At a time when immobility continues to define patient care, not having the right space to help patient’s recover is a major health risk. For many patients, especially the elderly, therapy is a clinical necessity — not an optional extra. Evidence suggests that hospitalised patients spend up to 95 per cent of their time in bed. For older adults, this is particularly concerning as they are 61 times more likely to experience functional decline following hospital admission. Case studies show that inpatient mobilisation efforts can result in a 37% reduction in falls and 86% fewer pressure ulcers.
To address these gaps and unmet needs, a multidisciplinary team came together at North Manchester General Hospital (NMGH) to investigate whether dedicated inpatient rehabilitation spaces, located close to wards, could improve outcomes and efficiency. They arrived at clear and tangible ways we can improve the current state-of-play. Working with healthcare planners and designers, they illustrate what an effective acute inpatient rehabilitation space looks like.
The current state-of-play
After running a series of collaborative user group meetings with allied health professionals (AHPs) and health and social care professions (HSCPs) across the UK and Ireland, a common theme emerged. Physiotherapists and occupational therapists often feel underrepresented in hospital design and innovation.
Despite playing a vital role in patient recovery and discharge planning, their work is frequently undertaken in multifunctional or repurposed areas which are not suited for the recovery process. As such, this lack of dedicated space limits their ability to deliver timely, effective mobilisation and assessments, and, in turn, affects patient outcomes.
The current therapy spaces at NMGH illustrate this well. A single shared gym accommodates both inpatient and outpatient therapy. Assessments such as stair reviews, kitchen assessments, and basic mobility exercises must be scheduled around outpatient appointments or conducted in corridors and stairwells. These environments can compromise patient safety, privacy, and dignity, and can be challenging for older adults with cognitive impairments or delirium.
As the NHS 10 Year Plan shifts care delivery from hospitals to community-based neighbourhood health services, separating inpatient and outpatient pathways, physiotherapy provision will need to adapt by reconfiguring services to ensure high-quality rehabilitation is accessible both within acute settings and closer to patients’ homes.
The critical role of therapy in acute settings
Physiotherapists and occupational therapists do not simply support recovery; they enable it. Their assessments help determine if a patient can return to their previous level of independence, whether they can safely return home, any adaptations they may need, and whether additional support is required through community services or social care.
Mobilising patients early and often has been shown to significantly reduce falls, pressure injuries, and length of stay, while also improving patient experience. In fact, one study showed that older adults can lose up to 10% of their muscle mass for every 10 days spent immobile in hospital with an even greater percentage of impact on muscle strength.
A gap in the guidance
Despite the known benefits of early and targeted rehabilitation during hospital stays, national guidance has yet to catch up. Health Building Note (HBN) 11-01 outlines therapy facilities for primary and community care, including 64 sqm for a physiotherapy gym and up to 24 sqm for activities of daily living (ADL) spaces. However, there is no standard provision for dedicated inpatient rehabilitation spaces within acute hospitals.
In contrast, the Australasian Health Facility Guidelines explicitly recommend separate therapy areas for inpatient and outpatient use. Their model includes ward-adjacent ‘satellite therapy units’ designed to reduce travel distances, improve patient flow, facilitate quicker discharges, and to maintain patient safety and dignity. Replicating this model would provide obvious benefits to patients as well as the NHS, in terms of positive outcomes, service delivery, and cost.
The NMGH multidisciplinary team consists of healthcare planners, physiotherapy leads, hospital operations specialists, and data analysts. They assessed clinical demand, operational barriers, space requirements, and potential benefits of introducing dedicated acute inpatient gyms.
Evidence-based approach
Their investigation involved data collection across three core areas: the number and type of assessments currently undertaken, the percentage of patients by specialty who would benefit from therapy spaces, and a time-in-motion study examining the impact of current gym locations on staff efficiency.
Findings were compelling. In one week, the team of physiotherapists and occupational therapists recorded 58 stair assessments, 15 kitchen assessments, and a limited number of evaluations using plinths and parallel bars. It was stated that with better access to rehabilitation spaces, they could have carried out more assessments and interventions. This signals an unmet need for assessments requiring specialist equipment.
Further analysis showed that 77% of patients (Table 1) across five specialties could benefit from access to a dedicated inpatient therapy space, however only 21% were able to do so. The largest barriers were distance to the gym, limited space, and unpredictable caseload management.
AHPs are almost exclusively the ones to go to the patient’s bedside, help them transfer into a wheelchair and wheel them to the gym, unlike other clinical professions who use a hospital’s portering service.
A time-in-motion study based on productive ward principles showed that a round trip to the central gym, which included time in the gym for rehabilitation, took 110 minutes, limiting staff to just four assessments per day (Figure 1). This was due to the walking time of the AHP to the ward, finding a wheelchair, transferring a patient to a wheelchair, wheeling them to the gym (including waiting for lifts) and then reversing the journey at the end of the session. Of note, the less mobile a patient is, the more likely they are to take longer to transfer. By embedding an acute inpatient gym closer to the wards, that travel time dropped to five minutes allowing for up to seven assessments daily.
