8 June 2023 Seminars

This Presentation from Scottish Government Assoc. Chief Nursing Officer Mark Richards (and potentially Susan Grant Principal Architect NHSScotland) is on the development and pilot of a new tool to assess the quality and safety of NHSS mental health estate environments.

It is an update of NHSScotland's 2022 DIMH Conf presentation on self-harm reduction learning from Scotland, which recommended the above tool development. July 2022 Scottish Government Mental Health Directorate created a multi-agency & disciplinary Short Life Working Group to enable delivery of an environmental assessment tool specific to the mental health estate.

Group stakeholders include clinicians, people with lived experience, facility and design professionals, and health and safety experts. The work of the group will be underpinned by consideration of a literature review focused on the impact of mental health facility design on service users and staff. Initial pilot testing of the tool is due Spring 2023.

We selected: 3. Policy, Research and Standard, as this tool will likely be a mandated 'Standard' following pilot via a new NHSS Guidance publication (e.g. HBN / SHPN). However, this specific presentation actually encompasses all 8 of the conference themes, and therefore is likely best suited to a keynote session.

Since early 2021, a team within Sussex Partnership have taken an in-depth look at what it means for acute adult mental health wards to be 'Autism Friendly'. The team used a fully collaborative process, with Occupational Therapists, Speech and Language Therapists and Experts by Experience (EbEs) working alongside ward teams, Trust Estates and Facilities, project management and contracted teams on planned ward refurbishments, as well as future projects within the Trust.

The project had three key elements of focus: Environment; Training and Practice. This workshop will focus on the Environmental element of the project, explaining the background to the project (why now? why at all?); our process; findings and recommendations and will challenge attendees to consider how this can apply to their own work in the future.

Environmental aspects - the physical and sensory experience of the ward - were the starting point of the project, and drove huge changes within the planned refurbishments to ensure that the Expert by Experience voice was at the centre of the project.
A sensory environmental audit tool was used to assess two acute adult mental health wards, and recommendations were made by clinicians and EbEs, alongside the most up to date rapidly expanding research, to improve the experience of admission for autistic service users.
The team ensured that incorporated decision making was central to the whole process and the impact of this has been reflected upon by all involved.
The project has produced various guidelines that suggest 'standards' for good practice for each of the project elements. Within this workshop we will share relevant items when considering the impact of sensory aspects of hospital ward environments for individuals who are autistic, and may have sensory sensitivities.
We hope that this workshop will empower attendees to re-think their preconceptions about the inclusive design process, EbE involvement and future project output to maximise benefit for those who are neurodivergent using mental health services, and how this can ultimately benefit all users.

Format:
• PowerPoint presentation - 2x in-person speakers (clinicians), with Expert-by-Experience support TBC
• Interactive talk
• Small group activity - to discuss how recommendations could be applied and what is one thing they will take away to use/reflections
• Feedback
• Individual reflection

Please register for your place at the workshop on site

Stonebow - Acute Adult Inpatient Hospital Hereford

We spent a day talking to staff and patients to understand the challenges faced by the current service. We are carrying out some design and construction work to improve the unit and are gather some thoughts and views on how we can make the ward environment better. We will follow up with a staff and patient survey based on the observations to benchmark the improvements works will make by revisiting the unit once the works are complete for feedback and to collect evidence measures. Carrying out this process will help understand how design can impact and make improvements on the working and living environment.

The study has captured thoughts and views against the following categories
- Observation
- Privacy and dignity
- Recovery
- Staff culture
- Environment

The design opportunities in response gives areas for qualitative and evidence measures that can be captured through desktop studies and feedback forms for staff and patients.

There are three patient groups for the study
- Mortimer ward 21 bedded Adult Acute
- Jenny Lind 8 bedded mixed Older Adult Functional
- Cantaloupe ward 10 bedded Older Adult Organic

We design our built environment and the places we inhabit to meet a series of technical standards, developed to accommodate diversity through built form and to provide spaces that support physical ability, motor, visual and auditory impairments.
In developing truly inclusive environments, we need to support the mind and the needs of people who experience sensory and neurological differences. Designing for the mind should be considered an enriching and integral part of the design process.

