Worry etched the faces of everyone circling my father-in-law's hospital bed. He came in for "a few days" that turned into three weeks before he passed away from cancer just before New Year's Eve. Meal times were especially difficult — tray after tray of pre-packaged items with ingredients that were almost unpronounceable, left uneaten. My father-in-law refused them, he gave up after trying several, saying they were unpalatable.
Doctors suggested Ensure, a sugar-laden nutritional shake, which he also had trouble with. My mother-in-law brought in her own homemade broths and soups because those, at least, he would eat.
Hospitals across Ontario and beyond have been struggling to serve healthy and tasteful food amid limited budgets. Health-care dietitians want to feed patients the best meals possible, but struggle to do so on the quotas devoted to food.
"We are all being asked to rethink how we do business with limited/reduced resources; improve efficiencies, look at lean processes, while being more client-focused," says Leslie Carson, former manager of food and nutritional service at Guelph’s St. Joseph’s Health Centre. "It takes very skilled leaders and visionaries to help organizations think and act outside the traditional norms of our institutions. And it's likely one of the biggest challenges in health care."
Carson, who now works as manager of nutrition and food services, at Whitehorse General Hospital, was one of those leaders in Guelph. She was awarded the 2011 Green Health Care Award in the individual leadership category and was recognized as a leader in the local food movement. Carson was fired from the Guelph hospital in 2012 and never given a reason — something allowed under the contract she had signed.
“If you have a strong will and commitment, you can make it happen. I don't know that a lot of my peers have the energy and passion to serve nutritious food to patients — if you have to go to bat with executives about it all the time, it can run you down,” Carson says.
Budgets and how they are administered are among the biggest barriers to scratch-made, wholesome food versus the pre-packaged, reheated food a lot of hospitals serve today. Carson outlines the following example: the foodservice operating budgets in most health-care institutions are 70 per cent salaries and benefits, and 30 per cent supplies, including food.
"Too often when it comes to finding efficiencies, foodservice managers will avoid the 70 per cent and focus on the 30 per cent. As managers, we need to address and manage the 70 per cent more effectively to make significant financial improvements to our bottom lines and leave the 30 per cent alone," Carson says. That’s because any support service not directly related to patient care will likely get hit first. Apart from housekeeping and laundry, this includes food services.
Costs go up every year in health care and prioritizing funds is important, says Tracy Maccarone, director of nutrition and commercial services at Toronto's SickKids hospital.
"Think about our aging population," she says. "Where does it make sense to direct funds? Is it in long-term health-care facilities, acute-care centres? Year after year, we're faced with financial constraints and the reality is there is no extra money, so now it's about how to best use what we've got."
In 2012, the Ministry of Health and Long-Term Care began implementing measures to shift the province's health-care system funding towards one tailored to the size of the hospitals and the types of treatment provided there. Jensen says hospital funding in Ontario has risen from $11.3 billion in 2003-04 to $17.3 billion in 2015-16 – a 53 per cent increase. But experts in the field still struggle with funding for food.
Today, the estimated cost of three meals a day, including snacks, is between $8 and $15 for food alone, depending on the hospital, Maccarone says. When food activist, educator, chef and TVO food panellist Joshna Maharaj worked with the Scarborough Hospital in 2011, the allotment was $7.33 per patient, per day.
"Twenty-five years ago, the government forced the hand of hospital administrators to cut budgets. At six Toronto-area hospitals, staff made the decision to stop serving soup because they couldn't get the resources to do it properly," Maharaj says.
The move, she says, sent a clear message to the administration about the dire reality of food services. "The situation that hospital kitchens are put in this position to have to cut something as therapeutic as soup is what is ludicrous. They cut the one thing patients need to get better. Soup is easy to make, it's easy to digest and doesn't cost much per serving."
Maharaj argues that food is one of the least expensive, most effective ways to economize. At $1,200 to $1,500 a day for a hospital bed (with the average ranging from four to six days), shorter times could save big money.
"Food is often considered hospitality and not placed on par with medical treatment. We need to remember that food is medicine and change our awareness of these issues with respect to providing quality food to patients when they want to eat it, and reducing any barriers to food intake," says Heather Keller, professor at the University of Waterloo and chair of the Canadian Malnutrition Taskforce. It's almost always easier, she says, to garner interest and fundraise for a new, expensive machine, while the basic care of patients, including what they eat, is overlooked.
Keller was a part of a 2013 study by the Canadian Malnutrition Task Force of the Canadian Nutrition Society, one that points to food as necessary to patient recovery. It identified, in over 1,000 Canadian patients from 18 hospitals across eight provinces, that 45 per cent of patients are malnourished when they are admitted. Malnutrition is predictive of longer hospital stays, according to Keller.
Patients ate less than 50 per cent of the tray, she says, which also predicted a longer length of stay. "Limited variety and the incapacity to provide desired foods like soups and comfort foods while an individual is recovering were also an issue."
Some hospitals outsource almost all food services and have no working kitchens on-site, opting instead to reheat outsourced foods. Others, such as SickKids (which spends $12 per day per patient on food), have the flexibility to cook from scratch in their own kitchen using a room-service type model. The latter has proven to have a higher satisfaction rating among patients, with less food waste. In remote or northern areas, transport costs and time, coupled with severe weather, for example, mean that food costs significantly more to get to a hospital, Carson says. This is why she advocates for buying raw, local ingredients that can be used to make meals suitable to patients' therapeutic needs and tastes.
Jensen says that although public hospitals and local health integration networks are funded by the minister, they are "independent corporations run by their boards of directors. This is set out under provisions of the Public Hospitals Act and other legislation." In other words, it's entirely up to hospital administration to manage the day-to-day business of their hospitals, including food services.
The obvious question then becomes what can we do to incite change? Maharaj advises patients to fill out their satisfaction surveys carefully.
"The feedback from patients needs to be angrier than it is when it comes to food. Administrators don't have an accurate enough sense that people are dissatisfied. Average numbers mean inaction. We need to vocalize our outrage and understand that this is our system too and we're all paying into it."
Keller takes Maharaj's suggestion a step further by saying Ontarians can write to hospital administrators, quality health councils and MPPs about the need for "quality and sufficient food in hospital to support recovery and the need for prevention, detection and treatment of malnutrition through the care system."
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