Version 1, 1 November 2022

Foreword

Every healthcare organisation has a responsibility to provide the highest level of care possible for their patients, staff and visitors. This includes the quality, nutritional value and the sustainable aspects of the food and drink that is served, as well as the overall experience and environment in which it is eaten.

It is important that all healthcare organisations see the intrinsic value in the view of ‘food as medicine’ and that it remains a standing item on the board agenda. Senior NHS leaders must be held accountable for the standard and quality of food served in their organisation, and patient and staff nutrition must be prioritised.

Many healthcare organisations already provide high quality food and drink to their patients, staff and visitors, but the variation across the country is still too great. Not enough healthy options are consistently available, sustainability is poorly embedded and too much food is wasted.  The Food Leadership team has recognised that things need to improve; the publication of the standards is an important step in that journey.

The Healthcare Food Standards and Strategy Group was set up by NHS England to consider, and follow on from, the work started by the Hospital Food Panel in 2014. Comprising individuals, NHS organisations, suppliers and specialists, the group considered recent reviews and reports, seeking to align direction and to link the reports’ chairs and advisors, who have responded with their support for these standards.

The standards describe the methods by which organisations must ensure the quality and sustainability of their food and drink provision for patients, staff and visitors, and how they should be applied and monitored, as well as recommending future improvement aspirations and actions.

Chief executives are ultimately responsible for ensuring that patients have a positive experience during their stay and that their workforce can access healthy, nutritious and sustainable food and drink in the workplace. These standards will provide you and your teams with the guidance and tools to help achieve this. The maturity matrix (section 5) will not only measure your current position but will help you and your team to identify the pathway to growth and excellence.

As an indication of how seriously we take nutrition and healthcare food, these standards will form part of the legally binding standards in the NHS Standard Contract as well as already being part of the NHS Long Term Plan.

The Food Standards and Strategy Group will continue to monitor the implementation and impact of these standards with a view to supporting organisations to meet and exceed them and will continue to maintain a strong link with the NHS Food Review Expert Group to give suitable assurance on development with notable recommendations.

Although the way we procure, produce and serve our food and drink varies, we must achieve a consistent level of high quality, healthy and sustainable food throughout healthcare catering. The NHS will continue to drive this by adopting these standards.

Simon Corben
Director and Head of Profession, NHS Estates NHS England

The standards

There are eight standards that all NHS organisations are required to meet

1. Organisations must have a designated board director responsible for food (nutrition and safety) and report on compliance with the healthcare food and drink standards at board level as a standing agenda item.
2. Organisations must have a food and drink strategy.
3. Organisations must consider the level of input from a named food service dietitian to ensure choices are appropriate.
4. Organisations must nominate a food safety specialist.
5. Organisations must invest in a high calibre workforce, improved staffing and recognise the complex knowledge and skills required by chefs and food service teams in the provision of safe food and drink services.
6. Organisations must be able to demonstrate that they have an established training matrix and a learning and development programme for all staff involved in healthcare food and drink services.
7. Organisations must monitor, manage and actively reduce their food waste from production waste, plate waste and unserved meals.
8. NHS organisations must be able to demonstrate that they have suitable 24/7 food service provision, which is appropriate for their demographic.

Introduction

These standards build on previous hospital food standards and consider the extensive recommendations in the Independent review of NHS hospital food, as well as key priorities for both the NHS and the government. They will be kept up to date to take account of the changing policy context. The standards cover:

• Section 1: All healthcare food and drink
• Section 2: Patient food and drink
• Section 3: Retail, staff and visitor food and drink
• Section 4: Sustainable procurement and food waste

All organisations must meet sections 1 and 4 of the standards. Sections 2 and 3 apply only where relevant.

Please note:

• in the case of patients, these standards relate to the provision of food and drink only and do not cover specialist nutrition support beyond this.
• there are already statutory standards that healthcare organisations must meet, such as the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically:
  • Regulation 14: Meeting nutritional and hydration needs
  • Regulation 17: Good governance.

Nothing that follows retracts from these.

NHS Standard Contract

The NHS Standard Contract is mandated by NHS England for use by commissioners for all contracts for healthcare services. SC19 specifies: “The Provider must comply with NHS Food Standards”, and thus all organisations subject to the Standard Contract will be required to deliver against these standards.

Improvement through the maturity matrix

These standards introduce a phased approach to embedding improvement in healthcare food and drink services using the Maturity matrix that accompany these standards. This provides guidance, tools, and support materials to enable gradual progress across four key components:

• policy and management
• procurement and commercial
• measurement and results
• people and communications.

The matrix summarises the standards for each area and outlines supporting tools and resources to assess compliance. Organisations can also develop their own framework for achieving these standards and demonstrating continuous improvement.

Monitoring

NHS England will monitor progress through data collections including the Estates Returns Information Collection (ERIC) and Premises Assurance Model (PAM). Organisations will be expected to report annually on their level of compliance for each section of the standards and provide evidence.