This presentation will investigate Neurodiversity and its complexity with unusual insights revealing some of the enhanced abilities and extraordinary skill sets of this group. How can design underpin Neurodiversity by creating inclusive spaces that support health and wellbeing in our community and as individuals?

Will we be choreographing environments to be sensorially and technologically responsive as well as adaptive to multiple neural and sensory landscapes. Could we benefit from such design tools as Hypo/Hyper Sensory Scales, Emotional Mapping, Sensory Plans, Proxemics and Sense Sensitive Design supported by Evidence Based Research. Where would these insights take us? What does good look like in tomorrow's new world of design?

Informed Choices is a testing standard to reliably assess the suitability of products for use in mental health environments.

The standard has been developed by the Design in Mental Health Network in partnership with Building Research Establishment (BRE), working with experts from the field. Rather than a pass or fail test, it is a way to grade products for a range of clinical uses so that teams can make more informed choices.

Frank Ellis will examine the implications of the standard from the specifier and client perspective, whilst Laura Critien will give practical insight about the product testing and manufacture.

Facilities for children and young people's mental health services need to accommodate a particularly diverse patient group. How do we do this well?

For example
The difference in maturity from someone 4 vs. 18 is significantly different, far greater than throughout working-adult age: 18 to 65. How do we create an environment that feels appropriate for all in this age group?

• The size of furniture, and height of fixtures and fittings vary depending on age and size.
• At earlier ages, children may not need to be separated by gender, however separation becomes necessary at older ages, as they become aware of their own sexual identity.
• There are a diverse range of patients within children and young people's mental health services with differing mental health needs. Learning disabilities vs. eating disorders, and acute vs. forensic services have quite different requirements, as do does the spectrum of neurodiversity and autism.

Challenge
• How do we accommodate specific needs of this diverse group while retaining long term flexibility?
• Can we design something that caters for all needs without looking or feeling different?
• What is the right balance between dedicated facilities that address specific needs vs. shared facilities.
• How do we separate quite different patient groups within the same ward?

Book your workshop place on site. 

On July 16th 2022, the 988 Crisis Hotline will activate, allowing a nationwide network of crisis centers & support facilities across America to respond in concert.
With the funding provided by the Behavioral Crisis Services Expansion Act, among other bills recently passed and soon to be signed, we've prototyped design and planning approaches for the evolving mental health crisis system in the US.
At the time of this submission , some communities will only use the 988 number as a standalone hotline. Approximately 60% of communities will have a plan to coordinate with clinical care organizations or providers in some capacity.
Of these, a mere 28% of communities will have access to urgent care units for mental health or similar facility services.
Emergency Departments across the US are often crowded and ill equipped to treat this vulnerable patient population. It is all too common to hear that a patient can spend days in a small 10'x10' secure holding room with no access to daylight or nature. Thankfully, health systems and public policymakers are responding to these trends. Government funding for treatment programs and medical research has increased over the years, with billions allocated for the Substance Abuse and Mental Health Services Administration (SAMHSA) to implement crisis stabilization efforts, resulting in greater capital investment in behavioral health facilities by health systems nationwide.
This has catalyzed a growing trend of standalone Psych EDs and Crisis Stabilization centers across the country to divert these cases from hospitals or law enforcement settings to more appropriate, therapeutic environment.
This "Alameda" approach has proven that these high-functioning crisis response centers can eliminate ED boarding as well as increase access to care while decreasing wait times, resulting in fewer inpatient admissions (up to 75%) and overall decreased health costs. Stantec is on the forefront of designing behavioral and mental health facilities that lessen stigma, challenge barriers to treatment and social determinants of health. The need for patient-centered, cost effective, empathetic care drives our behavioral health practice today.
Attendees will learn how applying evidenced-based behavioral health practices can lead to better outcomes and shorter lengths of stay. Architecture and the built environment can support best practice medicine and a patient in crisis by creating calming environments with a focus on de-escalation, not re-traumatization. Increasingly, designers and planners employ Trauma-Informed design principles to create spaces for patients that have a sense of dignity, respect, control, safety, and a connection to their community.
The session will cover trends that have manifested in US-based FGI 2022 guidelines for behavioral health crisis units following the "EmPATH" model. The EmPATH model is a concept that focuses on treating "patients in a calming, living room setting" with artwork, natural light, and sensory rooms" (Hoff). This dovetails with the use of subacute inpatient settings for crisis stabilization, which is often driven by the 16-bed count, below the regulatory threshold that more acute settings require. It is not uncommon to see multiple 16 bed "buildings" on a small campus or other distinctly separated in a facility to overcome this hurdle.
These are just a few design concepts for crisis diversion facilities we'll highlight from across North America.

