§ 7.53 p.m.
§ LORD BEAUMONT OF WHITLEY
My Lords, I beg leave to ask Her Majesty's Government whether they will acknowledge the right to privacy in hospital, and in particular the ability to choose to be in a single room, as something to be established as soon as financially possible. I have read the Question in full at the beginning in order to make clear to your Lordships, as I am sure it will be already to most, the things for which I am not asking. I am not asking that this matter of single rooms in large quantities be given a high priority. I am as aware as those noble Lords interested in health matters of the sad difficulties under which the Health Service operates to-day: of the shortage of staff; of the shortage of money and of the bad old hospitals which need to be replaced, and I do not think that what I am talking about to-night takes precedence over any of those matters.
The second thing I am not asking for is that we should have all private rooms 422 in hospitals, even eventually when the millennium comes. I accept that many people, when they are ill and in hospital would rather be with other people in hospital wards. Some of them would rather be in big hospital wards which give a large element of companionship and yet do not leave them at the mercy of one or two people, as they might be in a much smaller ward. On the other hand, some people would prefer to be in smaller rooms with two or three or six people; but again these have their drawbacks.
I do not seek to establish how many people would prefer to have single rooms, because that is still largely an unknown quantity. There have been one or two investigations but, like many investigations into something which does not really exist, the results are not very reliable. Therefore I do not seek to base my Question on anything to do with what the public want in the way of rooms. All I am asking the Government to do is to acknowledge, as something which they should grant and work towards, the right of the patient to choose what degree of privacy he wants.
Privacy is something which we all value at some time or other in our lives and most of us for most of the time. It is not a thing which is confined to any age or sex or to any class. One of the things which poor people who get glimpses of the public schools most dislike and disapprove of is the dormitory system. On the whole, in our kind of civilised society it is taken for granted that people should have a room of their own, if they possibly can, for the whole of their lives. Of course, it is not always possible, but that is a matter which we very much deplore. We try to get away from the overcrowding of houses and the sharing of rooms, and if we do have people sharing rooms it is usually with close relatives or people they know well. Universities and colleges try as much as possible to give students single rooms; for their work and living. Even in prisons we regard it as a great disadvantage if people have to share cells.
It is only when people are at their lowest ebb, with their resistance at its lowest, that they are often pitchforked into a situation where they suddenly find themselves cheek by jowl, day and night, with 20 or 30 complete and utter 423 strangers, most of them sick and ill them-selves. I do not think that this is something which we should accept. We have to accept it for the time being, because of the shortage of money and because of priorities, but it is something which in the long term we should not accept.
I am informed that the clinical need for single rooms is estimated at 14 per cent. of bed space in hospitals. That does not include amenity beds, which are beds which people in the National Health Service can get by the payment of some-thing extra, or beds for private patients who are not on the National Health Ser-vice. The present recommended rate for the building of hospitals, I am in-formed, is 20 per cent. of single rooms, which presumably includes the 14 per cent. of clinical need and allows only 6 per cent. for amenity and private rooms together. I feel that in the long run that will not be enough; and even in the short run it is possibly not enough. And what is more disturbing is that I am informed that in a number of hospitals which have been built recently the number of private rooms built is considerably lower than the recommended rate: Greenwich is an example at 14 per cent.
My Lords, I apologise to the noble Lord for interrupting, but when he talks about "private rooms" does he mean rooms for non-paying patients?
§ LORD BEAUMONT OF WHITLEY
I beg your Lordships' pardon: I should have said single rooms. If I may "recap", so that there is no misapprehension, 20 per cent. is the recommended rate, to include clinically needed single rooms, amenity single rooms and rooms for private patients. But what I am saying is that a lesser proportion than that is being provided at the moment; indeed at Greenwich only enough is provided for the clinical needs, without provision for either the amenity needs or the needs of private patients.
