Three senior personnel at London-headquartered public service consultants, The PSC, Smriti Singh, David Chappell, and Sesha Nicholson-Lailey, discuss the implications of the New Hospital Programme (NHP)’s announcement that all new hospitals in England must include 100% single patient rooms. They explore such rooms’ history, their potential benefits and challenges, and the importance of involving clinicians in the planning stage, and discuss developing new ways of working, and leveraging digital solutions, ‘to fully realise single patient rooms’ benefits, and mitigate their challenges’.
The case for and against the mass adoption of single patient rooms has long been discussed in healthcare. Despite this debate, the shift to single patient rooms has long been on the NHS’s agenda,1 and on the agenda of the Conservative Party, for over a decade.2 In spite of the political position, Trusts in England have, until now, been allowed to decide the number of single patient rooms in new-builds. As a result, uptake has varied, and while other parts of the UK have opened a number of hospitals with all single patient rooms,3 England currently only has two. The first hospital in England to provide only single patient rooms, in Tunbridge Wells, and the second, the Royal Liverpool Hospital, opened their doors in 2011,4 and October 2022, respectively.5,6
Threat from airborne infection
Following the COVID-19 pandemic, the view in England has changed. The pandemic meant that NHS health leaders had to consider the threat from airborne infection at a serious level and scale. In October 2021, NHS England and NHS Improvement’s National Medical director, Stephen Powis, signalled that single patient rooms should be the ‘default’ for inpatients in English hospitals.7 Following this, leaders of the NHP announced at the December 2022 NHP Industry Day that all new hospitals in England would have 100% single patient rooms.8
Despite this change in policy on single patient rooms, there is an incomplete picture of their impact, with the significance and evidence of their benefits still hotly debated across the sector. Speaking at the NHP Industry Day, the programme’s leaders said that there was no ‘empirical scientific evidence’ to justify the announcement.8
While evidence in the UK is limited, a literature review of US studies, where single patient rooms are a regulatory requirement, found that the advantages seem to outweigh the potential disadvantages.9 We will consider what the potential benefits and challenges of single patient rooms are for hospitals in the UK.
Benefits
Studies show that single patient rooms bring a number of benefits, to both patients, and healthcare providers and systems
Patient outcomes and experience
In addition to the widely accepted improvements to patient experience, single patient rooms’ increased protection and privacy supports better doctorpatient communication, which in turn translates to patients feeling informed about their care, and confident in discussing their needs.10
Single patient rooms are also quieter than open wards. As a result, patients report less stress over patient interactions, and a greater ability to rest and sleep without being disturbed,11 which in turn have been linked to better patient outcomes.12 One study found that single patient rooms resulted in decreased risk of delirium in elderly patients, a disorder that has been linked to higher noise levels in hospitals.13
A 2022 study found that single patient rooms significantly reduced the number of intrahospital transfers,14 which have been linked to increased risk of hospital acquired infections,15 and adverse patient outcomes.16 These improvements to patient outcomes, coupled with surveys of patients frequently showing that they prefer single patient rooms – for reasons including increased dignity and privacy, and easier visitation by family and friends,11 form a clear picture of improvements for patients in single room settings.
