Nutrition and Health, 1991, Vol. 7, pp. 101-110 0260-1061/91/$10 © 1991 A B Academic Publishers. Printed in Great Britain.
101
INTRODUCING HEALTHY CATERING PRACTICE INTO HOSPITALS: A CASE STUDY FROM WALES JOHANNA CLARKSON
Health Promotion Authority for Wales, Cardiff, UK* DON NUTBEAM
University of Sydney, Australia ABSTRACT This paper describes results from a study examining the introduction of policies to promote healthy catering in 102 hospitals in Wales. Policy development and implementation followed the publication of two major reports in the UK highlighting the relationship between poor nutrition and subsequent high levels of cardiovascular disease and cancer. Changes in hospital catering services were advocated in response to these reports. The study examines the translation of policy intentions into practical action in hospitals. It identifies achievements in implementing changes in catering practice, and promotion of healthier meals for staff, patients and visitors to hospitals. Important organisational problems and external constraints, including cost, are also highlighted. The authors recommend that greater effort is put into the implementation process following policy decisions, including consideration of training needs, the development of effective communication, and establishment of mechanisms for feedback and review.
INTRODUC TION
Two UK government reports published in the mid 1980s highlighted the relationship between diet and a range of diseases, notably cardiovascular disease and cancer, and proposed changes in the-nutritional composition of the British diet along with specific dietary goals and targets (National Advisory Committee Nutrition Education, NACNE 1983; Committee on Medical Aspects of food policy, COMA 1984). However, no overt steps were taken to coordinate action nationally to achieve these goals and targets, and in the absence of a central co-ordinating body, the initiative was left to the 192 local District Health Authorities in England and Wales. This led to a *.Address for correspondence: Dr. Johanna Clarkson, Health Promotion Authority For Wales, Brunei House (8 Floor), 2 Fitzalan Road, Cardiff, CF2 IEB.
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wide variety of responses, which in many cases were focussed on the development of local policies to promote healthy nutrition. In most cases, part of the policy action at local level has been to examine the potential for introducing healthy catering practice into hospitals. In the UK National Health Service (NHS), hospitals are seen as having an important exemplary role in promoting health. They are frequently the largest employers within a community, and publicly represent the "shop windows" of the National Health Service (Woolaway, Nelson and Herfst, 1985). NHS hospitals are generally responsible for the management and direct provision of catering for staff and patients. They are often large catering establishments with significant in-house expertise, and with the potential to promote food and health policies for the general public (Anderson and Lean, 1987). In recent years initiatives to reduce smoking in hospitals have achieved measurable success through policy development and implementation (Catford and Nutbeam, 1983, Shakespeare and Woolaway, 1989). Similar change has been sought with the introduction of change in catering practice. In Wales between 1984 and 1988 all of the 9 District Health Authorities either introduced or initiated food and health policies in line with COMA and NACNE recommendations alongside a series oflocal health promotion initiatives which were established in support of the work ofthe Welsh Heart Programme. The Welsh Heart Programme (Heartbeat Wales) was established and launched in 1985 as a national (UK) demonstration project to develop and evaluate a regional strategy that would contribute to a sustained reduction in coronary heart disease incidence, morbidity and mortality in the 3 million population of Wales, and particularly those under the age of 65. Details of the basic intervention design and evaluation strategy are published elsewhere (Catford and Parish 1989, Nutbeam and Catford 1987). A key element to the intervention has been the promotion of healthy nutrition based on recommendations of the UK Department of Health (1984), and the World Health Organisation (1982). The nutrition intervention strategy has comprised complementary components consisting of public education, combined with support for policy development and environmental changes (Parish, Catford, Howson 1987). As a part of this work, Heartbeat Wales provided advice to Heillth Authorities in Wales on the process of setting up local nutrition policies, and has helped to monitor progress in implementation. The study reported here was undertaken as a part of the monitoring role of the Heartbeat Wales programme. It identifies the development and content of the policy statements on food and health from individual Health Authorities in Wales, together with an examination of the practicalities of policy implementation in hospitals.
