Breaches of rules enforcing separate men’s and women’s accommodation are creeping up again, finds Emma Wilkinson, while patients call for the rules to be made even stronger
Dolly Sen from Norfolk remembers being an inpatient in a bay on a mental health ward and men coming in to ask for sex. She had stayed in mixed sex hospital accommodation many times, and on this occasion a man pushed her against a wall and assaulted her, she told The BMJ.
“You’re feeling vulnerable. A hospital ward should be a safe space. It does not feel safe being around men who don’t have inhibitions,” she said.
Sen’s experience was in the early 2000s, before the government’s 2011 pledge to abolish all mixed sex NHS hospital accommodation in England except in intensive care units and emergency departments. Scotland, Wales, and Northern Ireland had by then already scrapped mixed sex accommodation.
The 2011 pledge was limited to stopping the sexes sharing sleeping areas, bathrooms, and toilets or having to cross mixed sex areas to reach these facilities. To meet the rules hospitals could use single rooms, wards for men or women only, or mixed wards but with separate bays or rooms for men and women. The caveat “except where it is in the overall best interest of the patient” gave trusts wiggle room in emergency situations or when patients need highly specialised treatment in a critical care unit.1 The rules have been suspended in times of peak winter pressure.
But the 2011 rules aren’t always followed, and incidents such as Sen’s persist. And many patients and doctors think that the rules don’t go far enough in the first place.
In 2018, after inspectors found an unnamed trust to be breaching the rules and several patients reported sexual incidents, the English regulator the Care Quality Commission reviewed accommodation at 54 mental health trusts.2 The review found 1120 reports of sexual incidents involving patients, staff, or visitors on mental health wards over a three month period in 2017, including 273 allegations of assault.
A “significant number” of incidents had occurred in communal areas, the CQC said, and on mixed sex wards “it is often difficult to ensure that gender separation is maintained effectively.”
The CQC considers mixed sex accommodation in its regular hospital inspections and can require improvements. In its latest annual inpatient survey 9% of 76 668 respondents reported sleeping in a mixed sex area in hospital in July 2018, a proportion similar to that in recent years.3
Fines for rule breaches
Hospitals are required to report breaches publicly and can be fined £250 for every patient who spends a night in mixed sex accommodation.
After the rules were brought in the number of patients sleeping in mixed sex accommodation fell sharply, from 11 802 in December 2010 to 907 a year later (fig 1). By 2013 breaches reached a steady rate of between 100 and 200 a month.4
Fig 1
Fig 1
Breaches of rules on mixed sex wards are rising again
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Trusts invested in ward redesign, including innovations such as movable walls to create single sex spaces with flexible capacity. Yet, despite this and the political rhetoric, trusts did not completely eradicate breaches. And by 2015 the number of breaches began to rise again.
With hospitals coming under more pressure, trusts reported more than 10 000 breaches in the first six months of 2019; in 2016 there were 3295 in the same period. Despite a greater volume of patients the rules are clear: lack of beds or staff cannot justify a breach. Neither can predictable seasonal pressures or having old buildings that make it difficult to separate patients.5
Many hospitals continue to do well to separate the sexes. June 2019 figures, for example, show that 64% (94 of 146 acute care trusts) reported no breaches.4
Many hospital inpatients consider factors such as cleanliness more important than being in single sex accommodation, surveys show, but some may find mixing distressing, especially older patients, women, and patients having sex specific treatment such as hysterectomy or prostatectomy.6
Patients’ expectations
Separating men and women is a particular priority in mental health facilities. Before the Department of Health set out to banish the practice, the 2008 Mental Health Act Code of Practice stated, “All sleeping areas (bedrooms and bed bays) must be segregated, and members of one sex should not have to walk through an area occupied by the other sex to reach toilets or bathrooms. Separate male and female-only toilets and bathrooms must be provided, as should separate day rooms.”7
The code also asks staff to “protect the patient’s privacy against intrusions—particularly in sleeping accommodation, toilets and bathrooms.”
Mental health service providers report few breaches of the NHS rules. In June 2019 only three reported any breaches and in August only two.
Yet there is a disconnect between what counts as a breach and what some patients expect. Rivkah Grant, 30, from north London, was staying on a ward run by Barnet, Enfield and Haringey Mental Health NHS Trust this year. It had designated male and female sections but a mixed dining area; patients congregated around the nurses’ station in the middle; and male patients wandered up and down the women only corridor to get to the only outside space.
