Scottish Government

THE EVIDENCE BASE FOR CHANGE

Census of Current Provision of Single Room Accommodation

This census was undertaken with the assistance of ISD based on a questionnaire issued to Health Boards. It is not intended to be a definitive statement on the level of single room accommodation within the NHSScotland estate but to give an indication of the level of such provision.

Figure 1: The level of provision of single room accommodation by NHSScotland Board at the time of the survey in November/December 2006.

A fuller breakdown of the current numbers of single rooms in Scottish hospitals is provided at Annex 4.

The key points which emerged from this census were:

• Single room provision was clustered between 22%-30%.
• 50% of current single rooms have a WC, WHB and shower.
• 22% of single rooms currently have no en-suite facilities.
• Of all staffed beds:
  • 10% are allocated to single rooms in acute medicine and surgery
  • 9% are allocated to single rooms in mental health
  • 4% are allocated to single rooms in geriatric medicine.

Recognising that this census represented a snapshot in time largely influenced by the historic, incremental approach to hospital provision in Scotland, the Group sought a perspective on the current trends by considering a cross-section of comparatively recent Scottish projects. These projects had either been completed recently or were well advanced in the project planning stage. Thirteen projects were analysed which showed a wide range of single room provision from 20% to 98%. Within the acute sector the range was much narrower being 23% to 52%. This exercise found there to be a distinct trend towards a higher proportion of single rooms in these projects. This reflected the current trend across all healthcare systems.

Since that census was conducted there have been examples of single room provision being planned at significantly higher percentages than we have seen before in Scotland. These examples include the proposal to complete the new South Glasgow Hospitals project, where 1109 beds will be developed in the new adult hospital. At the Outline Business Case stage of this project, the beds were planned to be accommodated within single rooms with en-suite facilities. The children's hospital which is also being developed on the Southern General Hospital Campus has a planned single room provision of 57%.

Literature Review

Much of the focus of the Group's early discussions centred around the control of infection, where the view generally held was that a high percentage of single room provision would help manage Healthcare Associated Infections ( HAIs). It was recognised that the scientific evidence base supporting single room provision and the incidence of HAI is not robust. The Group concluded that it would be appropriate as an initial task to undertake a high level review of the literature which would examine any additional evidence not included in EuHPN report. This work was taken forward by two Infection Control Nurses from NHS Scotland on behalf of the Steering Group. This high level literature review not only considered the literature around the control of infection but also reviewed the literature around healthcare associated infections, patient environment, the impact on staffing ratios and financial impact.

This element of the steering group's work concluded that the review undertaken by Dowdeswell et al (2004) provided the most comprehensive overview of the available literature at that time, further supporting the EuHPN Report conclusion that there is insufficient available evidence to determine a scientifically based estimate of the optimum ratio of single room provision.

This literature review also highlighted some significant gaps in previous papers, particularly the systematic failure to provide a definition for a single room. This was perceived as an important factor as it would appear that patients' experiences may differ depending on the style and facilities provided in a single room.

It was evident from the literature review that there remains a lack of reliable scientific evidence on the benefits, particularly from an infection control perspective, of single room provision. There is also a lack of evidence around the actual level of single room provision which should be provided. The review also highlighted that there is an increased public expectation that our healthcare facilities should provide single room accommodation but recognised that existing evidence was inconclusive and that therefore there is a need for ongoing research on the impact on treatment, care and recovery in single and multi-bed rooms. The view of the Steering Group is that it is intuitively convincing that the greater use of single rooms, the better the chances of preventing and controlling infection.

The full text of the Literature Review is contained at Annex 5.

Nurse Staffing Report

This Report was based on a survey of the senior nurses and midwives from all NHSScotland Health Boards carried out from July to September 2006 with a further opportunity afforded to all Nurse Directors to comment and contribute through structured discussion in the early part of 2007.

It was evident from the response from senior nurses and midwives that there was a considerable level of awareness of proposals to increase the provision of single rooms in new healthcare facilities. The nursing community considered whether there was a need to preserve some multi-occupancy rooms in some patient care areas, i.e. where patients are more dependent on nursing care, where patient mobility is reduced or where greater levels of supervision are required. It was recognised that such patients can feel insecure and isolated and are often reassured by nurse visibility. The report concluded that this could be achieved by adequate staffing levels and appropriate design and the consensus within the Report was that 100% single room accommodation should be the starting point with risk assessment processes used to identify in which cases this level of provision shouldn't apply for particular patient groups.

The Report also concluded that there was a consensus amongst Nurse Directors that single room accommodation in itself should not increase the number of nurses required to care for patients, although recognising that where appropriate staffing levels are already compromised, the position could be exacerbated by a move to 100% single room accommodation. This Report made a number of recommendations:

• Development of assessment processes to identify why patients should not be cared for in single rooms.
• A review of housekeeping and care assistant roles which would support the domestic management of single rooms.
• Requirement for adequate social areas and planned activities spaces to be built into care plans to encourage mobility out of single rooms and reduce loneliness.
• A requirement for good planning of storage space in single rooms and within ward areas.
• Good planning and investment in technology to support the care of patients in single rooms.
• Adequately designed and properly tested nurse staffing levels.
• More evidence-based UK research into the benefits and risks of single room accommodation.