1. The standards for all healthcare food and drink

This table details the mandatory standards with which organisations must comply and tools to help.

1. Organisations must have a designated board director responsible for food (nutrition and safety) and report on compliance with the Healthcare Food and Drink Standards at board level as a standing agenda item.

What this means in practice: Board-level reporting provides each trust with the assurance that its organisation is complying, or working towards complying with these food and drink standards, highlighting associated risks and actions. This establishes engagement, knowledge and safety.

Further details of requirements are highlighted in section 2.

Tools: See the summary and ‘A checklist for trust catering managers and chief executives’ in the Independent review of NHS hospital food.

Impact: No cost; should already be in place.

2. Organisations must have a food and drink strategy.

What this means in practice: Each trust must develop its own ‘live’ strategy for improving nutrition and hydration for patients, staff and visitors.

Tools: See the summary, ‘A checklist for trust catering managers and chief executives’ and Chapter 6 ‘Hospital food and drink standards’ in the Independent review of NHS hospital food.

There are a number of excellent examples of food and drink strategies from trusts available directly online.
Impact: No cost; should already be in place.

3. Organisations must ensure they have access to appropriate catering dietetic advice and support.

What this means in practice: Each trust must assess how many posts, or what proportion of time spent on food and beverage services, are appropriate in its hospital. These posts should be responsible for overseeing patient, staff and visitor food and drink.

tools: Food service dietitian job description and person specification.

For detail on the role of a food service dietitian in brief see Chapter 2 ‘Food as medicine’ of the Independent review of NHS hospital food, and in detail see the Nutrition and Hydration Digest.

Impact: No cost; part of business as usual for hospital food services. This can be achieved via the national dietitian, suppliers, facilities management providers or in-house and would not constitute an additional cost unless a trust wished to recruit specifically.

4. Organisations must have a nominated food safety specialist.

What this means in practice: Trusts must recognise their legal obligations as food business operators and ensure effective compliance with robust food safety procedures at all levels. Trusts are responsible for assuring themselves their supply chain is safe.

Our expectations are that trusts have a named Responsible Person, Competent Person, Authorised Person with the Chief Executive Officer being notified for assurance.

Tools: Food safety specialist job description.

See Chapter 3 ‘Safe and sound’ and Annex B in the Independent review of NHS hospital food for further detail on food safety legal obligation.

Impact: No cost; this is an existing legal requirement and therefore should be met from trusts’ existing budget.

5. Organisations must invest in a high calibre workforce and improved staffing and recognise the complex knowledge and skills required by chefs and food service teams in the provision of safe food and drink services.

What this means in practice: Trusts must recognise the complexity of delivering healthcare food and drink services and ensure correct levels of staff (back of house, front of house, housekeeping and support staff) as well as remunerating staff accordingly.

This standard supports food safety, nutritional safety and overall patient safety, as well as a better working environment contributing to staff wellbeing, morale and retention.

Tools: See Chapter 1 ‘Supporting the food heroes’ and Chapter 2 ‘Food as medicine’ in the Independent review of NHS hospital food.

Impact: No additional impact: trusts are expected to remunerate all their staff fairly.

6. Organisations must be able to show they have an established training matrix and a learning and development programme for all staff involved in healthcare food and drink services.

What this means in practice: This standard gives assurance that all staff are practising safely and trained appropriately for their role. This includes ‘non-catering’ staff who handle food, such as nurses or porters, who require food safety training as well as everyone requiring a level of nutrition training.

Tools: See Chapter 1 ‘Supporting the food heroes’ and Chapter 2 ‘Food as medicine’ in the Independent review of NHS hospital food.

Impact: No cost: one-to-ones, appraisals and personal development conversations should already be part of the trust’s learning framework, to ensure staff are trained appropriately.

7. Organisations must monitor food waste, manage any waste produced and take action to reduce the food waste produce in their plate waste, production waste and unserved food.

What this means in practice: Trusts must recognise that reduction in food waste will support funding for better food services for patients, staff and visitors. They should ensure they understand where and why food waste is produced in their organisation to take steps to significantly reduce this.

Organisations will be required to report figures centrally for each type of food waste, and these will be published.

Tools: Appendices 11 and 12: the Balanced scorecard outlined in Annex D: Rationale and checklist for food waste prevention and reduction and WRAP – food waste reduction roadmap toolkit provides supportive detail for implementation.

See Chapter 7 ‘Going green’ and ‘A checklist for trust catering managers and chief executives’ in the Independent review of NHS hospital food.

WRAP’s Guardians of Grub cost-saving skills course can be completed in 15 minutes and will give teams the foundations to set their food waste reduction target, understand how to measure and take action.

NHS England will plan and promote webinars on applying a consistent process to reducing food waste.

Impact: These actions should be expected to deliver reductions in costs for food ingredients and waste disposal, as well as a positive impact on staff behaviour and accountability.

8. Organisations must have suitable food and drink solutions for all staff over a 24/7 service period.

What this means in practice: NHS organisations must be able to show they have suitable 24/7 service provision appropriate for their demographic.