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METHODS
The study consisted of two distinct components. Firstly, information on the development of district policies was collected through semi-structured interviews with senior managers responsible for catering services in each of the 9 districts in Wales. Key components of the interviews were: · i) ii)
a retrospective analysis of the steps involved in policy formation, the identification of the ways in which professional catering staff had been involved in this process, iii) the identification of whether policies had been promoted through specific training for catering staff and/or nutritional information for the public and for hospital staff, iv) assessment of the monitoring of policy effectiveness. The second part of the study was directed towards collecting information about the implementation process and its translation into catering practice in hospitals. Self-completion questionnaires were sent by post to 53 senior catering staff, representing all 141 hospitals in Wales which provided a catering service. Key questions included identification of: i) ii) iii) iv) v) vi)
the extent to which catering practice was in accordance with the COMA and NACNE recommendations, the range of food choices offered to both patients and hospital staff, whether or not all facilities selling food and snacks in hospitals conformed to the policy, constraints on policy implementation, whether healthy eating was promoted visibly in hospit;1ls and, whether the policy introduction had resulted in any chaQges in catering costs.
All districts nominated senior managers responsible for district catering services and all nominees volunteered to be interviewed for the first part of study. In the second part, 40 out of 53 self-completion questionnaires were returned by senior hospital catering staff (following two reminders). This represented a response rate of 75% and covered 102 hospitals. After the second reminder letter, non-responders were contacted by telephone and asked a short series of questions based on the original questionnaire. No differences in answers were found between the questionnaire results and the telephone responses. "Pressure of work" was the reason usually given for not returning questionnaires within the allocated time period. The fieldwork was conducted during January-May 1988 and the information collected was reviewed during July-September 1989 by short telephone interviews with the senior managers responsible for district catering services. The results presented here are based on the primary interviews
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104
with senior managers, and data available from the 40 returned questionnaires.
RESULTS District food and health policies
The results from the interview study showed that all nine District Health Authorities reported to be operating healthy eating policies at the time of the survey, although in two districts a policy had not been officially endorsed by the Authority at the time of the study. Six districts had set up multidisciplinary working parties to develop and/or implement policy recommendations, and in four districts these groups were continuing to meet to provide support for policy implementation. At the time of the study, only two districts reported to have run in-service training in healthy catering for their catering staff, and one other district planned to implement training during the next year. Four districts had produced some written guidelines for caterers in support of policy recommendations, two had included suggestions for recipe modifications in their policy statements and two other districts had produced separate documents containing additional guidelines for catering staff. All districts supplied some basic information to patients on healthy eating. This was provided on menus, or in patient handbooks, and in one district a public leaflet about the food and health policy had been produced. Five districts reported that no formal monitoring of the policy had taken place at the time of the survey, and in the other four districts the extent of monitoring activity varied widely. Two had established formal mechanisms to review policy implementation, and these had produced recommendations in order to make further progress. One of these had additionally set up a system for formally monitoring customer satisfaction with the available choices. Only two districts reported to be specifically monitoring catering costs associated with policy implementation. During the course of the interviews, concern was frequently expressed over the uncertainties for health service catering staff caused by the recent introduction of competitive tendering for catering services in the Health Services. This has meant that the catering services previously provided through direct employment by Health Authorities, have had to be set against open competition for the provision of services with commercial catering organisations. In addition, severe resource constraints had overshadowed the importance of the food and health policy for many senior managers.
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Catering practice in hospitals i) Reported policy implementation
Thirty-seven hospitals (36%) reported that they were fully operating their district policy, and a further 40% (41) claimed that they would be fully implementing it within 6 months of the survey. Against this, the information obtained on facilities run by voluntary organisations within hospitals showed that less than 20% of facilities (14 out of79) had introduced changes in practice to reflect the local food and health policy. ii) Provision of food choices
Table 1 summarises the main meal options offered by hospitals in the survey. Most offered a choice of main meal which included a 'healthier' option, for staff and for patients. A high percentage of hospitals also reported to serve vegetarian options at meal times, about fwo thirds did so for patients, and the great majority for staff at lunchtimes. TABLE 1 Percentage of hospitals offering meai choices Total sample= 102 Patients
Meal choices
Choice of ~ain meal Vegetarian option lunch Vegetarian option evening
Staff
%
N
%
N
81 63 66
(83) (64) (67)
98 80 69
(100) (82) (70)
iii) Recipe modifications
