Overall reported cases of food-borne disease have decreased in recent years. However, reported cases are only the tip of the iceberg, although modelling suggests that actual cases have reduced from some 1.3 million in 2000 to around 765,000 in 2005.
The Food Standards Agency (FSA) monitors food-borne illness in the UK, and its most recent estimations1 for 2007 are 926,000 cases, 18,900 hospitalisations, and 443 deaths. The estimated costs of food-borne illness for England and Wales in 2007 were around £1.5bn. The figures for previous years are shown in the table (below) from the 2008-09 report of the chief scientist from the Food Standards Agency (FSA).
Reducing the incidence of food-borne disease has been a key objective for the FSA for a number of years, and while considerable success has been achieved, it will remain a key focus in the FSA strategy for 2010 to 2015.
The FSA monitors five key bacteria (pathogens) which are responsible for most food-borne illnesses: Salmonella, Campylobacter, E. coli 0157, Listeria monocytogenes, and Clostridium perfringens. Incidence rates have varied with time between them, with significant reductions in cases of Salmonella, since the introduction of layer vaccination, as well as a reduction of 12% in cases of Campylobacter since 2000. The other three pathogens, while lower in actual numbers, have shown upward trends in recent times.
E.Coli 0157
E.coli 0157 has become a particular concern as only a few organisms need to be consumed to cause illness. The young (under five) and the elderly (over 60) are particularly vulnerable. Symptoms can be severe, and infection in the vulnerable groups can lead to kidney failure and sometimes death. E.coli 0157 was responsible for the largest food-poisoning outbreak in the UK in 19962, resulting in the death of 17 elderly people. In 2005, a second large outbreak occurred in South Wales, affecting 44 schools and resulting in the death of a young boy. The outbreak has been the subject of a public inquiry, chaired by professor Hugh Pennington, and the final report was published in March 2009.3 The inquiry report made 24 recommendations which are likely to have a significant impact on the expectations for food safety management and regulatory control in the future.
Listeria monocytogenes
Listeria monocytogenes is similar in that it can cause serious illness and death after consumption of a small number of organisms, particularly in the 60+ age group. In 2008 there were 162 deaths, compared with 68 in 2000. It is an organism that is problematic to control as it is ubiquitous in the environment and strongly associated with ready-to-eat foods.
While cases of Campylobacter infection have gone down, it remains the most common cause of food poisoning. In 2007, there were an estimated 334,000 cases in England and Wales. A recent survey of fresh chicken on retail sale showed that around 65% was contaminated with Campylobacter, making the risk of cross-contamination in storage and preparation significant.4 There are also emerging trends that show, like Listeria, an increase in Campylobacter infection in the 60+ age group. This will increase the urgency of introducing more effective interventions, as demographic shifts create a larger proportion of older people in the population. Although there is significant work taking place to understand the mechanisms of Campylobacter colonisation in chicken, the interactions are complex and an effective reduction strategy, at source, seems to be some way off. As a consequence, an even greater focus on hygiene in food handling is likely to be required if levels of illness are to be reduced.
Safety regulations
The European Food Hygiene Regulations5 place responsibility for the production of safe food on the food business operator.
There are two areas where action is required. First there are minimum standards set for the structure and layout of premises, specific requirements for facilities such as handwash basins, effective cleaning, appropriate temperature control and good personal hygiene, including the reporting of illness. On top of these prerequisites is the requirement for a food safety management system based on the principles of the Hazard Analysis and Critical Control Point system (HACCP).
HACCP
The development of the HACCP was linked to the increase in space travel. Avoidance of food poisoning in space was a key requirement, not least because of the implications of zero gravity on symptoms such as diarrhoea and vomiting. The HACCP food safety management system was developed to identify potential hazards in food production and introduce controls to prevent the hazards being realised. It focuses on the main risks by prioritising the hazards for attention, reducing the time and effort required to manage food safety while maximising effects and cost-effectiveness.
HACCP is now accepted worldwide as the most effective way to reduce the risk of food contamination and subsequent illness in the commercial food production sector. The global standard has been established by the Codex Alimentarius Commission,6 a part of the World Health Organisation (WHO). However, HACCP was developed for the manufacturing sector, where there is little product variation, unlike the situation in the catering sector.
In catering, food production is hugely variable, with menus changing to meet customer requirements, to reflect seasonality, or often as a result of fluctuating food prices. This means that HACCP can be a somewhat difficult fit, often requiring changes in controls and practices as the menu varies. Alongside such variation, the food industry also suffers from challenges such as rapid staff turnover, variable technical expertise and skill, a wide range of languages, and often literacy issues. All these issues make compliance with hygiene controls complicated, and when failures occur, food safety can be compromised and illness may result.
Food safety systems
However, when food safety management systems are properly designed and applied, they provide the best assurance of food safety. The challenges are to make sure that the systems are fit for purpose, problems are identified at the earliest possible stage, and appropriate corrective action taken. The systems need to be flexible to allow adaptation, and staff need to be trained to fully understand and apply the controls.
There are a range of ‘off the peg’ systems – eg, Safer Food Better Business7 – that can be suitable for smaller, less complex food businesses. Although these will still need some adaptation to ensure they properly fit each individual business, the need for technical expertise has mainly been eliminated. For larger, more complex businesses, bespoke systems drawn up by a team of experts are more likely to be required. The FSA’s website (www.food.gov.uk) contains considerable information on HACCP systems. The starting point for safe food production will be the implementation of a food safety management system that is appropriate for the business and proportionate to the food safety risks.
