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NHS: Hospital Feeding

Volume 701: debated on Thursday 15 May 2008

rose to call attention to the case for improving arrangements for feeding patients in NHS hospitals; and to move for Papers.

The noble Baroness said: My Lords, noble Lords will be aware that I have raised this question on a number of previous occasions and they may wonder why I am doing so again. I regret to state that it is because I have never, in answer to numerous Questions, letters to—and even interviews with—Ministers, as well as several speeches in debates and an attempted parliamentary Bill, had any real indication that the wrong I seek to address is being effectively tackled. Yet that wrong is not a minor one. We are talking about sick people in hospitals being deprived of food, liquids and care to such an extent that, sometimes, they do not survive.

When I first raised this matter, some Members of this House and, of course hospital trusts, rubbished my allegations and refused to accept that any of it was happening at all. They really cannot do so today. There is a mass of hard evidence that my claims are only too true. Television programmes have highlighted it. There is hardly anyone who has not heard of the familiar allegation of nurses placing food or a cup of tea too far from a bed-ridden patient for the plate, cup or tray to be reached. The nurse bustles in some 15 minutes later, exclaiming, “I see you don’t want that, then”, and whisks it away before the patient can say a word.

People have given me explicit examples of their relatives or friends not being given any food or liquid at all, with no explanation or excuse. Others have reported that if they do not take food in, the patient will either get nothing or be given totally unsuitable or inedible food. Some patients get cheese slices, wrapped in something that they cannot undo; sandwiches are also wrapped that way. Some get hard-crust bread with which their dentures cannot cope. Of course, this does not happen in every hospital, as thousands and thousands of really exemplary nurses are caring devotedly for their patients. I make no criticism whatever of them, but we deceive ourselves if we think that standard is universal. It is not. We must recognise the truth and seek to be effective.

Last summer, my noble friend Lord Patten and the noble Lord, Lord Carlile, both of whom, by the way, wrote to me this morning greatly regretting that they were not able to attend or speak in this debate, came with me to see the then Minister, the noble Lord, Lord Hunt, about my complaints. Perfectly reasonably, he asked for some solid proof—names, addresses, dates, hospitals and all of the relevant details.

I had a large file of cases, and spent some two to three weeks contacting every single such complainant personally, by phone and letter. I asked whether they minded my reporting, and possibly making public, the details of their experience. A large number did mind. Quite frankly, some of them were scared, which worried me. They knew what happened to whistleblowers and feared facing unpleasant consequences if they needed hospital treatment themselves. Some said that there was really no point at all in complaining, as the relative or friend about whose treatment they had complained had died of it and was gone. As for taking legal action, that is never really possible unless someone is very rich. The NHS is the biggest and mightiest business in all of Europe, and it is difficult indeed to take a case up against it. In fact, I am told that it is nearly impossible to find a lawyer who will do so.

With the agreement of some complainants, however, I was able to give the Minister a dossier of 22 cases where bad nursing and no feeding were alleged. Names, ages, addresses, dates and hospitals where deficiencies occurred were all accurately listed. I do not blame the noble Lord, Lord Hunt, for what happened next. He passed on the cases for investigation, perfectly properly. I blame those charged with investigating; their arrogance and blindness to the facts was absolutely appalling. Not all—a few hospitals tried hard to respond properly, the health authority in the north-east being one, although I still do not quite understand why or how the families’ sworn allegations to me were not judged to be evidence. However, most authorities did not respond as they should have. Eight out of my 22 cases, so carefully detailed, did not get one word of comment. Other authorities commented on only parts of the complaint but totally ignored other parts.

Allegations about lack of feeding were hardly ever referred to, although one or two mentioned a rather mysterious red tray—but no explanation of what that meant was ever made to me. I have since found out that, if a red tray comes along carrying the food, it is meant to signal that the patient needs help to eat. The authorities did not tell me that, and gave me no clue at all whether, or how, or to what extent the red tray signal actually results in help being given. Nurses are extremely busy and do not have time to spoon-feed people. I recognise that difficulty. Yet complaints are coming in all the time about lack of feeding, red tray or no.

An old MP friend and colleague of mine in the other place visited his wife, who had cancer. He sat by her bed as long as he could. After three days, he thought, “That’s strange; I haven’t once seen this girl being fed”, so he asked the nurse, “When do you feed my wife.” “Oh, we’re not feeding her”, the nurse said. “Not feeding her”, he said, “Why? Who said that? Did she ask for it? Did I ask for it?”. He created an awful row, and the result was that his wife was fed and things got better. I listed all this carefully in my complaint. The response was, “In this case, communications failed”. That was it, nothing else. The authority admitted the allegations were true, but there was no explanation and no apology.

Other allegations of poor care, in addition to lack of feeding, which were totally ignored included two examples of deaf aids being removed and never returned because they were lost. If you are reliant on a deaf aid and you cannot hear what is being said to you, you give rather peculiar answers, you are immediately put down as being a bit gaga and therefore your feeding is not normal. Nothing of that was ever referred to, although I think it is a very serious complaint. A man who was told to arrive at the hospital no later than 7 am when no bed or food was available until 10 pm was another complaint not mentioned. A husband who had to dress his wife’s bedsores because nobody else did was not mentioned either. There may be perfectly reasonable reasons why all these things happened. If so, the reports I received failed to respond to them.

The letter from the health chief executive summing up the whole matter said:

“I am assured that adequate policies on nutrition and hydration are in operation and that negligence has not occurred. In the light of the depth of the investigation and findings, I do not consider that a further investigation will be necessary”.

How could he possibly say that in the light of what I have told the House? Considering that eight of my cases were never investigated or commented on and a number of specific complaints were not referred to in the responses made, I find those words from the chief executive astounding in their complacence and arrogance. They are also extremely depressing because they obviously show that he is perfectly satisfied with the situation as it is and will take no steps to alter what is going on.

Further examples are coming up all the time. In the past 24 hours, I have received lengthy communications from Age Concern, the Stroke Association, the Royal College of Nursing, Help the Aged and others concerning up-to-date cases of this happening. A headline in the Daily Telegraph of 8 February 2008 read:

“One in five patients leaves hospital malnourished”.

An earlier headline read:

“Thousands of patients are being allowed to starve on NHS wards”.

I admit that some patients come into hospital undernourished before they ever step over the threshold, but the Department of Health’s own figures show that the nutritional condition of at least 8,500 patients a year worsens while in hospital.

I believe that Ministers acknowledge that when patients are in the care of the National Health Service a clear responsibility lies on that service to give them the ordinary essentials of life. There are no more basic essentials for the business of living than food and liquid, as well as medical care. Ministers must be less trusting of the reports they sometimes get from chief executives and trusts that flatly refuse to see that anything is wrong.

There is a very great deal wrong. All of us have a duty and an obligation to see it righted. There are many ways to do that. Hospitals could ask patients’ relatives if they would be able to come in to help feed them, which would save the nurses a lot of trouble. They could ensure better quality meals to which a patient can address himself and eat. They could arrange for help for patients with immobilising conditions such as multiple sclerosis or motor neurone disease. I had complaints about that that were not addressed. They could order that meals must be put in reach of patients. Since the May elections, government spokesmen have repeatedly assured us that they will listen. All right, then—listen. I beg to move for Papers.

My Lords, I congratulate the noble Baroness on securing today’s debate, and on her tenacity in pursuing this important issue. Hospital food and the nutrition of patients is an extremely important issue. I have more reason than many people to know that, because I have more experience of hospital food than is desirable for anybody. As someone who has spent a considerable part of recent years in NHS hospitals, once for a continuous period of almost seven months, I know only too well what important punctuation marks in a hospital day the mealtimes are, and how important the food is. The ordering, expectation and eating of it acquire an importance way beyond that of simple nutrition, important though that is, as the noble Baroness has reminded us.

Before I turn to some of the specific points I want to make about food, I mention nutrition more generally. The nutrition of patients goes wider than the food they receive. For four and a half months of my longest stay in hospital I could take no food whatsoever, and was kept alive, as many patients are, through intravenous Hickman lines, which had to be put in under general anaesthetic, constantly monitored and renewed each day with a bag of artificial food. This had to be done with great skill by specially trained nurses and at huge cost to the NHS. I believe every bag of food cost at least £75. I am enormously grateful. Because of the way I received this food, I never tasted it, but I am very grateful that it kept me alive. I mention this only because we must remember that the nutrition of patients is a wide issue, which engages many skilled and experienced staff in our hospitals. Once I had the Hickman line removed, I had to learn to eat again, which was not easy. At that point I was very well supported by dieticians, special calorie-laden items and very close attention. There are not many times in one’s life when one asks for more calories.

That was all on an acute ward. I know that many people are concerned about the nutrition of patients on acute wards and in long-term care, where perhaps not enough attention is given, not only to the food, as the noble Baroness has reminded us, but to helping people eat it. We should rightly be concerned about that, but we should also keep a sense of proportion. In that regard, I quote from the Healthcare Commission’s report, which came out yesterday, in a timely fashion. A higher percentage of patients said that the quality of food was now very good. Only 18 per cent said that in 2002, and 19 per cent in 2007, but yesterday’s report said that over half said that the food was either good or very good.

However, there was certainly far too much variation among those who need help with eating. In the lowest-scoring trusts, 42 per cent said that they did not receive enough help with food, while in the highest-scoring trusts the figure was only 3 per cent. The commission’s chief executive, Anna Walker, said:

“The government has made absolutely plain that it wants the NHS to listen to the views of patients and respond to their concerns”.

That is very important in light of what the noble Baroness said about the professionals’ response. These reports are based on the views of patients. Anna Walker goes on to say:

“It gives the most comprehensive picture available of how patients feel about NHS hospitals … Overall, it’s encouraging that a steadily increasing percentage of patients say care is excellent. It is good to see advances on issues like the quality of food … and team working between doctors and nurses.