The trust told The BMJ that it meets the rules on mixed sex accommodation and that it is planning to phase out mixed sex wards in 2020 as it redevelops its buildings. It is also taking part in a programme led by NHS Improvement, the CQC, and the Royal College of Psychiatrists looking at sexual safety on wards.
But Grant says she did not feel safe. Finding herself in what she considered essentially to be mixed sex accommodation was distressing, particularly as she’d been sexually assaulted by a male staff member during a previous stay at a different hospital.
“I couldn’t leave my room to eat or drink or get medicine,” she told The BMJ. “I had to be in a space with men, and people are very unwell and can be very disinhibited. It was terrifying. The idea of being unwell again and having to go there again—I don’t know what I’d do.”
“There should be no mixed sex wards in 2019,” says Grant, who has started a petition to call for such a ban. “The CQC states that as long as bedrooms and bathrooms are separate it’s ok. But it’s not. The main areas were all male dominated, and the one female only room available was often taken up by staff on their break.”
Patients need to feel safe
Alison Cobb, specialist policy adviser at the mental health charity Mind, told The BMJ that the breach data are not representative because, as Grant’s case shows, patients can mix routinely in communal areas without breaching NHS rules.
“These breaches are very common in mental health sites, and I don’t think it should be happening at all,” she said. “When people are at their most unwell they really need to feel safe, and if that means being in a single sex ward then that’s what needs to happen.” Co-design with patients is key to ensuring that psychiatric wards are safe and therapeutic, she said.
Grant’s plea resonates with the findings of a 2018 review of the Mental Health Act commissioned by the government. The review, chaired by Simon Wessely, former president of the Royal College of Psychiatrists, reported, “We have heard of many instances where vulnerable patients have been placed on mixed wards, or in rooms where the access is not limited to single sex patients. This has led to serious sexual assaults, as well as to patients feeling unsafe.”8
The review called for single sex accommodation to be redefined “to make sure that sleeping accommodation, bathrooms and daytime spaces are genuinely single sex” and for facilities’ physical environment to be redesigned with patients’ involvement.
The CQC’s review, however, did not recommend having only single sex mental health wards, noting that this would require significant investment and may restrict flexibility, resulting in more placements of patients out of their area. But it did call for more secure segregation in mixed sex wards and supervision in communal areas, noting that single sex areas must “work in practice.” In addition, where a patient has a history of sexual abuse or exploitation “a clear care plan must be put in place and, where it is in the person’s interests or they express a preference, they should be cared for in a single-sex ward.”
Hospitals under pressure
Some breaches are hard to avoid, trusts say. “Considerable increases in the demand for our services has made the mixed sex accommodation standard slightly more challenging,” says Steve Hams, director of quality and chief nurse at Gloucestershire Hospitals NHS Foundation Trust. “But we remain committed to meeting the mixed sex accommodation standards.” He cites the timely discharge of patients from critical care as a key cause of breaches.
Simone Hay, deputy director of nursing at Medway NHS Foundation Trust, says, “Approximately half of our breaches are for patients based in critical care who have been deemed ready to be moved to a ward but have experienced a delay in doing so.”
The trust has introduced new measures to improve patient flow and reduce breaches, it says. “On the rare occasion there are some circumstances when we will have different sex patients on the same ward to ensure safe treatment,” says Hay. “However, we do this for the absolute minimum possible time, and will revert wards back to single sex as soon as we are able to do so.”
Lucy Watson, chair of the advocacy group the Patients Association, says, “Hospitals are under huge pressure, and we accept that at times hospitals may not have a choice.” But if they put patients in mixed sex wards, she says, they must “inform patients why it is happening and the steps that they are taking to maintain a patient’s dignity.”
Julia Roberts, from Kent, was admitted to hospital recently for total hysterectomy and a bowel operation to treat extensive and long term endometriosis. She had bladder complications and ended up on a mixed renal-urology ward with individual rooms and single sex bays sleeping four that were open to the ward corridor. During her stay a man with dementia tried to undress in the middle of the ward and wandered into her bay to use the toilet.
“It wasn’t the most serious of incidents, but women should not be placed in a situation where a man is potentially exposing himself,” she told The BMJ. She said it was “very odd” that mixed wards still existed. “Being ill or recovering from surgery is bad enough without having to deal with any loss of privacy or dignity,” she said. “My teenage daughter had been on the same ward a few months earlier, and I was not comfortable leaving her at night on a mixed ward.”