In recent years much has been written about patients having to travel hundreds of miles across the country to find a hospital bed, often with an adverse impact on their health.
Yet little attention has so far been made to the vast journeys travelled by hospital food - and the health and environmental costs of ingredients being sourced from far-flung corners of the globe.
This could be set to change, following the latest annual report on the state of public health by the chief medical officer (CMO) for England, Sir Liam Donaldson.
Sir Liam has called on the NHS to buy its food from local farmers and suppliers. In his report, he set out how the NHS, as the largest public purchaser of food in Europe, could fundamentally shift the procurement, production and consumption of locally produced healthy food.
The greater the distance food travels (known as food miles), the greater the adverse health and environmental consequences. As Karen Jochelson, public health researcher at healthcare thinktank the King's Fund, says:
"If you're able to increase the amount of local food, you're also reducing the amount of traffic, because produce isn't transported so far. This in turn reduces pollution that has an impact on respiratory diseases."
With an annual food expenditure of around £500m - of which £300m is spent on ingredients - the financial clout of the NHS is immense.
Over 300m meals are served each year for patients, staff and visitors in approximately 1,200 hospitals. The NHS purchases 6.3m loaves of bread per year; approximately 60 tonnes of chips per week; has meat contracts worth £12m annually; and fruit and vegetable contracts worth £11m per year.
Yet, as the CMO's report and new research by the King's Fund reveals, NHS food procurement is at present far from sustainable.
According to the CMO's report, a typical catering contractor currently sources only about 15% of their lamb and a quarter of their bacon from the UK, while 75% of fruit comes from abroad.
The King's Fund found that from farm to kitchen, lasagne served in hospitals travelled about 27,800km while steak and kidney pie ingredients travelled about 31,200km. Beef was imported 11,100km from Argentina. Lamb travelled 18,800km from New Zealand.
So how has this happened? In part it is blamed on the government's food procurement policy, which emphasises the need for value for money in contracts.
The CMO believes that NHS managers have interpreted this requirement too narrowly, buying cheap food lacking in nutrition. His report suggests that hospital managers look at the longer-term financial consequences of poor diet, such as obesity, and the financial burden they place on the NHS, when evaluating what foods really represent value for money.
Dr Jochelson, who has compiled a report on NHS food procurement for the Better Hospital Food programme, agrees that hospital managers need a change in mindset.
"What surprised me was that food is seen as something entirely separate to the NHS ethos of health promotion. The food provided is simply seen as a service, rather than an essential part of prevention and treatment," she said.
The thinktank's survey of several NHS trusts found none had policies about procuring from local, small or medium-sized businesses, or any ethical food policies.
No trusts had policies about the procurement of fair trade products, or the procurement of food certified by environmental schemes. One trust required its suppliers to provide food without any genetically modified ingredients, but this was "just a policy and no one checks that it works".
Dr Jochelson admits there are some practical hindrances to switching to local suppliers from a national contract. Rather than ordering through a single supplier, food must be sourced from a variety of producers and wholesalers. Some managers remarked that it was far easier dealing with problems about quality when they only dealt with one central supplier.
However, Dr Jochelson contends there would be longer-term cost benefits. Sustainable procurement would stimulate the local economy, creating jobs in food production. This in turn could raise standards of living and reduce health inequalities.
To illustrate this, the CMO report notes that every £10 spent on locally produced food generates around £25 for the local economy. In contrast, the same amount spent in a supermarket generates only £14, as much of the food comes from overseas.
The King's Fund did find a few isolated examples of good practice. The Cornwall Food Programme, involving 23 hospitals in five NHS trusts in the region, has substantially increased the proportion of ingredients sourced from local suppliers. Sixty percent of the annual food budget (£1.2m) is now spent locally, up from 40% five years ago.
Meanwhile, London Food Link and the Soil Association run a project covering Ealing, St George's, the Royal Brompton and the Royal Bethlehem hospitals, which now purchase fruit from Kent and Sussex and organic milk and beef from Hampshire. The hospitals have run special promotional events for organic and sustainable food, with taste-testing days for local produce.
Dr Jochelson said: "These schemes operate within the existing NHS food procurement system, so it just goes to show that with some ingenuity, sustainability is a realistic goal."