But the survey also shows that in some hospitals the NHS is struggling to deliver on some of the basics of hospital care … Those performing poorly must learn from those who perform well”.

I am sure all noble Lords will agree with that. She goes on to say:

“It is crucial that trusts take this information on board. The patient voice must be heard loudly on the boards of trusts across the country”.

This annual assessment, as the voice of patients, is very important. It is clear that some progress has been made, but we all acknowledge that there is a lot more to do.

Let me point out some of things that the Government have done in regard to nutrition. Improving Nutritional Care was published in October 2007 and the programme is monitored through a delivery board chaired by the head of Age Concern, a very important point. That board is accountable to my honourable friend in another place, the Minister for Care Services. There will be an in-year progress report this summer, which we should all watch out for, and then an update in December.

We will all remember the Better Hospital Food programme, which was set up in 2001, if only because of the involvement of Lloyd Grossman, who chaired it. It made great progress in improving the quality of hospital food.

I should also mention the introduction of ward housekeepers to look after the basic non-clinical needs of patients, some of which have been mentioned by the noble Baroness, Lady Knight. Nurses have a responsibility for food service but they now have someone to support them in delivery. By the end of 2004, housekeepers had been introduced into 53 per cent of all hospitals. In larger hospitals, where the majority of patients receive treatment, that figure rose to 70 per cent. These figures continue to rise.

Given the reputation that some hospital food has it may seem odd to think about an NHS recipe book, but hospital meals have been redesigned to introduce better ingredients, to improve flavour and to include patients’ favourites such as curry and other kinds of world cuisine. Many patients find it difficult to identify the name of the dish when choosing from menus, and important progress has been made by introducing photographs of what the food looks like to help patients choose.

From my own experience, I know that important progress has been made by making proper food available 24 hours a day. As the noble Baroness reminded us, it is not acceptable for you to wake up from surgery to have only a sandwich—still less a bit of cheese in wrapping that you cannot deal with—available to you. Eighty-nine per cent of hospitals have introduced ward kitchen services to provide light snacks, 80 per cent have snack boxes and 84 per cent also provide extra snacks during the day. Again, it is very important that patients can choose a hot meal in the evening—before there was only soup or a sandwich—and 94 per cent of hospitals now provide this service.

Progress has been made in quality. However, we have to understand that providing food in large quantities to a large number of people on a necessarily limited budget is never going to be easy. We always have to remember that when we consider food in hospitals.

As nurses and ancillary staff are so important in monitoring eating in patients, we should also acknowledge that the huge increases in funding for the NHS and the increase in nursing staff—there are now 80,000 more nurses than in 1997—has played an important part. But, of course, an increase in nurse numbers will not help if nurses do not see helping patients to feed themselves as part of their essential duties. We must therefore ensure that nurse training includes this as a priority. Where hospitals have reintroduced matrons, it has had the effect of helping nurses to remember that nursing is about caring as well as about technicality and targets. I do not in any way downgrade the importance of the technical side of nursing because I have reason to know how very important that is. We must remember, however, its caring side as well.

I do not think this is too much of a digression, and I also want to mention that, though we are concentrating on food in hospitals, we must remember that this issue is also of concern in residential care homes and nursing homes where many elderly people are cared for. People with dementia, learning difficulties or severe physical disabilities would have the same problems the noble Baroness set out for hospital patients. We must remember how important food is in these places, too. The Commission for Social Care Inspection has always made that part of their inspection process. We must make sure that that inspection and regulation is carried forward to the Care Quality Commission which is now being considered under the Health and Social Care Bill currently passing through your Lordships’ House. I believe that the menu improvements that have been made in hospitals must be included in care homes.

Some of the difficulties raised by the noble Baroness could also have been circumvented in hospitals and in care homes by the use of volunteers. Many hospitals and community facilities, not to mention hospices, have excellent teams of volunteers who help out at mealtimes. They can collect the menu choices, help with serving and, most importantly, sit with patients to see that they can eat the food served. Some health and safety issues have to be addressed, but often all the patient needs is someone who will not feed them but sit with them while they eat. Most of us expect mealtimes to be a sociable occasion and volunteers can alert the staff if the patient is not eating.

The recent excellent report on volunteering by the noble Baroness, Lady Neuberger—I declare an interest as president of Volunteering England—pointed out the potential of volunteers in situations such as this. As someone who used to be a voluntary services co-ordinator for a health authority, I certainly commend the idea and I hope that this debate will focus more attention on the potential of volunteers in this regard.

I certainly would not want to suggest a lack of seriousness in the complaints the noble Baroness has brought to our attention in this debate, but we should also acknowledge that a lot of progress has been made. Certainly there are still shortcomings and we must continue to tackle these with urgency and with determination for the sake of all patients in our hospitals and outside.

My Lords, I welcome the opportunity to join in this discussion and I thank the noble Baroness for initiating it. In Wales, we have our own regime, as health is devolved. One thing that has followed from that is that a nutrition catering framework was produced by the All Wales Catering/Nutrition Group for the Welsh Assembly Government some years ago. The aim was to improve patient nutrition and hospital catering services. NHS trusts in Wales were required to implement the framework at all hospital sites. This framework emphasised the importance of nutrition to in-patient care in NHS hospitals in Wales. As we know, this can impact on the speed with which a patient recovers and contribute to an early discharge from hospital. It is most valuable.

The framework also stresses the importance of choice of meals for patients, assistance with eating their food, if that is required, and uninterrupted time in which to eat. It also recommends the availability, as has been mentioned, of meals and snacks when mealtimes are missed. The framework covers issues such as allergy, feeding problems and measuring intake of food and fluid. It also covers language, because in parts of Wales Welsh is the first language and the most homely language for patients, nurses and staff to discuss things together. It also deals with nutrition adequacies, patient-feeding assistance and menu structure.

In 20 years or so as a hospital chaplain I have often spoken to patients in different hospitals. The situation regarding hospital food has varied tremendously from hospital to hospital. I do not in any way condemn the majority of hospitals. What they provide is good and the way they provide it is totally acceptable. Those that receive complaints are in a minority. Only this Monday I was in Glan Clwyd hospital—a large hospital in north Wales—where I met members of the community health council who were carrying out an inspection visit. The response was favourable and positive, as I suggest is the case in most hospitals, at least in Wales.

Do community health councils have sufficient input? When they visit hospitals, can they make recommendations and, if so, are they accepted? What standard of food are they expecting? In the Grand Committee debate on the Health and Social Care Bill on 6 May, the noble Baroness, Lady Knight, mentioned that hospital meals cost about £2.65 each. Given rising food prices, is that sum adequate for the needs of patients, who need the best food possible? I was speaking this morning to catering staff in this very establishment. Poor-quality meat is likely to be unacceptable, especially to those who are frail and need special attention.

If I do not have a boiled egg available I am lost, but some folk are expert at making meals out of hardly anything. With a low allocation of funds for food, catering staff are sometimes in a dilemma about how they can best meet the needs of the patient and still remain within their allocation. How much training is there for the staff involved in preparing hospital food? Do our catering colleges have a special course in feeding patients for people who will be involved in hospital nutrition? Surely this is a specialised area that we should consider. What is the standard of those who come from our catering establishments? Is it appropriate for today’s needs?

If patients are frail and a tray of food is placed out of their reach, it could be the best meal in the world and it would make no difference. Also, plastic knives and forks are not easy implements to handle. When I am sitting in a plane—and I always travel economy, if I travel at all—I wonder how on earth I will be able to cut any meat with these plastic implements. If you are frail, it is a problem in itself.

Some patients need help with their meals and even assistance with feeding. Most of the hospitals provide this; the nurses go out of their way to meet this need. The University Hospital of Wales in Cardiff has had a volunteering scheme for some time—the noble Baroness, Lady Finlay, might mention this. I was told this morning by the previous Minister, Jenny Randerson, that having volunteers and family coming in at mealtimes to help patients had improved the situation 100 per cent. It involves families and the community in supporting their local hospital. We need somehow to increase the number of hospitals and perhaps even care homes that have this facility so that no patient is unable to access a good meal and make the most of it.

What assessment is made of the eating needs of patients when they are admitted to hospital? People can sometimes be embarrassed. Hospital meals might include chocolate, cheese and heavy cream, which people with migraine, for instance, are unable to touch. What assessment is made of people with migraine and with allergies, such as those who cannot eat wheat in any form? What are the alternatives? As we become a more multicultural society, what assessment is made of the religious needs of those from other faiths in our hospitals? I am sure that such assessment takes place but I would like to know exactly how much is done in this area and what the difficulties are.

Certain other things can be embarrassing, such as ill-fitting dentures. You cannot easily tackle a meal unless you are able to chew it. When people come into a hospital, an elementary basic assessment should be made. Are there any problems? Are there any things that might increase embarrassment? That would help tremendously, so that stage one of a patient’s introduction to hospital food is at least knowing that his requirements have been considered.

Finally, let me say a word of tremendous appreciation to all those involved at every level in providing food in our hospitals. In my experience over many years, they do a tremendous job. As has been said, they have come a long way and many improvements have taken place. Much more needs to be done, but we should encourage the staff and not discourage them with any words of condemnation.

My Lords, I, too, thank the noble Baroness, Lady Knight, for securing this important debate and, as has been mentioned, for her tenacity in following though this subject. It is fitting that this debate should fall the day after the service in Westminster Abbey filled by 2,000 people—mostly nurses, midwives and health visitors—to commemorate the life of Florence Nightingale. She died 98 years ago but is still remembered for her valuable contribution in establishing the nursing profession and promoting basic nursing care. One of her well known sayings comes from 1863:

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm”.