This may include, but not limited to, the following options:

• Retail solution
• Auto cafés
• Staff break areas
• Hydration stations
• Delivery solution
• Smart fridges

Tools: Effective conversations with all staff, procurement, facilities and clinical teams to understand an appropriate solution for the type and size of healthcare site.

Impact: This service should already be in place. Staff work in 24/7 environments, so it is vital that trusts plan to support initiatives focused on sustainability, innovation, staff health and wellbeing, recognising the challenges involved in all staff roles.

Effective leadership

Organisations should identify the key stakeholders responsible for ensuring patients, staff and visitors have a positive experience relating to their nutrition and hydration needs. This could include as a minimum: caterers, dietitians, nurses, speech and language therapists, facilities teams and patient and carer groups.

Board-level reporting

This should include designating a director at board level responsible for food and drink services, including safety and nutrition, and showing that compliance with the standards supports a culture of continuous improvement. They will be responsible for ensuring:

• the organisation achieves agreed targets to increase the level of patient, staff and visitor satisfaction with their food service
• the national standards for healthcare food and drink are implemented across the organisation
• the organisation has a food and drink strategy, evidencing a clear ambition to improve and how this will be achieved
• there is evidence of regular board reporting and compliance status, eg minutes of meeting discussing compliance checklists and documenting actions to be taken
• action plans generated are appropriately concluded
• risks are identified and appropriately managed
• good quality evidence reflects current practice across the organisation, eg Patient Lead Assessment of the Care Environment (PLACE) results
• patient and staff nutrition and hydration are prioritised
• health promotion for visitors is embedded in food and drink services
• they become the food champion for their community and engage in the national programme
• a healthy, safe and sustainable food and drink culture is established.

Food and drink strategy

All NHS organisations should maintain a food and drink strategy viewed as a living document. It captures how the organisation addresses safe delivery of nutritious and quality food and drink for patients; how healthier food and the right environment for staff and visitors are provided; and embeds sustainable practices in its service, such as buying food more sustainably and wasting less.

Outcomes should be detailed and measured, allowing the organisation to demonstrate how it is meeting required standards. This strategy is the blueprint for how the organisation values food and drink as medicine; it will form part of the annual returns required by NHS organisations to evidence compliance with the Food and Drink Standards, and will form part of PAM.

Food service dietitians

Dietitians are the only nutrition professionals to be regulated by law (Health and Care Profession Council ) working in the NHS and wider health and care services. Registered dietitians assess, diagnose and treat dietary and nutritional issues at an individual and wider public health level. Food service dietitians specialise in food and beverage services, specifically how they can support food and nutrition safety and promote health and wellbeing throughout the organisation.

The NHS food standards require organisations to consider what level of input from a food service dietitian is appropriate for their food services. The Independent review of NHS hospital food recommends every organisation has a food service dietitian. This role can be the main interface between catering and clinical services, ensuring constant communication and co-operation between the relevant teams, as well as leading on the food and drink strategy.

Food safety

Ensuring that food served is safe to eat is a legal obligation. The Food Standards Agency outlines guidance for food businesses to minimise the risk of harm to the consumer. Complying with food safety covers the management of food hygiene and food standards. Several key pieces of legislation underpin this:

• Food Standards Act 1999
• Food Safety Act 1990
• the Food Safety Order 1991
• general food law
• Food Information Regulations 2014.

Organisations must have a nominated food safety specialist, responsible for reporting at board level.

Training, learning and development framework

Establishing a framework

Establish a structured learning framework, appropriate to your regional demographics and patient acuity, which is supported at board level to ensure all team members are appropriately trained. Appoint an authorised leader to oversee this and ensure best practice is observed and regularly monitored.

Standards

Outline commonly expected standards for chefs and other catering support staff from back of house to front of house to ward level, including competencies and responsibilities. Establish, teach and refresh professional and technical skills from knife work to menu costing, procurement to presentation.

Acknowledgement

Celebrate tasty and nutritious food and focus on recognising the chefs and food service teams who provide this.

The annual NHS chef competition is a nationally recognised method of celebrating innovation and sharing regional and national menu perspectives. Exemplar trust meetings also provide a platform to collaborate on menu transition.

Training

Everyone involved in handling food should receive appropriate food safety training, including ‘non-catering’ staff such as nurses or porters who may come into contact with food. This can be held locally or through a course accredited by, for example, the Chartered Institute of Environmental Health or Royal Society of Public Health.

Food service staff and all others involved in preparing and serving food must undertake training in food allergy and the importance of avoiding cross-contamination with other foods.

Knowledge

All food service staff should:

• have a basic knowledge and understanding of the importance of nutrition and hydration in improving outcomes
• be able to identify the dietary coding used on hospital menus
• understand menu ordering and provision of special diets, including modified textures, religious and cultural requirements
• appreciate the importance of the method of cooking and presentation.

