Catering for all

The importance of meeting patients’ nutritional needs to aid recovery has long been recognised and has resulted in moves to implement malnutrition screening for all inpatients and improvements in the quality and availability of hospital food for patients (Council of Europe 10 key characteristics of good nutritional care 2007).
    
The ‘Standards for Better Health’ form part of the Annual Health Check, which was launched by the Healthcare Commission in April 2005 and is now the responsibility of the Care Quality Commission. This requires all NHS organisations to make a declaration on compliance against 24 core standards which cover areas agreed with patients as basic requirements for healthcare. These include the need to provide evidence of appropriate catering for all groups including those from different ethnic minority groups.

Menu planning
To meet a patient’s nutritional needs, the food available must be capable of meeting the nutritional, cultural, social and religious needs of the population and also be something that the patient wants and is able to eat! Menu planning for hospital inpatients has always been challenging as there is a diverse range of dietary needs for any hospital population. Large acute hospitals increasingly have to cater for a variety of ages from newborn to elderly, a large number of different cultures with specific religious food needs and also specific therapeutic diets depending on their area of speciality e.g. ‘clean’ diets for transplant patients and complex modified protein diets for patients with metabolic disease.
    
Issues associated with bulk catering for a large number of people over a short meal period and at a controlled cost have resulted in the need to develop menus that attempt to meet all of the patients needs in a limited number of food choices on a daily basis. Menu planning is now extremely challenging and should involve the caterer and dietitian to work to balance all of these needs.
    
If we accept these menu planning principles and recognise the importance of helping patients to eat via providing appropriate food choices then surely it should be simple? However practically there are issues that need to be considered when agreeing a menu which reveals how complex and challenging this has become.

Don’t make assumptions
Firstly, it is essential that assumptions concerning food choices are not made. In many hospitals where there is a high percentage of patients from a particular ethnic group a separate ‘ethnic’ menu is made available. This menu may only be available to those patients who are considered to be from that particular ethnic group. So how can this be policed? Who decides who should have this particular food choice? Is this inappropriately based on a patients name or how they look and will that person actually be adhering to the requirements of their culture? For many ethnic groups the young are from second and third generation and have developed a more westernised diet which may or may not still adhere to their cultural requirements. Increases in the availability of food from a whole range of cultures within restaurants, takeaways and the local supermarket has increased the variety of food eaten by much of the population and these foods are now seen as part of the “British” diet and eaten by a wide variety of people from a range of age groups. It is wrong to assume that for example the elderly will not eat lasagne any more than a Muslim patient will only want to eat curry. Personal taste and preference are now a very strong factor in food choice and this can often become more important to patients who are unwell and within an environment in which they do not feel at home. Hospital menus do contain foods from a range of different countries and are enjoyed by a wide range of different cultures.

Understanding ethnic needs
Secondly, is the challenge of how many different cultures a hospital menu can practically serve and when is it essential that a specific choice be included? This is a complex area and I attempt to explain. For many hospitals serving major city populations there is a large percentage of people from a particular ethnic group but a number of other groups in smaller but still significant numbers. For example within Bradford there are a number of South Asian patients who are either Muslim, Hindu or Sikh and also a smaller number who are African-Caribbean, Chinese or Eastern European. There is also a small Jewish population. So should cultural choices from each of these groups be included on the menus together with those deemed appropriate for the larger white British population?
    
In an ideal world this would be nice but within the confines of the large scale catering systems and cost pressures applied is actually impossible. It can be extremely difficult as cultural groups often apply significant pressure to Hospital Trusts to cater for them individually and this is where it is important that the need for ethnic diets is understood.
    
It is important here to separate cultural food likes from religious food requirements. To clarify, Orthodox Jewish patients cannot consume pork at all and need other meat to be slain in a particular way and approved as Kosher. These foods cannot be cooked with or served with non-kosher foods and it would cause extreme distress to a patient to be offered food that did not comply with these requirements. To simplify it would be like offering many of us rat stew or serving our ordinary stew with a spoon that had previously served rat. For these groups it is essential that appropriate food is made available as otherwise they would be unable to eat and malnutrition would result. For these groups it is essential that there are systems to provide appropriate food choices however small a minority they are in. Within Bradford there is a very small Jewish population but kosher foods are made available via an a la carte menu and the food is appropriately sourced and stored frozen until needed. Jewish patients are able to choose from both the Kosher and normal menus to improve the level of choice.
    
So where does this leave groups whose food requirements are around preference rather than religion? For many Trusts who have a large percentage of their population from these groups it is possible to provide a menu that includes these foods but for those where these groups are in very small numbers it can become economically and practically difficult and therefore impossible to include them on the main menu. How this issue is resolved will vary by area but needs to be considered when reviewing and setting up catering systems.

Culturally diverse Bradford
Finally, here is an example of how catering for different religions and cultural groups have been approached within Bradford.
    
Bradford menus have been designed to include a choice of Halal and vegetarian curry for lunch and supper sourced from an approved local supplier to meet the needs of the traditional orthodox south Asian patients. There is a children’s menu which offers Halal kids meat choices e.g. chicken nuggets and sausages as well as their non-Halal versions. These are never offered on the same day to prevent confusion. It is important to remember that Sikh patients who do eat meat will not consume that which is Halal and so menus need to be carefully coded.
    
To deal with the issues of cultural food likes Bradford has developed a separate a la carte menu for African-Caribbean clients as these are required in small but regular numbers and this food is sourced frozen and can be stored until needed.
    
Menus ask patients to discuss their dietary requirements with the nurses or catering team and if their needs are not being met appropriate food is sourced and provided via the dietitian in consultation with the diet kitchen e.g. vegan or food allergy.
    
In conclusion, catering for the dietary needs of the wide range of patients from different ethnic groups within hospitals is challenging but is essential in the bid to meet nutritional needs and prevent malnutrition.