Here we are in 2008, 145 years later, and, although I acknowledge the progress that has been made, as the noble Baroness, Lady Pitkeathley, described, we are faced with evidence that some patients are harmed through poor nutrition and some are suffering from malnutrition.

I was fascinated to read some recently discovered manuscripts about a 2,000-bed hospital in Jerusalem in 1099. A list of basic care was given, with one item relating to nutrition. There were two kitchens—one general and one for the diets of patients suffering from digestive disorders. Fresh meat was served three times a week, with plenty of bread, water and a wide range of fresh fruit.

Some 10 centuries later, however, we are faced with evidence of poor nutrition. Only this week, I heard of a patient suffering from coeliac disease who had informed the hospital prior to admission that she required a gluten-free diet. Joy oh joy, as she travelled down the corridor to the ward, a large poster advertised coeliac disease and the importance of a gluten-free diet. She thought that all was well but, as she went though the ward door, all was not well. No gluten-free diet appeared and the nurses were unaware of what coeliac disease was or of the need for a gluten-free diet.

One could spend the whole length of this debate repeating anecdotes of patients’ experiences, but we are all familiar with hearing and reading of hardships suffered by patients. I declare an interest in that my profession was nursing for 40 years and I spent eight years as an NHS trust chairman. I am currently president of the Florence Nightingale Foundation.

The Royal College of Physicians states that nutrition is “a doctor’s responsibility”. The nursing regulatory body states that it is the qualified nurse who is responsible for ensuring that food is provided appropriate to patient care. I was a nurse in training in the 1950s. In our introductory course, we were given instruction in invalid cookery. In those days, each ward had a kitchen and nurses could supplement patients’ diets by cooking boiled or scrambled eggs, for example. We were taught nutrition and the importance of diets. We served breakfast—and what a nightmare that was, with two nurses serving 30 patients. There was a choice of cereals or porridge, or a cooked breakfast with each egg cooked for a different number of minutes. Then there was toast and marmalade—and this was just at the end of rationing.

Lunch was the main meal of the day. The ward closed at 11.45 am and patients prepared for the meal, which was served at midday by the ward sister or the staff nurse in charge. Nurses helped to feed those who needed assistance; any meals left were reported and if necessary a supplement was given. Patients were weighed weekly. The ward reopened at 1.30 pm, the patients having had a rest time after their meal. Supper was served at 6 pm, consisting of a light meal followed by a hot milk drink of cocoa, Horlicks or Ovaltine at 8.30 pm. Today, mealtimes are not always well spaced and there is not always a protected main meal.

There is available to the NHS a great deal of guidance, from NICE, the Healthcare Commission, the Food Standards Agency and the Department of Health, to name but a few. Yet we learn year on year that more people are being discharged with malnutrition. Evidence shows that good nutrition aids recovery, healing wounds and preventing infection, and therefore is cost-effective in discharging patients earlier than those suffering from delayed wound healing or infection.

Why is it, then, that guidance is not being followed everywhere and why are patients’ complaints about food escalating? The Healthcare Commission is reporting improvements, but in a survey conducted by Which?, the consumer watchdog, 250 patients out of 1,000 said that they were reliant on relatives or friends bringing in edible food. Some food served was still frozen in the middle or congealed on the plate and most were unhappy at the presentation of food to a point of repulsion. Dietary needs were not met.

Some 13 million meals, mainly untouched, were thrown away last year. In answer to a Question in the other place last year, the Health Minister said that £162 million of taxpayers’ money was thrown away by the NHS in the past five years. The average cost of an NHS meal was £2.65 in August 2007. Malnutrition is common, but it is often not recognised, not prevented and not treated. What an indictment, when it is known that good nutrition is a cost-effective method of treatment.

Within the NHS there are pockets of good practice, where leadership usually comes from the director of nursing, who pays great attention to the practice of serving meals in an orderly way and with great determination introduces protected mealtimes. This often requires shift patterns for nurses to be changed, as well as the routines of other healthcare professionals, to ensure that the patients’ mealtimes are sacrosanct. I know of one director of nursing who has introduced a weekly meal-tasting routine, visiting wards at random and not only tasting food but monitoring the serving of meals and the patient care given. A few directors of nursing have been given responsibility for the catering services.

The noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Roberts, referred to the use of volunteers. I could not support their views more strongly, having been a volunteer myself. It is important that they are used.

Within a few weeks, the noble Lord, Lord Darzi, will publish his final report on Our NHS, Our Future. His most recent report, Leading Local Change, which was published last week, ahead of nine local strategic health authorities’ visions, to set them in the context of the next-stage review, emphasises the importance of clinician-led services and evidence-based change and sets out the principles governing local service change. I pay tribute to the work of the noble Lord, Lord Darzi, who has led the many healthcare professionals and stakeholder groups that have been working with him over the past year. The number of working groups and consultations that have taken place and continue to take place is absolutely staggering, covering not only the clinical pathways of all specialties but future education and training requirements, workforce planning and career developments.

Last week’s report contained a section entitled “Our Pledges to You”, which states:

“Change will always be to the benefit of patients. This means that they will improve the quality of care that patients receive—whether in terms of clinical outcomes, experience, or safety”.

The context of this debate is to call attention to the case for improving arrangements for feeding patients in NHS hospitals. We take that as an excellent example of where nutrition ties into the quality of care in terms of clinical outcomes, patient experience and the safety of patients. There is enough evidence to indicate that change is necessary in meeting nutritional standards, which affect clinical outcomes in terms of healing and the prevention of infection. There will be a need to see local service changes that ensure that patients have a choice of edible food in suitable portion sizes and attractively presented. Patients should have regular meals served and supervised, with assistance given with feeding where needed and with adequate reporting.

The clinical pathways led by the clinician will need to be designed to include the nutritional content determined by the clinical condition. The patient’s weight should be recorded and monitored regularly to prevent malnutrition. Menus should be reviewed regularly and the patient experience should include attractively served meals that are well cooked and nutritious. Patient safety should require health and safety regulations to be followed for the preparation and serving of food.

However, none of those changes will happen unless there is leadership in the organisation concerned with the delivery of high-quality care. Evidence from the number of complaints and the increase in the number of patients with malnutrition demonstrates the lack of attention paid to nutrition. As has been mentioned, guidance is available in abundance, but in many instances it is not applied.

I am sure that the Minister and Members of this House will expect me at this stage to re-emphasise my passion to improve the quality of care to patients. That requires accountability from the patient to the board and authority and accountability from the board to the patient. Unless that is brought about, nothing will change. There must be an officer at board level with authority and accountability for the performance management of care delivery. Nutrition is but one aspect of many. Unless there is a culture change within the NHS with regard to the delivery to the patient of the care required for good nutrition, again, nothing will happen.

The noble Lord, Lord Darzi, has repeatedly said that change must be determined locally according to circumstances, but surely there must be some central requirements for governance, accountability and authority. Otherwise, nothing will change. Current arrangements are often too comfortable to introduce changes, as those might present problems, but this is where culture change is required. Indeed, board members—executive and non-executive—need to re-examine their governance arrangements to ensure that attention at board meetings is not constrained to matters relating to finance and government service targets, but is balanced with the inclusion of performance management of care and patient satisfaction.

I hope that the Minister will refer to the noble Lord, Lord Darzi, the example of nutrition, which clearly demonstrates the need for performance management of care with accountability and authority from the patient to the board and the board to the bed. The Minister should note the need for central requirements with regard to governance issues, requiring culture change and education and training, from the board through the whole NHS organisation. That would ensure improved quality of care, patient experience and patient satisfaction, endorsed by safety regulations. Again, I thank the noble Baroness, Lady Knight, for raising this issue.

My Lords, I thank the noble Baroness, Lady Knight of Collingtree, for this most timely debate, and congratulate her on winning the ballot. The debate is timely because your Lordships are scrutinising the Health and Social Care Bill, and I hope your Lordships can see the need for a good standard of nutrition to be written into the legislation.

The Royal College of Nursing says that the body’s immune system is highly dependent on nutritional status, and research shows that malnourished medical and surgical patients experience higher rates of complications and stay in hospital 30 per cent longer than nourished patients. With the great concern most people now have when being admitted to hospital of the dangers of hospital-acquired infections, that serious problem may have overshadowed the need of some hospital trusts to consider the importance of having good standards of food and beverages for their patients.

The noble Baroness has continued to bring to the notice of Parliament the need for good standards of food and feeding. She has cited some terrible cases in the past of neglect and downright cruelty to patients who have been denied food and drink in hospitals. I congratulate her on her humane persistence on this matter. Now is our chance to raise standards across the country. That will be done only by getting that enshrined in legislation.

I declare an interest: I have been a patient at Stoke Mandeville Hospital on a few occasions. For years, patients’ food has never been a high priority. Patients on the spinal unit are there for long periods, and food becomes more than nutritional need: it can lower or raise morale, depending on its quality and desirability. When patients are in spinal shock and at risk of pressure sores, good nutrition is essential. Also, spinal patients who have been waiting for a bed in a spinal unit because there are not enough beds often arrive in a terrible condition as there has been lack of knowledge about how to treat them in a general hospital. They have to be built up, because of the effects of infection, sepsis and terrible pressure sores. Nutritional needs are vital for these patients’ recovery.

When I broke my legs and was on the spinal unit for several weeks a few years ago, I found the food bland and uninteresting. That is not surprising, as I think it comes precooked from somewhere in Wales. I craved fresh vegetables, and my late friend Baroness Darcy de Knayth, who visited me in hospital, brought me raw carrots and celery, which kept me going. Some years ago I became friendly with a young man from Kuwait who had broken his neck and was paying an enormous amount of money for being a private patient in that hospital. The food was so unsuitable that his mother brought him food every day from the embassy. There were also many patients who sent out for takeaway food, which was delivered to the hospital. The problem was that some of the patients then got into debt and had to borrow money.

