Caring through catering
Ask Ron McKenzie why Darlington Memorial Hospital is so often singled out as an example of best practice in hospital food and you get a long pause before the answer comes: "It's about that extra step - making a difference, caring about what you do, treating patients as guests. And don't serve anything you wouldn't eat yourself."
The hospital is part of the County Durham and Darlington Acute Hospitals Trust, which has two other general hospitals and four smaller community hospitals in County Durham. The Darlington Memorial gets the highest possible service and quality score in the NHS performance ratings - three stars - and although food is just one part of the overall assessment, McKenzie, head of catering and housekeeping, says no areas of the food operation were marked down by the independent audit team.
Darlington has 450 beds and about 1,300 staff, all fed from an on-site central production kitchen using cook-chill. The use of cook-chill is fairly uniform throughout the NHS, but the commitment to making a difference at Darlington begins with food sourcing. Despite the widespread availability of national purchasing contracts and one-drop deliveries, McKenzie chooses to buy as much as possible from independent wholesalers in the North-east.
He is happy with the prices, and having local suppliers gives him greater quality control. Not only is the milk from a local dairy, but the hospital has recently switched to organic milk at neutral cost. Even with meat, arguably one of the most expensive basic ingredients, McKenzie insists on buying British and has an eye on quality as well as price. "I have a reputation for good food, and there's no way I want to lose it by using cheap ingredients," he says.
The food cost per patient is scary. For three meals, snacks, beverages and the ward snack box, there is an allowance of just £2.20 a day. Although that is at the lower end of NHS costings, McKenzie still manages to save enough money to put on occasional specials in addition to Christmas Day. These can range from a celebration afternoon tea to mark the Queen's Golden Jubilee to strawberries and cream during Wimbledon. All specials come with a printed tent card explaining the reason for the surprise, printed by catering staff and distributed around the wards.
The central food production kitchen is compact. It has four combi-ovens, one small solid-top boiling table, four deep-fat fryers, two bratt pans, an orbital mixer and a steam-jacketed boiling kettle. McKenzie says the tilting kettle has been one of the best equipment buys he has made, with its ability to cook anything from smooth sauces to fresh potatoes.
Patients order meals from the 14-day menu cycle the previous lunchtime on tick-cards, which are used to calculate daily production runs. Once cooked, the food is racked into gastronorms and wheeled into a bank of blast chillers set in the wall. The blast chillers are double-doored, leading into the picking and chilled holding rooms area. There are different staffs for cooking and food assembly, separated by a wall and the blast chillers.
The picking system is for multi-portions made up for each ward. These can be individual portions for special diets, but are usually in foils of two, four, six or eight. Most patients want comfort food rather than experimentation, which sees the menu cycle having lots of familiar and traditional foods, such as roast dinners, meat in sauces and pies.
Until recently, the pies were bought in from a local bakery, but that has changed. The hospital now makes its own fillings and buys only the raw pastry from the bakery. "That way we know what's going into the pies," says McKenzie. The pastry is cut to size for each foil tray, baked and chilled separately, then put on top of the chilled filling during meal assembly. In another example of care with presentation, the pastry topping is cut before regeneration to avoid crumbling during service.
The meals are loaded into regeneration trolleys and wheeled to ward kitchens before each service time. Each ward kitchen has a fridge-freezer for holding snacks, drinks and snacky items such as yogurts, a cabinet dishwasher, microwave oven, the ward snack box, beverage facilities, a toaster for breakfast and a plug for the regeneration trolley.
Catering staff take responsibility for regeneration of food and make fresh custard and gravy from dried mixes just before service. They also distribute meals to patients by wheeling the trolley down the ward, using the patients' own tick-cards from the day before to deliver the meals ordered. The hospital operates protected meal times, which allow nursing staff to assist patients with eating where needed.
Ward catering staff work a three-shift system each day. A team comes on from 7am to 2pm to do Continental breakfast and lunch. The second shift is noon to 6pm for lunch and supper, and the last shift is 4.30pm to 7.30pm for supper. The overlap in timing means there is maximum staffing around the two main meal points of the day.
Hospital catering staff are notoriously transient, not least because of the pay structure, but the length of service of the hospital's five chefs says much about their shared commitment and enthusiasm for the service they provide. McKenzie estimates that the chefs' average length of service is 20 years.
A key feature of the NHS Better Hospital Food programme has been to shift the main meal of the day from lunchtime to the evening to reflect modern eating habits.
The Darlington hospital view is that patients should choose when they want their main meal of the day. Both lunch and supper have a choice of full meals and lighter, snacky meals, and patients can choose to eat light at lunch and heavier in the evening, vice versa, or have two substantial meals or two light meals.
Another push from the Department of Health is for food to be available outside main meal times for new arrivals or those who have missed a meal for clinical reasons. Every ward carries sweet and savoury snacks, and if the kitchen is warned, it can make up a cold meal or a chilled dish for the microwave.
Although physical contact between patient and catering staff ends with meal delivery, communication between them is given high importance. This includes something as simple as a booklet in the bedside cabinet that has colour photographs of the dishes on the menu cycle and descriptions of what they are. So while the menu tick-card might offer chilli con carne, the booklet shows a picture of the dish and an explanation that it is minced beef with red kidney beans in a spicy sauce served on a bed of boiled rice.
A separate booklet is available on each ward that explains multicultural menu offerings. There is not a large Asian community in Darlington, unlike nearby Middlesbrough, but having a picture of a halal dish such as lamb and potato with boiled rice helps patients order the food they want.
Each ward has a multicultural laminated menu with menu descriptions written in the five main languages of the subcontinent. This borders on the extravagant, but the catering team has also bought a Braille printer to produce a daily menu for the visually impaired. McKenzie says there is little take-up, but it is just another little extra. "It helps those who can read Braille feel independent, rather than having a menu read out to them."
All in-house NHS food operations are constantly looking over their shoulder for predatory attacks from commercial contractors. Two of the hospitals within the Durham trust have commercial contractors as a fallout from a privately financed building expansion. It is here that perhaps the best tribute to the quality of the food produced at Darlington hospital comes.
The in-house operators successfully tendered to supply freshly cooked meals to Bishop Auckland General Hospital, where catering is handled by contractor ISS Mediclean. "It was a straight tendering process and we were up against outside providers," says McKenzie. "We won the contract on strict commercial and quality grounds." Meals for the 420-bed Bishop Auckland hospital are assembled in the Darlington production kitchen in the normal way and trucked 10 miles north each day to the other trust hospital.
McKenzie is forever looking at ways to lift the food service at Darlington hospital. His ideas have included giving terminally ill patients anything they want, irrespective of budget. "I once had a patient who said he longed to taste his favourite sausages from his favourite local butcher. We just went out and bought some."
The idea currently in McKenzie's sights is at the opposite end of life - to provide candlelight private suppers for new mothers, their babies and partners. "I might have a problem getting a free half-bottle of wine sanctioned by the trust, but it's just such a nice thing to do at a very special time in people's lives."
Accolades In addition to being voted Dinner Man of the Year in BBC Radio 4's Food & Farming Awards 2004, Ron McKenzie won the Hospital Caterer of the Year award from the Hospital Caterers Association in 2002. County Durham and Darlington Acute Hospitals Trust was given the highest possible score of three stars in the latest NHSperformance rating.