Food service and nursing teams should receive training to identify patients who are at risk of malnutrition or those who need assistance at mealtimes. All teams should understand food requirements for nutritionally well people, the focus on choices lower in fat, salt and sugar and higher in fibre, and the importance of including more fruit and vegetables and ensuring adequate and timely drinks.

Suitable health and wellbeing programmes to support mental and physical health such as the British Dietetic Associations ‘work ready’ should be instigated, reflected in ‘Our NHS People Promise’.

 Working together across the organisation successfully implementing nutritious, safe and effective food services depends on catering, nursing and dietitian teams collaborating. But they cannot work in isolation. Partnerships between other teams must continue to be recognised as part of the wider scope by which we deliver our food and drink services. Such teams include procurement and information technology, and external providers such as the food supply chain, catering contractors and equipment and technology suppliers.

Sharing best practice, challenging the way food and drink services are delivered and using the combined experience of people with different knowledge and skills will help develop effective interventions.

2. Improving patients’ food and drink

Organisations must show they comply with these five areas to support their progress within the maturity matrix.

1. Organisations must assess their compliance with the 10 key characteristics of good nutrition and hydration care.

What this means in practice: These provide a framework by which organisations can assess the quality of their food and drink service, identify improvements and enhance patient experience.

An assessment checklist and details of RAG rating and actions to be taken must be included in the board report.

Tools: See 10 key characteristics of good nutrition and hydration care – compliance assessment tool, which can be used to check against implementation of this standard.

2. Organisations must show they comply with the BDA’s Nutrition and Hydration Digest.

What this means in practice: This supports quality and safety in patients’ food and drink. Inclusion of an assessment checklist and details of RAG rating and actions to be taken must be included in the board report.

Please note: some elements also reflect evidence in relation to other standards in this document.

Tools: Format can be NHS organisation’s own, but an example is included at The Nutrition and Hydration Digest – compliance Assessment tool.

See Chapter 2 ‘Food as medicine’ and ‘A checklist for NHS organisation catering managers and chief executives’ in the Independent review of NHS hospital food.

3. Organisations to implement digital meal ordering that uses patient names and aligns to their dietary information and care plans: eg type of therapeutic diet required or food allergy information.

What this means in practice: Organisations may need time to fund this development and link with IT infrastructures, but it should be seen as an essential element of patient care.

Tools: See Chapter 5 ‘Making it easy’ of the Independent review of NHS hospital food.

4. Organisations must have a ward assurance programme that reviews nutrition and hydration in relation to quality, safety, patient experience and clinical effectiveness.

What this means in practice: The programme should provide evidence that the whole ward team knows what they are doing about nutrition and hydration and if there is a gap the organisation knows what it is doing about it.

There should be evidence of measures relating to nutrition and hydration, such as those based on 10 key characteristics of good nutrition and hydration care compliance assessment. At least annually, all wards and relevant departments must achieve the organisation’s agreed baseline standard, with data included in the board report using the RAG rating.

Tools: Format can be the NHS organisation’s own, but an example is included in Appendix 8: Ward assurance programme, which can be used to check against implementation of this standard.

5. Organisations must have a nutrition and hydration quality improvement programme.

What this means in practice: This supports ongoing efforts and proves the organisation’s dedication to continuous improvement in providing best quality, safe and nutritious patient food and drink services as well as patient experience.

Implementation of quality improvement methodologies across all wards/departments must be included in the board report. Quality improvement programmes should be publicly available via the organisation’s website.

Tools: An organisation readiness assessment is included in Appendix 9: Quality improvement readiness questionnaire; and an example of the process in ‘How to implement a nutrition and hydration quality improvement programme’ is also provided.

Patient nutrition and hydration

Patients’ nutritional safety is paramount; all colleagues must understand their accountability for this.

Prevention of malnutrition

Malnutrition is common – it affects a quarter of all patients in hospital, including a fifth of all children admitted and a third of cancer patients – and is under-recognised and under-treated. It is harder for undernourished patients to fight infection and recover from illness, increasing the risk of longer stays with more complications and associated clinical interventions. The cost of caring for a malnourished patient is two-to-three times higher than a non-malnourished patient. (bsna.co.uk)

Often, there is only a very small window of opportunity to act and prevent a person’s further decline. Malnutrition can be life-threatening and those most nutritionally at risk are often the most vulnerable: eg infants and young children, older people, those with long-term conditions and/or multiple co-morbidities, people undergoing complex surgery or treatment (Gandy J (ed) (2019) The manual of dietetic practice (sixth edition). British Dietetic Association). They may be scared, socially isolated, overwhelmed or too acutely unwell to express their nutritional needs.

The signs of malnutrition can be easy to miss, particularly in busy environments. Organisation should therefore regularly raise awareness of the importance of good nutrition and hydration among relevant staff groups, as well as listening to concerns raised by visitors and patients.

Nutritional screening

People in care settings should be routinely screened (and monitored) for the risk of malnutrition (Nutrition support in adults). Identifying a person’s nutrition, allergen and assisted feeding and drinking needs is essential to safeguarding patients. The assisted mealtimes approach ensures those who are – or are at risk of becoming – malnourished can receive the nutritional support they need. Nutritional care needs to continue as patients are discharged into a social care setting. A joined-up approach between health and social care is a huge benefit to the nutritional care of patients.

