NHS Tayside and NHS Western Isles. 6
Not all boards have fully developed Half of boards have catering Only seven boards have systems for ensuring the nutritional specifications undertaken a full nutritional balance of patient meals 17. In the absence of an agreed analysis of their standard menus national specification, boards should 21. Nutritional analysis of menus 2003 Recommendation: Boards still be working to the Scottish Diet helps to ensure that patients should ensure that catering Action Plan’s recommendation that are provided with nutritionally specifications comply with the catering specifications should comply balanced meals. Half of boards model nutritional guidelines for with the model nutritional guidelines have undertaken an analysis of the catering specifications in the for catering specifications in the nutritional content of each item on public sector in Scotland. public sector in Scotland.15 However, the standard menu and seven boards only eight boards have developed have analysed their entire standard 2003 Recommendation: The catering specifications which comply menu to ensure it is nutritionally Departmental Implementation with the model nutritional balanced.17 Group should develop or guidelines.16 commission national catering 22. Nutritional analysis of menus is and nutrition specifications for Three-quarters of hospitals use less likely to have taken place for the NHS in Scotland. some standard recipes to provide special diets (Exhibit 1).18 nutritionally balanced meals 2003 Recommendation: All 18. Standard recipes ensure that 23. Catering departments and menus should be nutritionally the same ingredients and cooking dieticians need to work together to analysed. methods are used each time a menu ensure that any changes to menus item is prepared. These should or recipes are accompanied by an 2003 Recommendation: All include details of the ingredients to updated nutritional analysis. Boards catering production units should be used, the quantities needed, the reported a wide degree of variation use standard recipes. method for making the meal and the in the frequency and accuracy of number of portions of a set size that the nutritional analysis in place. The SEHD has not yet produced will be produced. Case study 1 gives an example of a national catering and nutrition the work involved in creating and specification for the NHS in 19. This helps control the costs of maintaining nutritionally analysed Scotland but plans to do so in 2007 ingredients purchased and limits the menus. 16. The Scottish Executive Health waste produced in the kitchen. It Department (SEHD) set up a is also the only way to ensure that Progress is being made but Departmental Implementation the nutritional content of each menu patients’ nutritional care is not Group in 2001 to give advice to the item does not vary from day to yet consistently prioritised at NHS on providing nutritional care in day. Standard recipes are therefore ward level hospitals. This group did not produce necessary to ensure that nutritionally a national catering and nutrition analysed menus deliver balanced 2003 Recommendation: Boards specification for the NHS in Scotland nutritional meals to patients. should encourage communication which we recommended in our between ward staff and the baseline report.14 In April 2006, the 20. Three-quarters of hospitals are catering department. SEHD appointed a national Food using standard recipes to control and Nutrition Adviser from within the nutritional balance of meals. the NHS whose role is to produce However, only 58 per cent reported a national catering and nutrition that they used standard recipes for specification. This is due to be all meals on the menu. published in April 2007.
14 A catering and nutrition specification details the service’s approach to issues such as nutritional needs, food safety, procurement and menu choice. 15 Eating for health – A diet action plan for Scotland, Scottish Office, 1996. 16 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Grampian, NHS Highland, NHS Lanarkshire, NHS Orkney, NHS Shetland and NHS Western Isles have catering specifications which comply with model nutritional guidelines for the public sector. 17 NHS Ayrshire and Arran, NHS Borders, NHS Forth Valley, NHS Grampian, NHS Highland, NHS Lanarkshire, NHS Orkney and the Golden Jubilee National Hospital have undertaken an analysis of each item on their standard menus. These same boards – with the exception of NHS Forth Valley – have also analysed their entire standard menu to ensure it is nutritionally balanced. 18 NHS Highland and NHS Lanarkshire reported that they have fully nutritionally analysed all of their special diet menus. Part 2. Meeting patients’ needs and preferences 7
Exhibit 1 Number of boards with fully analysednutritionally menus analysed menus for special diets
Full nutritional analysis of menus is not yet in place across all boards.
Type of menu BoardsBoards with withfully analysedfully analysed menus menus NormalVegetarian 98 VegetarianVegan 84 VeganTherapeutic 48 TherapeuticMinority ethnic 85 MinorityChildren ethnic 54 ChildrenAll of the above 42 All of the above 2
19 Source: Audit Scotland survey, June-August 2006
Case study 1 NHS Tayside
NHS Tayside’s Nutrition Standards Project was established in 2003 to implement the NHS QIS standards on food, fluid and nutritional care in hospitals. This involved addressing food preparation and producing a core list of dishes for the menu cycles; developing nutritionally analysed dishes from a recipe list with a list of measured ingredients and an explicit method; and seeking the views of staff and patients about the new recipes. A project dietician and a project catering adviser were employed part-time for two years to produce over 600 recipes that were each nutritionally analysed. The recipes were incorporated into individual recipe files for each kitchen in NHS Tayside.
Caterers were then asked to use the recipes and feed back their comments to the project team over a three- month period. Patients were also asked to give their views on the meals produced by these recipes by responding to questionnaires. The caterers had difficulties in manually calculating ingredients, resulting in further consultation and testing. The new recipes are due to be implemented by the end of 2006.
Using a dedicated resource to develop the standard recipes was a significant step towards ensuring the use of fully nutritionally analysed menus. However, a number of challenges have been identified:
• Standard recipes involve additional work for chefs to manually calculate ingredients. • Some areas still prefer established recipes rather than the standard versions which have been tested. However, local variations can be incorporated into the recipe file if they are of acceptable nutritional value. • Each time a change is made to the ingredients or method of a recipe this requires an updated nutritional analysis to be carried out. • The nutritional analysis of dishes and menus can only be relied upon if standard recipes are followed by caterers.
19 The survey included fourteen NHS boards, the State Hospital and the Golden Jubilee National Hospital. 8
Case study 2 NHS Fife
In addition to a formal protocol for communication between ward and catering staff, NHS Fife catering departments distribute an A-Z directory which covers the main areas of the catering service. The directory gives ward staff an overview of the catering services provided in the hospital. It summarises the main policies and procedures for catering and aims to provide clinical staff with simple to read answers to queries they are likely to have about the catering services.