The majority of hospitals had modified their catering practice in line with national nutritional guidelines to increase the amount of fibre in recipes and to reduce fat, sugar and salt. A wide variety of food preparation methods were in use in different hospitals to achieve these recommendations. Table 2 summarises the main catering practices adopted by hospitals in the survey. This includes methods reported for increasing fibre in the diet such as using wholemeal flour, and serving whole grain rice and wholemeal pasta. Reported methods for reducing fat in the diet included cutting down on added fat in recipes, using reduced fat milk, and offering alternatives to fried potatoes. iv) Promotion of healthy eating
Where policies exist, It is a pre-requisite for success that catering staff, other hospital staff, patients and visitors are made aware of them. In general, food and health policies were not widely promoted in the hospitals in the survey. Only 43% (44) of the hospitals identified the healthy food choices on menus
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106 TABLE 2 Percentage of hospitals reporting healthy catering practices Total sample= 102 Catering method
%
N
using wholemeal flour for sauces making pastry with a proportion of wholemeal flour using brown rice/pasta when serving these reducing fat in recipes using skimmed/semi-skimmed milk in hot drinks offering alternative forms of potatoes when serving fried potatoes reducing added salt in recipes reducing added sugar in recipes
42
(43) (89) (88) (81) (59)
87
86 79
58 78 87
94
(80) (89) (96)
for patients, and only a quarter (27%) did so for staff. Forty percent (42) of hospitals claimed to have run in-service training on healthy eating for catering staff, and a similar proportion (44%) had run "healthy eating days" to draw attention to the policy and its implementation. Forty-two percent (44) hospitals had changed their serving methods since the introduction of a policy. v) The cost of healthy eating
In the present economic climate in the UK public sector, the cost of changing catering practice has been an important consideration in developing and implementing a policy. Only one hospital reported that the introduction of a food and health policy had reduced their overall catering costs. Thirty-five percent (35) reported an increase in costs and 47% (47) reported that there had been no overall change in costs since a policy was introduced. vi) Review procedures
Only 44% (45) of hospitals in the study identified a formal procedure for reporting back on the progress of policies to their Health Authority. The most widely reported mechanism was through meetings of a local, interdisciplinary health promotion group. No information was sought from senior caterers about how regularly these review procedures were used. However, from the interviews with senior·managers at district level, it was apparent that in general, systems for regularly and systematically reviewing food policies were not being used at the time of this study. Discussion
The results of the study indicate that all 9 District Health Authorities in Wales had developed policies on food and health, and that a high
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proportion of hospitals reported to be either implementing their district policy at the time of the study, or planned to do so within six months. In practice the majority of hospitals had adopted a number of healthy catering methods in line with national nutritional guidelines (NACNE 1983), and also reported to regularly offer a choice of meal options for staff and patients. These findings indicate that there have been important improvements in the nutritional content of hospital food in comparison with the results from an earlier study in England (Woolaway, Nelson and Herfst 1985). The development and implementation of policies have almost certainly facilitated such improvements by providing a clear statement of intent, by legitimising action, and by initiating the process of change. However, the study also provides a practical illustration of the problems of translating policy into practice. Although the development of a policy statement is a crucial first step in achieving change, on its own it will not necessarily be translated into effective action. A dislocation between policy development and the management of change implied by such developments is hardly unique. The implementation process has to be planned with as much care as is usually put into the wording of policy statements. Previous studies which have examined the process 9f translating policies designed to minimise smoking in NHS hospitals into good practice have identified this same type of dislocation, but have also helped to clarify a number of conditions to achieve effective policy implementation. These include: i) informing staff and securing their co-operation in implementation, ii) planning a timescale and defining actions for implementation, and iii) promoting and "selling" the policy to the public (Nutbeam 1985). These general principles also need to be applied in the case of food and health policies if such initiatives are to be effective. The achievement of these three basic conditions in the implementation process has been variable in Wales, and as a consequence the introduction of healthy catering to NHS hospitals has been compromised. The current study has highlighted some of the practical difficulties which threaten the translation of policy guidelines into action. Firstly, the study exposed a lack of awareness, and adequate preparation for the introduction of the policy in some districts. There were few examples of specific training opportunities for catering staff, and relatively few examples of more general promotion of healthy eating to staff and patients as part of a positive move towards achieving healthier lifestyles. Secondly, the study identified a reduction in the initial momentum which led to the development of a policy statement in some districts, with a subsequent loss of interest from senior management. This may well reflect a lack of detailed attention being given to the process of implementation. Thirdly, there were inconsistencies within hospitals between different food outlets, so that policies were sometimes being implemented by the catering service but not