Defining the right space
The team worked with 35 physiotherapists, occupational therapists, rehabilitation assistants, and students to define what a functional therapy space should include. They reviewed four areas: orthopaedics, acute medical unit (AMU) and frailty, respiratory and surgery, and general medicine. Through a workshop and task-mapping exercise, they identified which assessments and rehabilitation could take place in a patient’s single-bedroom, which required specialist space (Table 2), and the equipment requirements. They identified base requirements for all areas and then equipment for each specialist area (Table 2 and 3). These informed both the space assumptions and the room data sheets.
After the team identified the base components, they looked at their specialist area and defined the function and specific requirements. Each specialty brings distinct rehabilitation needs that shape the design of inpatient therapy spaces. Orthopaedic patients often require riser recliners, walking aids, and floor markings to rebuild strength and confidence after surgery, alongside small aids and exercise bands to restore fine motor skills and functional independence.
In contrast, the acute medical unit and frailty require equipment that encourages safety and confidence, such as baths with seats, high-backed chairs, and manual handling tools along with group exercise areas and kitchen trolleys that stimulate social interaction and provide support with day-to-day tasks. For respiratory and surgical patients, therapy focuses on cardiorespiratory capacity and resistance exercise, so ergometer machines, weights, balance boards, and gym balls enable safe training and strengthening, while height-adjustable tables and wheelchairs ensure inclusivity. Finally, the general medicine cohort requires spaces tailored to fall prevention and practical readiness for discharge, with movable stairs, plinths, multi-surface falls assessment areas, and balance equipment enabling therapists to test real-world mobility in a controlled environment.
Design for functionality and flexibility
Guided by clinical engagement and operational priorities, a design brief was developed to ensure therapy spaces uphold patient dignity, safety, and outcomes while remaining space-efficient and adaptable. Each unit was sized at 40 sqm for the gym and 10 sqm for storage, which should be compact enough to sit within the ward core yet large enough to accommodate essential rehabilitation equipment.
The design emphasises a therapeutic environment, particularly for patients with cognitive impairments. Quiet, calming surroundings, natural light, and non-slip seamless flooring support wellbeing and safety, while standard ventilation and an optional link to outdoor space enhance comfort. A ceiling-mounted hoist spans the gym to ensure safe patient handling.
The gym is accessed directly from the ward core via a wide, automated, wheelchair-accessible doorway. Inside, a circuit-based layout supports activities such as stair practice, walking, ADL simulation, and strength training, with patients moving seamlessly between their bedrooms and the therapy space. A small waiting area and accessible equipment store maintain comfort and efficiency.
Key features include:
- Ceiling track hoist enables safe, efficient patient transfers across the entire space.
- Bobath plinth provides a firm surface for therapy interventions which can be used by all patients.
- Collapsible parallel bars facilitate gait training, balance work, and lower limb strength exercises.
- Mock front door and step simulate real-world discharge scenarios to test readiness for home.
- 13 step staircase supports comprehensive stair assessments and practice.
- 11 m walking track enables functional capacity assessments, particularly for cardiology and respiratory patients.
- Kitchenette for physical and cognitive rehabilitation and ADL practice.
- Dedicated storage room ensures a clutter-free, safe, and flexible working environment.
- Access to piped medical gases supports acute care requirements and future adaptability.
- Adjustable lighting enhances patient comfort and supports diverse therapy needs.
Key assumptions
Key assumptions underpinning the design are that all patients have ensuite rooms for personal care assessments, outpatient rehabilitation is delivered elsewhere, and certain activities (e.g. lying therapy) require specialist equipment. The gym space should be flexible and future-proof, with the option to convert into standard inpatient accommodation if required — for pandemic resilience, for example.
As aforementioned, the health planning and clinical teams identified that each acute inpatient gym would require approximately 40 sqm for the therapy area, supported by a 10 sqm equipment store. This estimate was tested and refined through a detailed space feasibility study, taking into account projected utilisation, clinical needs, and estate constraints.
The proposed footprint is intentionally smaller than the 64 sqm recommended in HBN 11-01 for primary care physiotherapy gyms. This is due to the anticipated deployment of up to eight therapy spaces across a medium-sized acute hospital (approximately 500 beds), making space efficiency a critical design consideration.
The ideal location for these therapy spaces is within the ward core; a support area shared between two or three adjacent wards. The ward core provides accommodation for essential clinical and support functions that do not need to sit within individual wards. It features distinct zones for staff and patient-facing functions, and offers an ideal location for the therapy gym due to its proximity, shared access, and operational efficiency.
Using the clinical design brief and room data sheets (RDS), a Revit model was developed to produce a 1:50 layout. This allowed for detailed testing with clinical teams, ensuring the space was both functional and flexible for real-world use.
Design intention
The rehabilitation space is designed to replicate key features of a typical UK home, enabling patients to undergo realistic training and assessment before returning to their own environments. Core elements include a mock front door with step, a full-height staircase, and a functional kitchen with sink, tap, hob, and storage cupboards, all complemented by access to an outdoor garden space.
Although these features may appear ordinary in daily life, for frail or older people, they can pose significant challenges for patients recovering from acute illness or surgery. Within this controlled and supportive environment, patients can practise essential activities safely, gradually rebuilding both their skills and their confidence to live independently after discharge.