The directory can be used for training new staff or bank staff and provides a quick reference guide for all staff working on wards.
Communication between ward staff and needs at different hospitals but • to focus ward activities on the and catering staff has improved outlines seven objectives for wards service of food, providing patients 24. The baseline report noted the adopting the policy: with support at mealtimes importance of good communication between ward staff and catering • to provide mealtimes free from • to emphasise to all staff, patients staff as an essential part of providing avoidable and unnecessary and visitors the importance of a quality patient meal service. Our interruption mealtimes as part of care and study found that 13 boards have a treatment for patients. written protocol for communication • to create a quiet and relaxed between wards and catering atmosphere in which patients 26. Less than a quarter of hospitals departments.20 Case study 2 have time to enjoy meals, limiting reported that they are operating gives an example of how catering unwanted traffic through the ward protected mealtimes policies. Our departments can proactively pass on during mealtimes, eg, estates ward observations indicated that information to ward staff. work and linen deliveries there is variation in the extent to which they have been implemented Practices which help patients • to recognise and support the at ward level. to eat a nutritious diet while in social aspects of eating hospital need to be more widely 27. Difficulty in prioritising the adopted across all hospitals • to provide an environment nutritional care of patients was 25. In 2004, the Hospital Caterers conducive to eating, that is highlighted in a recent survey Association and the Royal College welcoming, clean and tidy commissioned by Age Concern.22 of Nursing developed a protected This found that nine out of ten nurses mealtimes policy which recognises • to limit ward-based activities, reported that they do not always the importance of mealtimes and the both clinical (eg, drug rounds) have time to help patients who need to ensure ward staff are able to and non-clinical (eg, cleaning need assistance with eating. These focus on patients’ nutritional care at tasks) to those that are relevant findings are consistent with our own mealtimes.21 The policy recognises to mealtimes or ‘essential’ to ward observations and underline the the different healthcare environments undertake at that time need to ensure that ward managers
20 NHS Shetland, NHS Tayside and the Golden Jubilee National Hospital do not have written protocols for communication between wards and catering departments. 21 http://www.hospitalcaterers.org/pages/Library/protmealpol.html. 22 ICM Research interviewed a sample of 500 nurses across Britain between 3-7 August 2006. Part 2. Meeting patients’ needs and preferences 9
schedule enough time to prioritise 29. Our survey found that 93 per place to ensure that they are able to the nutritional needs of patients. cent of hospitals with long-stay beds provide for special diets where these were operating a menu cycle of at are identified at ward level. All boards have systems in place least three weeks. to offer patients choice and to Three-quarters of hospitals code cater for patients with special Ninety-seven per cent of hospitals their menus to help patients with dietary needs offer at least two meal choices at special dietary needs select meals both lunch and dinner 33. In order to help patients make 2003 Recommendation: Acute 30. Choice is an important factor in an informed choice about their hospitals with long-stay beds encouraging patients to maintain meals, menus can be coded to should ensure that they have a a balanced nutritional diet while in make it clear whether they are three-week menu cycle, at least hospital. Ninety-seven per cent of suitable for vegetarians, patients for these patients. hospitals offer at least two main on therapeutic diets, patients with meal choices at both lunch and allergies, or patients with eating or 2003 Recommendation: Menus dinner for patients ordering from the swallowing difficulties. Three-quarters should be reviewed to ensure standard menu. of hospitals are coding their menus that they offer sufficient choice with this information. to all patient groups. Where it is Boards have systems in place to necessary, separate menus should cater for patients with special Catering services are offering an be developed for ethnic meals and dietary needs and preferences improved level of choice to patients other special diets. 31. Boards reported that they are catering for an increasing number of 2003 Recommendation: Boards 2003 Recommendation: All menus patients with special diets. Therefore should remind all their staff of the should be dietary coded to help the meals available should provide procedures for offering, ordering patients make an informed choice. sufficient choice to meet these dietary and delivering meals and in needs and preferences. Nine out of particular meals for patients who Acute hospitals with long-stay ten hospitals provide menu options for require a special diet. beds operate at least a three-week vegetarian patients. Half of hospitals menu cycle to maintain variety in offer cultural or religious belief meals 2003 Recommendation: All the meal options for these patients from the menu and a third offer a catering services should aim to 28. In 2000, a report by the Clinical menu option for vegan patients. have patients ordering their meals Resource and Audit Group (CRAG) as close to the meal time as into the nutrition of elderly people 32. Although many hospitals do not possible and no more than two in long-term care recommended offer these meals from the daily meals in advance. that elderly patients in long-stay menus, there was evidence that wards should have at least a three- all hospitals (with the exception of Boards ensure that staff are aware week menu cycle to avoid patients New Craigs Hospital) have systems of processes for providing meals getting bored of the same menu in place to offer choice to patients to patients choices on too regular a basis.23 A with special dietary needs and 34. NHS QIS found that all boards report by Age Concern notes that this preferences. A flexible approach has ensure that staff who are in contact recommendation should be balanced been adopted by hospitals across with patients’ food are aware of: by the observation that many people Scotland to reflect the different the local protocol or processes for enjoy a simple diet at home and may demography of the populations ordering and delivering food and not want to try new meals during served. Many hospitals have drinks; meal and snack times; and their time in hospital.24 As a result, developed their systems to reflect procedures for ordering missed hospitals should provide a long menu their patient populations and do not meals. This is achieved through local cycle to avoid patients facing the put menu items for all special diets induction programmes and ward same choices too often but also need on the menu every day as this would orientation as well as the use of to be flexible to provide favourite have implications on cost and waste. posters, information leaflets and meals in line with patient preferences. This is discussed further in Part 3. guides which remind staff of this However, they have arrangements in information.25
23 The nutrition of elderly people and nutritional aspects of their care in long-term care settings, Clinical Resource and Audit Group (CRAG), August 2000. 24 Hungry to be Heard: The scandal of malnourished older people in hospital, Age Concern, August 2006. 25 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006. 10
Exhibit 2 Percentage of hospitals ordering meals in advance of the mealtime
Three-quarters of hospitals allow patients to order food two meals or less in advance of the mealtime.