The full text of the Nurse Staffing Report is contained at Annex 6

Attitude Surveys

Golden Jubilee National Hospital Survey

A survey of patients who had experienced a single room environment was undertaken in 2006 at the Golden Jubilee National Hospital. These were patients from across Scotland whose ages were in the 60 - 80 years range and who were undergoing surgery for primarily cardiac and orthopaedic conditions. 57 patients took part in the survey and analysis of their responses found that 81% had experience of both multi-bed and single room accommodation in hospitals. Furthermore, 93% of the patients expressed a preference to stay in single room accommodation for any future overnight stay in hospital.

Further detail on this survey is contained in the Nurse Staffing Report in Annex 6

Public Attitude Survey

One of the conclusions of the Peer Review Report was to highlight the need to understand the social and cultural attitudes of potential users of the Scottish healthcare system before any general conclusions could be made about an appropriate level of single room provision. The Steering Group recognised the lack of information about the needs and wants of the Scottish population in relation to this issue and therefore commissioned a public attitude survey of a representative sample of Scotland's population.

The specific research objectives were:

• To assess people's preference to be accommodated in single versus multiple occupancy hospital accommodation.
• To explore people's opinions on which groups should/should not be accommodated in single occupancy hospital accommodation.
• To examine the perceived benefits and risks associated with accommodating people in single or multiple occupancy accommodation.
• To examine the degree to which people are aware of the nature of hospital accommodation currently provided by NHS Scotland.

Between 23 and 28 November 2008, a representative sample of 990 adults aged 16 and over were interviewed in over 43 sampling points throughout Scotland. The views expressed in this report are the views of the research organisation and do not necessarily represent those of the Department or Scottish Ministers (now Health Directorate or Scottish Ministers).

The principal conclusions of the survey team were:

• The majority of respondents had some experience of hospitals in the last five years: either as in-patients (37%), visiting friends or relatives (76%), or in the course of their work (8%). In total, almost a quarter (24%) had personally stayed in a smaller multi bed ward (up to six people) as an in-patient, 13% in a single room, and 7% in a large ward (7+ people). Regarding visiting in-patients: 50% had visited friends or relatives in a smaller multi-bed ward, 27% in a single room, and 17% in a larger multi-bed ward. Linked to this, the majority of the sample (60%) felt that the smaller multi-bed wards were most common, followed by larger multi-bed wards (32%) and single rooms (5%).
• If admitted as an in-patient, the most frequently preferred type of accommodation would be a single room (41%), followed by people saying that they didn't mind (27%). Smaller multi-bed wards (22%) and larger multi-bed wards (3%) were considered less desirable. Looking at the sample based on their preferences, patterns of response by those who "don't mind" and those who prefer smaller multi-bedded wards were similar throughout.

Figure 2: Type of accommodation preferred if admitted to hospital
Base: All respondents (990)

• Previous experience of types of hospital accommodation makes little difference to future preferences, although those who have stayed in or visited a smaller multi-bed ward were slightly more likely to prefer to stay in one, should they be an in-patient in the future. Preference for single room accommodation increased with social grade (30% of those in the DE group increasing to 58% of ABs). The younger age groups were also more likely to prefer this type of accommodation (49% of those aged 16-34 falling to 28% of those aged 65 and over).
• The perceived advantages of staying in a single room were more privacy (75%) and that it would be less noisy (34%); both more likely to be cited by those who would prefer to stay in a single room. The major disadvantage given was that you would feel isolated or lack company (69%): in particular from those who would prefer to stay in a multi-bed ward. In conjunction with this, the major advantage of a multi-bed ward given was that people feel less isolated and have more company (78%), and the stated disadvantages were that people have less privacy (56%) and it is more noisy (48%). Those who preferred single rooms were more likely to see disadvantages of multi-bed rooms, and those who preferred multi-bed rooms were more likely to see disadvantages of single rooms.
• The main groups that the sample felt should stay in a single room were those who are seriously ill (57%), those who are dying (27%), and people who have an infectious disease (24%). Only 11% felt that everyone should stay in a single room. The main groups that the sample felt should stay in a multi-bed room were people who were in hospital for a routine procedure (27%) and everyone (26%).
• Despite the fact that the largest proportion of respondents would prefer to stay in single room accommodation, there was an acceptance that resources would not allow everybody to do so. There was little agreement overall about what sorts of groups should stay in single versus multiple accommodation, suggesting that people do not have very strong feelings on this topic. Although they did tend to feel that the judgement should be made based on severity of illness, this could reflect the pattern of allocation they have personally observed in the NHS today.

The full text of the Public Attitude Survey is contained at Annex 7.

Financial Impact

The financial impact of increasing the provision of single room accommodation can be split into two broad categories, namely capital and revenue costs.