Design features
- Flexible and adaptable
The testing model is based on a structural grid of 8.4 m x 8.4 m, accommodating a 40 sqm gym space and a 10 sqm storage area within a single grid bay. This allows flexibility and adaptability if the gym needs to be reconfigured for changing rehabilitation practices or repurposed for inpatient accommodation.
- Innovative spatial solutions
The 40 sqm footprint has been tested to accommodate all core equipment for five key assessments: kitchen, stairs, walking, physical, and front door. Among these, the full-height staircase is both the most challenging design element and an opportunity for innovative spatial solutions. By introducing a mezzanine element, the design makes partial use of the typical 4.5 m hospital ward ceiling height, creating a realistic stair environment without compromising headroom or safety.
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Spatial arrangement and zones
The space is planned to support multiple patients undertaking different activities simultaneously with carefully zoned equipment placement to ensure sufficient circulation and activity areas. The internal layout separates more active, noisy activities from quieter, fine-motor or cognitive exercises, supporting simultaneous use by multiple patients without interference, specifically zones for: assessment, cardio and endurance, strength training, and functional training.
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Integrating nature into recovery
The adjoining garden or terrace provides an important extension of the rehabilitation environment, offering direct access to outdoor spaces such as walking paths and landscaped areas for real-world mobility practice. Designed to be therapeutic, it broadens the scope of rehabilitation beyond the gym, enabling mobility assessments, functional exercises, and independent physical activity. Features such as level changes, varied walking surfaces, and planting schemes stimulate the senses while replicating everyday challenges patients may encounter at home or in the community. This outdoor link plays a vital role in supporting physical recovery, mental wellbeing, and patient motivation. Integrated with the gym and equipped with outdoor exercise stations, it transforms the garden into an active component of the rehabilitation journey.
Operational and clinical benefits
Embedding acute inpatient gyms within ward cores offers substantial operational benefits. These include shorter lengths of stay for inpatients, improved discharge rates which impact positively on ambulance and emergency department waits, and reduced re-admissions linked to deconditioning. It also allows for more efficient use of staff time by reducing patient transfer distances. Case studies show that inpatient mobilisation efforts can result in a 37% reduction in falls, 86% fewer pressure ulcers, and an 80% decrease in patient complaints. These improvements have tangible implications for patient outcomes and hospital performance metrics.
These spaces also have implications beyond patient care. AHPs and HSCPs often report feeling marginalised in healthcare environments, despite being the third largest workforce in hospitals after nurses and doctors. Creating visible, functional therapy spaces supports staff identity, facilitates interprofessional collaboration, and reinforces the essential role these professionals play in patient recovery and discharge planning.
To maximise the value and impact of these therapy spaces, careful consideration should be given to their use outside of standard clinical hours. Opportunities include hosting group education or exercise sessions, enabling independently mobile patients, once clinically assessed as safe, to access the space autonomously, and extending use to staff wellbeing initiatives.
While this study has focused primarily on older adults, there remains a subset of inpatients who, although hospitalised for medical reasons, are generally fit and active — children and younger people. For these individuals, prolonged bed rest may result in a disproportionate loss of strength and function. Where clinically appropriate, these patients could benefit from structured access to the therapy space to reduce the effects of deconditioning during their stay.
Additionally, the design should explore ways to support staff health and wellbeing. With appropriate safeguards and an initial induction, the gym could be made available to staff during out-of-hours periods (e.g. 17:00—08:00), providing a valuable opportunity for physical activity either post-shift or during overnight breaks. This approach aligns with NHS workforce wellbeing goals and contributes to a more holistic and sustainable use of the estate.
Although paediatric inpatients were not the focus of this study, they were excluded on the basis that they typically require less support for discharge, and deconditioning is not a significant barrier to their hospital stay. However, we did explore opportunities within modern paediatric ward templates to promote mobilisation and physical activity during admission. A modern 32 bed paediatric ward is already designed with several dedicated spaces that could support physical activity and rehabilitation, including: breakout areas, adolescent lounge, play therapy room sensory room, and school room.
With thoughtful design and appropriate equipment planning, these spaces could incorporate exercise or mobility focused equipment tailored to children’s needs and developmental stages. Furthermore, where outdoor space is available, the inclusion of a small, outdoor gym similar to those found in public parks could provide an engaging and age-appropriate way to encourage movement and support recovery during a child or young persons’ hospital stay.
A clear path to better recovery
We have a responsibility as healthcare planners and providers to create spaces that promote health and independence, not just treat illness. Designing hospitals that keep patients moving is not only aligned with public health goals, but also is a clinical necessity.
Ten days of immobility in hospital can equate to a significant irreversible muscle and strength loss in older adults. Nearly half of delayed discharges are linked to patient deconditioning, not medical need. We can change this. Embedding acute inpatient therapy spaces into hospital design isn’t just best practice, it’s essential to meeting the NHS’s goals for safe, efficient, and more personalised care.
Now is the time to build, test, and scale these solutions across our acute care environments. Mobilisation is medicine and our new hospital spaces must reflect that.