Could oat biscuits help to prop up our crumbling NHS? Might free cuppas alleviate the trouble brewing in the system, or free coffee help to perk up the daily grind for hard-pressed staff?
Two new studies now hint that gratis refreshments could be a perfect blend for docs who feel overworked and undervalued, and would be viewed as a welcome token of appreciation.
More critically perhaps, might the universal provision of free tea and biscuits contribute to alleviating the NHS's current recruitment and retention crisis? That is the novel suggestion of Andrew Tabner and Graham Johnson, emergency medicine consultants at the Royal Derby Hospital, along with colleagues from their hospital library service and the Universities of Plymouth and Nottingham.
Free Hot Drinks More Important to Workers Than Mental Health Support
Writing in the traditionally quirky Christmas edition of the British Medical Journal (BMJ), the researchers explained the background to their novel study: "Office workers have previously identified free hot drinks as a more important workplace benefit than free support for mental health." They also noted that in past office studies "free coffee is associated with improved morale and productivity", and that their new evidence suggests that "complementary hot drinks and biscuits benefit an overworked and highly stressed healthcare workforce".
Their research stemmed from a chance observation of signage in a hospital library requesting that patrons avoid "excessive" consumption of the free hot drinks and biscuits on offer. This led the team to wonder "if some people take more than others" and whether some staff might end up "getting the short end of the teaspoon". This in turn led to an intriguing study that also demonstrated the biscuit-based medical role hierarchy.
Given that "excessive" in this context is open to interpretation, "individuals may apply their own values and judgments", the team said. To determine the crunch question of "how much is too much?", they therefore ran an online survey over 4 weeks to establish the quantities of free refreshments healthcare staff believed represented 'excessive consumption' during a single visit to a hospital or academic library.
Among the 1874 healthcare workers and academics who responded - more than half (51%) of whom were doctors – results showed that respondents would take a mean of 3.32 drinks before considering it excessive. This was slightly higher than the mean number of hot drinks respondents consumed over a typical day when supplying their own refreshments (3.04).
Coffee Narrowly Beat Tea Among Healthcare Staff
Overall, coffee was the drink of choice for just over half (51%) of those completing the survey, while the highest number of acceptable free hot drinks and the excessive biscuit threshold varied:
- Free coffee drinkers would consume more cups per visit than those who preferred free tea (mean 3.44 v 3.29)
- GPs would consume more free hot drinks than staff working in emergency departments (mean 3.67 v 3.22), and indeed more than those working in all other departments or specialties combined (mean 3.67 v 3.28)
- On average respondents regarded more than 2.25 packets of free biscuits as excessive
- Doctors had a slightly higher threshold for acceptable number of biscuit packets taken than non-doctors (mean 2.35 v 2.14)
- Increasing time in role was associated with decreasing proclivity for free victuals (from <2 years: mean 2.89 to > 8 years: mean 2.16)
- 79% of respondents would accept a free doughnut instead of biscuits – and so would 36 of the 88 (41%) respondents who would not take any free biscuits
The team noted that the two respondents with a preference for free hot whisky "represented an important outlier", declaring they would need a mean of eight free drinks before considering it excessive.
Free text responses provided in the survey included the following insights:
- It's not excessive in my opinion if it's spread over the course of 8 hours
- I consider NHS-branded instant coffee hazardous for human consumption
- Anything that takes longer than 1 minute's walk from the ward and isn't barista-quality, is too far for me to justify
- Free biscuits in the library or workplace should be encouraged as part of a balanced diet
- I have absolutely no self control when things are free
- Access to high quality, fully caffeinated coffee should be considered essential to the maintenance of full cognitive function for clinicians in all clinical settings
- Biscuit consumption is directly proportional to how badly the day is going
- Tea and biscuits are the backbone of our businesses, NHS, and country. Without these, the people of the UK would crumble. Let's not squabble over free tea and coffee. Let's embrace this tradition with relish
Staff Have 'Reasonable Self-Imposed Biscuit Threshold'
The team said: "Responses to our survey imply that most staff have a reasonable self-imposed biscuit threshold, and would hardly drink the library dry, so setting restrictions may achieve nothing other than fostering resentment and may even counterintuitively increase consumption."