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by voluntary organisations or private operators who also sold food and refreshments on the premises. In addition to these important organisational threats to success, external constraints on policy implementation were also identified consistently throughout the study. These included a concern by catering staff over external tendering for catering contracts which could threaten their job security. Also, more than one third of hospitals reported that the introduction of changes in catering practice had resulted in increased catering costs (even though only two authorities in the study reported to be specifically monitoring catering costs in relation to food and health policies). This contrasts with a study of 3 Districts in England, which reported that none of the catering budgets had increased as a result the introduction of healthy catering practice, and in one district, catering costs were reported to be the lowest in the Region (Anderson and Lean 1987). However both the issue of job security, and the crucial issue of cost clearly represented a block to effective implementation in this study. The existence of all of these problems, internal and external, emphasise the importance of regular monitoring of the policy implementation process in order that such problems might be quickly identified, and relevant action taken. This case study from Wales provides some important lessons which may help others overcome or avoid some of the practical difficulties involved in policy implementation. These may be summarised as follows: i)
Define success through goal and target setting
Policy statements on food and health should give explicit support for staff implementing the policy by clearly defining overall goals and targets. In cases where specific action is demanded, a clear indication should be given to caterers on how to achieve nutritional goals. It may be appropriate to provide a separate document for caterers which gives specific information on expected changes in catering practices. ii)
Develop the skills needed for success
The importance of relevant in-service and pre-service training for caterers has to be recognised in policy statements, and targets for such activities could be identified. Providing caterers with tP,e skills needed for implementation is essential for successful implementation. iii)
Communicate and involve
Food and health policies must be communicated effectively to all
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hospital staff, patients and vtsttors so that hospitals fulfil their exemplary role to the community as health promoting environments. Involvement of staff in the process of policy formulation and implementation is critical for success. iv) Strive for consistency in application Food and health policies should apply to all food sold on hospital premises, whether this is supplied by hospital catering staff, private contractors or by voluntary organisations. Tendering contracts for catering services should clearly state that contractors must operate any food and health policy which has been formally approved by the Health Authority. v)
Review and modify
The implementation of policy guidelines needs to be carefully planned and regularly reviewed if policies are to have real impact. Target setting and review procedures should be established at the outset so that problems can be swiftly identified and obstacles to progress can be removed. Managers need the basic tools for management in order to secure success. ACKNOWLEDGEM ENT We would like to thank the Dietitians, District Catering Advisers, Catering Managers and other hospital catering staff who co-operated with this study. Thanks also to Dr. Zoann Nugent for statistical report, Mrs Gillian Bladon for fieldwork assistance and to Mrs Susan Avery and Tricia Thomas for their help in preparing the manuscript.
REFERENCES Anderson, A.S. and Lean, M.E.J. (1987). Setting an example: food and health policy within within the National Health Service. Health Education Research 2(3), 275-285. Catford, J. and Nutbeam, D. (1983). Smoking in hospitals. Lancet ii, 94-6. Catford, J. and Parish, R. (1989). Heartbeat Wales: New Horizons for Health Promotion in the Community; in Seedhouse D, Cribb A. Changing Ideas in Health Care, New York, Wiley. DHSS. Committee on the Medical Aspects of food policy (COMA). (1984). Diet and Cardiovascular Disease. London HMSO. National Advisory Committee on Nutrition Education (NACNE). (1983). A discussion paper on proposals for nutritional guidelines for health education in Britain. London, HEC. Nutbeam, D. (1985). A breath offresh air. Health and Social Service Journal. March 21,351. Nutbeam, D. and Catford, J. (1986). The Welsh Heart Programme Evaluation Strategy:
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110 Progress, plans and possibilities. Health Promotion 2(1), 5-18. Parish, R., Catford, J. and Howson, H. (1987). Promoting health through collaboration with industry and commerce. In: Community Based Prevention and Health Promotion. Report of an International Conference. German Society of Social Hygiene and Prophylactic Medicine, and WHO, Dusseldorf. March 1987. Shakespeare, R.M. and Woolaway, M.C. (1989). Smoking in hospitals: a measure of improvement. British Medical Journal 298, 4 February 1989. 293-4. Woolaway, M.C., Nelson, M. and Hansje Herfst, (1985). A study of the nutrient content of hospital meals. Community Medicine 7, 193-197. World Health Organisation ( 1982). Prevention of Coronary Heart Disease-Report ofa WHO Expert Committee. Technical Report Series No. 678-Geneva. (Received 7 August 1990)
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101
INTRODUCING HEALTHY CATERING PRACTICE INTO HOSPITALS: A CASE STUDY FROM WALES JOHANNA CLARKSON
Health Promotion Authority for Wales, Cardiff, UK* DON NUTBEAM
University of Sydney, Australia ABSTRACT This paper describes results from a study examining the introduction of policies to promote healthy catering in 102 hospitals in Wales. Policy development and implementation followed the publication of two major reports in the UK highlighting the relationship between poor nutrition and subsequent high levels of cardiovascular disease and cancer. Changes in hospital catering services were advocated in response to these reports. The study examines the translation of policy intentions into practical action in hospitals. It identifies achievements in implementing changes in catering practice, and promotion of healthier meals for staff, patients and visitors to hospitals. Important organisational problems and external constraints, including cost, are also highlighted. The authors recommend that greater effort is put into the implementation process following policy decisions, including consideration of training needs, the development of effective communication, and establishment of mechanisms for feedback and review.