Provider and system performance
The physical separation enabled by single patient rooms and reduced patient transfers improves infection control, which could reduce length of stay and hospital costs.17 Studies have shown that single patient rooms do reduce infections,18 although the impact on stay length (and consequently costs) is less clear.19
Another important aspect of single patient rooms is the flexibility they offer to hospitals and Trusts in how they use their bed base. Single patient rooms eradicate the issue of gender-based bed blocking, where patients cannot be allocated to an empty bed in a shared ward, as people of a different sex are occupying other beds on the ward.20 This, combined with the fact that single patient rooms allow for incremental changes in capacity (e.g. partitions or re-designation of rooms to reallocate resources as needed), increases how adaptable a hospital can be, allowing it to be resilient and flexible in responding to pressures
Challenges
Nevertheless, moving to a model of single patient rooms also comes with a number of challenges
Patient outcomes and experience
It is harder to monitor patients in single rooms, compared with in a ward with a central nursing station. Single patient rooms have been linked to delays in getting help, for example when a fall occurs.11, 21, 22 There are, however, studies with contradictory results, in which increases in falls were not statistically significant,23 or reversed in the subsequent months, as staff got used to the new ways of working.11 Similarly, both patients and staff raise concerns that single patient rooms will reduce the opportunities for patients to interact with each other and healthcare staff, reducing social support, and making patients feel isolated.11 This has been found to primarily affect patients with few passers-by.23 Despite discussions and concerns about isolation, the evidence is clear that most patients prefer single patient rooms.11,24
Provider and system performance
Another disadvantage of the single patient room model is that such rooms require greater square footage to implement. In space-constrained settings, this necessitates a trade-off between the number of beds and other clinical spaces. If trade-offs aren’t required, then the larger square footage will increase capital and certain operating costs, and pose staffing challenges
In fact, moving from 50% single patient rooms to 100% such rooms has been estimated to require an additional 5-10% in capital costs.11,25 In addition to the one-off capital costs, single patient rooms will also increase certain running costs. One study11 estimated that moving from 50% to 100% single patient rooms increased ongoing cleaning costs, but did not impact the costs of maintenance. While the authors of that study were unable to quantify the potential financial benefits, other studies25,26 have suggested that any increase in operating cost is outweighed by the cost-benefits from reduced patient transfers, reduced stay length, and improved infection control, and may be sufficient to recoup the higher capital costs within 3-5 years.25
The additional square footage also poses challenges for hospital staff. Surveys of such personnel have found that both perceptions of staff’s ability to deliver high-quality care, and teamwork and training, worsened following the move to single patient rooms.11 The current staffing pressures and vacancy rates across the NHS raise serious questions about what this means for patients in single patient room settings. While studies have shown that an increased share of single patient rooms increases the time staff spend walking,11 the impact on staff cost has been difficult to isolate.
Making single patient rooms a reality
To maximise the potential benefits of single patient rooms and mitigate the potential risks, such rooms require an approach and a model of care distinct from those in place for wards. Clinicallyled planning, redesigned processes, and digital innovation, should be integrated into Trusts’ business cases, designs, and estates strategies, from the outset.
Implementation approach – clinically led planning
Where a hospital is being designed with single patient rooms, we recommend a clinically-led approach to the design that ensures that any operational challenges are addressed upfront. Clinicians and designers can work together to come up with solutions to maximise the benefits and address the potential problems with single patient rooms. For example, handrails, adjustable height beds, and roll-in showers can reduce the risk of falls, while improving ventilation, appropriately placing basins, and selecting easily disinfected equipment, can improve infection control. Many of these elements were incorporated into the new Tunbridge Wells Hospital in Pembury in Kent – such as placing the clinical basin at the rooms’ entrance, including natural ventilation, and placing the bedhead on same side as the en-suite bathroom doors to reduce the risk of falls.27
Good design can also promote increased socialisation. In designing its majority single patient room decant ward, James Paget University Hospital in Great Yarmouth included a dementia-friendly outdoor courtyard to encourage patient socialisation.28 These spaces can host social activities. For example, the Tunbridge Wells Hospital started a lunch club in a shared social space to combat isolation and improve food intake at lunchtimes.1
Implementation approach: redesigning ways of working
Addressing the concerns of staff, and particularly nurses – who tend to be ward-based – will be crucial to ensure that hospitals adopt single patient rooms safely and efficiently. Doing so will include updating staffing models to reflect staff concerns, and encouraging a behavioural shift among staff. Staff concerns around delivering high-quality care, teamwork, and informal learning, can be mitigated through improved processes and smart designs. Trusts should review their rostering process, job plans, and team skill mix, to ensure that they have the right staff, with the right skills, in the right place, to meet patient needs. Incorporating touchdown bases and viewing windows improves patient monitoring, and combats both staff and patient isolation. Developing new communications approaches – for example using digital communication tools – and placing a focus on team-building activities and group training sessions, can promote teamwork and informal learning in the new environment. As well as addressing staff concerns, Trusts need a shift in mindset and behaviour to embed new ways of working, and reduce the impact that any confusion in the initial transfer that might otherwise lead to temporary increases in falls or medication errors. Trusts would do well to consider the influence model (see Figure 2),29 and how they can adopt its four building blocks of change: role-modelling, fostering understanding and conviction, developing talent and skills, and reinforcing with formal mechanisms.