They added: "Although no formal cost effectiveness evaluation was carried out," and excluding milk costs, given the growing diversity in milk types and wide range of milk volumes used, "back-of-a-biscuit-wrapper calculations" – while sharing the (self-financed) chocolate biscuit that provided the wrapper – enabled the authors to estimate that a centrally funded initiative to provide all NHS staff with three hot drinks daily would cost (about) £32,692,935 annually.
The additional daily provision of two snack sized biscuit packets for every NHS employee might cost £128,188,286 annually. This equates to a total refreshment cost of £160,881,221 per year, they said, equivalent to "a not excessive 0.084% of the NHS budget".
Biscuit Provision Could be Cheaper Than Staff Exodus
Given the estimated £21.7 billion cost of a potential staff exodus, amid current concerns over morale, recruitment, and retention of NHS staff, "the provision of free hot drinks and biscuits could be a worthy and cost effective expense", they concluded.
Dr Ellen Welch, co-chair of the Doctors' Association UK (DAUK) commented to Medscape News UK: "Obviously this story is tongue in cheek, but it is worth highlighting again that the biggest resource the NHS has is its staff. We need to look after the workforce. A cup of tea would be a great start, but focusing on bigger issues such as pay restoration will go a long way to retain staff."
Biscuit Dunking Qualities Explored
Meanwhile Drs Ceri Jones and John Francis from the Noah's Ark Children's Hospital at the University Hospital of Wales in Cardiff reported in the same issue of the BMJ that oat biscuits were the winners of their study of biscuit durability after dunking.
As scientific evidence on best snack practice is lacking, the researchers said, most healthcare workers are "forced to rely on their own experience". While freshly boiled water is crucial to the tea making process, this raises concerns about the risk of oral scalding if busy healthcare workers are tempted to consume a beverage before it reaches a safe temperature.
Their objective was "to identify the time taken to achieve optimal palatability of a cup of tea without risk of harm (oral scalding) using the resources available in a standard hospital staff room, and to identify the best accompanying biscuit for nutritional content, crunchiness, and integrity when dunking".
Their research: 'Direct Uptake of Nutrition and Caffeine Study (DUNCS), a biscuit based comparative study', was conducted in the staff room in the surgery department of a UK hospital, with four different varieties of round, non-chocolate biscuit most commonly found in staff biscuit tins: oat, digestive, rich tea, and shortie. "A standardised cup of tea was determined on the basis of the investigators' preference for colour and palatability, and pragmatic tea making methods," the authors said.
Time to drinkable tea (TTDT) was then recorded. Biscuit dunk times were set at 30 seconds and 60 seconds, representing natural first and second dunks during a tea break, based on the authors' empiric experience over many years of NHS endeavours. Biscuit crunch score were determined by breaking the biscuits in half next to a decibel meter app on a smartphone. Dunk tests involved the "universal dunking grip" with index finger and thumb grip, and moving each biscuit back and forth until the dunked portion broke away and sank (the dunk break point).
Biscuits were scored from 1-4, with penalty points for adverse events such as scalds and breakability. The authors reported that oat biscuits ranked first for both energy content and dunk break point. "Although tea making facilities are accessible to most NHS workers, constraints on time mean that certain compromises must be made when preparing a cup of tea," they said. However "biscuit dunking has a beneficial effect on tea cooling and should be encouraged", while oat biscuits were best at achieving this.
Tea and Biscuits 'Rocket Fuel' for NHS
"Although the choice of hot drinks now available is extensive, a cup of tea remains the preferred choice," they commented. "A healthcare worker can expect to enjoy a cup of tea in less than 10 minutes," they concluded. "When paired with a biscuit, this combination is rocket fuel for the National Health Service."