In this chapter:
- Adhering to key national food standards: a collaborative approach
- International and national influences
- Allergen information
- Legislation and guidelines for Northern Ireland, Wales and Scotland
- Local influences
Food and drink services are influenced by a broad range of legislation and standards. Understanding these supports effective planning of appropriate patient focused nutritional care.
Since the publication of the 2nd edition of The Nutrition and Hydration Digest, there have been several key updates to the increasingly broad range of legislation and guidance, including international, national and local influences, that need to be considered when planning food and drink services within healthcare settings. This chapter provides an overview of this legislation and guidance, with signposting to further information.
Adhering to key national food legislation and standards: a collaborative approach
Everyone with a responsibility for food and drink services should be aware of the international and national regulations and recommendations for its provision. Clinicians with this responsibility should also be aware of any local policies that influence the food service decisions in their area. The application of such policies to hospital food and drink provision needs to be appropriately patient-focused, especially for the nutritionally vulnerable. The principles of nutritional standards and their monitoring can equally apply to other care settings. When commissioning services in these settings, it is important the same standards are applied.
Food Service Dietetics can feel overwhelming to a new-starter in the speciality – there are numerous pieces of legislation to consider around key areas such as food labelling and allergens, as well as nutrition standards to comply with, including procurement considerations and menu planning. In the years since the 2nd edition of the Nutrition and Hydration Digest there have been several notable updates to the guidelines and legislation that a food service dietitian will need to be aware of. The 2020 Report of the Independent Review of NHS Hospital Food (1) and the 2022 National standards for healthcare food and drink (2) are two updates of significance. In particular, the National standards are an invaluable resource for dietitians and one that they would be wise to familiarise themselves with.
The National standards outline the procedures that organisations must follow to guarantee the high quality and sustainability of the food and drink they provide to patients, staff and visitors. They describe the methods by which these procedures should be put into practice and monitored. The standards also suggest future improvement aspirations and actions. This chapter and the accompanying appendices expand on the standards. Dietitians should be aware that they now form part of the legally binding standards in the NHS Standard Contract (3) and are a part of the NHS Long Term Plan (4). What this means in practice, is that all organisations subject to the Standard Contract will be legally obliged to deliver against these standards.
Whilst the National standards may be considered the overarching standards that NHS organisations are required to meet, the Digest is a core part of them and compliance to the recommendations outlined in this document fall under section 2 of the National standards, ‘improving patients’ food and drink’ (2). At a local level, organisations should have efficient nutrition steering groups that meet regularly and consist of various multidisciplinary members, with dietitians being an integral part of such groups. See the text under ‘Local influences’ in this chapter for more information on this requirement.
International and national influences
Dietitians are active contributors to policies affecting nutritional care across the UK. Some prominent examples of the invaluable dietetic contribution are introduced or discussed in this chapter, including the Report of the Independent Review of NHS Hospital Food (1) and the National standards for healthcare food and drink (2). Table 3.1 outlines the core food legislation, standards and influences (international and national) that should impact planning and decision making around food and drink in health and social care settings.
Throughout this document, there is a bias towards practices used in England – it is recognised that all home countries take a synergistic approach and each nation’s guidelines can complement one another. However, each country has developed population-specific guidance for their own food and drink services, which are outlined separately in this chapter.
Table 3.1 Summary of key food legislation, standards and influences
|
Standard/Legislation Name |
Controlling/ Responsible Body |
Brief Summary/Signpost for more information |
Legal standing |
|---|---|---|---|
|
Resolution ResAP, 2003 (International Influence) (5). |
The Council of Europe (CoE) |
Resolution ResAP advise that governments should implement national recommendations on food and nutritional care in hospitals based on nutritional assessment and treatment by nutritional care providers, food service practices, hospital food and health economics costs. There are over 100 recommendations within the resolution. These recommendations were summarised by the CoE Alliance into the 10 Key Characteristics. |
This report applies across the UK as a member state of the Partial Agreement in the Social and Public Health Field. The CoE Partial Agreement recommendations (called "resolutions") are not legally binding but aim to inspire political action at a national level. In 2015, the 10 Key characteristics of good nutrition and hydration care were adopted by NHS England and are part of the wider Food Standards. |
|
Regulation 14 of the Care Quality Commission (CQC), 2014 (National Influence, England) (6). |
CQC |
Hospital Trusts in England are regulated under the CQC. The CQC monitor, inspect and assess services against their fundamental standards, ensuring they meet the expected levels of quality and safety. See Appendix 5 for more details on Regulation 14 of the CQC (meeting nutritional and hydration needs). |
The Health and Social Care Act 2008 established the CQC as the regulator of all health and adult social care services. CQC Regulated Activities are legislation. |
|
Hospital Food Standards (HFS) Panel report on standards for food and drink in NHS hospitals, 2014 (National Influence) (7).