One of the porters at my block of flats has recently been a patient at St Thomas’s Hospital. His operation was a success, but he said the food was so awful that he lost weight as he could not eat it. He asked me to bring the matter up in your Lordships’ House. I told him about this debate, and he said, “I hope it comes up soon”. I will give him a copy of Hansard.

I have a physiotherapist who comes to me periodically. She told me that this year, her husband had a serious skiing accident and smashed his jaw, which had to be wired up. The accident happened in France and while he was in a French hospital, he was given suitable soft food. However, when he returned to England, he was given food that he could not chew or eat. Surely we could do better.

Much has been said about suitable food and care for elderly patients; but everybody, whatever their age, needs suitable food for their individual condition. Some very ill patients sleep at different times. We need a flexible approach, as they will need nutrition when they wake up. This flexible approach is often used in hospices. However, many people do not go there and their needs, too, should be catered for in national health hospitals.

Hospital trusts throughout the country vary in their standards of feeding patients. I heard praise for the Brompton hospital in London, so I contacted the hospital to hear about it first hand. It might be useful in helping to raise standards throughout the country—and, I hope, of interest to your Lordships—if I say something about the Brompton hospital. The trust has recognised the importance of how good-quality fresh food and drink contributes to the recovery of patients, especially those who have undergone surgery. The trust also believes that, when patients are well fed and enjoying their meals, they are happier and therefore more receptive to treatment by medical and nursing staff.

The hospital is fortunate in having a full production kitchen, which operates like a hotel kitchen. Chefs are allocated to areas—for instance, to the pastry section, where they make a cake daily for the patients’ tea. There is a larder section for daily salad production, a main area and a special-diet kitchen. Every dish on the menu is made on site. The hospital purchases 24 per cent of food locally from Kent farmers and small suppliers—making it fresher, tastier, seasonally British and more nutritious. Purchasing direct from the farmer is cheaper and therefore gives value for money to the trust. All milk in the hospital is organic, from a dairy farm in Bedfordshire; and commodities for children—for instance, beef burgers and chicken nuggets—are 100 per cent meat and are organic, additive-free and dairy-free. Emphasis is put on a healthier diet and staff try to educate patients in the importance of a healthy diet and lifestyle.

Hospital catering managers and dieticians also meet patients regularly to ensure that the service meets their requirements, and to make changes to the menu to ensure satisfaction. All meals are served at ward level by the catering staff—hosts and hostesses—and this personal service ensures that patients have a choice. The ward hostess service means that the catering department is responsible for ordering, preparing, distributing and finally serving the food. Staff feel that this is a significant factor in ensuring that a quality product reaches the patient.

I end by saying that, with many severely disabled patients—including blind patients—with frail, elderly patients who need help with feeding and with nurses saying that they do not have enough time to do this, it seems that there should be trained volunteers who could be mobilised when needed to help with this time-consuming but vital need. There is nothing worse than rushing the feeding of patients when there may be a swallowing problem—and a swallowing problem can become a choking problem. Volunteers would have to be trained and they could also become a very important befriending service, as some patients do not have much family support and live far from friends.

My Lords, I, too, congratulate the noble Baroness, Lady Knight, on giving the House the opportunity to discuss this important issue, which has such an effect on the quality of care for patients in our hospitals. I declare an interest as chair of Barnet and Chase Farm NHS Trust. It is a two-district general hospital trust, so the position is quite challenging.

I was delighted that the noble Baroness said that the experiences that she was sharing with us, horrendous as they were, were not typical; and that she was aware that people have much better experiences elsewhere. I will share with the House some very good experiences that patients who attend Barnet and Chase Farm hospitals go through. I agree with other noble Lords that nutrition in hospital has been a very important subject over several national campaigns. The noble Baroness, Lady Pitkeathley, raised the issue of the Government’s Better Hospital Food initiative in 2001, which was a real landmark for hospitals to move on from.

I am very proud of the Barnet and Chase Farm hospitals; and, having listened to some of the experiences that noble Lords have shared, I am even more proud to share with the House the best practice that goes on in them. All patients, within 12 hours of entering hospital, have an interview with a member of the nursing staff. That involves a scoring system. I know that we are not supposed to have props in this House, but I have a form here and I would like to mention the procedure that leads up to the red tray. What happens as a result of that discussion is that this form is completed. This form has a series of headings, underneath which are a series of questions. That dialogue between the patient and the medical staff ascertains where they are. They may have an issue around how they swallow or how quickly they can eat; or other issues that are specific to their nutritional needs, and where we may have to help them by referring to dieticians and the like. A red tray identification only results if that dialogue goes on consistently. The noble Baroness has made the point that this needs to happen everywhere and not be a stroke of luck. That is what happens in my trust.

It is important for all of us to respect and value the patient’s comfort and experience—not just in eating, but with surrounding issues that pertain in the ward. The national recommendations regarding nutrition in hospital have moved on from the purely practical issues about what food to serve and how this is done—again, that has been referred to by my noble friend Lady Pitkeathley. I think that the 2006 report Hungry to be Heard was a move forward for us in understanding how important this issue is.

At Barnet and Chase Farm, we have undertaken some excellent work to improve food and nutrition. We now have a food and nutrition steering group, which has patient involvement, which is very important—other noble Lords have referred to that. It is The important to involve patients because they have experienced—we hope—good things, but also things that are less than good, and it is most important to learn from that. Among the initiatives introduced through the work of that group is the red-tray system, to which the noble Baroness referred. I started to tell the story of how red trays are identified as the key way forward in supporting someone who needs extra care with feeding. Certainly no tray—whether it is red or, in the case of my trust, cream—should be too far away for the patient to be able to reach it, as the noble Baroness described. I agree that that is an incredible and unforgivable practice.

A couple of days ago, I visited a ward at Barnet and Chase Farm with a couple of nursing colleagues to refresh my memory about how the system works. That is something you do when the trust is set up to ensure that you know everything, but I also went round one of the wards ahead of this debate, to which I value the opportunity to contribute. The nursing staff and volunteers were delighted that this interest should be shown and they enthusiastically showed me what happens there. As noble Lords probably know, there is a white board in all wards, and when a patient at Barnet and Chase Farm has been identified as needing a red tray, a little red mark is put on the board. It does not identify anything to anyone who is not involved in the red-tray system, but it immediately brings to the attention of those who are involved that so-and-so needs a red tray and that they must ensure that all the facilities are in place for that to happen.

The process of observing is something to which the noble Baroness, Lady Knight, referred. We take for granted that certain things will happen to our loved ones, friends or neighbours when they are in hospital but we must ensure that we also keep an eye on what takes place. For me, besides identifying the need for a red tray, evaluation is most important. Having a red tray is great but if, for different health reasons, the individual does not get much nutritional value from the food, although it is not as bad as not having a red tray, it certainly becomes a cosmetic rather than a real exercise.

Therefore, in our hospitals we keep a checklist of every single meal throughout the day, whether it is a snack or a main meal—breakfast, lunch or dinner. Alongside that is a score which indicates whether individuals have eaten a quarter, a half or three-quarters of their meal. At the end of each day, when the score is looked at and the information gathered, if they have had not had the necessary nutritional value to keep them going, build them up and help towards their recovery, they receive a supplement, which may be a vanilla-flavoured or soup-like drink. This contains all the nutrients that they need for a whole day. The supplement, in fluid form, ensures that, even if the patient has not been able to eat what has been in front them, despite being cared for, fed and so on, then we can be assured that at the end of that day he or she will have received the nutrition about which everyone who has spoken so far has been concerned.

I have shared with noble Lords what happens at Barnet and Chase Farm hospitals, but surely all the best practice cannot be in just one trust. I agree with the noble Baroness, Lady Masham, that we need to ensure that good practice exists in all places. An example of that is food service assistants and ward housekeepers, who are to be found in my trust. Their priority is to ensure that the meals are identified correctly for the patients and that they are correctly delivered.

Other speakers mentioned the environment in which patients eat. My noble friend Lady Pitkeathley referred to something with which many of us would agree—that eating is also a social event, although that possibility is often limited in hospital. However, what is important in hospital is the environment in which the food is served, and something can be done about that. In my trust we have introduced, as I am sure others have too, a system in which there are no interruptions during mealtimes. Lunchtime, for example, is advertised outside the wards as being between noon and 1 pm or 1.30 pm, and not only are visitors not allowed but non-essential ward rounds do not occur. People are not taken for blood tests or X-rays, because the priority is for the patient to have the opportunity, with support if necessary, to sit quietly to eat a meal, just as the rest of us do. Perhaps we do not all do that too well—we interrupt our meals to answer mobile phones and so on—but in hospital mealtimes are very important private times. That is a new concept in hospitals and it has an important part to play in the whole cultural change that we need to see happening across the piece.

The other important issue, to which the noble Lord, Lord Roberts, and other noble Lords referred, is that there should be an opportunity for people to eat at different times. If you are poorly, you do not always feel like eating at the set time when lunch or dinner is served, or perhaps you are asleep. In my trust, we have introduced—I hope that this happens elsewhere—the “steamplicity” system. It sounds complex but it is very effective. The meals are cooked and plated off-site and are then regenerated in microwaves. That may not sound very appetising but the meals are steamed in a microwave using a patent system whereby a special valve is put into a container which keeps the moisture inside. Therefore, when the meal is delivered to the patient, it is nourishing and, one hopes, enjoyable. That means that if at any time a patient wakes up or feels hungry, he has the opportunity to have a proper meal rather than just a sandwich. A menu is also available, which, again, is great. Meals are described with photographs—something that was referred to earlier—so that individuals can say, “I really feel that I would like some of this”.