Incorporating digital solutions
Finally, digital innovation can support the transition to single patient rooms and new models of nursing, in addition to improving patient experience and outcomes more broadly. Mapping digital solutions at an early stage in the planning process allows Trusts to understand the options available to them, evaluate their impact on patients, and assess their feasibility. Possible solutions include wearable technology, cameras (with permission), patient entertainment and controls, and staffing interfaces
The introduction of wearable technology in hospitals can be used to help improve patient monitoring, and support more responsive care and better patient outcomes. Wearable technology such as fall alarms, glucose monitors, and heart rate monitors, can be used to monitor patients’ health, and alert staff to any changes in it, without requiring constant visibility. Additionally, most wearable devices will collect real-time data on patient location, supporting more accurate and timely diagnosis and treatment.
Cameras and intercoms
An alternative to wearable technology is the introduction of cameras and intercoms in patient rooms to support nursing. Cameras can be used to monitor patient conditions, and to ensure that any changes in health or behaviour can be quickly detected, while intercoms can be used for remote communication, improving infection control. Any introduction of cameras and intercoms should be done with clear monitoring guidelines, in line with good information governance, local buy-in, and informed patient consent, to ensure that patient privacy is respected.
Hospitals can promote patient wellbeing, socialisation, and feelings of control, through digital integration. Integrating entertainment, connectivity, and social media infrastructure, into single patient rooms can help make a patient’s stay more enjoyable, and allow them to stay connected with loved-ones and the outside world. Similarly, providing patients with access to room controls, such as thermostats and blinds, can help to keep them comfortable, and promote feelings of control.
Tablets and built-in stations, either in a patient’s room, or in touchdown bases, can allow staff to access patient records quickly and ‘on the go’. This can support the new ways of working, and help to reduce the chances of care errors
Conclusions
While the benefits and challenges of single patient room implementation are not fully understood, Trusts involved in the New Hospital Programme will need to engage with the full range of changes needed to inform design and business cases from the earliest opportunity if they are to ensure that their new hospitals deliver the best quality and value healthcare for their patients.
While there are a number of factors to consider, single patient rooms represent an exciting opportunity to adopt new designs, change how ward care is run, introduce innovations that improve patient experience and outcomes, and deliver efficiency benefits for hospitals and staff. Trusts should involve a variety of perspectives at an early stage, learn from early adopters of single patient rooms – both in and outside the NHS – and collaborate with the wider health system and local communities.
Smriti Singh
Smriti Singh, Associate partner at The PSC, provides strategic advice, and designs and delivers change programmes in the health and care sector. Her projects include business cases for capital investments, development of integrated care systems, process improvement and change, and transformation programmes. Smriti is passionate about making health and care services more responsive and person-centred. She has had articles published on health policy and future health system design in the British Journal of Nursing, Community Care, Health Estate Journal, and Building.
David Chappell
David Chappell, Consultant, is an experienced management consulting professional and qualified accountant (ACA), with a strong passion for deriving insights from data. Since joining The PSC, he has worked primarily on developing business cases, finance and activity models, and data strategies in healthcare
Sesha Nicholson-Lailey
Sesha Nicholson-Lailey, Associate consultant, has an interest in evidence-led design in both processes and infrastructure. As part of The PSC team, she has worked across strategy and process transformation in health and care settings, including clinically-led options development, and business case development for hospital redevelopment
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