BDA/HCA seminar on implementation of the Council of Europe recommendations on food and nutritional care in hospitals, London, 3 November 2004.

The Council of Europe (COE) is a political organisation, founded in 1949 to reinforce democracy, human rights and the rule of law, and is based in Strasbourg. It has a wider membership than the European Union (EU), with 44 member states currently, and in the field social and public health it publishes guidelines and recommendations based on reports from expert committees. In 2002 it published a comprehensive report, 'Food and nutritional care in hospitals: How to prevent undernutrition' (1). This well referenced and valuable document identified major barriers to proper nutritional care in hospitals, but concluded that there was no doubt of the efficacy of nutritional support in terms of improving undernutrition and its consequences for hospitalised patients. The report can be ordered at the COE publications web site (http://book.coe.in/EN/).

In November 2003 the Committee of Ministers of the COE adopted a resolution recommending that member states draw up and implement national recommendations on food and nutritional care in hospitals, based on 106 principles and measures identified in the resolution. These include routine nutritional assessment of all patients prior to or at admission, that ordinary food by the oral route should be the first choice to correct or prevent undernutrition, and that education of dietitians in Europe should be set at a higher level so that they assume a more central role in nutritional care and support than previously (2).

Following this, a joint committee was established between the British Dietetic Association (BDA) and the Hospital Caterers Association (HCA) to support implementation of the COE recommendations. The joint seminar I attended, with 135 dietitians and caterers from across the UK, was held in November 2004, to review results of a survey of current hospital practices in the UK, and to start developing plans for local implementation of the COE resolutions. A report from the seminar is available on the BDA web site (http://www.bda.uk.com/).

Of particular interest was a review of some of the achievements of the Better Hospital Food Program (BHFP), which hospitals in England were required to adopt by December 2001 (not Scotland, Wales or Northern Ireland). There were six key targets of the BHFP:

1. moving the main meal of the day to the evening (some problems in implementation)

2. introduce snack boxes for patients who were not available when meals were served (well accepted and widely implemented)

3. serve two additional meal snacks per day, in addition to three main meals (the most difficult to implement, for cost reasons)

4. introduce leading chef dishes--from a new NHS recipe book (easy and done)

5. provide patients with a standard format bedside menu (adopted, and has been good remarketing of food services)

6. introduce a ward kitchen service including 'light bites' and a meal with 24-hour availability (difficult for organisational, cost and hygiene reasons).

There have also been continuing improvements in 2004, but results have not been released publicly yet.

Possible new proposals that are to come from the BHFP include:

a. protected mealtimes--when no medical or other staff are allowed on the ward (being piloted in 300 hospitals)

b. universal screening and nutritional care plans

c. sustainable food procurement (reducing food miles)

d. food waste management (waste has increased with the move to bulk service)

e. better monitoring of patient satisfaction with standard surveys

f. Increasing patient choices with 'flexi-menus'.

It appeared from my discussions with dietitians at the meeting that there is little awareness yet of the Council of Europe resolution. A baseline survey of 503 hospitals in 2004 only achieved a response from 45 and, although there seems to be general support for the thrust of the recommendations, they are only just starting to think about what the practical implications and barriers may be. Dietitians are much less involved in food service in the UK than in Australia. Nonetheless some of the approaches that are being trialled (like the use of protected meal times and ward food assistants) may be relevant in Australian settings, as are the many resources, such as the cookbook, available from the BHFP web site (http://www.betterhospitalfood.com/). In particular the COE report and resolution provide valuable evidence that Australian dietitians could use in arguing for better support for nutritional care of inpatients.

Table 1. Recent tracking surveys of implementation of the BHFP show
increasing adoption of these mandatory elements (% hospitals complying)

                       2002  2003

Ward kitchens          71.5  89.6
Snack boxes            58.7  71.4
Additional snacks      51.1  65.3
Main meal in evening   78.2  91.6
Leading chef dishes    40.0  59.9

References

1. Council of Europe. Food and nutritional care in hospitals: how to prevent undernutrition. Strasbourg: Council of Europe; 2002.

2. Council of Europe Council of Ministers. Resolution ResAP(2003)3 on food and nutritional care in hospitals. 2003. Available at: http://www.bapen.org.uk/documents/council-of-europe/COE-adoption.pdf Accessed 14 January 2005

Peter Williams

Senior Lecturer

University of Wollongong