Nutritional standards

Hospital patients can be broadly categorised into two groups:[1]

• nutritionally well:
  • normal nutritional requirements and normal appetite or those with a condition requiring a diet that follows healthier eating principles
• nutritionally vulnerable:
  • normal nutritional requirements but with poor appetite and/or unable to eat normal quantities at mealtimes; or with increased nutritional needs.

The Nutrition and Hydration Digest [2] states that menus must be capable of providing the energy and protein requirements for both nutritionally well and nutritionally vulnerable adults, evidenced by a menu capacity analysis.

Many patients will require further assessment by clinical dietitians and may be prescribed oral nutritional support to include enhanced levels of protein, energy (calories) and vitamins and minerals. Dietitians strongly recommend a ‘food first’ approach, and you should consider enhancing the energy and protein intake of foods (fortification) without increasing the portion size (https://www.bda.uk.com/resource/malnutrition.html).

Consider support for eating ‘little and often’ or grazing-style menus as well as 24/7 access to food and drink for patients who need it.

Mental health

Understanding service users’ differing nutritional needs in acute mental health settings and specialist units is key in developing the overall service. Most service users still fall under the two groups described above and nutritional requirements are similar, so the general standards can be followed.

However, there are often other factors such as obesity, drug and alcohol dependency, confusion and paranoia, dementia, eating disorders, hyperactivity, drug regimens, depression and the effect of mood on food intake. For more guidance, see the Nutrition and Hydration Digest.

Community

An important role of the community hospital is the post-acute care of older people, those who are physically disabled or people with learning difficulties (both inpatients and outpatients). Again, nutritional requirements will be similar to the above, but other issues include dental problems, dexterity skills, confusion or depression, time taken to eat food, assisted mealtimes and support when eating, not enough fluids and other physical difficulties. Micronutrients, such as deficiencies in vitamin C and D, may also be an issue.

Continuity of nutritional care is important from acute to community and home (when achievable) to prevent malnutrition. For further guidance, see the Nutrition and Hydration Digest.

Nutritional safety

Menu design and planning, dietary coding and defined and executed policies are key to ensuring patient nutritional safety.

Standard and specialist menus should be planned jointly by food service dietitians and caterers. Dietary coding should only be undertaken by a registered dietitian who is qualified to review nutrition, allergen and ingredient data and decide on accurate and safe codes.

NHS England shares regular alerts identifying food safety and allergy issues. Effective communication is vital: nursing, dietetic and food service teams are all responsible for a patient’s safe nutritional care, and organisations should have an established process for nurses or dietitians collecting a patient’s food and drink requirements early and communicating them quickly to all food service staff. There should also be separate policies for food allergy and for modified texture food and drinks.

Patient food service technology

Organisations should invest in digital solutions/tablet technology free at point of use for food and drink services, and which support patient independence. However, digital solutions do not replace the need for assisted mealtimes, and some patients will need help to use the technology.

Adopting this technology may involve additional costs, but it should be implemented as soon as resources allow. Cost for bedside digital solutions will vary depending on the scope and scale of an organisation’s solution and its current digital infrastructure.

Every hospital must implement a digital meal ordering system.[3] These can be integrated with patients’ care plans and so support safe ordering. Hospitals will need to establish a method for using patient identification, so menu offers can be tailored to dietary needs and personal preferences: eg. only showing patients what is safe and suitable for their diet.

Systems must also be flexible. Allowing minimum times between ordering and food service, affording the ability to move and deliver meals based on a named person as necessary will reduce food waste. The ability to move and track patients could require additional manual intervention to electronic systems.

Linking with meal ordering systems allows teams to better monitor food waste at ward level; food service staff can then spend more time supporting patients at higher nutritional risk with their orders. Such systems should also in the future link the inpatient nutritional (food and drink) care plan on discharge with follow-up where required in the community.

Patient experience

Food needs to be at its best at the point of service, so focus on the ‘last nine yards’ of ward service. Areas to explore include:

• accountability at ward level
• adequate nutrition and allergen training for all those involved in food services
• the wider environment:
  • hygiene and safety
  • crockery and cutlery
  • assisted mealtimes or general support and encouragement.

Improving patient experience relating to nutrition and hydration is not simple and requires a multidisciplinary approach including collection, analysis and learning from patient feedback. Patient-led assessments of the care environment (PLACE) will motivate improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced.

Ward assurance

Organisations must implement a range of quality metrics specifically on nutrition and hydration care. All wards and relevant departments must demonstrate annually they have achieved the baseline standard for assuring excellence and improving patient experience.

Quality improvement

Organisations should use information from their compliance reporting on the 10 key characteristics of good nutrition and hydration care, the Nutrition and Hydration Digest compliance checklist and their PLACE scores to identify opportunities for continuous quality improvement. Improvement programmes should involve patients, residents, families and carers to truly enhance people’s experiences of nutrition and hydration care.

