"It’s the sort of place I would not mind going on holiday"
Both professionals and service users are singing high praises about the new therapeutic and light and airy mental health units springing up around the country. Are they really that good, asks Adam James?
January 7, 2010
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Mental health care has moved on in the Norwich suburb of Hellesdon.
The Norwich Pauper Lunatic Asylum which “held” 350 patients was built there in 1880. The institution had 100 single rooms, the rest being dormitories each for between four and 16 patients. Patients worked on the 50 acres of land, which was surrounded by high perimeter railings. The asylum had been designed by architect Richard Phipson, then known more for his attention to detail than creativity. His asylum design used the then fashionable "block system" as a template i.e. detached buildings connected by corridors.
Roll forward to July last year - the month that Norfolk and Waveney Mental Health Trust finished its spanking new £9.4million mental health facility on the grounds of the asylum’s cricket pitch. The trust’s chair Maggie Wheeler proclaimed that the two-ward psychiatric intensive care unit, called Justin Gardner House, resembled more a health spa than a psychiatric facility. “When we first came up with the design we said, let's not think mental health ward, let's think spa,” she said.
Indeed, since 1992 more than £2billion has been spent in England renewing what’s called the “mental health estate”. It has been – says the government - the most significant capital investment programme since the founding of the NHS in 1948. The Department of Health says there have been 25 major mental health builds costing more than £10m each. This totals £600m, with the other £1.4bn spent on smaller builds.
As almost every service user would testify, the design of a mental health unit is vital to facilitate a safe and therapeutic environment. “Indeed, there’s a wealth of evidence of how building design aids recovery – a better environment brings about better behaviour,” says Paul Rooney joint national acute care programme lead for the Care Services Improvement Partnership and the National Mental Health Development Unit.
NHS trusts have a large degree of autonomy when deciding on mental health unit design. But some aspects remain fundamental - rooms should be light and airy; a calm and therapeutic environment should be promoted while also ensuring patient safety; patients and carers should be widely consulted.
Justin Gardner House – consisting of a 10-bed intensive care ward, and a 12-bed low-secure unit – exemplifies this. Financed from the trust’s own reserves and a loan it is the result of five years of planning and consultation. London-based MAAP architects, renowned for supporting progressive mental health environments, was the trust’s design partner. “Plus, we are not a PFI build which I think gave us greater control” says Denise Zandbergen, project manager for Justin Gardner House. “And we ended up by being around £1m under-budget,” she adds.
Another example of contemporary mental health design is Langley Green, a £16.2million 69-bed four-ward psychiatric intensive care hospital in Crawley which opened in September 2008.
Langley Green psychiatric intensive care unit in
Crawley, Sussex. More like a hotel?
Christine Bowman, associate director for projects at West Sussex Health and Social Care Trust, told Mental Health Today how Langley Green was built “so I would be happy if a member of my family was admitted.” She said: “People walk in and think ‘crikey, this has been built like a hotel!’”
Indeed, that new units be judged on whether the mentally well would be willing to be admitted is paramount. “What is a building that we would like to stay in? That is the vital question,” says Mungo Smith of MAAP architects. “If it is not good enough for us why should it be good for anyone else. It should be about offering a bit of solitude - like a retreat or oasis”
Another priority is single ensuite rooms - all the more vital given that mixed-sex wards are universally accepted to be at best detrimental, at worst harmful. The government has promised that any wards not providing satisfactory single sex accommodation will from this year be fined.
Airy rooms and corridors with plenty of light are also all the rage for new-builds. In with light pastille colours, high ceilings, windows looking onto courtyard gardens. Out with long dark, windowless clinical corridors.
“We wanted our corridors to be not just about getting from A to B,” explains Ms Zandbergen. “They are part of a therapeutic environment – if they are light, airy and wide people can sit there, instead of just in their bedrooms and day room.”
In a further bid to cultivate a calming environment, wood has replaced external brick walls in many new-builds. Courtyard gardens are always accessible, instead of areas where patients need permission to go to. At Justin Gardner House, for example, window seats have been placed outside each patient room. “The idea of coming out of a bedroom can be a big thing for some people. So the window seat can help that transition,” says Ms Zandbergen.
As for Langley Green Hospital, when entering visitors find a contemporary café and two faith rooms called “sacred spaces”. There is a women-only lounge and a gym, plus a poets’ corner where people can sit looking out into a water garden. The hospital also commissioned local artists and sculptors to design interior artworks and garden water features. “Every inch of the building and grounds benefits from art projects specially-commissioned through the trust which use ideas from people who use services. The result is an inspirational environment to work in and one which will support people’s recovery,” says Ms Bowman. Justin Gardner House also has a multi-faith room, including an area where Muslims can wash their feet. CCTV cameras are unobtrusive.
Safety, however, still remains a top concern. Ensuite rooms are designed, for example, to minimise risks of self-harm. Details include curtain rails not being able to take heavy weights; doors opening both ways to prevent patients from barricading themselves in; staff being able to turn off electrics and water in each bathroom which themselves have no ligature points.
Such is the importance of getting the design of new-build mental health units right that at Justin Gardner House and Langley Green the plan-to-completion process took five years.
Justin Gardner House used a 30-person design reference group of architects, quantity surveyors, representatives from the trust’s estate department, service users, carers and clinical staff.
Ms Zandbergen, who felt NHS documentation was “too prescriptive”, emphasises how important architect input is. “Our architect, Chris Shaw, helped create enthusiasm,” she said.
Service user involvement and consultation is always crucial for new-builds. “It’s unimaginable to think any new-build could avoid it. Service users – as well as staff – should feel a sense of ownership of the process,” says Mr Rooney.
