If Florence Nightingale were walking through hospital wards in England today she might well be questioning our understanding of dignity, privacy and choice. In marked contrast with the rest of Western Europe and the US, most patients are still being placed in large wards and many of these are mixed sex. And this practice persists in new hospitals, despite the government's promises to scrap it.

Labour's 1997 manifesto included a commitment to "work towards the elimination of mixed-sex wards", and the 2001 manifesto stated: "Nightingale wards for older people and mixed-sex wards will be abolished." But the latest figures from the Healthcare Commission's 2005 survey of patient experience showed that a fifth of patients (22%) had shared accommodation with the opposite sex at some time during their hospital stay. In London teaching hospitals, one in four patients had been in a mixed ward and in some hospitals, in London and beyond, the proportion was well over half.

A separate Healthcare Commission census of mental health establishments in England and Wales published last month found that 55% of inpatients had to share sleeping accommodation or bathrooms with members of the opposite sex. A survey of 2,462 patients in 128 hospital trusts, carried out in February and March and published last week by the Commission for Patient and Public Involvement in Health, showed that a quarter of patients had been required to share a bay and toilet with the opposite sex.

Standards on privacy

Marcia Fry, head of operational development at the Healthcare Commission, told a recent conference that the issue of mixed-sex wards was far from sorted. "In our patient survey a fifth of patients say they have been treated on mixed-sex wards. Yet over 95% of trusts say they are meeting standards on privacy."

She added that lack of dignity and respect were the subject of 12% of complaints to the commission and many of the issues arose around the time of a patient's death. She read out a complaint from a family about their mother being placed on a mixed-sex ward where they found her without underwear. The woman's family, she said, saw "male and female genitalia on display every day", as patients were not covered properly.

Over lunch at the same conference, a geriatrician lamented that his new hospital built under the private finance initiative (PFI) was organised on mixed-sex lines. This despite the fact that most of those in NHS beds are older people who arrive as emergencies. "The NHS's predominant customer is someone who has arrived as an emergency and is likely to be feeling extremely vulnerable," says Philip Hurst, policy officer at Age Concern. "Two-thirds of those in hospital are over 65 and three-quarters of those come in as an emergency, meaning they have no choice whatsoever about where they go. Imagine what they are going to be feeling after days on a mixed admission ward."

Joyce Robins, director of the watchdog group Patient Concern, says mixed wards and lack of privacy are a source of continual complaints. But professionals can become oblivious to this. "In hospital, your most private functions are the most public they have ever been," she told nurses at a recent conference on improving privacy on wards.

She quoted a case of a 70-year-old woman spending weeks on a mixed Nightingale ward where a man with dementia tried to get into her bed. "Nobody came when she pressed the buzzer so she took him back to his bed. And when she told staff in the morning they seemed to think it was a huge laugh. "When it comes to dignity and privacy, it's perception that counts - and patients don't see single sex bays as single sex wards," she said.

Roger Ulrich, professor of architecture at Texas A&M University, who spent several months in England in 2005 and 2006 advising the Department of Health (DH) on healthcare design, argues that large wards and mixed accommodation make privacy and dignity impossible. "No other country inflicts this on their patients to the extent that the UK does. There is no privacy in an open bay. A curtain creates no verbal privacy. In the US we have strong regulations to protect verbal comments about patients," he says. "In a multi-bed room, in order to do their jobs properly, doctors and nurses must inevitably infringe dignity and privacy."

Ulrich, who has conducted research on the effects of design on patients, regrets that PFI hospitals in the UK consist primarily of shared accommodation. "These hospitals are being put up with 20%, or less, single rooms - and they will be in place for decades. But single rooms reduce infection and provide privacy and dignity".

This point is endorsed by Bryan Lawson, dean of architecture at Sheffield University, who has advised several health authorities and has produced a buildings assessment tool for DH. He recalls Florence Nightingale's dictum that hospitals should first do no harm. "On patient satisfaction, reduced infection and ease of management, single rooms win hands down," he says. "But, unfortunately, all the emphasis with PFI is on keeping capital costs down rather than operating costs. But the capital cost of any hospital will be exceeded by running costs within two years. Hospitals with single rooms are slightly more expensive to build, but are cheaper to run.

"The evidence on the benefits of single rooms is so overwhelming that we simply must address this," he urges. "Single rooms achieve privacy and dignity, reduce noise levels and increase comfort. They reduce enforced patient movements to almost zero and massively reduce the risk of hospital acquired infections, and are easier and quicker to disinfect."

Clinical errors

Moving patients is heavily correlated with cross-infection and clinical errors, he adds. Lawson says he knows of no research showing that more nurses are required to look after patients in single rooms, "although it does require different patterns of nursing, with decentralised nursing stations and stores". Single rooms with en suite bathrooms reduce hospital falls significantly, he adds.

Healthcare design must give much more attention to the patient experience, he says. "For me, the secondary-care environment should look much more like a good quality hotel - somewhere you are happy to spend time rather than feeling like a cog in a machine." But he admits that the prospect is some way off. "The approach at the last hospital I visited looked like a war zone."

There are signs of progress. The Scottish executive says it eliminated mixed-sex wards two years ago, following investment of £5m, and the Scotland Patients Association says no complaints have been received in the past two years. A senior hospital manager says it was made clear that failure to address the issue would be a sacking offence for chief executives.

In Northern Ireland, new hospitals are required to provide half their accommodation in single rooms. In 2010, a new 512-bed acute hospital, consisting entirely of single rooms with en suite bathrooms, is due to open in Pembury, Kent. "We took the view that we would put the pound where the patient sees it," says Bernard Place, director of nursing at Maidstone and Tunbridge Wells NHS trust. The aim is to create a building reflecting modern expectations. "We no longer expect to share a bathroom in a B&B so why should we in hospital?"

He hopes that the new hospital will point the direction of travel for the NHS, with the emphasis on patient choice. "I think in 20 years we will look back and wonder how we ever expected people to share a loo with 10 others." Doctors and nurses are behind the development, which is not expected to require extra staff, he adds.

But under current conditions, thousands of NHS patients will spend their time in hospital with only a skimpy curtain between themselves and many strangers, of both sexes. And many will die like that.

The British Geriatrics Society believes this infringes human rights. Submitting evidence to the UK parliament's joint committee on human rights in February, Peter Crome, president of the society, said: "Meeting targets is used as an excuse to sacrifice older persons' dignity and human rights. The perception that it is acceptable to use the toilet in a mixed ward next to a person of the opposite sex separated by an insubstantial curtain challenges the human rights of older people."

Crome, professor of geriatrics at Keele University, regrets that PFI hospitals are being built with a minority of individual rooms, and would wholeheartedly support a move towards single rooms with attached bathrooms in hospital. "But it seems a long way off," he says. "In my area we have just reopened a ward in a 130-year-old former workhouse."

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