INTRODUC TION
Two UK government reports published in the mid 1980s highlighted the relationship between diet and a range of diseases, notably cardiovascular disease and cancer, and proposed changes in the-nutritional composition of the British diet along with specific dietary goals and targets (National Advisory Committee Nutrition Education, NACNE 1983; Committee on Medical Aspects of food policy, COMA 1984). However, no overt steps were taken to coordinate action nationally to achieve these goals and targets, and in the absence of a central co-ordinating body, the initiative was left to the 192 local District Health Authorities in England and Wales. This led to a *.Address for correspondence: Dr. Johanna Clarkson, Health Promotion Authority For Wales, Brunei House (8 Floor), 2 Fitzalan Road, Cardiff, CF2 IEB.
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102
wide variety of responses, which in many cases were focussed on the development of local policies to promote healthy nutrition. In most cases, part of the policy action at local level has been to examine the potential for introducing healthy catering practice into hospitals. In the UK National Health Service (NHS), hospitals are seen as having an important exemplary role in promoting health. They are frequently the largest employers within a community, and publicly represent the "shop windows" of the National Health Service (Woolaway, Nelson and Herfst, 1985). NHS hospitals are generally responsible for the management and direct provision of catering for staff and patients. They are often large catering establishments with significant in-house expertise, and with the potential to promote food and health policies for the general public (Anderson and Lean, 1987). In recent years initiatives to reduce smoking in hospitals have achieved measurable success through policy development and implementation (Catford and Nutbeam, 1983, Shakespeare and Woolaway, 1989). Similar change has been sought with the introduction of change in catering practice. In Wales between 1984 and 1988 all of the 9 District Health Authorities either introduced or initiated food and health policies in line with COMA and NACNE recommendations alongside a series oflocal health promotion initiatives which were established in support of the work ofthe Welsh Heart Programme. The Welsh Heart Programme (Heartbeat Wales) was established and launched in 1985 as a national (UK) demonstration project to develop and evaluate a regional strategy that would contribute to a sustained reduction in coronary heart disease incidence, morbidity and mortality in the 3 million population of Wales, and particularly those under the age of 65. Details of the basic intervention design and evaluation strategy are published elsewhere (Catford and Parish 1989, Nutbeam and Catford 1987). A key element to the intervention has been the promotion of healthy nutrition based on recommendations of the UK Department of Health (1984), and the World Health Organisation (1982). The nutrition intervention strategy has comprised complementary components consisting of public education, combined with support for policy development and environmental changes (Parish, Catford, Howson 1987). As a part of this work, Heartbeat Wales provided advice to Heillth Authorities in Wales on the process of setting up local nutrition policies, and has helped to monitor progress in implementation. The study reported here was undertaken as a part of the monitoring role of the Heartbeat Wales programme. It identifies the development and content of the policy statements on food and health from individual Health Authorities in Wales, together with an examination of the practicalities of policy implementation in hospitals.
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103
METHODS
The study consisted of two distinct components. Firstly, information on the development of district policies was collected through semi-structured interviews with senior managers responsible for catering services in each of the 9 districts in Wales. Key components of the interviews were: · i) ii)
a retrospective analysis of the steps involved in policy formation, the identification of the ways in which professional catering staff had been involved in this process, iii) the identification of whether policies had been promoted through specific training for catering staff and/or nutritional information for the public and for hospital staff, iv) assessment of the monitoring of policy effectiveness. The second part of the study was directed towards collecting information about the implementation process and its translation into catering practice in hospitals. Self-completion questionnaires were sent by post to 53 senior catering staff, representing all 141 hospitals in Wales which provided a catering service. Key questions included identification of: i) ii) iii) iv) v) vi)
the extent to which catering practice was in accordance with the COMA and NACNE recommendations, the range of food choices offered to both patients and hospital staff, whether or not all facilities selling food and snacks in hospitals conformed to the policy, constraints on policy implementation, whether healthy eating was promoted visibly in hospit;1ls and, whether the policy introduction had resulted in any chaQges in catering costs.