At Justin Gardner House, service users, supported by building designers, made a point of opposing any traditional glass-walled nursing station. It has come to be seen as representative as all that is oppressive of psychiatric units. Service user groups detest Nurse Ratched-style observation units which foster a “them versus us” environment. Justin Gardner House has no such nursing station.
“Because of their [patient] input we did not have that kind of nursing station which can create a feeling of them and us with patients knocking on the glass to attract attention. It was a point of tension. Instead we got a room where staff can do administrative work,” said Ms Zandbergen. Staff take their breaks in a rest room.
Bob Murphy, chair of our Hellesdon’s service user council, confirmed the positive impression given by Ms Zandbergen. He also agreed that the trust took on board patient concerns around positioning of the seclusion room and colours and artwork.
“For example, we wanted to try and avoid splashes of red and certain kinds of patterns in any artwork where people in psychosis might see faces. The project team listened to all of this,” said Murphy.
But, come on, surely there must be some negatives to Justin Gardner House? Apparently not. “Everything has been thought of really. It’s the sort of place I would not mind going on holiday,” says Mr Murphy.
Nevertheless, it is only in 2008 that the Mental Health Act Commission reported that acute adult mental health wards in England and Wales are “tougher and scarier” places than they were 10 years ago. And professor Dinesh Bhugra, president of the Royal College of Psychiatrists, said of mental health inpatient units: “I would not use them, and neither would I let any of my relatives do so.”
So, while some patients may be reaping the benefits from highly-acclaimed design overhauls at units such as Justin Gardner House, such experiences are evidently not common place. It is something Mr Smith is happy to confirm. “I have found the whole experience of being on psychiatric units really quite miserable – even to this day it’s not much better,” he says. “However involved we are, we are only as good as our [mental health provider] clients.”
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Enlightened design?
* Ships of fools – in the Middle Ages madmen in Germany were expelled from towns and handed over to sailors. “Often the cities of Europe must have seen these ships of fools approaching their harbours,” wrote Michel Foucault in Madness and Civilization.
* Confinement – in 1575 a law stated that one house of correction per county should be built for the mad. Chains and dungeons were standard.
* Asylums - these huge self-sufficient multi-acre Victorian institutions, complete with landscaped gardens, were designed to be elegant and beautiful and less like a jail. Colney Hatch Lunatic Asylum in Barnet, north London, housed 3,500 patients. Patient work included cleaning, baking, carpentry, shoemaking, and farming.
* Light and airey - in 2008 the Department of Health published its 45-page Laying the Foundations workbook to assist in re-design of NHS adult acute mental health services. It emphasises a “generous provision” of circulation space to reduce a “pressure cooker” atmosphere. Sex separation is “fundamental” to achieving a safe and therapeutic environment. There should also be a dedicated space for visiting children, located adjacent to the ward, with sufficient play materials. The workbook states that service users have the right to receive care in a safe environment that is smoke-free and free from drug and alcohol misuse. The National Association of Psychiatric Intensive Care Units (NAPICU) is listed as a useful source of advice and information.
* This article originally appeared in Mental Health Today magazine
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Window dressing?
From: Phil Barker, honorary professor of medicine, nursing and dentistry, University of Dundee, Scotland
Date: January 13, 2010
This all sounds very impressive, so congratulations all round. However, as someone who is very visually-driven I often wonder what it would be like if I was blind (or grossly visually-impaired in PC terms). What would any of these visual aesthetics mean?
I suspect that most of this design/architecture stuff is just window dressing. The big question is: How would the 'team' make me feel? If you are saying that the team 'needs' a state-of-the-art building in order to care for me, then it doesn't say much for them. On the other hand, some of the most amazing professional people I have know, worked in some of the most awful physcial settings.
The fascination with architecture and design is just another reflection of our supeficical contemporary culture. "All fur coat and no drawers" as the saying goes.
By all means replicate this wonderful building If you have oodles of money to spare. But if you haven't, don't think that 'good' staff can make a silk purse out of a sow's ear. I know hundreds who did just that. It is easy to put up a plaque on a wall to recognise 'good design', but rarely are professional staff 'decorated' in anything like the same way.
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Physical comfort goes so far
From: Lousie Pembroke, service user, London
Date: January 14, 2010
I certainly appreciate a clean and comfortable environment. Enough chairs and spaces for people and ensuite facilitites are certainly conducive to a better physical environment as compared to the overly brightly-lit rabbit hutches with no privacy which are all too common of city acute units.
However, this is all very well, but what is changing in terms of staff-patient contact, routine use of close obs, and choice [not mandatory] of meaningful activity?
The physical comfort matters but only so far. People still need people, someone to have meaningful conversation with, human comfort and support. I've visited wards where there is no staff-patient contact other than at meal/medication times and during emergencies.
Shortage of staff is a problem, so staff become understandably demoralised and in their shoes, so would I. Then the culture of inpatient care is a problem, waiting for the medication to 'work' and not simply 'being with' people in distress, listening, reflecting, which doesn't have to be a set 'intervention' - perhaps better not to be really. Then there's the amount of paperwork all nurses [in all fields] are expected to produce. How much of that contributes to patient care? Then nurses are wasted on 'door duties' or escorting people somewhere for a cigarette. Surely good design could at least eliminate the latter.
As for wards being locked to stop people from absconding or vulnerable people leaving to hurt themselves - this can happen without a locked door. I'm not sure that a locked ward door truly benefits anyone. These are some of the issues which really need attention alongside decor because these are issues which make or break an admission for a person.