3. Improving retail, staff and visitor food and drink

Organisations must show they comply with these four areas to support their progress within the maturity matrix.

1. Organisations must review their food and drink menus and look for opportunities to make the choices healthier and more sustainable, for example building on the government’s Eatwell Guide and the BDA’s One Blue Dot campaign.

What this means in practice: This standard provides a framework for developing healthy and environmentally sustainable retail food and drink offer.

Tools: One Blue Dot – Eating patterns for health and environmental sustainability and the Eatwell Guide provide several tools to support this standard.

2. Organisations must implement the GBSF nutrition standards: GBS for food and catering services.

What this means in practice: This standard provides a framework by which organisations can ensure healthier options are available to help staff and visitors meet dietary recommendations.

The document covers both mandatory and best practice standards.

Tools: GBS nutrition standards: technical guidance provides the technical detail, compliance level. Examples of evidence are listed to help demonstrate compliance in relation to each standard.

3. Organisations must continue to meet the CQUIN related standards.

What this means in practice: This standard ensures continued compliance around advertising, promotions, and placement of high fat and sugary foods availability of and access to healthier options.

Tools: Staff health and wellbeing standards 2017-19 implementation support provides previous implementation detail to support this standard.

4. Organisations must provide access to suitable food and drink out of hours (based on the above nutrition standards).

What this means in practice: This standard ensures all staff and visitors are given equal opportunity to access food and drink that supports their nutrition and hydration needs 24/7 including drinking water.

Tools: See ‘A checklist for NHS Organisation catering managers and chief executives’ and Chapter 2 ‘Food as medicine’ in the Independent review of NHS hospital food.

Over half of all food provided in NHS hospitals is served to staff and visitors, whose nutrition and hydration needs can be quite different from those of patients. The Independent review of NHS hospital food discusses hospitals’ role in becoming places where healthier food and drinks are standard, where people can look after their own health, staff are nourished and hydrated to deliver optimal and safe clinical care and visitors are encouraged to focus on prevention and reducing their own risk to dietary-related illness.

Staff services

Both the Independent review, Rest, rehydrate, refuel and Caring for doctors, caring for patients recommended introducing minimum standards for access to nutritious food and drink for all staff.

24/7 access to food

Organisations should consider the needs of shift workers, who report poorer health and higher incidences of chronic illnesses (eg diabetes) than non-shift workers. Some hospitals provide overnight restaurant services for staff. This is ideal, provided staff have time to go to the restaurant and the facility is in a suitable location. Different solutions work for different hospitals, and trusts should be responsive to what their staff want; a useful baseline is the Fatigue and facilities charter.

It is important to consider convenience and value. To encourage healthier choices, NHS organisations should increase the availability of healthier food and consider subsidising the cost. These changes should be researched further to measure the effect on staff morale, wellbeing and absence.

While employers should continue to ensure that as far as possible staff are supported to take meal breaks and have places where they can go to do so, it should also be recognised that this won’t always be possible for all staff .Employers should therefore make sure staff can access healthy, balanced, hot and cold food options 24/7.

This should include:

• healthy, balanced meal options (providing animal and plant-based protein, starchy carbohydrates, fat, fibre and micronutrients including iron and calcium – eg milk and non-milk products)
• adequate and varied provision
• culturally appropriate options, taking account of local needs
• provision for a range of dietary requirements, eg vegetarian and vegan, and allergies, eg gluten and nut-free options.

It should also be recognised that many colleagues will prefer to bring in their own food and drink. Facilities where food can be stored and prepared should be easily available to all staff and where possible include sink, hotplate, kettle, toaster, fridge, microwave and hot drinks machine.

Food insecurity

Food insecurity refers to “the inability of individuals and households to obtain an adequate and nutritious diet”. Trusts should be aware that this may affect patients, staff and visitors, therefore both hot and cold nutritious options should be available to enable access to a meal.  

Trusts may wish to engage with their staff specifically on how they can further support their health and well-being by improving food and drink provision in the workplace.

Sustainable food and drink

NHS food and catering services produce approximately 6% of total NHS carbon emissions. Healthier, seasonal and locally sourced food can cut emissions and wider environmental impact related to agriculture, transport, storage and waste across the supply chain and on the NHS estate (see section 4), as well as supporting the local economy. (Delivering a ‘Net Zero’ National Health Service)

A good foundation for healthier, more sustainable menus is the government’s national food model, the Eatwell Guide, and the BDA’s One Blue Dot campaign. These recommend:

• fewer processed foods high in sugar, salt and fats
• a wide variety of protein sources including beans, pulses, nuts and soya
• a choice of seasonal, locally sourced fruits and vegetables.

Dietitians and caterers working together to create and promote a healthier and more sustainable diet will contribute to an organisation’s carbon reduction and wider sustainability goals.  