40 36 35
30 27
25
20 20 17
ercentage of hospitals of ercentage 15 P
10
5
0 At mealtime One meal in advance Two meals in advance More than two meals in advance
Source: Audit Scotland survey, June-August 2006
Almost all hospitals offer patients 37. If portion sizes are selected are not able to eat at regular a range of portion sizes and ordered in advance then mealtimes. It is therefore important 35. Giving patients the opportunity to catering departments can produce that hospitals respond to these pick the amount of food they want the correct amount of food, but needs and are flexible about increases the choice available and patients’ appetites may change providing snacks outwith normal allows them to reflect their normal between ordering the food and the mealtimes. eating preferences. When at home, mealtime. This can result in more some patients would normally have food being left uneaten by patients 39. In 95 per cent of hospitals, only a light lunch and then have (plate wastage). However, if portion wards are able to provide snacks their main meal at dinner time or size is selected at the mealtime for patients either to supplement vice versa. Hospital catering should then catering departments will not mealtimes or to compensate where be flexible to try to match individual know how many patients want large meals have been missed. We also eating patterns. portions and will have to estimate found that 85 per cent of hospitals how much food will be needed. This were able to offer patients snacks 36. Our survey found that all can result in surplus food being sent prepared in the catering department hospitals (with the exception of to wards to ensure that all patients outwith normal mealtimes. New Craigs Hospital) offer a range are given a choice (wastage in of portion sizes for menu items. This unserved meals). Therefore, giving Patients in three-quarters of gives each patient the opportunity choice to patients over the size of hospitals can order their meals to choose an amount of food to the portion they want can also affect two meals or less in advance match his or her appetite. The range the level of wastage. 40. Our baseline report of portion sizes available to patients recommended that patients should should be quantified in all standard Snacks are available to patients be given the chance to order their recipes and nutritional analysis of outside normal mealtimes meals no more than two meals in menu items (discussed in paragraphs 38. Due to clinical activity taking advance of the mealtime.26 Exhibit 2 18-23) to ensure that these analyses place throughout the day, some shows that 73 per cent of hospitals provide an accurate assessment of patients will miss mealtimes. are now achieving this, with 20 per nutritional intake. Similarly, medication may affect cent providing choice as the meal patients’ appetite or clinical is served. Less than half of the symptoms may mean that patients hospitals reviewed in 2003 were operating in this way. 26 Catering for Patients, Audit Scotland, November 2003. Part 2. Meeting patients’ needs and preferences 11
Boards have some processes in improve the quality of services both in meetings and then discussing these place to seek patients’ views on kitchens and on wards. An example of directly with catering staff. The minutes catering services this is given in Case study 3 (overleaf). of these meetings record where actions are agreed to improve services 2003 Recommendation: Boards 44. A variety of other patient as a result of the issues raised. should ensure that they obtain feedback systems are in place at local patients’ views on the catering level. Four-fifths of hospitals are using Recommendations service through the introduction of other systems such as patient forums regular (at least quarterly) patient or individual interviews in place of • Nutritional screening of all satisfaction surveys. a patient survey or to supplement patients on admission to hospital their findings. But 11 hospitals (seven should be a priority for all boards. A standard survey has been per cent) do not have any systems developed by the Health Facilities in place to gather or act on patients’ • Boards should put protected Scotland Catering Group views on hospital catering.27 mealtimes policies in place to 41. In January 2006, the Health ensure that mealtimes are free Facilities Scotland Catering Group 45. Another indicator of patient from non-essential clinical activity agreed the format of a patient satisfaction is the amount of food and that there are enough staff satisfaction questionnaire. This returned uneaten on patients’ plates. on wards to help all patients eat aimed to standardise the questions This measure can be influenced by a nutritious diet while in hospital. asked in each board and allow better a number of factors, such as loss of comparison of information on patient appetite caused by medication or • The SEHD should ensure satisfaction. All boards have made a symptoms of illness, but could be that the catering and nutrition commitment to carry out the survey linked with other patient feedback specification is published in annually and share the results. systems to provide a more complete 2007 as planned. picture of the level of satisfaction Only 30 per cent of hospitals with the food provided. • All boards should ensure that are regularly monitoring patient standard recipes are used for satisfaction with hospital catering Some hospitals are exploring all meals. These should detail through patient surveys innovative ways of encouraging all ingredients, quantities, cooking 42. The progress made in developing patient groups to be able to give method and the expected a standard survey for all boards is their views on hospital food number of portions. The SEHD not yet reflected in a coordinated 46. Some boards have undertaken should consider developing a approach at hospital level. Almost innovative work to ensure that the national database of standard a fifth of hospitals are not using methods used to record patients’ recipes for the NHS in Scotland patient satisfaction surveys at all. In views are appropriate to the client to promote this. the hospitals that are using patient group. For example, patients with surveys, the frequency of gaining learning difficulties may find it difficult • Catering departments and patient feedback varies widely to complete a questionnaire but dieticians should work together (Exhibit 3, overleaf). Regular monitoring trained staff can discuss satisfaction to ensure that all menus are of patient satisfaction is essential levels with patients in an informal way fully nutritionally analysed and if patients’ views are to be used to in order to get their views on catering. updated whenever any changes improve service delivery. But only 30 are made to recipes or menus. per cent of hospitals are meeting our 47. We also found examples of baseline recommendation that patient patients in long-stay hospitals being • All boards should regularly satisfacation surveys should take place encouraged to join catering groups, monitor patient feedback and at least once every three months. where patients meet with catering use this as part of quality staff on a regular basis to raise and improvement. This can be 43. However, we did find areas of good discuss issues with the service achieved through methods such practice where boards are developing (Case study 4, overleaf). Patients are as patient satisfaction surveys, comprehensive systems for gaining encouraged to raise issues by putting monitoring plate wastage and patient feedback and using this to concerns on the agenda for these reviewing feedback from carers.