|
Department of Health (DH) |
The HFS Panel published a report in 2014 which identified five food standards. These are now superseded by the 2022 National standards but information for reference regarding the 2014 standards can be seen in Appendix 6. |
Since April 2015, the HFS have been included in the NHS Standard Contract and are legally binding. |
|
International Dysphagia Diet Standardisation Initiative, 2019 (IDDSI) (International Influence) (8) |
IDDSI |
Meeting patient nutrition and hydration needs includes nutritionally vulnerable patients who require texture modified (TM) food and drink. When provided in care settings, TM food and drink should comply with the IDDSI Framework. This is discussed in further detail in Chapter 12. |
The IDDSI Framework is not mandatory. However, it is the only currently referenced standards for the provision of modified texture food and drink in key national standards. |
|
Report of the Independent Review of NHS Hospital Food, 2020 (National Influence) (1).
|
Department of Health and Social Care (DHSC) |
The Independent Review was announced following an outbreak of listeriosis in the NHS. The report was published in October 2020 and covered eight recommended areas for system level change (see Appendix 7 for more information). |
The Independent Review is based upon recommendations and is not legally binding. However, it contains reference to several key, very relevant pieces of food legislation including The Public Services (Social Value) Act, 2012 and legislation relating to food safety, hygiene and training. |
|
The Government Buying Standard for Food and Catering Services, 2021 (GBS) (National Influence) (9)
|
Department for Environment Food and Rural Affairs (DEFRA) |
The GBS for food and catering services forms part of the National standards for healthcare food and drink. GBS outline the standards required to procure sustainable food services. See Appendix 8 for more information on these standards. The nutrition standards outlined in the GBS apply to staff and visitor catering (see Chapter 4), while the nutrition standards outlined in Chapter 10 apply to patient catering. |
The GBS for food and catering services are made up of both mandatory and voluntary standards. |
|
National Standards for Healthcare Food and Drink, 2022 (National Influence) (2)
|
NHS England |
The National Standards for Healthcare Food and Drink build on the 2014 HFS report and consider the recommendations made in the Report of the Independent Review of NHS Hospital Food. The standards include key priorities for both the NHS and the government and cover four sections. See Appendix 9 for more information, including how NHS England will monitor progress with the standards (10). |
The National Standards form part of the legally binding standards in the NHS Standard Contract (SC19) and are a part of the NHS Long Term Plan. All organisations subject to the Standard Contract will be legally obliged to deliver against these standards. |
|
Patient Led Assessments of the Care Environment (National Influence) (PLACE) (11) |
NHS Digital |
PLACE audits include a comprehensive evaluation of the taste, flavour and presentation of hospital food as well as a set of organisational food questions that must be answered. |
PLACE assessments are conducted annually, and results are published. Organisations should use PLACE to provide good quality evidence of current practice and drive improvements in quality nutritional care. |
Allergen information
All catering establishments must provide allergen information, including for food sold loose. Across food service environments, 2021 saw some significant change to the legislation surrounding allergen labelling. On 1 October 2021, new government legislation, referred to as ‘Natasha’s Law’ (12) was introduced. Natasha’s Law requires all food which are prepared and packaged on the same premises from which they are sold, to be labelled with a full ingredients list with the 14 major allergens emphasised for easy identification (12). Food that fits this description is known as Prepacked for Direct Sale (PPDS). If an organisation sells or supplies PPDS food, they must comply with this law.
The Food Standards Agency (FSA) website is a useful resource for more information on Natasha’s Law and includes examples of what is considered a PPDS food, and an allergen and ingredients food labelling tool (13).