When I first became interested in this subject it seemed to me that the cost of producing a large number of single rooms would be astronomical. But I am in-formed (and these, I believe, are Ministry figures) that this is not in fact so. The 424 cost of building 50 per cent. single rooms in new hospitals would add 12½ per cent. to the cost of wards, and 15 per cent. more space would be needed. There would, of course, be greater running costs, and there would be a need for more labour. On the other hand, it is possible—and I do not think enough serious study has been done on this—that there are some advantages. I understand that it is dubious whether there would be a decrease in infection from having more single rooms, and therefore, less curtaining, although it would appear to the layman that curtaining must be a carrier of infection and that a big ward must carry more infection. However, if I am told by the scientists and doctors that this is not true, I must accept it.
I feel that one way in which economies would be made would be on bed occupancy. At the moment there are empty beds in some large wards because, under the ward system, it is necessary to fit in patients of a certain kind, or of a certain sex, or suffering from a certain disease, into a particular ward. Therefore, there may be overcrowding in one ward and under-occupancy in another. More single rooms would make the position more flexible. Bed occupancy in hospitals at the moment ranges from 80 to 87 per cent. With more single rooms one might get nearer to 100 per cent. occupancy. There are various things that would be easier, such as giving treatment to patients where they were, instead of taking them out. Visiting would be much easier from everybody's point of view.
One point about privacy that I think I ought to make here is that, in addition to the lack of privacy in big hospital wards, there is a lack of privacy for patients to talk to their doctor and to visitors. Patients may have a great many things to talk about. Some of them may be suffering from emotional weak-nesses, and it may be a good thing for them to cry to their relatives, and to talk to them openly and freely in a way that is not possible in big wards. It is envisaged by those who have most pressed for single-room accommodation that people should have a right to choose, and that probably more people would choose single rooms in the future if the present policy for building more day rooms in hospitals—rooms where patients can go and spend time together in the 425 afternoon when they can get up— were continued, because they would probably welcome having their own individual rooms to themselves for the rest of the time.
I think it is worth while taking up your Lordships' time on this matter, partly because there is an absence of pressure groups on it. There are all sorts of good causes which suffer from the lack of pressure groups. State education suffers, or has in the past suffered, from the lack of enough pressure groups because so many people who have influence send their children to private schools. There are so few people who want to know about this matter of private rooms in hospitals when they are not patients, but when they find themselves patients it is very different. I must pay tribute to the Patients' Association, which I think is doing very good work in this way.
I should like to wind up, my Lords, by repeating that I am not asking for a large number of additional private rooms to be built immediately. What I am asking for is an acknowledgment by the Government of the goal that we are all, I hope, seeking. There are two important aspects for any political action. There is, first of all, the goal that we want to see; secondly, there are the steps that can be taken, given the money, the political situation and everything else. If you concentrate only on the first you are a woolly-headed idealist; if you think only of the second, you run the risk that the steps you take will be moving in the wrong direction. I am frightened that we are going to build too many modern hospitals that are not adaptable to provide single rooms. I am frightened that we are not going to take any steps in this direction because the Government, quite rightly, do not want to raise people's hopes too much by saying immediately: "Of course we think this is a very good thing". My Lords, all we ask is that this right to privacy should be acknowledged as something which society, when it can, will provide to the individual. I beg to ask the Question standing in my name on the Order Paper.
§ 8.8 p.m.
§ LORD PLATT
My Lords, I speak for no particular pressure group of any kind, and I do not even know what that important body, the B.M.A., are thinking 426 about this subject. But I know what I think about it, and I support almost everything that the noble Lord has said. One thing I should like to say which is almost irrelevant (and this is, perhaps, the only instance where I differ from the noble Lord) concerns bed occupancy. I think an enormous amount of nonsense is talked about bed occupancy. A great deal is made of it by boards of governors and Regional Hospital Boards. It is supposed to be a great virtue if your beds are always full. But, in fact, it is an inhumane object, and what happens is that a patient who has been on the waiting list for two years for a hernia operation is sent a telegram to come in on Saturday morning because there happens to be a bed vacant, nothing is done for him until Monday evening, and then his operation is performed on the Tuesday morning. As I say, this is almost irrelevant to the noble Lord's Question, but I think we have to get it straight.