Obstacles
Unfortunately, even when appropriate systems have been developed, the outbreak data shows that failures continue to occur.8
Although it is not always easy to identify where failures happen, according to an FSA survey of UK food premises in 2005,9 the largest percentage of significant risks to public health was to be found in the catering sector. While risks might emerge from a range of areas, analysis suggests that problems are often linked to human factors stemming from ignorance, lack of commitment to the implementation of the controls, or deliberate compliance avoidance.
Such an understanding is helpful when seeking to ensure high standards, whether from the business manager’s position or from the regulatory perspective.
Ignorance can be addressed through appropriate training. However, when considering the best options, it is important to ensure that training meets the business need and the candidate need, and is of a high standard. While there will be a number of ways to achieve this, it will be important to ensure that any training is delivered by people who understand the subject, understand the context of application, and are skilled in delivering training. A failure to do this is unlikely to produce a good return or the investment – ie, appropriately skilled staff. One way of ensuring high training standards will be through use of Ofqual-recognised providers.
While training can address issues of ignorance, it should never be seen as a one-off. Continual reinforcement and updating will be required, and application of knowledge into practice will be essential. Good management supervision will be important, but the real need is to make good practice the norm, so that it is automatic.
In recent times, especially due to the government’s wish to reduce levels of smoking and improve diets, there has been much consideration of reasons why knowledge is not always translated into practice. People know that smoking is bad for them and that eating five portions of fruit or vegetables a day improves health, yet change is slow and limited. While government considerations have primarily been focused on lifestyle choices, there is growing recognition that a better understanding of behavioural sciences can lead to better practices in the workplace.
For some time, a ‘behaviour-shaping’ approach has been seen in the area of health and safety, where the development of a safety culture has been encouraged. Such a culture commits the business and staff to good health and safety practice, aimed at better OH and accident reduction. It has been shown to deliver benefits for all.
In the past few years, a more strategic approach to ‘behaviour shaping’ has been adopted by the government. In particular, this has led to the establishment of the National Social Marketing Centre (NSMC), sponsored by the Department of Health, to develop capacity and capability in the use of social marketing – a technique that has been used worldwide to achieve and sustain behaviour goals. Social marketing uses many of the concepts of private sector marketing to ‘sell’ behaviours for individual or societal good, rather than for profit.
The social marketing approach is now being widely applied in a range of government-sponsored initiatives, from national to local level. As it is more widely used, its potential for embedding specific behaviours is being recognised beyond the public sector. As a consequence, National Occupational Standards have been developed by the Marketing and Sales Standards Setting Body in partnership with the NSMC.
Food safety culture
The core concept of social marketing is developing ‘insight’ – ie, a focus on understanding why individuals or groups behave in the way that they do, and what would influence them to change. This approach recognises that in making any decision there is always a choice to be made, and it seeks to understand the factors that can act as motivators or blockers. Such an understanding creates the potential to positively influence choice and develop ‘an offer you can’t refuse’. This might mean making it the ‘easy’ choice, the ‘only acceptable choice for the group’, or perhaps ‘the rewarding choice’. This can assist in designing systems, procedures and practices aimed at ensuring safe food is produced in the workplace.
However, there may be some instances where education, support and design of procedures still do not deliver the required behaviours, so there must always be an option to ‘enforce’ requirements. Hopefully, in most cases, this would be the exception rather than the rule.
Reducing food-borne illness will always be a challenge but there are well-recognised ways to address the issues. There needs to be an organisational commitment to the task from the top of the organisation, where decisions are made about costs and resources, through the varying levels of management and supervision, to support and enable good systems and practice, to the food handlers themselves. This might be seen as the development of a good food safety culture.
There needs to be a commitment to good training to allow appropriate systems to be set up and implemented, change to be recognised and addressed, and action enabled to ensure safety is paramount if things go wrong. Safe food really is better business, and if things get out of control the consequences can be significant, not only through (temporary) loss of key personnel, but also through the potential loss of business and reputation.
Human factors will always play a part in the success or failure of a business and an approach that seeks to understand behaviours when setting up systems can pay significant dividends. Providing safe food in the workplace is important to everyone in the business, whether the business itself is a commercial food producer or food is provided to support effective business operation.
Jenny Morris is a chartered environmental health practitioner and principal policy officer at the Chartered Institute of Environmental Health.
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References
Food Standards Agency. Annual Report of the Chief Scientist 2008/09 www.food.gov.uk
The Scottish Office. Report on the circumstances leading to the 1996 outbreak of infection with E.coli O157 in Central Scotland, the implications for food safety and the lessons to be learned.
The Public Inquiry into the September 2005 Outbreak of E. coli O157 in South Wales.
A UK survey of Campylobacter and Salmonella contamination of fresh chicken at retail sale. http://www.food.gov.uk/multimedia/pdfs/fsis0409.pdf
Regulation 852/2004 on the Hygiene of foodstuffs.
Food Standards Agency. Safer Food Better Business. www.food.gov.uk
Health Protection Agency. Food borne outbreak surveillance and risk assessment.
Food Standards Agency. UK Survey of hygiene standards in food premises 2005
