What initiated the concern
Firstly, that the 100% single room policy emerged apparently without and public or parliamentary discussion. Secondly that neither NHS Dumfries and Galloway nor the Scottish Health Council conveyed to the Scottish Government the concerns that many hospital staff, members of the public and others have about the policy. Thirdly, that the evidence on which the policy is based has been interpreted ‘selectively’ and ignores several important issues.
Why it is important
The policy emerged after consideration of “available literature, a public attitude survey, a nurse staffing report, a financial impact study, a three-stage Expert consultation, the views of Clinical Specialty Advisors, and a review by the Chief Medical Officer taking into account the impact of increasing multidisciplinary team-working and anticipated new ways of delivering care.” The benefits of the policy are said to include “improved infection control, dignity and patient satisfaction; reduced lengths of stay; flexibility in the use of accommodation; families able to be more involved in care; and reduced medical errors. However, evidence that we have collated from various sources suggests that:
The statement by the Scottish Government’ (reported by Julie-Anne Barnes, Scottish Daily Mail, 17/08/12) that “patient feedback has consistently shown a desire for single rooms” is incorrect. In its own survey http://www.scotland.gov.uk/Publications/2008/12/04160144/9
http://www.scotland.gov.uk/Resource/Doc/253500/0075129.pdf
of 990 patients across Scotland only 41% expressed a preference for a single room, 25% preferred to share and 34% had no preference or view. And a survey in Dumfries and Galloway Royal Infirmary showed that 70% of patients in four-bedded bays and 40% of patients in single rooms would prefer shared accommodation if re-admitted: http://smj.rsmjournals.com/content/54/2/5.abstract
Health Protection Scotland knows of no study showing that single rooms per se reduce hospital acquired infection: only that an infection control policy that includes single rooms reduces the incidence of MRSA – hand-washing being the key. A 50/50% mix of single rooms and four-bed bays is sufficient to isolate patients during outbreaks of infections.
There is no evidence that being in a single room improves recovery or reduces length of stay. On the contrary the recovery and/or wellbeing of many patients improves in the company of others, particularly in specialties such as rehabilitation and palliative care. Patents in recovery and in rehabilitation often describe being in a single room as “solitary confinement”, feeling isolated, reducing motivation, hindering progress towards independence, and increasing their stay in hospital. In the event of a 100% single room policy about 25% of the patients admitted will be confined to their single room for over a week, 10% for over a fortnight and 5% for over three weeks.
Areas for ‘socialisation’ are to be provided. But many patients would need help to reach these areas and some would feel too ill to do so; and some patients need hoisting for transfers - time consuming and hardly ‘dignified’. Considerably more nursing, cleaning and other staff are required for single rooms, and very few nurses appear to support the 100% single room policy.
Many patients in hospital are comforted by looking out’ for one another, knowing that someone will buzz for help if anything goes wrong, and do their best to make sure that needs for food, water, good care and toileting are met. For many their main source of companionship and diversion from their problems is those they share a room with. These patients will have taken ‘dignity’ into account when stating their preference to share. There is little ‘dignity’ in being isolated in a room on your own, in being ‘hoisted’, or having to ask for help every time that you seek companionship.
In a single room cardiac arrest is likely to be unnoticed for considerably longer, and possibly until too late - unless there is continuous ECG monitoring, which is surely impractical. Electronic monitoring is no substitute for personal communication. What would be the situation in law if just one of the many patients who prefer the friendship and safely of company dies as a result of a cardiac arrest in a single room?
Conclusion
The debate is not about all single rooms or all shared accommodation. Around 50% single rooms appears adequate to isolate sick patients and patients with hospital acquired infections, whilst at the same time meeting the needs of those who express a preference (or whose circumstances require them) to be on their own. Having 100% single rooms removes all possibility of internal structural modifications that may be needed in response to changes in the delivery of medical care, and will make it difficult or impossible to cope with extra patients in a major emergency. A 50/50% mix of single rooms and 4- bed bays with adequate toilets would provide choice for everyone, with no downside and save 15-20% to building and running costs.
Suggested actions
• Retraction of the policy in favour of one recommending a mix of 50% single rooms in new-build hospitals and 50% multi-bedded bays with adequate toilet facilities, or
• Setting up an Independent Scrutiny Panel to assess all the evidence available and make recommendations accordingly.