While getting a one bed room on the NHS is a dream come true for many patients, for staff moving to single room acute care delivery it is an opportunity to break away from old working methods. Alison Moore reports

In 2011 Maidstone and Tunbridge Wells trust will replace its ageing Pembury Hospital with the NHS's first all single room acute hospital. The new site will provide all patients - except those in the special care baby unit - with their own ensuite room.

With Wales, Scotland and Northern Ireland also looking at dramatic increases in the percentage of single rooms, the day of the single room hospital has arrived - albeit at the tail end of one of the most significant hospital building programmes the NHS has ever seen. The Conservatives are so keen on the concept they have pledged to double the number of single rooms in its first term, if elected.

The effect of this move is more profound than it might initially appear. National Patient Safety Agency design lead Patricia Young says: "You can't just look at single rooms in isolation. You have to look at how care is delivered - it does change working methods."

Fans of single rooms point to the benefits of dignity and privacy, and their flexibility. Their doors usually have blinds into any corridor, so patients can "withdraw" into their own space, if appropriate; bathrooms are also usually ensuite.

Single rooms also overcome many of the difficulties faced by trusts in eliminating mixed sex wards or bays. Patients are more likely to remain in the same room throughout their stay - they will not need to be moved because a bay needs to "change sex" or because they need to be isolated. Liz King, project clinician for a planned all single room hospital in Ebbw Vale, says this could be safer for patients - transfer of beds is closely linked to medical incidents.

Patients should also get more control over their personal space, which may change the balance of power between clinicians and patients.

"We are talking about nurses always knocking before they go in and patients having control of the blind into the corridor," says Ms King.

The Patients Association welcomes the trend towards more single rooms but says problems with mixed sex bathrooms can remain, unless the rooms are ensuite - a move that is relatively easy with new builds but may be harder if existing facilities are being converted.

Single rooms may also reduce the chances of catching healthcare acquired infections - although this will also depend on staff behaviour. While one patient per room will reduce the chances of other patients catching airborne infections, transmission of other pathogens is likely to depend on how well other infection control methods are followed.

"It's not a substitute for clinical staff washing their hands," points out Ms Young.

Good design may help. The location of the wash basin, for example, can encourage or discourage hand washing among staff and visitors.

"If you have to walk right over to the window wall, then nine out of 10 people won't do it," says Ms Young. "You will have already walked past the reason why you have come into the room - the patient."

Designed for safety

Cleaning regimes - and adequate time to clean between patients - will be just as important in single rooms as they are in larger wards.

There is also the opportunity to standardise room design and to "design in" safety. Staff learn where equipment is in the standard design and may be less likely to make mistakes.

"In a stressful or panic situation, if everything is the same way around then you automatically know where everything is. It helps eliminate something else that may cause people to make a mistake," adds Ms Young. And new builds allow safety features such as handrails between bath and bed to be designed in from the start.

So what are the drawbacks? A single room hospital may be more expensive to build - although Health Estates and Facilities Management Association chair Kevin Oxley argues that such a move may be investing to save.

Making the new Pembury Hospital, which is being built through a private finance initiative deal, all single room, added around 1.8 per cent to the overall cost of the project, according to new hospital development director Graham Goddard. Current design guidance says beds should be
3.6 metres apart, so moving to single rooms does not necessarily add much to the floor space needed. But there are additional costs, such as far more sanitary ware being needed for ensuites.

Mr Oxley says there can be some savings on the number of treatment rooms as more procedures can be carried out in the patient's room. His own trust, North Tees and Hartlepool foundation trust, is planning a 100 per cent single room hospital but the move has only added about 4 per cent to its floor area.

And a working party comprising clinicians, managers and civil servants looking at introducing more single rooms in Scotland put a figure on the additional capital cost of 100 per cent single rooms of 2-4 per cent: substantial but not crippling.

But adapting old hospitals may be more expensive. It may be difficult to create more single rooms without losing beds - although the ongoing shift of work into the community and shorter hospital stays could mean bed reductions would be possible. However, hospital structure may make conversion expensive or even impossible in some areas.

There may also be some ongoing costs in having more single rooms - the Scottish working party suggested a ballpark figure of 2.5 per cent additional cost, which could be more in refurbished buildings. Some of these will be cleaning costs (all those extra toilets to clean) but some will be related to the number of staff needed and the skill mix of those staff.

But there may also be operational savings that could help to offset this. Mr Goddard points to the hidden costs of closing wards or bays because of outbreaks of infections: not only through the cost of carrying out deep cleaning but also of having those beds out of action. With the single room system, only one room and bed need to be taken out of service for cleaning and other patients should be unaffected.

But single rooms also require a different approach to nursing. Patients Association chair Roswyn Hakesley-Brown says it has concerns about patients being out of easy sight of nurses. "They require staff to go around routinely and check people are all right and have an effective call system in place - and that staff respond to that," she says.

Nurses' concerns centre on how patients can be monitored - especially if they are out of sight of the nursing team - and whether the design of the room and ward will aid nurses, or lead to them spending more time running around in and out of rooms than providing care for patients. Royal College of Nursing head of policy Howard Catton describes single rooms as needing to have a "work around rather than run around" design.

No nurses' station

Many designs for wards made up of single rooms do away with the old idea of a nurses' station, aiming instead to keep staff closer to the patient. This may involve nurses writing up notes in the patient's room, accessing computer points in the corridor outside, or having "decentralised" nursing stations serving small clusters of rooms.