Food labelling responsibilities and changes following the UK’s exit from the European Union
From December 2014, food labelling law in all four home countries became subject to Regulation (EU) No 1169/2011, The Provision of Food Information to Consumers (FIR) (14). Under the European Union (EU) (Withdrawal) Act 2018, this regulation was retained and incorporated into domestic law for England, Scotland and Wales (15). Following the UK’s exit from the EU, goods sold in Northern Ireland will continue to follow EU rules for food labelling (16).
The Health and Care Bill gives power to the Secretary of State in England and ministers in Scotland and Wales to make amendments to this retained legislation through regulations. Any regulations made under the new power are subject to the affirmative process and must be approved by their respective chambers (Houses of Parliament, Senedd Cymru or Scottish Parliament) (15). This means changes or new policies regarding food and drink labelling are debated and approved before they are implemented.
The professional bodies who bear responsibility for food labelling laws in each of the four nations can be seen in Table 3.2.
Table 3.2: Responsibilities of food labelling laws in the four home nations
|
Nation |
Policies (responsible bodies in brackets) |
|---|---|
|
England |
Note, it is the joint responsibility of the above organisations. |
|
Wales |
|
|
Scotland |
|
|
Northern Ireland |
|
Legislation and guidelines for Northern Ireland, Wales and Scotland
Northern Ireland (NI), Scotland and Wales each have their own core food legislation and guidelines, that in practice, can each complement one another and be used in synergy, along with guidance and standards specific to England. Table 3.3 outlines each of these key population-specific guidelines for Northern Ireland, Wales and Scotland. Appendix 10 provides additional information for these key guidelines from NI, Scotland and Wales, as well as information on other core policies on food and drink in each of these countries.
Table 3.3: Legislation and guidelines for Northern Ireland, Wales and Scotland
|
Country & Standard/Legislation Name |
Controlling/ Responsible Body |
Brief Summary/Signpost for more information |
Legal standing |
|---|---|---|---|
|
Northern Ireland (NI); Promoting Good Nutrition (PGN), A Strategy for the Good Nutritional Care of Adults in all Care Settings in Northern Ireland 2011-2016 (19). |
The Department of Health, Social Services and Public Safety |
The PGN strategy informs how healthcare professionals throughout NI aim to ensure good nutrition across all health care settings. It was built on and incorporates the initiatives published by the DH Chief Nursing Officer, in conjunction with the Royal College of Nursing (RCN), in the “Get your 10 a Day. Nursing Care Standards for Patient Food in Hospital” (20) For more information on the PGN strategy and assessing compliance with the standards, see Appendix 10.1. Supplementary guidance and resources are also available to help support the use of MUST across all care settings in NI (21). |
This is a mandatory standard in NI. |
|
Scotland; Food, Fluid and Nutritional Care Standards, 2014 (22)
Food in Hospitals – National Catering and Nutrition Specification for Food and Fluid Provision for Hospitals in Scotland, 2016 (23). |
Healthcare Improvement Scotland (HIS)
NHS Scotland |
Food, Fluid and Nutritional Care Standards are based on research and development and reflect on the whole patient journey with respect to nutritional care, not just food provision. See Appendix 10.2 for more on these standards and on the purpose of HIS. Food in Hospitals sets out the food and nutrient based standards including menu planning guidance alongside guidance for therapeutic dietary provision. The specification provides NHS Boards with the rationale and necessary practical guidance to allow compliance with the HIS Food, Fluid and Nutritional Care Standards. See Appendix 10.2 for more. |
Both these standards are mandatory in Scotland. |
|
Wales; Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients, 2012 (24). |
Welsh Government |
The All Wales Catering and Nutrition Standards for Food and Fluid Provision for Hospital Inpatients is for use in hospital settings in Wales and provides technical guidance for caterers, dietitians and nursing staff responsible for meeting the nutritional needs of patients who are capable of eating and drinking. The standards are key to the delivery of the All Wales Hospital Nutrition Care pathway protocol and to meeting Standards for Health in Wales. The guidance included covers nutrient and food-based standards which provide for the needs of a diverse hospital population of all ages, nutrition status and those with different therapeutic and cultural requirements. See Appendix 10.3 for more. |
This is a mandatory standard in Wales. |
Local influences
Dietitians and clinical colleagues should lead on the development, implementation and monitoring of nutrition related policies as part of clinical governance, developing relevant and workable guidelines, protocols and training to support service improvement in nutritional care. Many healthcare organisations have contracts with external providers for food services, or service agreements with internal providers. Dietitians working for healthcare organisations and catering contractors, food suppliers and manufacturers should take part in the planning and negotiation of these documents. To do this, both contractor and Trust dietitians must be familiar with the relevant national and local standards and implement monitoring processes, such as audits and patient satisfaction surveys, to evaluate food provision.