Working with NHFT for over 10 years - Fleet will be sharing the work on 2 retrofit projects with the Trust - the first is a relocation of CAMHS into an existing PFI operated estate including a modest extension to accommodate art and education activities. The second is a respite residential care facility for guest from 4 to 16 years old derived from an existing and very tired Local Authority run facilty.

Both projects are a result of a very productive user-architect relationship and both push the limits of retro-upgrades to existing estate with distinct complications and limitations.

Focussing on the design and use of commercial, public and residential buildings the new BSI guidance document PAS 6463 Design for the mind (Neurodiversity and the built environment) recommends ways to make spaces accessible and inclusive to people who have differences in sensory processing. This may include people have been assessed as neurodivergent, people with a brain injury or those with a neurodegenerative health condition. Many others without a formal assessment are also negatively affected by the sensory impact of buildings.
This makes up a significant number of our population who may find buildings uncomfortable or difficult to use
Sensory overload is often a contributing factor; it raises stress levels and increases cognitive load, leading to anxiety and, in some cases, poor physical and mental health. Sound is often a key element in sensory overload and so acoustics and noise management forms an integral part of the PAS document
This presentation references the acoustic detail from the PAS guidance and uses example from refurbishment projects in public spaces including an interactive science museum, a children's centre and a community hall to showing in a practical way how good acoustic design can reduce or eliminate noise challenges, so helping to create places which are easy to use and where people can flourish.

Funding has been given by NHS England to make inpatient wards more therapeutic for people on the autistic spectrum. Many autistic people have sensory difficulties, where they are over-sensitive or under-sensitive to the world around them. The project is intended to focus on four wards to create change which can be applied across the remaining 50 plus wards in the Trust. The project will run from September 2021 to October 2022.
Organisations who are partners in the projects
Experts by experience (EBE Network) - To be part of the Task Force group to over see the implementation of changes.
Autism West Midlands - To deliver training to bring the experience of inpatient wards for people with LDA to life for ward teams.
Estates partners internal and external - To support estates solution and take forward practical changes to the environment.
Birmingham and Solihull CCG
The project aims to improve four (3 acute) inpatient ward environments to improve service user and family experience and clinical outcomes. It is also expected that paying attention to sensory impact will reduce distress and restrictive practice and improve the experience of care. The project has 4 main stages.
1 -Training of staff and the wider multi professional team to increase their awareness, knowledge, and skills in understanding the sensory impact of a ward environment and an ability to develop and put in place simple strategies to support patients in their recovery. This will also include identifying and training key staff to further increase skills to take a lead in the future.
2 -Establishing a task force (working with EBEs, current inpatients, external experts, estates team and the wider staff team) to identify and make changes to the ward environment. These changes will include the addition of equipment and physical adaptations to the environment.
3 -Making the changes and maintaining the momentum through a regular task force group and local weekly ward meetings.
4 -Measuring and understanding the impact of changes and sharing learning. The Trust use a quality improvement methodology which is suited to measuring the impact of the changes to allow learning and sharing across the Trust.