Therefore, lots of good things are happening, as the noble Baroness and other noble Lords acknowledged. A lot of issues surround providing everyone in hospital with tasty food, but that is very difficult to do. It is a question not just of what can be afforded but of people’s different tastes, and we need to debate that in this House. Places that are not up to the mark have a long way to go. Barnet and Chase Farm Hospitals NHS Trust will be very happy to share our ideas on best practice. Importantly, as the noble Baroness, Lady Emerton, said, we ensure that patient care is the first thing on our agenda at board meetings. We put the patient experience before finance and everything else, and I am very proud that that ethos has been introduced since I became involved as chair of the trust. It leads every other thing that happens to patients when they walk through our gates or are driven in by ambulance.

My Lords, like other noble Lords, I congratulate the noble Baroness, Lady Knight of Collingtree, who has been a tireless champion for the welfare of patients and, in particular, for ensuring that they are fed when they are in hospital.

In some ways, I am sorry that the debate is confined to hospitals, because real concerns also exist in relation to care homes and to patients who are isolated in their own homes and are reliant on care coming into the home. These are people who can suffer long-term malnutrition over many years. Indeed, it is long-stay patients who are at particular risk if their feeding fails. During the debate, we have heard about examples of good practice, and I hope that they will be taken up and rolled out by other hospitals and areas.

I want to address the important issue of a patient’s nutritional status for treatment response and healing, and how feeding is a human instinct in caring that we may be failing to recognise. Our failure to address nutrition may reflect a cultural issue in our society—perhaps we do not value the quality of our food as much as we should. I have been particularly struck by the quality of food for patients and staff in hospitals in France, which has much more of a food culture. There, mealtimes are sacrosanct for both patients and staff. I am not sure that a glass of wine at lunch is always such a good idea, and it is not something that I would recommend for staff.

To return to nutrition, it is important to differentiate between starvation, which is food deprivation and results in death after days, weeks or months—usually weeks or months—and malnutrition, which occurs when there is a paucity of lean body mass that can exist for years and years undetected. The commonest form of malnutrition is protein energy under-nutrition where patients suffer from a lack of protein. The other big problem is dehydration, from which people die within days, irrespective of their nutritional status.

I do not think nutrition and hydration should be lumped together without very careful thought. Chronic dehydration is the most common cause of clinical deterioration in frail, elderly patients. Through poor perfusion of the kidney, patients slip into acute renal failure and, as a consequence, they do not excrete drugs very well. They often have other metabolic disturbances, become confused, drink less and enter a cycle of rapid decline. This process was dramatically seen in 2003 in the heat wave in Paris, where an estimated 15,000 mainly elderly people died. I am glad to see that the noble Earl, Lord Howe, is having a drink at the thought. Chronic dehydration is quite a big problem in our society. Urinary incontinence is common as people get older, afflicting about 40 per cent of women over the age of 40. People often think that if they drink less, they will leak less, so they tip into a downward spiral of chronic dehydration. That undermines their appetite, meaning that they do not eat well and have long-term poor nutrition. When they finally go into hospital, they are already malnourished.

There are lots of reasons why people lose their appetite when they are ill, including the side effects of many drugs, a loss of taste, a loss of smell, the disease itself, depression and social isolation. Anorexia compounds a malnutrition that already exists and causes under-nutrition. Malnutrition is a really serious issue in our hospitals and increases the patient’s risk of infection, affects the function and recovery of every organ system, increases the risk of pressure sores, extends the stay of patients in hospital and makes readmission more likely. Last year it was estimated that more than 130,000 patients were malnourished when they were admitted to hospital. That was an increase of 12 per cent on the previous year. The data for patients leaving hospital are no better, with estimates that malnutrition levels have risen by 85 per cent in the past 10 years to almost 140,000 patients last year. So the problem is not being addressed while they are in hospital, and indeed, many are only there for a short time. It seems that almost as many enter hospital malnourished as then leave hospital malnourished.

These figures become even more worrying when you consider that malnutrition is undiagnosed in about 70 per cent of patients. It is difficult to diagnose because blood results become altered by disease processes, making interpretation difficult. Most worrying of all was the survey from Age Concern that reported that nine out of 10 nurses think that they do not have time to help patients who require assistance with eating. The Healthcare Commission’s national survey of inpatients, as already referred to, reports 20 per cent of patients saying that they did not get enough help from staff to eat meals and another 20 per cent saying that they got enough help only some of the time. It seems from that survey that the quality of food is good but physical difficulties are just not being seen to.

Malnutrition does not only affect the thin. On admission to hospital, many obese patients are severely malnourished. They have eaten badly for years and they lack the essential trace elements and nutrients to cope with their illness. So what is the answer to the problem? The five-step Malnutrition Universal Screening Tool is easy to use and has been validated in most patients’ groups. Furthermore, NICE has stated that every patient should undergo nutritional assessment and monitoring. I should like to ask the Minister how successfully the 2006 NICE guidelines have been taken up in screening for malnutrition and whether she has any idea how many hospitals have audited their malnutrition screening and management processes.

For most patients in hospital, loss of appetite is part of their disease process. They need encouragement to eat, with nutritional balance being presented in an appetising format. It has already been said that around 13 million perfectly good meals in hospital are thrown away of the 300 million meals prepared each year. This comes to around £34 million of wasted food. Some of this is understandable—for example, if the patient has gone home, died or deteriorated—but if it is because the patient cannot feed themselves, then that wasted meal represents meal deprivation.

Many patients have culturally diverse dietary habits, such as being used to eating highly spiced foods or very bland foods. Unfortunately, health and safety regulations seem to have been overinterpreted in many hospitals, so families are not encouraged, or even allowed, to bring in food for a patient, even when it would match the patient’s appetite far better than the standard hospital fare. Health and safety regulations also get quoted when relatives want to use the microwave to heat up food. It seems that in some hospitals the only thing that you can get is toast, and the large number of times the fire alarm goes off means that toasters have been removed because of the bill when the fire brigade gets called out.

Relatives are a wonderful resource at mealtimes, yet sadly they are often underused for patients and visiting hours sometimes actually exclude mealtimes. Nevertheless, families need to be taught about effective food intake and they may need to learn new feeding techniques for patients who, for example, have had head and neck surgery. Families themselves are keen. I am often asked, “What should I give him or her to eat? What would be the right thing to prepare as food?” Actually, for many patients, any food is good food. Eating is a social activity and it is so much easier to eat when others around you are eating with you. I am grateful to the noble Baroness, Lady Pitkeathley, for referring to hospices, which have done a great deal to ensure that food is presented in a pleasant way, using volunteers to sit and encourage patients to eat. I am also grateful to the noble Lord, Lord Roberts of Llandudno, who cited the University Hospital of Wales, where some years ago my own registrar did an audit and found an appalling number of times that meals were not within reach of patients; for example, meals being put on the disabled side of someone who had had a stroke. That has been picked up by management and addressed. I feel quite proud of what Wales has done to address nutrition in hospitals.

So why do we not encourage more families to bring a snack in with them to eat? If you visit a hospital in India and many parts of the world, families are camped outside, preparing food for their relatives. Make no mistake, I am not advocating Primus stoves in the car parks, but I wonder whether we have gone a bit too far the other way and forgotten the interpersonal importance of meals. Eating with people around stimulates the appetite. In my own hospital in the cancer centre we have protected mealtimes. The patients get meals from an old-fashioned trolley and one of the advantages is that there is a nice smell to the food. Quite often the patients’ food is a lot more appetising than the food that I find in the staff canteen. There is also help to encourage these patients to eat and patients can choose how much they want.

What about those patients deemed unable to eat? A sign saying “Nil by mouth” is readily put up over a patient’s bed and yet an assessment of their swallowing may not happen that day or, in fact, for some days. I wonder whether the Department of Health knows of a hospital that has audited their use of “Nil by mouth” signs for patients other than those who are going for an anaesthetic.

When food is made on site and kitchen staff come to the wards and know that patients and relatives approve of and enjoy what they prepare, they become aware of how important their job is. That is something that can happen in small units, small hospitals or hospices and helps kitchen staff to value their job.

Families really want to show love through feeding and often when the patient has lost their appetite or just cannot eat, families become very distressed. Even when someone is clearly dying, families still want to feed them. Let me illustrate this. Some years ago I was asked to visit the only son of a family of ice-cream makers. He was dying, could not swallow and was barely responsive to anything. His parents were understandably overwhelmingly distraught. His mother said that she could accept him dying of his disease, but not of starvation. After careful explanation of the risks, I put down a nasogastric tube there in the house so that she could feed him. After he died, his mother remained very grateful. Her comment to me when I met her some time later was, “We put our best ice cream down the tube, so I know that he was still being fed and died of his disease”. In reality he probably would have died at the same time, whatever I had done, but the family had to live with it afterwards. It just demonstrates how families want to be involved.

When someone is clearly dying, investigations and treatment, including many drugs, become inappropriate and of course should be stopped. Trying to push nutrition becomes futile, but that does not mean that fluids become futile. Fluids can be given as sips by mouth, carefully and gently, to dying patients. However, some people need to have a drip. This can be done at home; patients do not have to be admitted to hospital. They can have a subcutaneous line put in through a tiny butterfly needle and a drip-bag hung from a picture-hook in the wall; indeed, I have done that myself. Then the district nurse can change the bag every 12 or 24 hours, which might be enough to maintain comfort.

Nutrition is terribly important in people who are ill. It cannot be considered in isolation from all other aspects of patient care. I wonder how many hospital boards have nutrition as a specific item on their agenda. The attitude must improve at grass-roots level. It is a sad indictment of the professionals that we, as doctors and nurses, have failed to say, “This is our responsibility”. We have the resources of dieticians, but this is a core part of the clinical care of every patient. We must address the nutritional needs of every patient. If the professions address this, inappropriate blame will no longer be dumped at the Minister’s door.