When the noble Lord says in his Question,"to choose to be in a single room, as something to be established as soon as financially possible ",I would go further and say, "something quite essential in any up-to-date hospital". I must give a few reasons for saying that. When the Health Service started there were to be amenity beds, and for a very small sum of money, which I think was then four or five guineas a week, you could elect, provided it was not needed for somebody much more ill than yourself, for some dire clinical need, to have a room to yourself. That system, so far as any hospital I have ever worked in, failed simply because there were not enough amenity beds. In the hospital in which I did most of my work for the last twenty years before I retired, the Manchester Royal Infirmary, and in my own wards, there were, so far as I remember, about 25 beds in a ward and there were only two single rooms. There was one room with three people in it. I can think of nothing worse than a ward that contains three people, except being in a ward which contains two people, because you have to be polite to somebody, and being polite as well as being ill is almost too much to contemplate.
There are various reasons why certain people want to be by themselves; certain people have intellectual resources of 427 their own, others do not, and prefer to live in groups. Among the major annoyances of the big wards and multiple wards are television, smoking, unpleasant noises and, occasionally, unpleasant smells. Nevertheless, I concede with the noble Lord, Lord Beaumont, that there are a number of people who would much rather be sharing a ward with four, five or six people; and, like the noble Lord, I would agree that they should have every right to do so. I would rather be in a ward for one or in a ward for 30, because on neither occasion need I be polite to anybody else. Those who like company are very well catered for in a modern hospital by the much greater pro-vision of day rooms and common dining rooms. Very recently I visited a patient, a lady, who was in a mixed ward one part of which was for men and another part for women. There was a common dining room in between them, with day rooms, and so on. Sometime we must consider the two nuisances of television and smoking, but this is getting a little irrelevant.
Certain absurdities also creep into this. Surgery is more and more a matter of team work. There are these wonderful operations that can now be done on the heart, and they have to be done in a modern hospital where there is a trained team and every possible amenity. It is no longer possible to do this kind of operation in the ordinary nursing home. So these people have to come into hospital, people who would much rather have private treatment and be in a private room. They are looked after very well in intensive care units, which have grown up so much in the past few years, and these are quite splendid. It does not matter whether you are next to a man or a woman or anything else—well, I sup-pose there is nothing else. While you are intensely ill, being looked after for these few critical days, you are splendidly cared for in the modern intensive care unit. After that there is the stage of convalescence.
We also have to remember that there are a very large number of people in hospital who are not ill at all. I am sure your Lordships do not take me quite literally when I say that, but there are a lot of people who need to come in for 428 investigation. They walk into the hospital, they come in on public transport, they were working the day before and are not direly ill. They do not have to be put to bed immediately and nursed by a highly trained team of nurses. These people have to be looked after as well.
I have had rather special experiences of the needs of the kind of people who like to be by themselves. For twenty years I was a Professor of medicine and, therefore, not in the private practice of medicine, not receiving fees from patients that I saw, and I was quite content for it to be so. I saw a lot of people, my own colleagues, their wives, doctors, all kinds of people who wanted to see me, and I had nowhere to put them except in a general ward with a lot of other people, which most of these people disliked intensely. If I had an amenity ward, if I had a single ward, almost certainly by the evening it would have to be taken up by some emergency for which it was needed. So I am very much in favour of the provision of private, single wards. I do not think that the difficulties of provision are unsurmountable. I do not think every hospital can be converted to-morrow in this way, but this is an ideal for which we should work, and a very proper one at the present time.
I would finally mention two other reasons for the provision of more single rooms. One, which the noble Lord, Lord Beaumont, has already mentioned, is privacy of conversation, not only with your friends and relatives but also with your doctor, and this might improve doctoring a great deal in our public hospitals. The other reason is the little matter of death. If you have only two single rooms in a ward of 25 or 30 people and you say to one of your patients, "I think you need more rest and we ought to put you in a room to yourself", he thinks he is going to die. And he is usually right.
§ 8.17 p.m.