GBS for food and catering services: nutrition standards

The Government Buying Standard (GBS) for food and catering services outlines minimum standards for healthier food and drink options across the public sector, to:

• reduce salt, sugar and saturated fat intakes
• increase consumption of fruit, vegetables, fish and fibre
• revise availability and portion size of soft drinks, confectionery and savoury snacks.

The (voluntary) best practice standards go further and include calorie or allergen labelling and menu analysis. Organisations will need to assess their compliance with the nutrition standards – both mandatory and best practice – and set out a programme of implementation.

Technical guidance has been published alongside the updated nutrition standards to support this. There will be an implementation period of 12 months from when the written technical guidance is published except for the reducing salt mandatory and voluntary ‘best practice’ standard and the pre-packaged sandwiches component within the reducing saturated fat standard, where the overall implementation period will be three years. (Consultation outcome: The government buying standards for food and catering services – updating the nutrition standards: response to consultation).

Food service technology for staff and visitors

Food service technology in the retail environment mainly covers online ordering, self-checkouts and contactless payments to delivery and pick-up, stock management software and restaurant point of sale systems. (Seven restaurant technology trends to watch in 2022). People want to be able to order in advance, have food come to them or pick it up easily and quickly. Customers are using technology to understand more about food provenance, nutrition and allergen information and ingredients before ordering.

Technology also supports the back-of-house teams in understanding food ordering trends and customer satisfaction as well as reducing food waste. Hospital retail food and drink services will need to look at their technology to remain relevant and competitive.

Calorie labelling and other legal requirements

Mandatory calorie labelling came into force in April 2022, affecting businesses with 250 or more employees that sell food or drink that is not pre-packed and is suitable for immediate consumption. Implementation guidance can be found on the government website.

NHS organisations need to look ahead to comply with upcoming changes to food and drink legislation, including Natasha’s Law, which will change the way food and drink are presented and served for retail, staff and visitors.

4. Improving sustainable procurement and reducing food waste

Organisations must show they comply with these six areas to support their progress within the maturity matrix.

1. Organisations must assess their food and drink services against the GBS for food and catering services.

What this means in practice: The GBS provides a framework for organisations to ensure they procure their food and catering services against a set of minimum mandatory standards. 

Tools: The GBS Checklist to check whether these are met/not met and monitor against the GBS standards.

See Chapter 7 ‘Going Green’ and ‘A checklist for NHS organisation catering managers and chief executives’ in the Independent review of NHS hospital food.

2. Organisations must assess their food and drink services against the balanced scorecard.

What this means in practice: The balanced scorecard includes the GBS mandatory requirements as ‘mandatory criteria’ and best practice is represented in the ‘award criteria’. The award criteria elements are rated from satisfactory to excellent allowing organisations easy visibility of where they go beyond the minimum.

Tools: The Balanced scorecard – criteria for a balanced scorecard for the procurement of food and catering services outlines the details and criteria to use to measure against the balanced scorecard standards.

See Chapter 7 ‘Going Green’ and ‘A checklist for NHS organisation catering managers and chief executives’ in the Independent review of NHS hospital food.

3. Organisations must assess their level of food waste, set food waste reduction targets and minimisation plans using the WRAP approach – ‘target, measure, act’.

What this means in practice: This standard, while encapsulated by standards 1 and 2 above, has been highlighted as its own individual standard. If organisations prioritise reducing food waste this will allow for financial savings to progress other elements of these standards as well as highlighting the importance of food waste improvements as a whole.

Tools: The balanced scorecard rationale and checklist for food waste prevention and reduction and WRAP – Food Waste Reduction Roadmap Toolkit provides supportive detail for implementation. See Chapter 7 ‘Going Green’ and ‘A checklist for NHS organisation catering managers and chief executives’ in the Independent review of NHS hospital food.

WRAP’s Guardians of Grub Cost Saving Skills course can be completed in 15 minutes and will give teams the foundations to set their food waste reduction target, understand how to measure and take action.

4. Organisations must commit to stop procuring single use plastic items for their catering service. Organisations must commit to sustainable alternatives to plastic.

What this means in practice: This standard supports the reduction of single use plastics in the catering environment such as stirrers, cutlery, plates, and cups.

Tools: Legislation is also expected on the use of single-use plastic plates, cutlery, expanded and extruded polystyrene cups and food and beverage containers.

5. Organisations must apply the Net Zero and Social Value Model in all procurement decision-making.

What this means in practice: A minimum 10% weighting on Net Zero and Social Value must be applied to all tenders and monitored throughout the contract.

Tools: NHS England has created net zero and social value guidance for NHS procurement teams to help unlock health-specific outcomes in all procurement. This guidance is complementary to the Cabinet Office Social Value Model.

6. Organisations must ensure suppliers are aware of and complying with the Net Zero Supplier Roadmap.

What this means in practice: Suppliers must demonstrate compliance with milestones to be awarded new NHS contracts.

Tools: To help the NHS reach zero by 2040 for the emissions we control directly and by 2045 for the emissions we influence, through the goods and services we buy from our partners and suppliers, we have provided the NHS Net Zero Supplier Roadmap to help suppliers align with our net zero ambition between now and 2030. This approach builds on UK Government procurement policy (PPN 06/20 and PPN 06/21).