Many of our inpatient staff lack knowledge in this area and are therefore missing opportunities to make simple changes to reduce the negative impact of a ward environment. The project will seek to enhance staff knowledge and skills, identify, and deliver changes which will improve the environment to respond to the needs of service users in particular those with autism and / or learning disability whose recovery could be adversely affected by the environment. It is believed that through increasing our understanding of the experience of people with autism /LD we can make practical changes which will not only reduce distress, but also reduce restrictive practice improving the effectiveness of treatment, reducing length of stay and improving the experience of service users and their families.

Much of our estate is older and has not been designed with sensory considerations in mind and the physical environment can create stress due to noise, light, and a lack of soft furnishings. We believe this will also support the recovery of service users who do not have autism or LD and the well-being of staff who work in the ward setting.
Aims
Improved service user experience in an inpatient ward
Improved co production and a better understanding of the needs of individuals with autism and / or LD
Improved environment reducing distress and creating a calmer more therapeutic environment.
Reduced restrictive practice ie seclusion, restraint etc
Reduced incidents of self-harm, violence
Improve understanding of staff about the impact of the environment and how to regulate this for the benefit of all
Improve staff satisfaction and morale about working more effectively with this client group

There have been various change ideas that have been implemented

A thicket of useful knowledge has grown within the fields of planning and design for people who are experiencing mental illnesses and those that care for them.  This development of new learnings, research, and best practices has certainly been helpful in our work to improve care environments for both service users and care providers.  Nonetheless, at points along this journey a thoughtful clinician or designer might have had reason to pause and reflect for a moment about some of the contradictions that are inherent in our work and wonder how we might proceed without what we have currently accepted as a necessary dissonance.

Our focus on patient safety, as an example, can easily lead to environments that, while safe, are also some combination of sterile, featureless, or containing an abundance of alien (but safe) fixtures. Similarly, the vast literature on whether nurse stations/care desks should be open or closed is replete with seemingly contradictory impulses that either favor openness for clinician patient communication or enclosed to provide staff with the comfort of an impregnable safe place.   Can we have one without the other?  Where and how do we achieve a proper balance?

Our natural tendency to see and hear care providers and service users through the prism of their roles compounded by their own natural tendencies to speak and advocate from the place of those roles in the care process inevitably adds a series of very concrete project drivers and expectations that inevitably adds additional sources of transactional dissonance.  We all compartmentalize around what we see as our role in a given situation to the disadvantage of what we might see, understand, request or provide through the essential lens of our own basic humanity.  In a very real sense, this natural focus on roles and the needs arising from roles is a basic building block of stigma.

This presentation is the outcome of an ongoing personal conversation about how to cut through this thicket of knowledge and roles by finding a way to understand what is absolutely essential to a successful care process for both the service user and a care provider.  The presenter's thesis is that by taking the time to discern the essential, and then giving the essential priority in satisfying the needs of the important, we might create better environments with far less contradiction.

Our conversation will be about an ongoing working process; one where the path is more important than the current conclusions.  While these will be shared as a catalog of the important in the context of those essentials and a catalog of design examples as a response, that sharing is only meant to be  a start of a conversation about the need to attend to the important only in the context of the consideration of the essential.  The field will be more likely to come to agreement about the essential and the place of the important within those essentials if we in initiate a conversation among care providers, service users, and designers who are considering the problem from this perspective.

Designing a Digital Pathway for Severe Mental Illness

This design took place in an inner London borough with the 3^rd highest rate for severe mental illness in England. It was driven by feedback from people with lived experience of severe mental illness, who highlighted absence of care plans and support post discharge from secondary care.