§ BARONESS STOCKS
My Lords, my first impression on reading the Motion of the noble Lord, Lord Beaumont, was that it was a very tall order. I would question whether it should be regarded as a right for every National Health patient to have, at his own choice, a private 429 room. To take the last sentence of his Motion:… as something to be established as soon as financially possible.it seems to me that with the present pressure on the National Health Service it is not really a priority; a great many things should be done and a great deal of money should be spent before we can acknowledge the right of every National Health Service patient to have a private room. There are great advantages in having a private room: you can have visitors whenever you like, although that is an advantage which is perhaps sometimes a mixed blessing. You can listen to the wireless without having to put a head-phone on your head, and you may smoke or not smoke as you choose. That is something that if you really want it you should have to pay for it—at least under present conditions. The trouble is that you have to pay a devil of a lot!
The noble Lord referred to pressure groups. The pressure group in this case is the Patients' Association, which is a body which has done, still does and will do very useful and valuable work. The case that the Patients' Association makes out for the right of the National Health patient to have a private room is mis-leading. I have it here:If privacy is the most precious right we have,"—I can think of more precious rights—this right is forfeited the moment one becomes a hospital patient under the N.H.S. Wards designed to accommodate the sick poor in charitable institutions are not only still in use but provide the pattern for hospitals now being built and planned,"—I cannot believe that that is the case—so that patients in the next century can look forward to enduring the same conditions as the objects of Victorian charity in the last. People who would rather not share a bedroom with members of their own family have no choice of companions with whom to share the embarrassment and distress of affliction. The patient is not able to talk privately to doctors and nurses, nor to his visitors. He has perforce to adapt himself"—and so on.
Well, that is surely not true of a modern hospital. It may have been true of some of those old hospitals we still have in use. I had experience of one, which was formerly a workhouse. The plumbing was out of order and it was very understaffed—but I have no 430 doubt that it is a lot better now than it was in 1951. But I am referring to a modern hospital. I have in mind, for instance, visiting a patient in St. Bartholomew's. The wards are not over-crowded; the curtains are very adequate. One can obtain a very high degree of privacy, and I cannot think there is any hardship in being nursed in such a general ward. It is asking a lot, I think, to regard that as not good enough for the ordinary patient.
The statement of the Patients' Association goes on to point out that… student hostels and halls of residence are designed to allow each student a study-bedroom to himself ";and points out the amenities of being in prison wherePeople sentenced to imprisonment are not herded into dormitories as are those who have the misfortune to fall ill.One of the "amenities" of prison life, I imagine, is that of being shut in your cell for very long hours; although in a male prison one may have to share it with two other inmates. All this is really an overstatement of the hardships of a general ward in a modern hospital. One of the hardships which is pointed out by the Patients' Association is what is regarded as the outrage of being examined in a teaching hospital by students, or in the presence of students. The statement says:In addition to the extra anxiety, pain and discomfort which are often occasioned, many patients experience embarrassment, and a sense of outrage, and those involved would do well to ponder the legal implications of examining patients in such circumstances without obtaining their consent.I believe it is now possible for a patient in a teaching hospital to state that he or she does not consent to such examinations. Is that not so at the present time? I think it is. Even so, I cannot help thinking that we have gone a long way since the days when that was the kind of treatment which the poor were subjected to in charitable institutions, which hospitals then were, in order that the doctors could be trained in the service of the rich.
I think anyone who takes advantage of the National Health Service should regard it as a public duty to play his part in medical education, on which he Is subsequently dependent. It is not asking a great deal. Therefore, I think that the 431 demand that every National Health patient should, as of right, be entitled to a private room is an unduly tall order; and I cannot think it will be within the bounds of National Health finance in the near future, or even in the far future, to make it a reality.
§ LORD BEAUMONT OF WHITLEY
My Lords, before the noble Baroness sits down would she make one point clear? I have listened with great interest to her observations. Presumably her comments were not addressed to any case I made out; I hope she will acknowledge that the matters she referred to were a very long way down the list of my priorities. And I certainly did not put the case for the Patients' Association, for which I have a great admiration, on which she was commenting.
§ 8.25 p.m.