Capital Costs

A study was undertaken for NHSScotland prior to the Peer Review Event to explore the additional capital and revenue costs which would be incurred by increasing the space around hospital beds. This study did not consider the impact of a higher provision of single rooms but the impact of increased bed spacing was deemed to be a reasonable proxy as far as the impact of capital costs is concerned, as these are directly attributable to the footprint of the building. It was recognised that the design of ward accommodation would have a significant effect on this and much activity is now taking place across the UK and Europe on different models of ward design incorporating single rooms with en-suite facilities. This paper does not consider these in detail but it is important to acknowledge that an increased focus on appropriate design can have a significant impact on the subsequent capital (and revenue) costs. The study based on increased bed spacing identified capital cost, increases which at a hospital level range from approximately 0.5% to 3% for large hospitals and approximately 1% to 5.5% for small hospitals.

The Group also benefited from a Northern Ireland study which supported the general conclusions of the Atkins Report. The Northern Ireland study found that the additional capital cost of increasing the ratio of single rooms from 50% provision (the then current policy position in Northern Ireland) to 100% would be between 2% and 4% dependent on the size of the hospital in terms of bed numbers. The higher percentage increase being for the larger hospital.

Although there is inevitably an increase in the capital cost of a hospital associated with an increased level of single room provision, it is important to bear in mind that the investment must be measured against the added health benefits which result. As noted by the European Health Property Network:

"lifecycle costing should involve an assessment of a building's contribution to healthcare over its lifetime by balancing questions of short-term affordability with future needs for adaptability and longer-term functional effectiveness".

Revenue Costs

The evidence from the Atkins Report which looked at the revenue cost of bed spacing recognised this relationship to be less directly relevant when considering the revenue cost impact from a higher level of single room provision. What was considered crucial was the additional floor area needed and the supply of the services contained in the additional en-suite facilities, which will need to be maintained and cleaned. It is likely, therefore that this report has understated the increase in revenue costs which can be anticipated from a higher level of single room provision. However it is recognised in all studies into additional revenue costs that as a minimum there will be an increase proportionate to the increased floor area in the ongoing cost of heat, light, power, cleaning, maintenance etc.

The Atkins Report, based on increased bed spacing, identified the increased revenue costs to be around 0.5% to 1.5%, but the Steering Group recognises that this assessment is likely to have understated the full impact from additional single room accommodation, in particular, on facilities management/capital charge costs.

As with capital costs the Group were able to draw on the outcomes of studies undertaken in Northern Ireland which suggested that the increased revenue costs associated with moving from a position of 50% provision of single rooms to 100% provision would be around 2% to 2.75%, dependent on the number of beds with the greater bed number increases reflecting larger hospitals.

Health Facilities Scotland considered the issues raised by increasing the provision of single rooms. This exercise involving HFS's major stakeholders raised a significant number of issues, including:

• Individual room controls would add marginally to the cost but may mean better environmental conditions for the patient.
• Sanitary facilities will be more numerous increasing both installation and maintenance costs.
• With proper design the patient environment is likely to be enhanced with better natural light, views, lower ambient noise levels and some degree of individual control of room conditions.
• Potential increase of general utility costs as a result of increased maintenance lighting, ventilation and facilities.

The paper noted that any additional costs arising from areas of concern such as those detailed above can be viewed as marginal. This paper also looked at examples published by the Department of Health which identify the cost of additional space, cleaning and nursing could range from 0.5% to 1.5% of a typical revenue budget.

The overall view of Health Facilities Scotland was that in developing a new healthcare facility, the percentage of single rooms chosen could have less impact on construction and maintenance costs than other decisions routinely made in the design and planning process. The HFS Group also believed there were grounds for optimism in that individual control of environmental conditions would bring a significant improvement in patient satisfaction.

Having considered all relevant information (including the Atkins Report; the Northern Ireland Study; the examples produced by the Department Of Health; the assessment carried out by Health Facilities Scotland and the Nurse Staffing Report) the Group has concluded that the potential revenue impact from increased single room provision/bed spacing could be up to 2.5% of overall running costs. This assessment assumes that any clinical staffing implications will be off-set by savings from reductions in patient transfers, reduced ward closures and better use of patient accommodation.

For refurbishment options where accommodation has to be extended due to physical space constraints/maintain bed capacity, the Group recognised that the revenue implications are likely to be considerably higher than the overall average of 2.5% of hospital running costs. The NHS Body concerned will need to determine the extent of the revenue implications as part of the business case justification on how best to address local needs. In reaching a decision in each particular project the dimensions of existing multi-bed areas will be significant as it may not be possible to conveniently alter the space to take additional en-suite facilities and provide the necessary space recommended around the bed. Where the number of beds for a given patient group cannot be accommodated within the physical space available and it is appropriate for that patient group to be accommodated in single rooms it may mean the use of additional space and this could have a significant financial impact.

The Group also recognised that other benefits may be realised. Experience from elsewhere in Europe, America and Canada tends to support the case that increased provision of single room accommodation will enable increased patient turnover as a result of improved bed utilisation, reduced length of stay and improved infection control. An enhanced level of single room could enable patient throughput to increase by a level greater than the increase in running costs thereby offering the possibility of improved overall hospital performance.

The full text of the Health Facilities Scotland paper is contained at Annex 8.