My Lords, I, too, thank the noble Baroness, Lady Knight of Collingtree, for her assiduous attention to this issue. It is important, and requires people like her to keep it on the agenda and moving forward. I very much thank her for doing so.

The issue of food and medicine is not easy; it is quite complex. We have concentrated a lot today on the poor old NHS, but it is more complicated than that. I know a gentleman, a practitioner of complementary medicine, who told me about being in an Ayurvedic—traditional Indian medicine—hospital in southern India. He and a bunch of other students were being taken around by an Ayurvedic doctor. They stood by the bed of a very ill lady and were asked to make their diagnoses. As is often the case in groups of students, they tried to outdo each other with their smart diagnoses. They were all way off. The doctor said, “No, what wrong with this lady is that she is starving. She needs some food. Once we do that, she will be fine”.

Equally, the story of the noble Baroness, Lady Finlay, made me think about an incident that I know of. A gentleman was admitted to a major American hospital because he had high levels of arsenic in his blood and, unsurprisingly, was feeling very ill. For the first few days in hospital, he showed a remarkable recovery, but then the arsenic levels kept going back up. It was something of a puzzle to the clinicians until they discovered that the cakes that his wife was bringing in to him were the source and part of her long-term plan to poison him and collect on his insurance. So relatives are not always good news.

I was most interested to think about why so many people go into hospital malnourished. In a debate like this, it is important to say that things which happen in the community can always have an impact in acute hospitals. Many older people suffer malnutrition for two reasons, one of them alluded to by my noble friend Lord Roberts. Lots of older men, principally, think that kitchens are dangerous places into which one should never go. They do not know how to cook. They may eat—rather well; they might go out to eat—but can still end up malnourished, as the noble Baroness, Lady Finlay, said. Other people simply do not like eating on their own, and do not bother. We cut the funding to lunch clubs at our peril.

Like the noble Baroness, Lady Finlay, I too was interested in the article in the BMJ about malnourishment. As she said, 70 per cent of people with malnutrition in hospital are undiagnosed. Today, we have concentrated, perhaps understandably, on those who wind up, say, in surgical wards and so on for some time. The noble Baroness is right that people who are in hospital for a long time often suffer the most. The people who are in hospitals most are those with mental health problems. We would do well to remember that when people are receiving compulsory mental health treatment, they are often being given very toxic drugs, the side effects of which are often to make them put on weight and so on. It would be understandable if, in those circumstances, people were reluctant to eat. We should not confine ourselves to looking at this in terms of physical health.

We have also not looked at another obvious area: accident and emergency. I happened to accompany somebody who was diabetic to A&E at three o’clock in the morning. By 8 am, it was only when a nurse was perceptive enough to ask, “Are you diabetic?”, that we realised that that person could have had some complications had a very simple thing not been understood.

The article in the BMJ alluded to the fact that clinicians can use quite a number of different practices, such as the MUST—malnutrition universal screening tool—that has been devised. I say to the noble Baroness, Lady Knight, that the Social Care Institute for Excellence has also gathered together a number of different models—not just red trays, but having knife-and-fork symbols by people’s beds. Crucially, the Alzheimer’s Society has produced a training video to enable staff, without being patronising, to deal with people who cannot eat. Sometimes being fed can be a very undignified process if it is not done properly.

A strong point made in the BMJ editorial was that nutritional support should be an enforceable requirement, and universal throughout the health system. Nutritional support should be on a par with how medication is treated within the health service. Additionally, the BMJ article made the worthwhile point that nutrition should be recognised as a discrete discipline which all medical graduates ought to have studied to a basic level. I understand that a formal sub-group of the Academy of Medical Royal Colleges has established a course on human nutrition, which is mandatory if you are to go into certain medical disciplines, particularly gastroenterology and metabolic medicine. However, as we have heard today, nutrition is important across a whole range of conditions: cancer treatment, cardiology and diabetes.

I do not wish to go over many of the points which other people have made, but the noble Baroness, Lady Masham, talked about the scheme at the Royal Brompton Hospital. I was intrigued to discover how that change in its food regime came about. Its new director of catering discovered that it was serving people with food that had absolutely no food whatsoever in it. It had no nutritional value at all and was made up just of colouring, which prompted that big rethink.

The NHS is a major purchaser of food in this country. It purchases 300 million meals, so it has a role to play in developing sustainability. The scheme that I read about and was impressed by was that of the Royal Cornwall Hospitals Trust, which, in conjunction with the Soil Association, has gone through a process of growing, buying and sourcing its food locally. That has meant a great increase in locally produced and organic food, which has helped not only with nutritional standards in its hospitals but with the health economy of that area.

There were some really interesting examples of what that trust had done. The noble Baroness, Lady Pitkeathley, talked about powdered, nutritional drinks, which I know are important as I have relatives who are alive because of their availability. Yet the Royal Cornwall, in its scheme, looked at using locally made clotted cream ice-cream for people who needed calorific intake. Let us be honest; who, given the choice, would go for the powdered milk drink in that circumstance?

Having a whole strategy of concentrating on locally produced fruit, vegetables, eggs and milk has made an enormous difference there, and has been achieved within the budget of £2.50 per patient per day. That is the trust’s rough figure for expenditure on patients. More than that, it has managed a 67 per cent reduction in food miles, which has to help the environment. Although that may be a return to the days of 1947, when the health service started, there is much to be said for it as an approach for the whole NHS. Indeed, other hospitals, in addition to the Royal Brompton, are beginning to do the same.

I want to pick up on two other points that people have made during this debate. Noble Lords have talked about the use of volunteers, and I understand their wish to do so. It is, obviously, preferable that a volunteer spends their time rather than a highly skilled medic, but I caution your Lordships that the use of volunteers should be additional. Important here is making sure that food and nutrition takes a more central place throughout all NHS processes—from governance to management and right through to practice. Never mind what the Healthcare Commission does; if the board of the trust will not eat the food in a hospital, that is the biggest indicator anybody needs. We need to see the role of food becoming much more central in medicine.

Finally, I agree with the noble Baroness, Lady Finlay; as ever, the French have much to show us in the area of food. I would not take on everything that they do as an approach—giving pregnant women red wine seems uniquely French—but in the French health system, it is realised what a role food plays in patients’ recovery and in the maintenance of good health. With the National Health Service, we really should be able to take some of their best practice and adopt it.

My Lords, the whole House will, I am sure, hold my noble friend Lady Knight in the highest regard for her unwavering commitment to the issue of hospital nutrition and her staunch defence of the dignity and autonomy of seriously ill patients. I welcome the debate that she has initiated and congratulate her on her powerful opening speech.

Malnutrition in hospital is no longer a subject relying on anecdote or hearsay in order to prove its existence. The hard evidence for it is unfortunately all too abundant, as we have heard from all speakers—it is not simply the findings of occasional consumer surveys but the hard data collected by trusts and government agencies, all of which tell the same story. As my noble friend said, we are talking about wards and hospitals where the food is unappetising, unsuitable, insufficient or inaccessible—sometimes all four. It is right to pay tribute to Ministers, particularly Mr Ivan Lewis, for the frank way in which they have acknowledged the scale and gravity of the problem. That acknowledgement is surely the first step towards solving it.

Of course, things are not all terrible. There are shining examples of good practice, such as the Royal Brompton, which, as the noble Baroness, Lady Masham, described, serves wonderful, fresh organic food as well as additive-free, gluten-free and low-fat food for those who need it. As we have heard, hospitals in Cornwall serve locally sourced food so delicious that one almost sees people who are perfectly well queueing up to eat it, while the Barnet and Chase Farm Hospitals NHS Trust also sets a fine example—I congratulate the noble Baroness, Lady Wall, on her part in bringing that about. Yet inevitably it is bad practice on which much of the focus rests. That is as it should be, because serving unappetising or inadequate food in a health service that professes to be world-class should be enough to eliminate you in round one of the competition.

The noble Baroness, Lady Finlay, gave us the statistics. In the 10 years to 2006-07, the number of people admitted to hospital with a diagnosis of undernutrition has gone up from 70,000 to 130,000, an increase of 85 per cent—and those are only the people whom we know about, because by no means all hospitals screen patients for malnutrition as they are supposed to do. NICE guidance recommends that all patients should be screened for nutritional risk on admission to hospital. However, NICE itself has estimated that only about 30 per cent of patients are screened and a recent survey by the British Association for Parenteral and Enteral Nutrition found that more than one in 10 hospitals did not have a nutrition screening policy in place.

The Age Concern campaign Hungry to be Heard highlights, among other things, the greatly increased prevalence of malnutrition among hospital patients over 80 compared to those under 50, which chimes in well with what we heard from the noble Baroness, Lady Finlay. In many of those people malnutrition is often not identified. The most shameful fact of all is that more people are discharged from hospital in a malnourished state than are admitted. Those figures are an indictment not only of the care given in certain hospitals but of the way in which malnutrition goes unrecognised in the community.

The strange thing is that hospitals have every reason in the world to make sure that patients are properly fed. The effects of malnutrition are well documented and we have heard many of them today. They are prolonged bed occupancy, delayed recovery, an increased risk of contracting healthcare-associated infections and poor respiratory function. In some studies, undernourished patients are estimated to have a mortality rate up to eight times higher than that for well nourished patients. Yet that condition is relatively easy to diagnose.

The malnutrition universal screening tool, or MUST, which the noble Baroness, Lady Barker, mentioned, is available for healthcare professionals’ use. Once hospital patients are identified as being at risk, they can be supported in their nutritional needs by a variety of measures. Some are simple: noble Lords have mentioned red tray schemes and protected mealtimes. Specially formulated foods can also be taken by mouth or tube. Once the diagnosis is made, as long as there is good nursing, the tools and remedies are there.