All districts nominated senior managers responsible for district catering services and all nominees volunteered to be interviewed for the first part of study. In the second part, 40 out of 53 self-completion questionnaires were returned by senior hospital catering staff (following two reminders). This represented a response rate of 75% and covered 102 hospitals. After the second reminder letter, non-responders were contacted by telephone and asked a short series of questions based on the original questionnaire. No differences in answers were found between the questionnaire results and the telephone responses. "Pressure of work" was the reason usually given for not returning questionnaires within the allocated time period. The fieldwork was conducted during January-May 1988 and the information collected was reviewed during July-September 1989 by short telephone interviews with the senior managers responsible for district catering services. The results presented here are based on the primary interviews
Downloaded from nah.sagepub.com at UNIV WASHINGTON LIBRARIES on March 24, 2015
104
with senior managers, and data available from the 40 returned questionnaires.
RESULTS District food and health policies
The results from the interview study showed that all nine District Health Authorities reported to be operating healthy eating policies at the time of the survey, although in two districts a policy had not been officially endorsed by the Authority at the time of the study. Six districts had set up multidisciplinary working parties to develop and/or implement policy recommendations, and in four districts these groups were continuing to meet to provide support for policy implementation. At the time of the study, only two districts reported to have run in-service training in healthy catering for their catering staff, and one other district planned to implement training during the next year. Four districts had produced some written guidelines for caterers in support of policy recommendations, two had included suggestions for recipe modifications in their policy statements and two other districts had produced separate documents containing additional guidelines for catering staff. All districts supplied some basic information to patients on healthy eating. This was provided on menus, or in patient handbooks, and in one district a public leaflet about the food and health policy had been produced. Five districts reported that no formal monitoring of the policy had taken place at the time of the survey, and in the other four districts the extent of monitoring activity varied widely. Two had established formal mechanisms to review policy implementation, and these had produced recommendations in order to make further progress. One of these had additionally set up a system for formally monitoring customer satisfaction with the available choices. Only two districts reported to be specifically monitoring catering costs associated with policy implementation. During the course of the interviews, concern was frequently expressed over the uncertainties for health service catering staff caused by the recent introduction of competitive tendering for catering services in the Health Services. This has meant that the catering services previously provided through direct employment by Health Authorities, have had to be set against open competition for the provision of services with commercial catering organisations. In addition, severe resource constraints had overshadowed the importance of the food and health policy for many senior managers.
Downloaded from nah.sagepub.com at UNIV WASHINGTON LIBRARIES on March 24, 2015
"105
Catering practice in hospitals i) Reported policy implementation
Thirty-seven hospitals (36%) reported that they were fully operating their district policy, and a further 40% (41) claimed that they would be fully implementing it within 6 months of the survey. Against this, the information obtained on facilities run by voluntary organisations within hospitals showed that less than 20% of facilities (14 out of79) had introduced changes in practice to reflect the local food and health policy. ii) Provision of food choices
Table 1 summarises the main meal options offered by hospitals in the survey. Most offered a choice of main meal which included a 'healthier' option, for staff and for patients. A high percentage of hospitals also reported to serve vegetarian options at meal times, about fwo thirds did so for patients, and the great majority for staff at lunchtimes. TABLE 1 Percentage of hospitals offering meai choices Total sample= 102 Patients
Meal choices
Choice of ~ain meal Vegetarian option lunch Vegetarian option evening
Staff
%
N
%
N
81 63 66
(83) (64) (67)
98 80 69
(100) (82) (70)
iii) Recipe modifications
The majority of hospitals had modified their catering practice in line with national nutritional guidelines to increase the amount of fibre in recipes and to reduce fat, sugar and salt. A wide variety of food preparation methods were in use in different hospitals to achieve these recommendations. Table 2 summarises the main catering practices adopted by hospitals in the survey. This includes methods reported for increasing fibre in the diet such as using wholemeal flour, and serving whole grain rice and wholemeal pasta. Reported methods for reducing fat in the diet included cutting down on added fat in recipes, using reduced fat milk, and offering alternatives to fried potatoes. iv) Promotion of healthy eating
