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A blueprint for better care?

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With the Conservative Party calling for more single rooms in all hospitals, Helen Mooney examines the pros and cons for nurses and patients

Earlier this year, as part of its future plans for the NHS, the Conservative Party pledged to vastly increase the number of single rooms available to patients in hospital.

Shadow health secretary Andrew Lansley promised that if the Conservatives won the next election, their government would ramp up the number of single rooms dramatically - creating an extra 45,000 by the end of their first term.

Currently single rooms account for just 28% of beds across the NHS. Mr Lansley wants to see this figure rise to 55% in what the party says is a bid to both tackle healthcare-associated infections and improve the patient experience.

In his speech to the Conservatives' annual conference in Birmingham in September, Mr Lansley said Labour had failed to meet targets on providing more single rooms in new hospitals and increasing single-sex accommodation across the NHS.

'No one should be forced to suffer the indignity of staying on a mixed-sex ward,' he stated.

Under the Tory plans, the number of rooms set aside for treating people with HCAIs will be increased by 7%. In a further guarantee, all patients admitted for planned care - excluding children - will have the option of having a single room.

The Tories estimate that about 93,200 single-room beds will be needed, up from the 48,000 now available. On the basis
of recent and existing schemes to create single hospital rooms, the party believes the project will require an annual expenditure of£314m over five years.

Mr Lansley explains that the idea for the greater use of single rooms stemmed from a strategy to control HCAIs. 'The availability of single rooms would help to reduce infection because hospital staff would be able to better isolate infected patients,' he says.

He highlights an Ipsos MORI survey conducted last year which found that 35% of patients would choose a single room on a stay in hospital. 'Achieving the number of beds needed to be able to offer that to these patients is not unreachable,' he emphasises.

The Conservatives are confident that offering single rooms is the right thing to do for patients. Significantly, they are also sure it will be a vote-winner. But what are the benefits of such provision and what are the drawbacks?

The incumbent government also has an aspiration to increase the number of single rooms. Since 2001 the Department of Health's guidance has been that 'the proportion of single rooms in new hospital developments should aim to be 50% but should not fall below 20% and must be higher than the facilities they are replacing'.

A DH spokesperson says: 'Each trust makes an informed choice regarding the appropriate percentage of single bed provision based on practical considerations such as site restrictions and affordability, as well as clinical and operational limitations.'

He adds that the government 'does not consider that an additional target on the NHS is appropriate at this time', which means that hospitals will not be forced to significantly up their single room provision.

Despite evidence from both the US and Scandinavia on the case for single rooms in improving infection control and patient choice and dignity, there is little research on the pros and cons of such provision in the UK.

In 2004 the European Health Property Network (EuHPN) conducted a study on behalf of the DH's NHS Estates department. Jonathan Erskine, executive director of EuHPN and one of the report's authors, says that he remains sceptical as to the evidence for single rooms in helping to reduce infection.

'There might be some benefits for some kinds of healthcare-acquired infections but there have been no real longitudinal studies. However, in terms of privacy and dignity, if you look across Europe this definitely appears to be the direction of travel,' he says.

Howard Catton, head of policy at the RCN, agrees and says that he is also not convinced that every patient would want a single room.

'Although there are undoubtedly some people who will want a single room, I think you will have a significant number, maybe even a majority, who don't want the social isolation. If they are unwell and anxious then being in an environment where there are other people around can actually be important,' he says.

Advantages and disadvantages of single rooms
  • Better sleep
  • Improved contact for families and carers
  • Privacy and dignity for patients
  • More flexibility - rooms can be used by any gender, age or clinical condition
  • Control of infection
  • 24-hour admission without disruption to other patients
  • More personalised contact with patients
  • Medical storage in rooms - decreased chance of prescribing errors and less walking for nurses
  • Patient isolation - patients, especially older people or children, can become isolated when treated in a single room and may become distressed due to a lack of social interaction
  • Single rooms can potentially require higher staffing levels and the hospital's staff skill-mix may also need to be adjusted to accommodate the rooms
  • Single rooms are inherently expensive and there remains no clear evidence as yet as to whether their benefits outweigh the costs

Martin Smits, director of nursing and patient services at Poole Hospital, which has 50% single-room provision, agrees
that isolation is an issue for patients.

'We have had feedback from an increasing proportion of older people who feel that they have a negative effect in terms of isolation and disorientation so we are having a rethink about whether it is right to have single rooms for older people and also for children's services,' he says. 'We are not going to go to all single rooms.'

However Helen Maughan, senior nurse and modern matron at Hexham General Hospital in Northumberland, which has a total of 89 single rooms, is confident that patients there do not experience isolation. 'This has been addressed by having a day room which staff encourage patients to use,' she explains.

Robert Gregory, who works in the facilities and estates department at a strategic health authority, has recently completed an MSc paper on the issue at London South Bank University.

