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Fish custard anyone? The food of healing and punishment

Food is a sensitive issue. To humans, food is not just fuel – it’s filled with emotion and meaning, whether it be positive, negative, risky or life-giving. Food is a focus for politics, economics, philosophy and even religion. So when it comes to running large institutions with a duty of care like hospitals and prisons, it goes without saying that we should pay attention to the food – shouldn’t we?

As a nation, we seem to have a general picture of what the food in institutions is like. Jamie Oliver did school dinners, didn’t he? In hospitals, offerings are generally deemed to be disgusting – jokes about hospital food are almost a national sport. Do we even consider prison food? Perhaps it conjures up images of gruel and dry bread.

“But what should the food in these places actually be like?” asks Dr Jennifer Crane, a public engagement research fellow in the Department of History at the University of Warwick, working on the Wellcome Trust project, The Cultural History of the NHS. “Should hospital food be tea and biscuits and pudding and custard – all nursery food and comfort eating? Or should it be strictly measured health food designed for the nourishment and healing of patients?”hospital_food_ny.jpg

The quality of hospital food actually is the subject of much consideration, both culturally and politically. Between 1992 and 2015 there were 21 initiatives to improve hospital food equating to £54m of government spending.

But where hospital food receives a lot of attention, and the average NHS hospital food budget is £10.75 per person per day, the prison food budget is as low as £2.02. This throws up a lot of issues around food, heath and punishment.

Dr Margaret Charleroy, a research fellow at Warwick's Department of History working on another Wellcome Trust project, Prisoners, Medical Care and Entitlement to Health in England and Ireland, explains: “Even though there have been massive advances in the understanding of food science and dietetics, issues over the diet of prisoners are very similar now to those which occurred in the 1800s. And, the roots of current policy and practice of diet in the English prison system lie in the genesis of prison food practice in the nineteenth and twentieth centuries.”

To discuss these issues and move the agenda forward, Dr Crane and Dr Charleroy have brought together experts, commentators and campaigners from the field of nutrition and public health for a policy conference at the University of Warwick. The event, which takes place this month, will examine concepts of control, management, and the choices of patients, prisoners and medical staff in relation to institutional diets in the twentieth century, using a historical narrative to understand current nutritional policy.

Dr Crane and Dr Charleroy will be putting the current policy into context using evidence on the historical provision of food in institutions of care. In Dr Crane’s research and public events, she has found that the stereotype of hospital food as disgusting is very powerful and pervasive, reflected in television, film, media representations, and humour.

The fried spleen, or the fish custard sir?

“Part of this stereotype in modern culture emerges because some of the dishes offered in hospitals historically sound unappealing to current tastes,” says Dr Crane. “Foods in 18th century were generally plain – primarily oatmeal, barley, milk and bread baps. But at this time patients were often also served beer – a provision which has been reduced since the 1800s!

“The Lothian Health Archive has found that in the 1920s, the ‘spleen diet’ was offered, involving ‘serving pulp scraped from the fibrous part of the spleen, tossed in oatmeal and fried’. A recipe for ‘fish custard’ discovered in the Royal Infirmary of Edinburgh archive, involves 1 filleted haddock, 6 ounces of milk, 1 egg, seasonings, lemon, and parsley – delicious!”

It is clear from these disparate examples that what patients and public expect of the food in hospitals has altered over time. Diets and tastes have changed and nutritional science has shifted rapidly. More modern records, looking at hospital food provided by the NHS since its foundation in 1948, show that the public and media concerns about hospital food now centre around the idea that it is poor quality.

Certainly, Dr Crane’s research shows instances where food was so bad that even small boys wrote about it. She says: “In 1954, the Manchester Guardian published a letter from a school boy to a friend about hospital, writing that he had only been fed, “orable [sic, horrible] chips and peas an fish so if you are having it god Helb [sic, help] you.” In 1972, inspectors from the Egon Ronay food monitoring group visited 31 hospitals, and found overall that the meals in many were of a ‘scandalously low standard’”.

“This kind of idea is echoed in the joke often heard on hospital wards – well, if we gave you nice food you may not want to leave. This is not the full picture though: throughout the post-war period, there have also been letters to newspapers defending hospital food, in specific areas, and indeed the Egon Ronay inspectors did also find examples of excellence (in Cambridge, Bath, Edinburgh and Leeds). Recently, the food at Kingston Hospital in London was greatly improved by the institution’s director of nursing and patient experience. There is still great regional and local variation in the quality of hospital food.”

I predict a riot

But where bad food in the health sector leads to a nationwide in-joke about the NHS, in the prison sector it can lead to riots.

“Food is critical to the health and wellbeing of incarcerated individuals,” says Dr Charleroy. “Poor nutrition and unhealthy food choices have lasting physical and behavioural effects on prisoners, including diabetes, vitamin deficiencies, and increased and sometimes decreased aggression.