Where policies exist, It is a pre-requisite for success that catering staff, other hospital staff, patients and visitors are made aware of them. In general, food and health policies were not widely promoted in the hospitals in the survey. Only 43% (44) of the hospitals identified the healthy food choices on menus
Downloaded from nah.sagepub.com at UNIV WASHINGTON LIBRARIES on March 24, 2015
106 TABLE 2 Percentage of hospitals reporting healthy catering practices Total sample= 102 Catering method
%
N
using wholemeal flour for sauces making pastry with a proportion of wholemeal flour using brown rice/pasta when serving these reducing fat in recipes using skimmed/semi-skimmed milk in hot drinks offering alternative forms of potatoes when serving fried potatoes reducing added salt in recipes reducing added sugar in recipes
42
(43) (89) (88) (81) (59)
87
86 79
58 78 87
94
(80) (89) (96)
for patients, and only a quarter (27%) did so for staff. Forty percent (42) of hospitals claimed to have run in-service training on healthy eating for catering staff, and a similar proportion (44%) had run "healthy eating days" to draw attention to the policy and its implementation. Forty-two percent (44) hospitals had changed their serving methods since the introduction of a policy. v) The cost of healthy eating
In the present economic climate in the UK public sector, the cost of changing catering practice has been an important consideration in developing and implementing a policy. Only one hospital reported that the introduction of a food and health policy had reduced their overall catering costs. Thirty-five percent (35) reported an increase in costs and 47% (47) reported that there had been no overall change in costs since a policy was introduced. vi) Review procedures
Only 44% (45) of hospitals in the study identified a formal procedure for reporting back on the progress of policies to their Health Authority. The most widely reported mechanism was through meetings of a local, interdisciplinary health promotion group. No information was sought from senior caterers about how regularly these review procedures were used. However, from the interviews with senior·managers at district level, it was apparent that in general, systems for regularly and systematically reviewing food policies were not being used at the time of this study. Discussion
The results of the study indicate that all 9 District Health Authorities in Wales had developed policies on food and health, and that a high
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proportion of hospitals reported to be either implementing their district policy at the time of the study, or planned to do so within six months. In practice the majority of hospitals had adopted a number of healthy catering methods in line with national nutritional guidelines (NACNE 1983), and also reported to regularly offer a choice of meal options for staff and patients. These findings indicate that there have been important improvements in the nutritional content of hospital food in comparison with the results from an earlier study in England (Woolaway, Nelson and Herfst 1985). The development and implementation of policies have almost certainly facilitated such improvements by providing a clear statement of intent, by legitimising action, and by initiating the process of change. However, the study also provides a practical illustration of the problems of translating policy into practice. Although the development of a policy statement is a crucial first step in achieving change, on its own it will not necessarily be translated into effective action. A dislocation between policy development and the management of change implied by such developments is hardly unique. The implementation process has to be planned with as much care as is usually put into the wording of policy statements. Previous studies which have examined the process 9f translating policies designed to minimise smoking in NHS hospitals into good practice have identified this same type of dislocation, but have also helped to clarify a number of conditions to achieve effective policy implementation. These include: i) informing staff and securing their co-operation in implementation, ii) planning a timescale and defining actions for implementation, and iii) promoting and "selling" the policy to the public (Nutbeam 1985). These general principles also need to be applied in the case of food and health policies if such initiatives are to be effective. The achievement of these three basic conditions in the implementation process has been variable in Wales, and as a consequence the introduction of healthy catering to NHS hospitals has been compromised. The current study has highlighted some of the practical difficulties which threaten the translation of policy guidelines into action. Firstly, the study exposed a lack of awareness, and adequate preparation for the introduction of the policy in some districts. There were few examples of specific training opportunities for catering staff, and relatively few examples of more general promotion of healthy eating to staff and patients as part of a positive move towards achieving healthier lifestyles. Secondly, the study identified a reduction in the initial momentum which led to the development of a policy statement in some districts, with a subsequent loss of interest from senior management. This may well reflect a lack of detailed attention being given to the process of implementation. Thirdly, there were inconsistencies within hospitals between different food outlets, so that policies were sometimes being implemented by the catering service but not