He adds there are some concerns about staff being able to spot the early signs of decline in patients, and among those patients who feel reassured when they are within sight of staff all the time.

Mr Goddard says the biggest challenge is not in getting a hospital built but in the organisational development programme that needs to accompany it. Some staff will be moving from longstanding Nightingale wards in the current Pembury Hospital to a radically different environment with a more high-tech approach, for example.

It has been modelled around care being delivered close to the patient, rather than patients moving around the hospital. In some cases this will be in their room, but the design adopted also has on-ward therapy rooms, where physiotherapy and other rehabilitation can take place.

"Nurses have to change the way they work. They have to be able to use the new technology and we believe that there are also some additional staff costs. We may or may not need more staff," he says.

"The work we did said that if you compare a 100 per cent single bed environment with a bay environment you probably need the same number of staff but a richer staff mix."

Bidders for the private finance initiative deal mocked up rooms so that staff and potential patients could get a feel for how they would work. Mr Catton says clinical involvement in design is crucial in minimising possible problems.

There are also concerns patients will suffer from the isolation of single rooms - especially those who are in for longer spells, such as many elderly patients, who may prefer the company that comes with having a bed in a bay.

Evidence on this is mixed - research carried out in Scotland suggested only two out of five patients had a clear preference for single rooms while around a quarter would prefer to be in small bays.

But when nurses in Pembury asked parents of young patients whether they would prefer to have a communal ward, they preferred the option of single rooms, with some communal areas to play in.

Ms Hakesley-Brown agrees some patients prefer company - although this can depend on the mix. Communal areas can help, but some patients, especially those with a drip or catheter, cannot access these. Some new build schemes are looking at dining areas where patients sit together. As well as being sociable, this can encourage them to eat more, adds Ms King.

Mr Catton suggests the optimal position is to have a mix of single rooms and bays, which might allow patients to exercise some choice - and allow staff to put patients who would benefit from company together. The number of single rooms needs to increase, he says, but he is reluctant to see them as a panacea.

So why should a trust put the extra money - and inevitable hassle - into moving to a single room environment? The short answer is patient choice. "We believe this is going to be the hospital of choice, that people will want to exercise choice and come to us," says Mr Goddard.

Single rooms: the UK picture

Guidance says that new hospitals in England should aim for 50 per cent single rooms, but that provision may fall below this as long as the percentage is higher than in the hospitals being replaced and is not less than 20 per cent. The Department of Health says there are 31 per cent single rooms across the NHS, compared with 23 per cent five years ago.

Wales will have the first all single room NHS facility when the Aneurin Bevan hospital opens in Ebbw Vale in 2010. Its 107 rooms will all be ensuite. A second hospital planned to open the following year in Caerphilly will also have all single rooms - but the Welsh Assembly government says "local need" should determine the design of new hospitals.

Northern Ireland is committed to new builds being planned on the basis of 100 per cent single rooms unless there are special circumstances - but the Northern Ireland government says refurbishments can have a lower proportion if 100 per cent is not achievable or is disproportionately expensive. A new hospital planned for Enniskillen will have 315 single bed rooms when it opens in 2011-12.

The Scottish government has accepted a report calling for a presumption in favour of all single rooms (with exceptions individually approved) in new build hospitals. Refurbishments should aim for the maximum number of single rooms with a minimum of 50 per cent.

Trials at Hillingdon Hospital trust

London's Hillingdon Hospital trust is trialling three types of single rooms in a pilot looking at single rooms' impact on everything from healthcare acquired infections to patient sleep.

The 24 beds in a modular building are just coming into use for oncology and gastroenterology patients.

Some have more natural light as the ensuite is set against an interior wall; others have the ensuite against the outside wall, which improves vision into the room from the corridor but restricts natural light. The third set of rooms is a mixture of the two, but with a wider corridor to provide a communal area with chairs and coffee tables where patients can socialise.

Some rooms have a reclining chair allowing a relative to stay overnight if appropriate.

Trust director of nursing Marie Batey says some patients are likely to have experience of being nursed in a more standard ward and in the new model, allowing comparisons of their experience.

Another innovation is that nursing stations have been abolished.

"We recognise nurses migrate towards them and the whole point of this is to be near to patient care. We have the nurses close to or at the bedside," says Ms Batey.

The impact of design on working practices is immense. Some drugs will be mixed at the bedside, for example, which may reduce medication errors.

Handovers will no longer be done centrally. Instead, there will be a brief meeting of all staff followed by individual handovers involving staff caring for each patient in their room, allowing the patient to contribute and - crucially - say how they are feeling.

There could also be improvements to the working lives of staff. Many nurses spend a great deal of time gathering supplies, whereas the design of the new ward should ensure adequate supplies are close at hand.

But relations between staff and patients could also be subtly affected: does the room become the patient's private area? Will staff feel the need to knock or ask permission to enter?

"It will be interesting to see how nurses and patients have a dialogue on this," says Ms Batey. "It's not necessarily about asking permission, it may be about establishing boundaries."

She hopes that if the pilot is successful single rooms could be used more widely in the hospital. Patient and staff experience will be assessed over the next year. But Ms Batey and many of her staff - and those patients and public who have seen the module - are excited.

"Most people were convinced we would be using this [only] for private patients," she says.

HSJ's Rebuilding the NHS conference is in London on 10-11 March, www.hsj-buildings.com