My Lords, I am very glad that the noble Lord, Lord Beaumont of Whitley, has put this Question. He raised it in, if I may say so, a most restrained and reasonable way. I should like to comment on it from two directions. One is the personal view. As the noble Lord, Lord Platt, and the noble Lord, Lord Beaumont, have said, some patients like company in wards, and others like privacy. Having, un-fortunately, had to spend quite a considerable time in hospital last year, I am in the second category. And as I cannot afford private rooms—£60 a week nowadays in our hospitals—I was extremely grateful to get into a little annex of a ward, which gave me privacy and made the whole difference to me.
I speak as chairman of a hospice for terminal illness. I am glad to say that the noble Baroness who has just spoken is associated with me as a Vice-President; three other Members of your Lordships' House also are Vice-Presidents—suitably, two on the Government side, two on this side, and one on the Liberal Benches, Lord Amulree. I know quite well that many of our patients prefer being in a small ward of eight beds, with television. But the important thing, at least in this particular hospice, which of course is for very seriously ill patients, is that it demands very heavy nursing, and one is always 432 up against the problem of getting enough nursing staff and enough administrative staff. This is an important point because in all the hospitals in this country we are very short of nurses, and of cleaning and administrative staff; and, of course, numbers of small rooms definitely increase the amount of work that has to be done. With the heavy nursing that is required in the hospital with which I am associated, it is very important that the staff are able to keep an eye on the patients without having to dart into room after room: they must be able to see them all together.
So I entirely agree with the noble Lord that, in the long term, it would be excellent if we plan for more private rooms, not for paying patients, but for those patients whom the noble Lord, Lord Platt, mentioned, who prefer privacy, as I certainly did myself. I agree also with what was said about students. Patients should be asked to agree before a large number of medical students come to take part in examinations and in subsequent treatment. I do not entirely agree with what was said about lack of privacy in a ward. From what I have seen when visiting patients in hospitals, and from what I might call my own hospice, I think that with curtains and screens one can produce the privacy that is required for ordinary conversation and visits. But I agree very much with what the noble Lord said about the last hours of a patient's life. It would be a very good thing if at that time patients could go to a private room.
So, on the whole, I should like to support the noble Lord in his plea, in long-term planning, for an increase in the number of private rooms for non-paying, National Health, patients. But I agree with the noble Baroness, Lady Stocks, in that I am afraid it is a long-term plan and we must look first at a great many other important priorities.
§ 8.30 p.m.
§ BARONESS SEROTA
My Lords, at the beginning may I agree with the noble Lord, Lord Beaumont of Whitley, and I think every other noble Lord who has spoken to-night on the Question, that patients should have the right to privacy to which as individuals they are entitled, and that privacy is certainly one of the many aspects of hospital life, quite apart 433 from the effectiveness of clinical treatment, which loom very large indeed from the point of view of the patient.
We are all aware of all the other factors which come into play when a patient enters hospital, and also, I think, of the fact that overcrowded wards, inadequate bed space and the close proximity of patients together in large wards are among the worst features of daily life in some of our present hospitals. Even where, on occasion, one sees that space standards are adequate, the large, old "Nightingale" wards built in the past are really quite unsuitable for the needs of patients, and indeed of doctors and nursing staff to-day. The noble Lord, Lord Platt, with his great experience in the health service, has reminded us, I thought very graphically indeed, of the kind of issues that arise in this situation. In the large ward there can be too much noise, too much disturbance. The recent introduction of television, which has proved such a boon in some of our long stay hospitals, can be a constant irritant to a patient who is unable to bear noise in his immediate surroundings. The other problem, as the noble Lord also reminded us, is that the seriously ill and the less ill cannot be sufficiently separated and it is then very difficult to sustain privacy in any reasonable form.
In discussing this subject most of your Lordships have been concerned with the planning of hospitals in the future, recognising that this is, for reasons of priority, a plan which we can only make for the future. However, I still believe that by upgrading existing hospitals one can create the kind of atmosphere which gives greater privacy to patients. Although one noble Lord mentioned that curtains might be a source of infection, to my mind the greatest upgrading and the greatest improvement that we produced in any local hospital was by the curtaining in every single ward in that old 1750-style workhouse building.