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by voluntary organisations or private operators who also sold food and refreshments on the premises. In addition to these important organisational threats to success, external constraints on policy implementation were also identified consistently throughout the study. These included a concern by catering staff over external tendering for catering contracts which could threaten their job security. Also, more than one third of hospitals reported that the introduction of changes in catering practice had resulted in increased catering costs (even though only two authorities in the study reported to be specifically monitoring catering costs in relation to food and health policies). This contrasts with a study of 3 Districts in England, which reported that none of the catering budgets had increased as a result the introduction of healthy catering practice, and in one district, catering costs were reported to be the lowest in the Region (Anderson and Lean 1987). However both the issue of job security, and the crucial issue of cost clearly represented a block to effective implementation in this study. The existence of all of these problems, internal and external, emphasise the importance of regular monitoring of the policy implementation process in order that such problems might be quickly identified, and relevant action taken. This case study from Wales provides some important lessons which may help others overcome or avoid some of the practical difficulties involved in policy implementation. These may be summarised as follows: i)
Define success through goal and target setting
Policy statements on food and health should give explicit support for staff implementing the policy by clearly defining overall goals and targets. In cases where specific action is demanded, a clear indication should be given to caterers on how to achieve nutritional goals. It may be appropriate to provide a separate document for caterers which gives specific information on expected changes in catering practices. ii)
Develop the skills needed for success
The importance of relevant in-service and pre-service training for caterers has to be recognised in policy statements, and targets for such activities could be identified. Providing caterers with tP,e skills needed for implementation is essential for successful implementation. iii)
Communicate and involve
Food and health policies must be communicated effectively to all
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hospital staff, patients and vtsttors so that hospitals fulfil their exemplary role to the community as health promoting environments. Involvement of staff in the process of policy formulation and implementation is critical for success. iv) Strive for consistency in application Food and health policies should apply to all food sold on hospital premises, whether this is supplied by hospital catering staff, private contractors or by voluntary organisations. Tendering contracts for catering services should clearly state that contractors must operate any food and health policy which has been formally approved by the Health Authority. v)
Review and modify
The implementation of policy guidelines needs to be carefully planned and regularly reviewed if policies are to have real impact. Target setting and review procedures should be established at the outset so that problems can be swiftly identified and obstacles to progress can be removed. Managers need the basic tools for management in order to secure success. ACKNOWLEDGEM ENT We would like to thank the Dietitians, District Catering Advisers, Catering Managers and other hospital catering staff who co-operated with this study. Thanks also to Dr. Zoann Nugent for statistical report, Mrs Gillian Bladon for fieldwork assistance and to Mrs Susan Avery and Tricia Thomas for their help in preparing the manuscript.
REFERENCES Anderson, A.S. and Lean, M.E.J. (1987). Setting an example: food and health policy within within the National Health Service. Health Education Research 2(3), 275-285. Catford, J. and Nutbeam, D. (1983). Smoking in hospitals. Lancet ii, 94-6. Catford, J. and Parish, R. (1989). Heartbeat Wales: New Horizons for Health Promotion in the Community; in Seedhouse D, Cribb A. Changing Ideas in Health Care, New York, Wiley. DHSS. Committee on the Medical Aspects of food policy (COMA). (1984). Diet and Cardiovascular Disease. London HMSO. National Advisory Committee on Nutrition Education (NACNE). (1983). A discussion paper on proposals for nutritional guidelines for health education in Britain. London, HEC. Nutbeam, D. (1985). A breath offresh air. Health and Social Service Journal. March 21,351. Nutbeam, D. and Catford, J. (1986). The Welsh Heart Programme Evaluation Strategy:
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110 Progress, plans and possibilities. Health Promotion 2(1), 5-18. Parish, R., Catford, J. and Howson, H. (1987). Promoting health through collaboration with industry and commerce. In: Community Based Prevention and Health Promotion. Report of an International Conference. German Society of Social Hygiene and Prophylactic Medicine, and WHO, Dusseldorf. March 1987. Shakespeare, R.M. and Woolaway, M.C. (1989). Smoking in hospitals: a measure of improvement. British Medical Journal 298, 4 February 1989. 293-4. Woolaway, M.C., Nelson, M. and Hansje Herfst, (1985). A study of the nutrient content of hospital meals. Community Medicine 7, 193-197. World Health Organisation ( 1982). Prevention of Coronary Heart Disease-Report ofa WHO Expert Committee. Technical Report Series No. 678-Geneva. (Received 7 August 1990)
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