It is important that healthcare organisations have established nutrition steering groups with multidisciplinary representation. Each Trust will have their own governance arrangements to monitor and link in with activities undertaken on their behalf by the nutrition steering group. It is good practice to operate these services within the governance framework of the Trust and ensure that there is regular feedback to the Trust Board. The role of the food service dietitian in a multidisciplinary team is covered in more detail in Chapter 2.
Table 3.4 lists some examples of service level agreements at a local level. Outcomes for these agreements should focus on patient-centred care and ensuring positive patient experiences related to food and drink provision in healthcare settings.
Table 3.4: Local service requirements
|
Local Provision |
Examples of Service Level Agreements |
Outcomes |
|---|---|---|
|
Service planning and support |
|
Provision of nutrition to meet all patient clinical and personal needs and agreed locally |
|
Service provision |
|
The meal service and environment meet patient needs and agreed local standards |
|
Service monitoring and audit |
|
Positive patient experience illustrates patient needs are met to agreed levels |
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References
- Department of Health and Social Care. Report of the Independent Review of NHS Hospital Food. https://www.gov.uk/government/publications/independent-review-of-nhs-hospital-food [Accessed 11th April 2023]
- NHS England. National standards for healthcare food and drink. https://www.england.nhs.uk/publication/national-standards-for-healthcare-food-and-drink/ [Accessed 11th April 2023]
- NHS England. NHS Standard Contract. https://www.england.nhs.uk/nhs-standard-contract/ [Accessed 11th April 2023]
- NHS England. NHS Long Term Plan. https://www.longtermplan.nhs.uk/ [Accessed 11th April 2023]
- Council of Europe. Resolution RESAP(2003)3 on food and nutritional care in hospitals. https://wcd.coe.int/ViewDoc.jsp?id=85747 [Accessed 11th April 2023]
- Care Quality Commission (CQC) Regulations for service providers and managers: relevant guidance. https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-providers-managers-relevant-guidance [Accessed 11th April 2023]
- Department of Health and Social Care. Establishing food standards for NHS hospitals. https://www.gov.uk/government/publications/establishing-food-standards-for-nhs-hospitals [Accessed 11th April 2023]
- International Dysphagia Diet Standardisation Initiative (IDDSI). The IDDSI Framework. https://iddsi.org/Framework [Accessed 11th April 2023]
- Department for Environment Food and Rural Affairs (DEFRA). Government Buying Standard for food and catering services. https://www.gov.uk/government/publications/sustainable-procurement-the-gbs-for-food-and-catering-services#full-publication-update-history [Accessed 11th April 2023]
- British Dietetic Association. The Nutrition and Hydration Digest improving outcomes through food and beverage services, 2nd Edition. https://www.bda.uk.com/uploads/assets/c24296fe-8b4d-4626-aeebb6cf2d92fccb/NutritionHydrationDigest.pdf [Accessed 11th April 2023]
- NHS Digital. Patient-Led Assessments of the Care Environment (PLACE). https://digital.nhs.uk/data-and-information/areas-of-interest/estates-and-facilities/patient-led-assessments-of-the-care-environment-place [Accessed 11th April 2023]
- Allergy UK. Allergen Labelling Changes. https://www.allergyuk.org/news/allergen-labelling-changes/ [Accessed 11th April 2023]
- Food Standards Agency (FSA). Allergens and ingredients food labelling decision tool. https://www.food.gov.uk/allergen-ingredients-food-labelling-decision-tool [Accessed 11th April 2023]
- European Parliament and of the Council. Food Information Regulations. https://www.legislation.gov.uk/eur/2011/1169/contents [Accessed 11th April 2023]
- Department of Health and Social Care. Health and Care Bill: food information for consumers – powers to amend retained EU law. https://www.gov.uk/government/publications/health-and-care-bill-factsheets/health-and-care-bill-food-information-for-consumers-powers-to-amend-retained-eu-law [Accessed 11th April 2023]