27 Arbroath Infirmary, Blairgowrie Community Hospital, Crieff Community Hospital, Irvine Memorial Hospital, Little Cairnie Hospital, Royal Dundee Liff Hospital, Royal Victoria Hospital, St Margaret’s Hospital, Stracathro Hospital, Strathmartine Hospital and Whitehalls Health & Community Care Centre do not have systems to gather patients’ views on catering services. 12
Exhibit 3 Frequency of gathering patient feedback through surveys
Thirty per cent of hospitals are gathering patient feedback through surveys at least four times each year.
Frequency of patient satisfaction surveys Number of hospitals At least once every three months 45 Once every six months 14 Once every 12 months 30 No set frequency 33 Never 27
Source: Audit Scotland survey, June-August 2006
Case study 3 NHS Lanarkshire
The Property Support Services Department has worked with the Dietetics, Patient Affairs and Clinical Effectiveness departments to develop a patient catering opinion survey. The survey is issued quarterly and covers all 17 hospitals including both acute and primary care. The survey analyses quality in three key areas: patient meals; service; and therapeutic and special diet meals.
Patients can comment on breakfast, lunch and evening meals. A detailed analysis of responses allows for targeted service improvement in each of these three areas.
As the system continues to be developed, in conjunction with the Clinical Effectiveness Department, the results of the surveys will be made available to staff via the Intranet. Information will be available to be viewed at ward or hospital level enabling managers, catering staff, dieticians and ward staff to analyse the results relevant to their work.
Case study 4 The State Hospital
At the State Hospital, members of the catering and dietetic staff meet with patient representatives on a regular basis in a subgroup of the Patient Partnership Group. This group gives patients an opportunity to raise concerns about meals provided and discuss ideas for improvement.
Topics discussed by the group include the quality of particular menu items, the availability of fresh fruit, the provision of kosher diets and the size of food portions. Catering and dietetic staff give a direct response to the issues raised and either change the services provided to take account of these or else explain why this is not possible.
The minutes of these meetings record agreement on any further action that is needed to resolve the issues discussed. This enables patients who attend the group to monitor progress against the commitments made to service improvement. 13 Part 3. Financial management
Key findings Hospital catering costs have risen 49. Catering costs have risen more more slowly than other slowly than other operating costs. • Catering costs have risen by operating costs Between 2003/04 and 2004/05, a third since the baseline. spending on catering rose by 1.8 per Catering staff costs have 2003 Recommendation: Boards cent (this was less than the rate of risen due in part to the low should ensure that they have inflation).30 Over the same period the pay agreement, whereas the appropriate financial information total operating costs for the hospital costs of food and beverages on the catering service to allow sector rose by 11.1 per cent.31 per patient day have remained informed decision-making. stable. There remains wide variation in 2003 Recommendation: Boards the amount spent on catering • Hospital catering costs have should base their catering budgets services risen more slowly than other on the most recent, relevant and operating costs. There remains accurate information available. 50. The average catering costs per wide variation in the amount inpatient week vary from £42 in spent on catering services Spending on catering has risen by NHS Highland to £280 at the Golden across boards. a third since our baseline report Jubilee National Hospital. Exhibit 5 48. In 2004/05, the NHS spent (overleaf) shows that catering costs • Catering services for NHS £73 million on catering services in per inpatient week are much higher staff and visitors are not Scottish hospitals.28 Spending on in Orkney, Shetland and the Golden breaking even. catering services has risen by 33 per Jubilee than in the other boards cent since the baseline report. but this is due in part to the smaller • Boards have reduced the Exhibit 4 (overleaf) shows that most amount of inpatient activity in these number of unserved meals that of this increase took place between areas. In the other 14 boards where are wasted. 2002/03 and 2003/04 and is due inpatient activity is higher, the catering in part to the low pay agreement costs per inpatient week still vary introduced at that time.29 from £42 to £68.
28 Scottish Health Services Costs, year ended 31 March 2005, ISD. 29 NHSScotland – Low Pay Agreement, SEHD HDL (2003) 15. 30 Hospital & Community Health Services pay and price index, Department of Health, 2006. 31 Scottish Health Services Costs, years ending 31 March 2004 and 31 March 2005, ISD. 14
Exhibit 4 Catering services costs between 2001/02 and 2004/05
Year Spending (£000) Number of patient Cost per patient consumer weeks consumer week (£) 2001-02 54,717 1,350,623 40.5 2002-03 59,249 1,304,046 45 2003-04 71,742 1,281,093 56 2004-05 73,017 1,234,322 59
Source: Scottish Health Services Costs, ISD
Exhibit 5 Boards’ catering costs per inpatient week, 2004/05
Costs per inpatient week vary across boards.
300
250 £
200
150
100 Cost per inpatient week week inpatient per Cost
50
0 y d y e y al al w de ilee Fif hian side alle b t owa orders ay Ju Orkne Lo T B th V th Shetland Highlan r tern Isles tern Grampian s Lanarkshire Fo ate Hospit ate We St Argyll & Cly & Argyll Golden Golden yrshire & Arran & yrshire A Greater Glasgo Greater Dumfries & Gall & Dumfries
NHS boards and special boards
32 Source: Scottish Health Services Costs, year ended 31 March 2005, ISD
32 An error in NHS Lanarkshire’s accounts meant that the catering costs for 2004/05 were overstated by £554,000 at Monklands Hospital. The revised figure for NHS Lanarkshire would be £62 per inpatient week. Part 3. Financial management 15
Exhibit 6 Comparison of components of total cost 2001/02 and 2005/06
Catering staff costs have increased more quickly than the costs of food and beverages.