After doing very little for a number of years, the Government have now, to their credit, taken some useful steps, not least in publishing the nutrition action plan in October last year. The implementation of the plan is being overseen by the Nutrition Action Plan Delivery Board, which includes dieticians and representatives of charities, CSCI and the Healthcare Commission. That is all very positive, except that, as I understand it, the board is going to exist only until December 2008 before being wound up. If that is so, it would be helpful to hear from the Minister what, if anything, is going to replace it.

Nutritional care is also prioritised in the core standards monitored by the Healthcare Commission. Core standard C15b shows that an individual’s nutritional, personal and clinical dietary requirements are being met. That ought to ensure that we know exactly how good or bad the picture is. Unfortunately, it is not quite like that, because hospitals are left to assess themselves on how well they are doing in adhering to the standard. The reliability of self-assessment is seriously questionable: in 2006-07, none of the 34 NHS trusts that discharged the highest number of patients in an undernourished state failed the Healthcare Commission’s core standard C15b.

A similar point could be made about overreliance on what patients say. The noble Baroness, Lady Thornton, said in last week’s Grand Committee debate on the Health and Social Care Bill that the Government are tackling undernutrition through the NHS operating framework, which now takes account of the patient experience. The patient experience is important, but I question whether in this context it tells us much. Many people at risk of undernutrition are not going to know it or will be unable, or too frightened, to report that they have had a bad experience. There are 63 targets flowing from the operating framework, classified into tier 1, tier 2 and tier 3. Nutrition is not listed in any of them. I find that extraordinary. I am no fan of having too many targets, but the tier 3 indicators are designed essentially as internal management tools and nutrition could easily have been included in them. I ask the Minister why it was not. I am advised that there is a readily available published indicator that could act as a good proxy for the quality of nutritional care commissioned by PCTs, but it is not made use of.

There are other missed opportunities. One of them relates, again, to nutritional screening. Even though screening is one of the most basic tools in nutritional care, historically the Government have not collected data on how many hospitals actually do it. That changed last year when, for the first time, the National Patient Safety Agency asked each hospital whether it nutritionally screened all its patients. Do we have the results of that questionnaire? No, because this component of the inspection was aggregated into a more general score about the quality of hospital food. The various components of the score, we are told, cannot be disaggregated. I ask the Minister why the basic data about screening have apparently been destroyed and whether she will use her good offices to ensure that the NPSA does not do the same thing again this year. The information would be useful for commissioners in performance-managing their providers.

However, we know from the NPSA that the uptake of screening in hospital is often hindered by lack of equipment, such as weighing scales. It is also hindered by less tangible but equally serious things such as a lack of leadership at ward level, a lack of staff training and a culture that does not place enough importance on the weighing of patients. I was heartened to read the brief sent to me by the Royal College of Nursing, which brings home how seriously it is confronting the issue of malnutrition and how much emphasis it is placing on nurse training and education in this area. This field is likely to become ever more sophisticated as hospital treatment becomes more complex, not least in areas such as intensive care, kidney disease and cancer, where the needs of patients can be very specialised.

I hope that the Minister will agree that the Government, the Healthcare Commission, the NPSA and, when it arrives, the Care Quality Commission need to keep their eye on the ball. There is a good case for conducting a national audit. We simply cannot have an NHS that fails to recognise and treat a condition as basic as malnutrition. When we return to this issue in future, as I do not doubt we will, we must all hope that the efforts that so many people are now making to improve nutritional care in the NHS will have resulted in some visible and substantial progress.

My Lords, this has been an excellent debate on a crucial subject, both the good and the bad, and I am grateful to the noble Baroness, Lady Knight, for enabling the discussion to take place. I agree with noble Lords that we owe her a debt of gratitude for her determination to keep this issue up the agenda, and she is right that only by constant vigilance will improvement be achieved.

The nutrition of hospital patients, so clearly described by the noble Baroness, Lady Finlay, has been a major concern for this Government. We know that malnutrition predisposes individuals to disease, delays recovery and impacts negatively on clinical outcomes, personal health and well-being. It also impacts on the length of stay, delays discharge or transfer and causes enormous distress if not got right. It is therefore something that hospitals must get right.

We know that in the general population people over 65 are at higher risk of malnutrition and that this risk can be increased when people are living in institutional settings or at home alone. This means that some patients will be malnourished when they are admitted to hospital, as many noble Lords mentioned. Poor nutrition can also arise when responsibility is diffuse and when there is a lack of integrated infrastructure within hospitals and between healthcare organisations.

It is tempting to hark back to the good old days, but we should not fall prey to the myth that this is a recent problem brought about by a “generation of uncaring nurses”. The noble Baroness, Lady Emerton, reminded us of the history and the challenges that nurses have faced over time. Many studies dating back to the 1950s show that nurses struggled with the same issues then as they do now. A 1963 study that examined food intakes in 153 hospitals reported that the preparation, cooking and service of food was regarded as a second-rate activity, an unfortunate necessity and an inconvenient intrusion into the real work of the ward. There was no excuse for poor nutritional care then and there is none now. We should not fall prey to the idea that this is a recent problem. Feeding an anorexic or confused patient or one who cannot swallow is extremely difficult and ensuring adequate food consumption can sometimes feel impossible. It is easy to identify poor care, but we should not underestimate how difficult good care can be. We may call it “basic care”, but it is anything but simple, as has been recognised by several noble Lords.

We know that there have been some significant achievements in improving nutrition. That can be seen in the HCC adult in-patient survey referred to by my noble friend in which 54 per cent of respondents rated the food as good or very good and just over three-quarters of respondents—79 per cent—were always offered a choice of hospital food. However, despite the sterling efforts of dedicated catering and care staff and increased staffing levels on the frontline of care, reports from key organisation such as Help the Aged, in its Hungry to Be Heard report in 2007, and observations from patients and visitors show that there is still more to do.

I shall mention some of the things that we are doing. Patient environment action teams now evaluate the quality of hospital food every year. The Better Hospital Food programme introduced 24-hour availability of food, snack boxes and daily snacks and, in partnership with the Royal College of Nursing and the British Dietetic Association, introduced protected mealtimes to create an oasis of calm where unnecessary activity gives way to allow patients and staff to concentrate on enjoying good food.

In 2001 we launched the “Essence of Care” benchmarking toolkit for front-line practitioners to evaluate aspects of the care given to patients. Food and nutrition were identified, unsurprisingly, as among the first fundamental areas of care to be benchmarked. That has had a big impact on the quality of care that patients receive, including nutritional screening of patients on admission to hospital, regular weight monitoring for at-risk patients, and discreet ways of identifying patients for extra assistance by means of coloured trays.

Last October we published the nutrition action plan Improving Nutritional Care, which is monitored by a delivery board chaired by Gordon Lishman of Age Concern. The board’s work is progressing very well and the chair is due to report in the summer, as part of the mid-year progress update, to my honourable friend Ivan Lewis, Minister for Care Services, on how far the plan has been implemented. I thank the noble Earl for his remarks about my honourable friend’s commitment. Indeed, he has shown great determination in taking this issue forward. As a result of all this activity, statistics are improving, although I absolutely acknowledge that there is still a way to go. The PEAT assessments show year-on-year improvement since 2002, so we have much on which to congratulate NHS staff. I take this opportunity to thank hard-working doctors, nurses and other health professionals for helping to bring about these welcome improvements.

However, we are not content to rest here; of course we are not. There is still work to do. Having installed what we hope will be a robust framework for raising the quality of food for patients, we have turned our attention to how we can make sure that they eat it, and in sufficient amounts to ensure that they are well nourished. While this is not entirely a nursing responsibility, good healthcare is always a team effort, as referred to by my noble friend Lady Pitkeathley. I know that nurses consider the nutrition of patients a central tenet of their work, so much so that the Nursing and Midwifery Council has included this as an essential core skill, which all nurses must master before being admitted to the register.

We have heard today that events can conspire to prevent patients getting the help they need at the right time. We must help our nursing staff to fulfil the key role of ensuring that all patients have the food and drink they need. My noble friend Lady Wall has described the model in her hospital. I congratulate her and agree that that hospital is not alone in this excellence. However, it is totally unacceptable that any patient in our NHS hospitals should go without food they can eat when they want it, or that untouched food goes unnoticed and is not acted on. I agree with the noble Baroness, Lady Masham, in her praise of the Royal Brompton Hospital. We cannot underestimate the importance of food and drink in aiding recovery. That is why proper nutrition of patients remains high on our agenda. I was struck by the perceptive remarks of the noble Baroness, Lady Barker, about the mentally ill and the problems faced by accident and emergency departments. I remember being in an accident and emergency department at 3 am with one of my children, thinking that I was about to expire with hunger. If I were diabetic that would, indeed, be a huge problem.

Turning to further activity, we are now working with SHAs to roll out the Productive Ward: Releasing Time to Care programme, which encourages staff to review the ward environment and working practices to find ways of releasing time to spend on patients. Ministers have visited wards involved in the scheme, and have been impressed by the improvements that they have seen. This is being led by the nurses and sisters on those wards, with front-line staff finding that by making such small changes as altering patient handover times, reorganising storage facilities, and making better use of data, they can double the time that can be spent with patients, reduce time spent on paperwork, improve the accuracy of patient observation and minimise food wastage. The vital component of this programme is that it is inspired and led by those nurses who are implementing the changes. The Secretary of State announced on 8 May that £50 million is to be made available to enable all patients in all wards, across the NHS, to benefit.