- Northern Ireland Office. Brexit transition: How-To-Prepare guide for changes to labelling food sold in Northern Ireland. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/941774/BREXIT_TRANSITION__HOW-TO-PREPARE_GUIDE_FOR_NI_FOOD_LABELLERS.pdf [Accessed 11th April 2023]
- Food Standards Agency. Food and Feed Law Guide. https://www.food.gov.uk/sites/default/files/media/document/food-and-feed-law-guide-july-2020.pdf [Accessed 11th April 2023]
- Department for Environment, Food & Rural Affairs. Food Standards: Labelling and Composition. https://www.gov.uk/guidance/food-standards-labelling-durability-and-composition [Accessed 11th April 2023]
- Department of Health, Social Services and Public Safety. Promoting Good Nutrition: A Strategy for good nutritional care for adults in all care settings in Northern Ireland 2011-2016. https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/promoting-good-nutrition_0.pdf [Accessed 11th April 2023]
- Department of Health, Social Services and Public Safety. Get your 10 a day! THE NURSING CARE STANDARDS FOR PATIENT FOOD IN HOSPITAL. https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/10-a-day.pdf [Accessed 11th April 2023]
- Health and Social Care (HSC). PROMOTING GOOD NUTRITION Guidance and resources to support the use of Malnutrition Universal Screening Tool (MUST) across all care settings. https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/pgn-must_0.pdf [Accessed 11th April 2023]
- Healthcare Improvement Scotland (HIS). Food, Fluid and Nutritional Care Standards. https://www.healthcareimprovementscotland.org/our_work/standards_and_guidelines/stnds/nutritional_care_standards.aspx [Accessed 11th April 2023]
- NHS Scotland. Food in Hospitals. https://www.nss.nhs.scot/media/1097/1479818118-food-in-hospitals-revised-march-2016.pdf [Accessed 11th April 2023]
- Welsh Government. All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients. https://www.bapen.org.uk/pdfs/e-learning/WalesNutritionCateringStandardsHospitalInpatients.pdf [Accessed 11th April 2023]
Further Reading
British Association for Parenteral and Enteral Nutrition (BAPEN). A Toolkit for Commissioners and Providers in England. Second Edition. Malnutrition Matters: Meeting Quality Standards in Nutritional Care. https://www.bapen.org.uk/pdfs/bapen_pubs/bapen-toolkit-for-commissioners-and-providers.pdf [Accessed 11th April 2023]
Department for Environment, Food and Rural Affairs (DEFRA). Policy paper: Government food strategy. https://www.gov.uk/government/publications/government-food-strategy [Accessed 11th April 2023]
European Society for Clinical Nutrition and Metabolism (ESPEN). ESPEN Guidelines & Consensus Papers. https://www.espen.org/guidelines-home/espen-guidelines [Accessed 11th April 2023]
Food Standards Agency (FSA). http://www.food.gov.uk/ [Accessed 11th April 2023]
Hospital Caterers Association (HCA). Publications. http://www.hospitalcaterers.org/publications/?c=1557 [Accessed 11th April 2023]
National Association of Care Catering. NACC Publications: How to provide good nutritional care and comply with CQC Fundamental Standards. https://www.thenacc.co.uk/shop/publications [Accessed 11th April 2023]
National Food Strategy. National Food Strategy: An Independent Review for Government. https://www.nationalfoodstrategy.org/ [Accessed 11th April 2023]
NHS England. Guidance – Commissioning Excellent Nutrition and Hydration 2015-2018. https://www.england.nhs.uk/wp-content/uploads/2015/10/nut-hyd-guid.pdf [Accessed 11th April 2023]
National Institute for Health and Care Excellence (NICE). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition (CG32). https://www.nice.org.uk/guidance/cg32/chapter/Introduction [Accessed 11th April 2023]
Public Health England. Healthier and more sustainable catering. https://www.gov.uk/government/publications/healthier-and-more-sustainable-catering-a-toolkit-for-serving-food-to-adults [Accessed 11th April 2023]