15
12 2003
2006 9 n £ millio £ 6
3
0 Staff Food & Beverages Other
33 Source: Audit Scotland survey, June-August 2006
Catering staff costs have risen 37.5 hours instead of 39 hours.34 to purchase food and beverages more quickly than the costs of However, any increase in staff costs played a key role in managing the food and beverages due to the new terms and conditions increase in these costs. for staff currently being implemented 51. In the small sample of hospitals under Agenda for Change are not yet Catering services for NHS staff and we reviewed, staffing accounts for the included in these figures.35 visitors are not breaking even largest part of catering costs. Since our baseline report, their catering There has been little change in the 2003 Recommendation: All staff costs have risen by 44 per cent, cost of food and beverages per catering departments should have due mainly to the introduction of patient day systems in place which allow the low pay agreement. Over the 53. The cost of patients’ food and them to accurately calculate the same period, spending on food and beverages per patient day in the costs of providing patient and non- beverages increased by seven per sample of hospitals we reviewed patient catering. cent. The actual changes in costs for has remained the same. Exhibit 7 the sample hospitals reviewed are (overleaf) shows the cost of patients’ 2003 Recommendation: Boards shown in Exhibit 6. food and beverages per patient day in should set pricing policies and 2005/06 for 21 of the sample hospitals income generation targets that 52. The number of staff employed in reviewed. Although these costs vary aim to at least break even on non- catering departments has remained among hospitals, the average level patient catering activities or have a relatively constant at around 2,150 for the sample hospitals where we clear stated policy on the level and whole time equivalent (WTE) between can compare across both years rose cost of subsidisation. 2001/02 and 2004/05. One factor that from £2.23 in 2001/02 to £2.34 in increased catering staff costs was the 2005/06.36 This rise is lower than the The extent to which boards are introduction of the low pay agreement rate of inflation over the same period.37 subsidising non-patient catering is in 2003. Under this no NHS employee becoming more transparent would earn less than £5.18 per hour 54. Boards reported that the 55. Most hospitals provide catering for and overtime rates took effect after continued use of national contracts NHS staff and visitors – this is known
33 These results are based on a sample of 15 hospitals which provided financial information for 2001/02 and 2005/06. 34 NHSScotland – Low Pay Agreement, SEHD HDL (2003) 15. 35 Once boards have implemented new terms and conditions under Agenda for Change, these will be backdated to October 2004. 36 Based on 19 of the sample hospitals which returned this information for 2001/02 and 2005/06. 37 Hospital & Community Health Services pay and price index, Department of Health, 2006. This reports a non-pay price increase of 5.5 per cent over this period. 16
Exhibit 7 Cost of patients’ food and beverages per patient day, 2005/06
Spending on patients’ food and beverages varies among hospitals.
Gartnavel General Hospital
Royal Cornhill Hospital
Crosshouse Hospital
Liberton Hospital
St John’s Hospital
Falkirk & District Royal Infirmary
Stirling Royal Infirmary
Ailsa Hospital
Ninewells Hospital
Dumfries & Galloway Royal Infirmary
Caithness General Hospital
Perth Royal Infirmary
Western General Hospital
Raigmore Hospital
Astley Ainslie Hospital
Southern General Hospital
Royal Edinburgh Hospital
Western Isles Hospital
State Hospital
Sunnyside Royal Hospital
Bo'ness Hospital
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Cost (£)
Source: Audit Scotland survey, June-August 2006 Part 3. Financial management 17
as non-patient catering. In July 2005, have clearly defined pricing policies Wastage levels need to be managed the SEHD issued guidance which and income generation targets to balance the cost implications with requires that non-patient catering which aim to at least break even.41 the quality of the service offered. activities must now at least break even Exhibit 8 (overleaf) shows the level or NHS bodies should have a clear, of contribution or subsidy achieved in 60. Wastage can occur in production written policy on the level and costs of 2005/06 for the sample of hospitals (kitchen wastage), in the wards subsidisation.38 The guidance requires who returned this information. (unserved meals), or in uneaten boards to produce trading accounts in food left by patients (plate wastage). 2006/07 for each catering department 58. Boards reported that price Monitoring wastage levels at these showing if non-patient catering is: increases will be necessary to reduce three stages provides hospitals with these subsidy levels. However, they useful information to help control • breaking even against the budget also reported that where prices had costs and understand patients’ been increased too quickly this had preferences. Twelve boards have set • budgeting for anticipated wage resulted in opposition from Partnership wastage targets ranging from zero increases Forums or a reduction in the number per cent to 12 per cent and two- of staff using hospital catering facilities. thirds of hospitals are monitoring • contributing to overhead costs wastage against these targets. such as training, travel, hardware Boards have reduced wastage due and crockery to unserved meals There has been a significant reduction in wastage due to • being subsidised, and if so to 2003 Recommendation: All unserved meals provide clear justification for hospitals should aim to reduce the 61. Exhibit 9 (page 19) shows the subsidisation. level of ward wastage (unserved change in wastage levels recorded meals) to ten per cent. for unserved meals for the hospitals 56. We found that half of boards reviewed in 2003 compared with are operating trading accounts for Two-thirds of hospitals are 2006. Seventy-five per cent of the all their catering departments.39 monitoring wastage against targets hospitals in this sample have reduced Eighty-nine hospitals reported that 59. Food waste has an effect on their wastage levels and 21 of the they could split the costs of patient the cost of catering services and 24 have achieved the recommended and non-patient catering services. unnecessary waste should therefore target wastage level of ten per cent. Of these, 40 hospitals reported that be kept to a minimum. Since the they were subsidising non-patient baseline report, boards have been Recommendations meals and 32 hospitals reported required to have waste management that they were not subsidising non- procedures to monitor and reduce • Boards should set pricing patient meals. Fourteen hospitals waste.42 However, wastage is also policies and income generation reported that they did not know if linked to the amount of choice targets that aim to at least they were subsidising non-patient available to patients. It can be affected break even on non-patient catering services and three hospitals by the number of options on the catering activities or have a used private contractors who would menu as well as how far in advance clear stated policy on the level not provide this information. meals are ordered. For example, and cost of subsidisation. allowing patients to choose their meal Boards are still subsidising non- at the mealtime rather than 24 hours • All boards should continue to patient services in advance should mean that the meal monitor and control wastage. 57. A year after the SEHD issued will better reflect their preference at All hospitals should reduce its guidance, half of boards have a that time. But in order to provide that or maintain ward wastage at policy on subsidisation of non-patient level of choice, extra meals have to be below ten per cent. catering services.40 Only seven boards produced to give all patients choice.