In Single Rooms: The Case for Change he says that current international evidence on single-room usage suggests that there is no 'one size fits all' solution.

'From the available evidence that I have seen there is a strong suggestion that the 'right' percentage of single rooms in
acute hospitals is probably somewhere between 50 to 100%. This will depend upon such variables as clinical specialty, patient acuity, nurse staffing policy, skill-mix and models of care.'

There is also the important question of whether more nurses are needed to work on wards which have single rooms.

Mr Catton says an issue that needs to be investigated is the way single rooms affect the time taken by nurses to go from patient to patient.

'Clinical involvement in the design of single-room wards is absolutely critical-more single rooms may well mean that wards need more staff because it takes longer to get to patients, to treat them and to observe them. All this needs to be factored in because it will lead to increased costs,' he says.

Mr Gregory says there is not yet 'sufficient' evidence available in the UK to be able to draw 'valid and reliable conclusions in terms of the impact on nursing workforce requirements'.

'Some of the limited evidence available suggests that if sufficient attention is paid to redesigning the clinical workforce to deliver this new model of care, [single room] hospitals ought not to cost more in terms of nursing manpower,' he says.

However, he warns that this assumption has yet to be properly tested.

As well as the argument for provision of single rooms in terms of general benefits, the question of their impact on nursing staff has yet to be tested robustly. Some commentators argue that the increase in single rooms will not mean the need for more nursing staff or extra work and time, while others argue the opposite.

Mr Smits is adamant that there is an increased cost. 'They do require more staff; nursing staff need to observe patients in single rooms more often, whereas if patients are on wards they sometimes look after each other,' he says.

He explains that nurses have to walk further during their working day. 'There are cost savings on infection control but there are ongoing costs for staffing levels. I do not advocate full 100% single-room hospitals.'

Mr Lansley, however, believes that nurses' time will actually be saved in the move to single rooms.

'In one hospital I visited where they were using single rooms they had got rid of nursing stations entirely and medication was stored in each room which cut down on walking time. Trusts need to think laterally about this. Nurses need to be at patients' bedsides - technology can be used to help with this,' he says.

And Ms Maughan says that Hexham General Hospital has not found that it has made a 'significant difference in terms of staff numbers'.

'It is about how we manage nursing staff. I think the nursing staff here would probably not go back to the having full Nightingale wards,' she says.

There is a strong argument that single rooms improve infection control. A research paper Evidence-based Healthcare Architecture, published in The Lancet in 2006, suggests that although the full implementation of single-patient room design features in new builds would add 5.3% to initial construction costs, these additional costs would be recouped within one year through improved efficiencies linked to the use of single rooms especially in infection control.

Mr Smits says: 'They do help in the clinical management of the patients and in controlling infection we are able to isolate people in single rooms much more easily.'

And Ms Maughan agrees, saying that single rooms have given the trust better infection control management both in terms of stricter adherence to handwashing and in isolating infected patients.

For the time being, however, the jury seems to be out on the use of single rooms. Pauline Ford, the RCN's nursing adviser for older people and dignity, says that ultimately trusts need to realise that all patients will not want a single room: 'Going forward, there needs to be a mixture of single rooms and small-bay wards.'

Developing an evidence base for single rooms

The Hillingdon Hospital Single Room Pilot Ward is an initiative to develop a 24-bed unit of single bedrooms (see picture) with en-suite facilities at the hospital in Middlesex.

The Department of Health and the National Patient Safety Agency are providing support and funding to pilot the use of single rooms on three wards, each with a different design. The trust will decide which is the most effective, efficient and best value for money and then plans to build a new hospital in this style. The DH intends the pilot to provide a stronger evidence base for the case for single rooms.

The research will compare current ward provision with the pilot wards to evaluate outcomes, including:

  • HCAI reduction;

  • Patient privacy;

  • Sleep quality;

  • Staff workload and walking distances;

  • Patient satisfaction;

  • Staff satisfaction.

The 24-bed pilot ward has been designed in the shape of a 'T' with three separate clusters, each containing eight en-suite bedrooms, each testing one of three room designs. A central support zone, containing reception, kitchen and social areas, links the three clusters.

Marie Batey, Hillingdon Hospital's director of nursing, says that, although the trust is not planning to increase nursing numbers, she does expect that there will be a change in skill-mix.
'We are currently talking with ward staff, cataloguing the skills they have, plotting what skills the wards ought to have and what new roles can be brought in, such as having more healthcare assistants.'

Although Ms Batey admits the move to introduce single wards was a 'leap of faith' due to the lack of a UK evidence base, she says evidence from the US and Scandinavia was enough to persuade the trust of the benefits. She emphasises the trust is 'keeping an open mind' and will be 'receptive' to the opinions of staff and patients.

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