When one turns to the planning of our new hospitals, where we need to take account not only of the best techniques and the most effective procedures and treatment of patients' clinical conditions, but also their needs as people, one is beginning to see that we should create a much quieter, much more domestic 434 atmosphere by grouping beds in smaller numbers and in separate bays. The plan which the Department has evolved for a standard ward in an acute hospital comprises 30 beds, of which six—that is 20 per cent.—are in single rooms and the remainder are in multiple bed bays of six beds each. We believe that grouping in this way will be welcomed and we hope that it will be found satisfactory by the great majority of people who experience a stay in hospital. The multi-bed bays that we are now designing are large enough to provide and sustain patients with the kind of companionship which some of them way wish for, yet I believe (and I have seen something of this in practice myself) are small enough to allow those who wish it to withdraw from social contact from time to time when they so desire.
The noble Lord, Lord Beaumont of Whitley, quoted the example of Greenwich District Hospital. It is quite true that in that hospital the number of single rooms amounted to 108 out of a total of 767 beds—that is only about 14 per cent. of the total number of beds provided— whereas now our standard wards provide for 20 per cent. The Greenwich decision was one taken locally by a group representing the Regional Board, the hospital management committee and the Department, on the ground that this was the appropriate percentage in the light of experience, to meet the needs of that area. I hope what I have said will put the noble Lord's mind at rest. That is all I wish to say on that question.
Several noble Lords have mentioned priorities and indicated that they accept that we can move towards these changes, which will provide greater privacy for patients, only within the resources available. But I think that the real problem that the noble Lord, Lord Beaumont, has posed in his Question is: what is the optimum point we should aim to reach? I do not think he would envisage a hospital, for example, consisting of all single rooms. Nor, I believe, would the noble Lord, Lord Platt. We have tried to determine what would be a suitable, and indeed an economical, provision of single rooms in a hospital, trying to weigh the different factors that come into play, of which privacy is certainly one; but there are also factors such as liability to 435 infect others, susceptibility to infection, and seriously ill, noisy patients who have to be admitted in the middle of the night. Moreover experience shows that the need will vary from season to season with the type of ward unit, the patient treated and the judgment of the individual clinical and nursing team.
But we are fairly confident, having tried to weigh and balance these factors, that the 20 per cent. that we are now advocating in our new buildings will provide an adequate number, balanced with the small bed bays that I referred to earlier, to enable clinical and nursing supervision to be carried out throughout the ward in the best way, and indeed to provide the kind of flexibility we should wish to see in our hospitals for the future. But as the noble Lord, Lord Beaumont, pointed out, we cannot really be confident that this 20 per cent. will be sufficient to allow every patient who wishes it, whether or not his clinical condition requires it, to have a single room, for the reasons which the noble Lord, Lord Platt, reminded us of—that people differ in their preferences and in their needs. Patients who have never been in hospital before often find that their views on the question change as a result of the actual experience.
The few studies which have been carried out during these last years on patients' preferences, and which we have used in our hospital planning studies, have not indicated anything like a large-scale, unmet demand for single room accommodation. In fact, the two most extensive surveys that have taken place have shown that the proportion of patients who wanted single rooms was 8 per cent. and 11 per cent. respectively. Clearly we have not yet come to the end of our thinking here. We are considering whether any further survey might usefully be undertaken in order that our studies, our forward planning, the best type of hospitals for this country for the future, can be assessed as accurately as possible.
My Lords, the hour is late and I am reluctant to detain the House on a number of matters that have been raised following this Question. I would only say in reply to the noble Baroness, Lady 436 Stocks, who raised the question of the participation of patients in teaching in hospitals and their rights to privacy in this context, that this is a subject in itself to which we have given careful consideration. We shall shortly be issuing new guidance to hospitals on this difficult and delicate matter, and yet one of central importance to the development of medical education.
As a result of the few things I have been able to say to-night I hope that noble Lords will accept that we are well aware that there is a great deal to be done in relation to privacy in our hospitals. We are trying to keep our priorities right and realistic, and these concepts of personal privacy and choice are an integral part of our planning for the hospital wards, both for to-day in our older hospitals, and also for tomorrow, in the hospitals of the future.