38 NHSScotland: Guidance on charging for non-patient catering and the production of catering trading accounts, SEHD HDL (2005) 31. 39 NHS Ayrshire and Arran, NHS Fife, NHS Grampian, NHS Orkney, NHS Tayside, NHS Western Isles, the Golden Jubilee National Hospital and the State Hospital are operating trading accounts for all their catering departments. 40 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Grampian, NHS Greater Glasgow and Clyde, NHS Lanarkshire, NHS Orkney, NHS Western Isles and the Golden Jubilee National Hospital have policies on the subsidisation of non-patient catering services. 41 NHS Ayrshire and Arran, NHS Borders, NHS Greater Glasgow and Clyde, NHS Highland, NHS Lanarkshire, NHS Lothian and NHS Western Isles have clearly defined pricing policies and income generation targets which aim to at least break even. 42 NHSScotland: Guidance on charging for non-patient catering and the production of catering trading accounts, SEHD HDL (2005) 31. 18
Exhibit 8 Contribution or subsidy level of non-patient catering services, 2005/06
Nearly two-thirds of the sample hospitals are still subsidising non-patient catering.
Southern General Hospital
Raigmore Hospital
Crosshouse Hospital
Ailsa Hospital
State Hospital
Coathill Hospital
Royal Edinburgh Hospital
Liberton Hospital
Dumfries & Galloway Royal Infirmary
Caithness General Hospital
Western Isles Hospital
Royal Cornhill Hospital
Falkirk & District Royal Infirmary
Stirling Royal Infirmary
Leverndale Hospital
Gartnavel General Hospital
Astley Ainslie Hospital
St John’s Hospital
Western General Hospital
-500 -400 -300 -200 -100 0 100 200 300
Subsidy (£000) Contribution (£000)
43 Source: Audit Scotland survey, June-August 2006
43 Based on 19 of the sample hospitals which returned this information. Part 3. Financial management 19
Exhibit 9 Comparison of wastage measured in unserved meals on wards in 2003 and 2006
The level of wastage measured in unserved meals has reduced.
Ailsa Hospital
St John’s Hospital 2003
Western General Hospital 2006 Caithness General Hospital
Falkirk & District Royal Infirmary
Gartnavel General Hospital
Victoria & Forth Park Hospital
Dr Gray's Hospital
Dumfries & Galloway Royal Infirmary
Aberdeen Royal Infirmary
Sunnyside Royal Hospital
Crosshouse Hospital
Perth Royal Infirmary
Raigmore Hospital
Hairmyres Hospital
Ninewells Hospital
Royal Alexandra Hospital
Queen Margaret Hospital
Southern General Hospital
Glasgow Royal Infirmary
Royal Dundee Liff Hospital
Leverndale Hospital
Western Isles Hospital
Stirling Royal Infirmary
0 10 20 30 40 50
Percentage
44 Source: Audit Scotland survey, June-August 2006
44 Based on 24 of the sample hospitals who returned this information in both 2003 and 2006. 20 Part 4. Strategic management
Key findings Catering services are becoming monitoring progress against their more of a strategic priority at strategies.45 Five boards have still • Catering services are becoming board level to develop a food and health policy a higher strategic priority in line with the Diet Action Plan for for boards. 2003 Recommendation: Boards Scotland.46 should ensure that a clear strategy • Catering staff vacancy rates has been approved for the future 63. In 2000, the government gave remain high. provision of catering services most public authorities in Britain a where other services are being legal duty to promote race equality. • Agenda for Change has reconfigured. As part of this duty, public bodies, not resulted in standard job including NHS boards, should descriptions or pay grades 2003 Recommendation: All assess and monitor policies for any for catering staff in different boards should have a food and effects they might have on people boards. health policy in line with the Diet from different racial groups.47 A Action Plan for Scotland. race equality impact assessment • A fully functioning national systematically assesses the possible eProcurement system for Eight boards have a clear written effects that a policy may have on catering is not yet in place strategy for the future provision people depending on their racial across the NHS in Scotland. of catering group. Although boards showed 62. There has been an increase in evidence of responsiveness to the number of boards with a catering equality issues at an operational strategy since the baseline report. level, only four had carried out Eight boards now have a catering an equality impact assessment strategy, although only seven are of their board’s strategic catering documents.48
45 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Forth Valley, NHS Grampian, NHS Lanarkshire, NHS Shetland, NHS Western Isles and the State Hospital have catering strategies (the State Hospital is not yet monitoring progress against their strategy). 46 NHS Dumfries and Galloway, NHS Forth Valley, NHS Highland, NHS Tayside and the Golden Jubilee National Hospital do not have food and health policies in line with the Diet Action Plan for Scotland. 47 The Race Relations Act 1976, as amended by the Race Relations (Amendment) Act 2000, gives public authorities a statutory general duty to promote race equality. 48 NHS Ayrshire and Arran, NHS Dumfries and Galloway, NHS Shetland and NHS Western Isles have carried out an equality impact assessment on their catering strategy. Part 4. Strategic management 21
64. Boards have developed work on Catering staff sickness absence 68. The FMS is a potential tool for catering strategies alongside, or as rates are still high managers to use to systematically part of, nutritional care strategies. 66. The average level of sickness analyse many of the key indicators NHS QIS found that three-quarters absence in the sample of hospitals reported in this review. The system of boards had started the process we reviewed has remained at the has the potential to assist in the of developing and implementing a same level as it was three years regular monitoring of performance nutritional care policy and strategic ago (7.2 per cent). Exhibit 11 (page to improve decision-making at an plan. While progress has been slow, 23) shows there have been large operational and strategic level. all boards now have nutritional care changes in sickness absence levels However, it will be dependent on groups in place which are central in some of these hospitals but this the quality of the data recorded in to the further development and may be due to the small number other computer systems such as implementation of catering and of staff employed in some catering the Scottish Workforce Information nutritional care at a strategic level.49 departments. Where sickness Standard System (SWISS) and levels are high, boards reported PECOS.50 Catering staff vacancy rates and that long-term sickness absence sickness absence rates remain high was a contributing factor. Some Implementation of Agenda for boards have introduced more Change varies among boards 2003 Recommendation: Boards robust sickness absence policies should monitor staff vacancy and accompanied by return-to-work 69. Catering staff are being given turnover rates on a regular basis. interviews to manage sickness new terms and conditions under the absence rates. Agenda for Change review. The new 2003 Recommendation: Staff terms and conditions cover standard vacancy and turnover rates are A Facilities Management System hours, overtime payments, annual high in some areas. Where this which aims to provide managers leave and basic pay. It also introduces is the case, boards should take with regular monitoring reports on the NHS Knowledge and Skills action to address these issues. catering services is being piloted Framework which links education in Tayside and development with career and Staff vacancy rates have reduced 67. In 2005, NHS Tayside received pay progression. but remain high £220,000 from the SEHD to develop 65. All boards except NHS Grampian a