“Beyond the nutritional and physiological aspects of food though, meals in an enclosed institution have a significant effect on mental health, moral, and community. Meals are a focal point of the day. But individuals in prison have little choice about what, when, or how much they eat. In this sense, prisoners lose control over aspects of their health and wellbeing, and not just physical health, but also morale and mental welfare, as food becomes a source of frustration and anxiety amongst prisoners.

“This is made clear in a quote from a report conducted by the National Audit Office in 2006: “Food,” commented one prisoner, “is one of the four things you must get right if you like having a roof on your prison.””

Dr Charleroy’s research documents advances in prison diet, with the aim to be able to use historical perspectives to inform modern social policy.

She explains: “A prisoner in the 1800s would have had a meagre diet, designed to discourage reoffending. In 1887, an inmate at Dartmoor, for example, received a diet of 12 oz of bread and a pint of gruel each day. Despite periodic reforms to prison food during the century, culminating in a standard, national prison diet in 1878, complaints about what ended up on prisoners’ plates persisted. The quality of food provided was a regular source of grievance.

“At the start of the twentieth century, the Prison Commission had established a departmental committee to examine prison diets (1924). The committee, reporting in 1925, suggested that diets across the English prison system were ‘somewhat low in fat and in fresh green food’ and proposed a number of improvements, including an expanded range of dinner dishes. Even bread, the focus of much complaint in the previous century, was improved,” continues Dr Charleroy.

Plum pudding

“Augmentation of diet began to occur in prisons in the nineteenth and twentieth centuries, mostly around holidays. Often the idea of augmentation was up for much debate when charity groups, like the Howard League or local charities, offered to donate items like oranges and puddings to the local prison at Christmas time. The prison staff, the Home Office and the medical staff discussed whether they could accept charity donations, if the augmentation of diet was ‘fair’ (in terms of moral economy), and if the donation was appropriate for the prison. Ultimately, all donations were turned away," says Dr Charleroy.

"But in some cases, it inspired prisons to include their own augmentation of diet, including Plum Pudding with a meal on Christmas Day. This held no nutritional or physiological benefit to the inmates confined to English prisons, but it came with significant moral value. The administrations were beginning to recognize and used food as a tool for governing behaviour and morale.

“It was around this time that prison medical staff experimented with scales of diet to understand the relationship between diet, behaviour, and health of the prison population. They further adjusted diets to curb aggressive behaviour and promote mindfulness. Until the advent of the NHS, prison nutrition was controlled by individual prisons; now it is under the auspices of the NHS Health and Justice Commission,” adds Dr Charleroy.

The slow food revolution

But even with everything we know about diet, nutrition, mood and wellbeing, there are still sticking points in policy making. The moral arguments about what people in institutions ‘deserve’ still exist. And there is no doubt changing process and policy around institutional food is slow – whichever institution you pick.

“Changing hospital food is difficult for a variety of reasons,” says Dr Crane. “The first hurdle is perhaps the cultural acceptance of hospital food as substandard, but then there are issues of funding, staffing, out-dated building and equipment stock, and the logistical challenges of standardisation over such a vast institution as the NHS.”

“Food remains a considerable source of frustration and anxiety amongst prisoners. We now know that diet is connected to physical health and well-being, but also to mental and behavioural health in the prison setting. Evidence from the nineteenth and twentieth century show a long history of medical and prison officials struggling with the recognition and balance of diet and food provision in the prison system. This continues today, as prison are caterers responsible for not only the physical, but mental and moral, wellbeing of an expanding prison population, on a decreasing budget,” concludes Dr Charleroy.

dr_jenny_crane.jpg Dr Jennifer Crane is a social and cultural historian of medicine interested in activism and voluntary action, social policy construction, health, expertise, experience, and childhood in twentieth century Britain. She is passionate about using rigorous research to engage with policymakers, practitioners, charities, and members of the public. She is currently a Public Engagement Research Fellow at the University of Warwick working on a Wellcome Trust Senior Investigator Award, The Cultural History of the NHS.

Dr Margaret Charleroy Dr Margaret Charleroy takes an integrative approach to medical history, drawing on questions and methods from population studies and social science history. She is currently a Research Fellow at the University of Warwick working on a Wellcome Trust Senior Investigator Award, Prisoners, Medical Care and Entitlement to Health in England and Ireland 1850-2000. She is examining the management of prisoner’s health, disease, and chronic illness in institutions shaped by imperatives to punish, control, and rehabilitate as well as efforts to improve conditions and prisoner’s wellbeing.

The policy conference about institutional diet and nutrition is funded by Warwick Food GRP and the Centre for the History of Medicine and will take place on 21 April 2017. The event is fully booked and features 35 specially selected speakers and guests discussing the choices around food in institutions, and how and why those decisions might differ in terms of funding, quality, and source in different settings. The workshop will particularly focus on hospitals and prisons.

You can find more on policy conference and the research projects here, or by following @histprisnhealth and @NHSHistory_

6 April 2017

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