Government Buying Standard for food and catering services

The Department for Environment, Food and Rural Affairs (DEFRA) sets out in the GBS for food and catering services the standards for procuring food and catering services.

Demonstrating GBS compliance for patient food and drink can be complex. The NHS will always prioritise preventing malnutrition and meeting patient food and drink needs. Menu planning is complex and not just a quantitative exercise; all menus should comply with the Nutrition and Hydration Digest Standards for patient food and drink supersede GBS.

A plan for procuring food and catering

The DEFRA balanced scorecard

The balanced scorecard combines the mandatory GBS requirements with optional best practice criteria (award criteria), created to assess contracts for public procurement. It ensures broader aspects of service are weighed against cost, giving suppliers an incentive to be better than the minimum and for procuring authorities to incorporate environmental and social considerations into their decision-making.

The scorecard encourages continuous improvement in sustainability and for priority themes such as farm assurance, food waste management and engagement with small and medium-sized enterprises to be built into procurement decisions.

Net zero and social value in procurement

Since April 2022, NHS organisations are required to include a minimum 10% net zero and social value weighting in all procurements, building on the government’s Social Value Model (PPN 06/20). Aligned with this, NHS England has created the net zero and social value guidance for NHS procurement teams to describe how procurement of NHS goods and services can help achieve these objectives.

Driving sustainability in the food supply chain: the NHS supplier roadmap

NHS England’s Net zero supplier roadmap helps suppliers align with the NHS 2045 net zero ambition between now and 2030. Requirements are introduced gradually, so that before the end of the decade the NHS will no longer procure from suppliers who do not meet or exceed the NHS net zero ambition. NHS organisations must include these requirements in food and catering procurement processes.

Preventing food waste

Limiting food waste offers an opportunity for organisations to make financial and environmental savings and improve the food service they provide to patients. Public sector reviews suggest 34% of total food production is wasted.

The food and drink waste hierarchy ranks prevention and redistribution activities as the most effective. Where NHS organisations have a large amount of food waste, they should consider redistribution whenever possible to reduce environmental impact. More refined food waste data needs to be collected to truly understand the amount of food waste across the NHS and how system changes can be made. (Preventing waste in the healthcare sector).

Avoiding food waste

Food waste is sometimes considered ‘unavoidable’. This needs to be challenged. Interventions can include behavioural changes, eg avoiding the preparation of unnecessary ‘just in case meals’. Training of catering professionals will help drive fundamental changes. Ensuring a sensible number of options based on engagement with staff and patients  is an easy change for NHS organisations to make.

Reducing food waste can save money through the avoided purchase of ingredients or meals, lower kitchen utility bills, more efficient use of staff time and lower waste disposal costs.

The catering equipment sector has invested heavily in ensuring that new equipment uses less water, gas and electricity. Other innovations allow single items of equipment to undertake multi-functional roles required to deliver innovative menus such as shallow fry, deep fry, boil, braise and pressure cook.

Evidence and reporting

The GBS requires organisations to provide evidence of managing and minimising the impacts of waste throughout their direct operations, including evidence of a continual improvement cycle of objective setting, measurement, analysis and review. WRAP’s Courtauld Commitment 2030 UK food waste reduction roadmap provides a framework for organisations to set targets, measure, act and report consistently.

All NHS organisations must report on their food waste annually through the estates return information collection (ERIC). However, good practice suggests a continuous measurement to ensure organisations are monitoring, measuring and reducing food waste. ERIC provides an incomplete picture on food waste: data is only collected for food waste sent to offsite aerobic digestion or composting facilities. Every NHS organisation must recognise its responsibility for monitoring, measuring and reducing food waste. Templates are available at Guardians of Grub to ensure more complete, consistent reporting.

Reducing single-use plastics

The NHS Long Term Plan committed to reductions in single-use plastics throughout the NHS supply chain, including NHS catering. These commitments were reaffirmed in Delivering a ‘Net Zero’ National Health Service, and reduction of single-use plastics is one of the key interventions to decarbonise the NHS supply chain.

Legislation is also expected on the use of single-use plastic plates, cutlery, expanded and extruded polystyrene cups and food and beverage containers. (Plans unveiled to ban single-use plastics). NHS organisations should therefore aim to stop procuring single-use plastic items for catering services, including but not limited to stirrers and straws (except where a person has a specific need), cutlery, plates, cups, covers and lids.

Footnotes

[1] Gandy J (ed) (2019) The manual of dietetic practice (sixth edition). British Dietetic Association (BDA).

[2] The BDA’s Nutrition and Hydration Digest mainly covers hospital patients but is partly relevant to people in care settings or recipients of nutritional care within the community. Organisations must check compliance to ensure they meet a range of standards – for example: dietetic input, menu design and content, nutritional standards, and therapeutic diets.

[3] https://www.gov.uk/government/publications/independent-review-of-nhs-hospital-food