national Facilities Management 70. NHS Ayrshire and Arran, NHS are formally monitoring sickness System (FMS) for the NHS in Orkney, and the State Hospital absence and staff vacancy rates for Scotland. The first phase of the have not yet changed the terms catering staff. Catering staff vacancy system, covering financial and and conditions of catering staff in rates across the sample hospitals are operational key performance line with Agenda for Change. Other on average two per cent lower than indicators (KPIs), is due to be rolled boards have changed terms and in 2001/02 but remain high at 7.8 out in NHS Tayside in November conditions for catering staff but have per cent. Exhibit 10 (overleaf) shows 2006. The FMS provides access not yet evaluated the job descriptions that there are large differences in to management information on for management, or clerical and vacancy levels among the sample the intranet, via NHSnet, allowing administrative staff involved in catering. hospitals. Some boards reported service managers, board directors that vacancies were being held and the SEHD to access and analyse 71. A benchmarking exercise carried open to allow for future flexibility in information at an appropriate level. out by the Health Facilities Scotland staff changes without the need for Monthly monitoring of the KPIs Catering Group confirmed the results redundancies. Boards also reported such as financial reports, sickness of our interviews which found that that high turnover rates were closely absence, overtime, headcount, Agenda for Change has not resulted linked to unsociable hours worked on staff turnover and vacancy can be in standard job descriptions or pay backshift and to the repetitive nature compared against previous years and grades for catering staff across of some of the jobs involved. benchmarked against other hospitals. different board areas. For example, The benchmarking tool is dependent head cooks’ pay bands vary on the successful roll-out of the FMS among boards. across Scotland.
49 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006. 50 Professional Electronic Commerce On-line System (PECOS) is an electronic procurement system. 22
Exhibit 10 Catering staff vacancy rates for 2005/06
Vacancy rates vary among sample hospitals.
Sunnyside Royal Hospital
Liberton Hospital
Stirling Royal Infirmary
Raigmore Hospital
Ailsa Hospital
Leverndale Hospital
Gartnavel General Hospital
St John’s Hospital
Crosshouse Hospital
Falkirk & District Royal Infirmary
Bo'ness Hospital
Southern General Hospital
Astley Ainslie Hospital
Coathill Hospital
Queen Margaret Hospital
State Hospital
Royal Edinburgh Hospital
Perth Royal Infirmary
Royal Alexandra Hospital
Western General Hospital
Victoria & Forth Park Hospital
Western Isles Hospital
Dumfries & Galloway Royal Infirmary
Ninewells Hospital
0 5 10 15 20 25
Percentage
Source: Audit Scotland survey, June-August 2006 Part 4. Strategic management 23
Exhibit 11 Catering staff sickness absence rates for 2001/02 and 2005/06
Sickness absence rates remain high.
2001/02
Sunnyside Royal Hospital 2005/06 Stirling Royal Infirmary
Falkirk & District Royal Infirmary
Coathill Hospital
Ninewells Hospital
Ailsa Hospital
Southern General Hospital
Liberton Hospital
Raigmore Hospital
State Hospital
Dumfries & Galloway Royal Infirmary
St John’s Hospital
Gartnavel General Hospital
Crosshouse Hospital
Royal Alexandra Hospital
Royal Edinburgh Hospital
Perth Royal Infirmary
Leverndale Hospital
Western Isles Hospital
Caithness General Hospital
Western General Hospital
Astley Ainslie Hospital
Bo'ness Hospital
0 5 10 15 20
Percentage
51 Source: Audit Scotland survey, June-August 2006
51 This is based on 23 of the sample hospitals who returned this information for 2001/02 and 2005/06. 24
Boards reported that this is affecting being rolled out across Scotland. 12 boards that we visited were able staff morale and could lead to Concerns include: to provide evidence of how these further difficulties in recruitment and systems are operating to manage the retention. • the slow speed at which the risks in areas such as temperature system operated control and food hygiene. Boards have found it difficult to plan for the financial impact of • problems in using the system Boards are continuing to meet changes to catering staff’s terms and which initially could not deal with their statutory requirements conditions under Agenda for Change decimal points in health and safety and food 72. The financial management hygiene training of Agenda for Change has been • incomplete and out-of-date lists of 78. NHS QIS found that all boards problematic. Boards have had to suppliers on the system. provide staff who are in contact earmark funding in the knowledge with patients’ food with training in that the Agenda for Change review 75. The intended roll-out of PECOS health and safety issues, and food will alter the pay rates of some staff will have cost implications for hygiene commensurate with their but without good information on the boards, therefore, many boards are duties. However, they also reported costs involved. waiting until the problems have been that difficulties in releasing staff resolved before making any further from their duties could reduce the A fully functioning national investment. As a result, boards are attendance rates on these courses. eProcurement system for catering still using different procurement Overall, boards were meeting their is not yet in place across the systems and some boards are statutory requirements in health and NHS in Scotland operating more than one system at safety and food hygiene training.52 different hospitals. This means that 73. The SEHD has selected many of the intended benefits of Ninety per cent of boards have eProcurement Scotland as the PECOS are not yet being realised. food safety manuals and infection common procurement service control policies which include for NHS Scotland. The software 76. Some boards are developing links catering services Professional Electronic Commerce between their electronic systems 79. Our survey found that catering On-line System (PECOS) is intended for recipes, menus, procurement services were included in the food to provide users with tools to and finance to provide a more safety manuals and infection control support procurement with intended coordinated delivery of catering policies of most boards. NHS Lothian benefits including: services. These aim to improve the and NHS Tayside reported that they speed and accuracy of management do not have a food safety manual in • making it easier to monitor information. place. And NHS Grampian and NHS contracts Shetland are the only two boards Boards have the required food that do not have an infection control • monitoring performance and safety and hygiene control systems policy that covers catering services.53 spend patterns in place Boards work with Environmental • improving the accuracy and ease Boards have Hazard Analysis Health Officers through a of maintaining contract items, Critical Control Points systems to programme of regular visits to prices and other data in a secure minimise risks to food safety ensure food safety and hygiene environment 77. Hazard Analysis Critical Control standards are being met Points (HACCP) is a food safety 80. Our survey showed that most • reducing costs and process cycle system that identifies the critical hospitals are inspected annually by times. control points in food production and Environmental Health Officers, but preparation processes, and monitors where concerns have arisen, the 74. However, boards have reported these to ensure that food is safe frequency of visits rose in order to a number of limitations with PECOS for consumption. Boards must have ensure that the hospital was taking which have delayed its progress in HACCP systems in place and the action to resolve problems.