Nurses have to find time to nurse. We are trying to reduce unnecessary pressures on them, but this is not all. We realise that one of the most important factors in improving nutritional standards for patients is what they are actually fed. We have to make sure that nurses and staff providing direct care have the skills and knowledge they need; the leadership to help them; are there in sufficient numbers to meet the needs of patients; and can access the support they need from others. My noble friend Lord Darzi is leading a programme on how we can maximise the contribution nurses make to the quality of care. This will strengthen nurse leadership so that such issues as patient nutrition become a matter for all. I will raise the points raised by the noble Baroness, Lady Emerton, to ensure that they have been included in the noble Lord’s survey.

I move now to some of the points raised by noble Lords. The noble Baroness, Lady Knight, raised the issue of patients saying that they have not been fed. I apologise if she felt that that the response of the Chief Nursing Officer, and Ian Phillips, who reviewed the investigations into the allegations, were not satisfactory. I have also reviewed that correspondence. I suggest to the noble Baroness that we meet and review it together, to make sure that she is satisfied. If she is not, I undertake to raise those issues again. The noble Baroness also raised the issue of patients leaving hospital in a worse state than they were in when they went in, as did the noble Earl, Lord Howe. Patients have a diagnosis recorded on admission and every time they see a new consultant. If they do not have a separate diagnosis recorded on discharge it means that doctors have built up a picture of a patient’s illness during their stay, so the last diagnosis may record something that has not been picked up earlier. It does not necessarily mean that that condition developed as a result of their care.

I undertake to look into the issue raised by the noble Earl and the noble Baroness, Lady Finlay, of the NICE guidelines and how effectively they are being rolled out. That is a legitimate area of concern. I also undertake to find out whether it is possible to disaggregate the information to which the noble Earl referred. We have to emphasise the importance of screening for nutritional needs on admission. That is absolutely right. Identifying a nutritional problem is the first step towards solving it.

The noble Baroness, Lady Knight, and the noble Lord, Lord Roberts, raised the issue of nursing support for eating and drinking. It is important to remind noble Lords that the level of trust in nurses’ competence remains extremely high at 96 per cent. When patients were asked whether they received enough help from staff to eat their meals, 79 per cent said “always” or “sometimes”. That is an improved figure, but is certainly not good enough. It means that 21 per cent possibly did not feel that, which is a large number of patients. I accept that.

There is little that I need to add about how the red tray system works. I apologise that it was not explained to the noble Baroness when she heard it for the first time. My noble friend Lady Wall has given us an adequate explanation of how the red tray system works and how it is helping to improve patient feeding. My noble friend Lady Pitkeathley raised the issue of the Better Hospital Food programme. I was pleased to hear mention of the value of housekeepers in supporting patients to eat. This, along with the other improvements of the Better Hospital Food programme, has made a real difference.

Central initiatives can go only so far. Funding previously allocated centrally is now being passed to the NHS to allow it to develop the services that are right at local level. The noble Lord, Lord Roberts, and the noble Baronesses, Lady Knight, Lady Emerton, and Lady Pitkeathley, all mentioned volunteering.

I do beg the noble Baroness’s pardon. The noble Baroness, Lady Masham, also mentioned volunteering. I am pleased to say to all those noble Lords that we fully support the proposals raised in the Age Concern report about the use of volunteers. They perform an important role, not only in helping patients to eat, but in keeping them connected to life outside the hospital. My noble friend Lady Pitkeathley and the noble Baroness, Lady Masham, both referred to the wide variation in the surveys about helping people to eat. This is not acceptable, and the worst definitely have to learn from the best.

Noble Lords who have been with me in the Grand Committee considering the Health and Social Care Bill will be aware that the draft registration requirements for the new Care Quality Commission, which are under consultation at the moment, include at point 5:

“Ensure, where meeting nutritional needs is part of the service, that people have access to safe and sufficient nourishment. This includes: the provision of support for eating, drinking or feeding where required; the provision of a sufficient choice of palatable food to meet religious or cultural needs; and the prevention of harm through lack of access to sufficient nutrition and hydration”.

That final point was mentioned by the noble Baroness. That requirement, or a version of it, will be part of the registration that the new Care Quality Commission will establish.

My noble friend Lady Pitkeathley was right to mention the issue of food in care homes. It is important that people in care homes also get good food. That is why we have included a representative from this sector in the nutritional action plan.

The noble Lord, Lord Roberts, referred to the cost of food. I am constantly impressed—this was borne out by the story told by the noble Baroness, Lady Masham, and my noble friend Lady Wall—by the high quality of food that so many hospitals manage to produce on a relatively small budget. Indeed, the Audit Commission 2002 found that there is no relationship between spending on food and its quality. It showed that excellence can be achieved within the current budgets; it is to do with the will to do it and the leadership to produce it.

Several noble Lords referred to the issue of screening for nutritional needs on admission. More than 80 per cent of trusts have a policy for nutrition screening. This includes attention to food needs, such as vegetarianism and wheat-free, and issues such as dentures. It includes an assessment of the nutritional state, including weight and recent weight loss.

The noble Baroness, Lady Emerton, raised an issue about the past. She mentioned that wards are closed at lunch-time—this was also mentioned by my noble friend Lady Wall—which shows that a modern hospital is also now adopting the system of closing wards, and quite right to.

The noble Baroness, Lady Masham, and other noble Lords raised the issue of the quality of hospital food. The Better Hospital Food programme has accomplished some very specific things: it has made sure that food is available around the clock, including snacks at all times; it has ensured that modern dishes are introduced alongside traditional ones; it has ensured that patients can choose a hot meal in the evenings; it has ensured that meals have been redesigned, using better ingredients to improve their flavour and nutritional content.

On the issue of relatives bringing in food, the NHS strives to provide food suitable for all—it is one of the central planks of the Better Hospital Food programme—but we should not assume that it is always a bad thing for friends and relatives to bring in food. When staff and family are working together they are able to provide a truly personalised service.

The noble Baroness, Lady Finlay, referred to the problem of dehydration in healthcare, which is important. The National Patient Safety Agency, with the Royal College of Nursing and the Hospital Caterers Association, launched a hydration best practice toolkit in September last year and support a hydration best practice award, which this year was won by the Salford Royal NHS Foundation Trust.

The noble Baroness, Lady Finlay, also raised the issue of protein energy malnutrition and its effect on recovery. We know that a malnourished patient takes longer to recover and a recent screening survey by the British Association of Parenteral and Enteral Nutrition shows that more than a quarter of patients are at risk from malnutrition when admitted, and the number is even higher among older patients. There are many reasons why sick people become malnourished, as so eloquently described by the noble Baroness.

The noble Earl, Lord Howe, and the noble Baroness, Lady Finlay, mentioned the implementation of NICE guidelines, which provide a clear set of instructions to inform clinical care. Although we do not audit them directly from the centre, we have a strong system for holding the NHS to account. This shows how seriously we take this issue.

I have covered many, but not all, of the points raised. I shall write to noble Lords on the issues that I have not mentioned. Perhaps I may say in winding up that, without the staff, good intentions remain at the hospital gates. We have increased the number of staff working in the NHS, especially in nursing. There has been an increase of more than 25 per cent since 1997.

I should like to finish by speaking very briefly about the multidisciplinary team and the contribution of the allied health professionals mentioned by my noble friend Lady Pitkeathley. As I said earlier, feeding patients is not solely a nursing responsibility. Dieticians assess patients and design treatment plans that may involve modified diets and nutritional supplements; speech and language therapists may need to assess whether patients can swallow; and occupational therapists may need to assess whether patients need adapted cutlery. Together with physiotherapists they can advise on the correct positioning of patients and equipment. This multiprofessional approach to feeding supports nurses to feed patients and identifies patients at risk of malnutrition. These are real, positive improvements for those in our care. We shall not stop in our efforts to secure the very best for our patients—whether in numbers, working practices, paperwork, knowledge, skills and leadership—so that no one leaves our care malnourished physically or mentally.

My Lords, I warmly thank the Minister for what she has just said. Clearly she is sincere and cares very much about the matter we have been discussing. I am grateful for the clear indication that she will continue to act in the way we have all been pressing her to.

I thank everyone who has spoken in the debate. I have been struck by the fact that, in a small way, the debate is indicative of the service that this House gives to the country. What we do, on the Back Benches and outside, we do for nothing—we receive no kind of pay—and yet we have in this Chamber a wonderful collection of knowledge and experience through the people who serve the House. We have heard some wonderful speeches, particularly from the noble Baronesses, Lady Emerton and Lady Finlay. Between them they have so much knowledge of being a doctor in the present health service and being a nurse for many years and seeing so much. The House is grateful for what they have said. The noble Baroness, Lady Masham, who is perhaps one of the favourites on all sides of the House, spoke from her experience and her knowledge.

I particularly thank the noble Baroness, Lady Wall. My complaint about that part of my dossier was that the words “red tray” were written without the slightest indication of what they meant. I am not a nurse or a doctor—I never have been—and I needed an explanation for any of it to make sense. It was that kind of attitude towards the complaints I made that prompted me to go on and make sure that the complaints go through. Without the knowledge of Members such as the noble Baroness, Lady Wall, and the noble Lord, Lord Roberts, who knows and visits his hospitals, we would have been much poorer in the debate today. I am most grateful.

Of all the information that I have had sent to me over the past couple of days, only the document from which the noble Baroness, Lady Pitkeathley, quoted freely and fully suggested that everything was all right and that the food that people in hospitals received was always absolutely perfect. My mind goes back only a very short time—perhaps two or three months—to when the Minister in the other place, who has already been referred to and complimented, said:

“A spoonful of mashed potato on a plate is not a sufficient meal for a hospital patient”.

Nor is it.

In thanking all noble Lords for their adherence to the problems we face and their universal determination to make things better, I have pleasure in begging leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.