The design solution involves a digital platform that supports people with severe mental illness to better manage their own care. The platform brings care elements such as health information, personal goals, journals, personal health budgets and psycho-educational materials all together in one place. It also enables the patient to dynamically interact with the people and organisations involved in their care and to move information seamlessly between organisations. The design was a result of a number of collaborative partnerships between people with lived experience, secondary care providers, primary care providers, the voluntary sector and the platform provider, Patients Know Best. The design of the pathway goes beyond the technological itself and involves clinicians making a cultural shift away from delivering care packages patients to, instead, co-producing goals with patients and supporting them through coaching to achieve their health goals.

The presentation by Rosemary Jenssen, Director Jenssen Architecture Ltd, will cover my personal perspective on:-

An update on the Mental Health Design Health Building Notes by the appointed Technical Co-Author.

Including work in progress on the Adult and C&YP Supplements for Low and Medium Secure, key changes and recommendations, Technical engagement feedback summary, design differentiations between services and "what good looks like". Next steps and future updates.

Coproduction has become a buzz phrase within the NHS mental health care. What does it really mean? How can designers, clinicians and architects truly meaningfully consult with people with lived experience – and get the most out of the experience to ensure that their plans are effectively coproduced? Issues of language and accessibility, hierarchy and interpretation all have a part to play – as does the role of peers and facilitators with lived experience in bringing out the voice of the service user in the area of design.

In this panel discussion, Raf Hamaizia Lived Experience Lead for Cygnet Healthcare and Emma Sithole, CEO The Recovery Foundation talk about their experience of meaningful coproduction, what constitutes and facilitates it, and how to maximise its impact in the built environment.

The provision for quality mental health facilities within our urban environments is a challenge many of our healthcare providers face. As our cities grown in scale and population, so do the mental health needs of residents - but how can we provide therapeutic, healing environments amongst the noise, chaos, and commotion of our urban settings?

Drawing on our work at the Pears Maudsley Centre for Children and Young People, we'll look at how we overcame the constraints of a dense urban site.

Learning points:

- Recognition of the requirement for densification for urban healthcare sites due to the worsening condition of the UK's mental health crisis. The growing mental health crisis in cities demands vast expansion on clinical mental health provisions. The existing building stock of the SLaM is no longer fit for purpose due to required growth in CAHMS services, with an estimated one in eight children suffering with mental health issues today.

- Explanation of the collaborative methods between clinicians and researchers which aim to reduce the requirement for projected physical expansion of estates. The Pears Maudsley Centre is designed as a collaborative hub accelerating the pace and societal impact of translational research offering a shift to preventative, as opposed to reactive treatment methods.

- Exploration of a design approach which enables both the densification of a site whilst retaining therapeutic environments and a connection with nature, and how a building with a briefed area of almost four times the area of its site can still meet the clinical requirements for a healthy and therapeutic environment.

'HBN 03-01 Adult mental health units: planning and design' states that 'Ground floor ward accommodation is recommended' but does not provide any further qualification. In this presentation, Mark will discuss principles and assumptions, drawing on a range of case studies that explore approaches to ground floor and multi-storey mental health accommodation, to test this statement.

Mark will review potential implications if the guidance is always taken at face value, and mental health inpatient accommodation is only provided in a single storey. These include:

• Cost and affordability
• Capacity, development density and site context
• De- stigmatisation of mental health services

Mark will also review some of the common challenges associated with multi-storey mental health that have contributed to the provision of the guidance. These include:

• Autonomy and access to outdoor space
• Safety and security (including fire)
• Staffing models

He will then demonstrate how these challenges can be overcome through thoughtful mental health facility design, drawing upon recent case studies that demonstrate cost-effective multi-storey mental health facilities that provide a therapeutic environment for the recovery of patients.

This includes evaluation of the performance of the Blossom Court inpatient unit at St Ann's Hospital which opened in 2020. The two-storey arrangement sees four wards stacked around two terraced courtyards, creating a therapeutic environment which promotes direct and independent access to outdoor space on both floors. Since completion, the Trust has reported that compared to the previous accommodation, seclusion and rapid tranquilisation of patients has significantly reduced, while physical restraint has almost entirely stopped, allowing better focus on the recovery of patients.