52 Food, Fluid and Nutritional Care in Hospitals – National Overview, NHS QIS, August 2006. 53 NHS Shetland uses private contractors to provide catering services so does not cover catering in its infection control policy. Part 4. Strategic management 25
Recommendations
• Boards should ensure that they have approved a clear strategy for the future provision of catering services.
• All boards should have a food and health policy in line with the Diet Action Plan for Scotland.
• Boards should take action to address issues where catering staff vacancy rates are high. 26 Part 5. Summary of recommendations
Part 2. Meeting patients’ needs 85. Catering departments and Part 4. Strategic management and preferences dieticians should work together 89. Boards should ensure that they 81. Nutritional screening of all to ensure that all menus are fully have approved a clear strategy for patients on admission to hospital nutritionally analysed and updated the future provision of catering should be a priority for all boards. whenever any changes are made to services. recipes or menus. 82. Boards should put protected 90. All boards should have a food mealtimes policies in place to ensure 86. All boards should regularly and health policy in line with the Diet that mealtimes are free from non- monitor patient feedback and use Action Plan for Scotland. essential clinical activity and that this as part of quality improvement. there are enough staff on wards to This can be achieved through 91. Boards should take action to help all patients eat a nutritious diet methods such as patient satisfaction address issues where catering staff while in hospital. surveys, monitoring plate wastage vacancy rates are high. and reviewing feedback from carers. 83. The SEHD should ensure that the catering and nutrition specification is Part 3. Financial management published in 2007 as planned. 87. Boards should set pricing policies and income generation targets that 84. All boards should ensure aim to at least break even on non- that standard recipes are used patient catering activities or have a for all meals. These should detail clear stated policy on the level and ingredients, quantities, cooking cost of subsidisation. method and the expected number of portions. The SEHD should consider 88. All boards should continue to developing a national database of monitor and control wastage. All standard recipes for the NHS in hospitals should reduce or maintain Scotland to promote this. ward wastage at below ten per cent. 27 Appendix 1. Boards and hospitals followed up from baseline
Board Hospital NHS Ayrshire & Arran Crosshouse Hospital Ailsa Hospital NHS Dumfries & Galloway Dumfries & Galloway Royal Infirmary NHS Fife Queen Margaret Hospital Victoria & Forth Park Hospital NHS Forth Valley Stirling Royal Infirmary Falkirk & District Royal Infirmary Bo’ness Hospital NHS Grampian Royal Cornhill Hospital Dr Gray’s Hospital Aberdeen Royal Infirmary NHS Greater Glasgow & Clyde Leverndale Hospital Gartnavel General Hospital Glasgow Royal Infirmary Royal Alexandra Hospital Southern General Hospital NHS Highland Raigmore Hospital New Craigs Hospital Caithness General Hospital NHS Lanarkshire Wishaw General Hospital Hairmyres Hospital Coathill Hospital NHS Lothian Astley Ainslie Hospital Royal Edinburgh Hospital Liberton Hospital Western General Hospital St John’s Hospital State Hospital State Hospital NHS Tayside Royal Dundee Liff Hospital Sunnyside Royal Hospital Perth Royal Infirmary Ninewells Hospital NHS Western Isles Western Isles Hospital 28 Appendix 2. Study advisory group
Members sat on the group in a personal capacity
Kenneth Birrell Project Manager, NHS Forth Valley Bid Team and Chairperson of the West of Scotland Hospital Caterers Association David Browning General Manager, Property and Support Services, NHS Lanarkshire Lynne Cameron Section Manager, Scottish Healthcare Supplies, NHS National Services Scotland Helen Davidson NHS Scotland Food and Nutrition Adviser, Scottish Executive Health Department Janice Gillan Catering Manager, Crosshouse Hospital, NHS Ayrshire & Arran and Co-ordinator of the Catering Sub group of Health Facilities Scotland Anne Hanley Review Manager, NHS Quality Improvement Scotland Caroline Hubbard Project Dietician, Nutrition Standards Project, NHS Tayside Myra Keenan FM Quality Manager, NHS Lothian and Chairperson of the Catering Sub group of Health Facilities Scotland George Reid Catering Manager, NHS Grampian Imran Shariff Project Manager, Race Equality, NHS Greater Glasgow & Clyde Derek Walker Finance Manager, NHS Grampian
Catering for patients A follow-up report
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