Green Theatre Seminars

We will present research on the significance of the physical environment for health and well-being in various closed settings such as forensic psychiatry, youth homes (SiS), and prisons.
Moreover, we will propose design suggestions that may have the potential to improve people’s wellbeing and health in these settings.

The healthcare environment serves as an active agent in the rehabilitation and habilitation of patients in psychiatric closed care. The design of the physical environment in psychiatric settings has been compared to the need for high-tech equipment in somatic healthcare. The physical environment itself becomes both a tool and support for patients and staff, primarily through its stress-reducing function, as highlighted by the field of Evidence Based Design (EBD). Our research shows that the environment can support the therapeutic alliance between patient/client and staff, especially by conveying a sense of trust, security, and autonomy. It is also reasonable to assume that the environment itself can reinforce or "redirect" and change the identity we carry.

The staff constitutes the essence of the care provided, and therefore, their need for a safe and secure working environment should be an integral part of the environment's design. Only then can the conditions for good care and interpersonal encounters be established.

In any closed facility the feeling of confinement is at the forefront, accompanied by many losses. The question is whether the environment can compensate for these losses, or at least not exacerbate them. Despite the limited living conditions within institutional care, there are ample opportunities through environmental design to promote well-being. We see that physical and mental health could be positively influenced by designs that encourage e.g. physical movement both indoors and outdoors, a better designed sleep environment, and not least a sense of belonging.

It is well recognised that in secure mental health inpatient units, boredom leads to challenging behaviours and poor physical health. This presentation will explore how considered planning and design can ensure ‘a meaningful day’ for all patients, promoting recovery through activity. The newly completed Sycamore at Northgate Hospital will be used as a case study to demonstrate this principle, with insight on the building design from Paul Yeomans (Medical Architecture).

Reflections on the new £32m Aspen Wood Low Secure Learning Disabilities Unit Project, Maghull, for Mersey Care NHS Foundation Trust. Including national context re LD services, service aspirations/key drivers, Service user engagement, cross sector learnings, Sensory design, security challenges, Landscape design, the Arts, construction delivery through COVID. Lessons learned/Influence and on two subsequent GDA LD specific projects currently in design in Lancashire and the Black Country (ie Blundell Brooke LD Unit and Heath Lane LD recovery Hub). Continuity of briefing/risk approach across different Trust clients. Finally, lessons learned and impact on wider Mental Health design best practice not just LD.

The Safe Home Environment Assessment (SHEA) was developed as a pragmatic way to capture risk issues and sensory preferences that need to be considered when designing a more bespoke home for someone. It was originally focused on the transforming care agenda where suitable housing has been acknowledged to be one of the potential barriers to someone leaving hospital.

Over the last 12 months the teams at Gilling Dod, Kingsway Group and Britplas have undertaken research, development, and collaboration to explore patient centred design around next generation CAMHS bedroom environments and in particular design responses around Autism, Neurodiversity and eating disorders.  The project is a vehicle to stimulate meaningful engagement and collaboration with a broad range of Service users, Experts by Experience, Clinical practitioners, carers, and providers in the sector. To give service user voices a platform, to stimulate design innovation/insight/learning and bring in supply chain experts/innovators to respond to bespoke needs. Aim was to create an innovative, responsive, sensory bedroom concept design which could be used to promote discussion/feedback/insights/learnings via real world mock ups to be encountered/explored/evolved with stakeholders moving forward.

Key to this project was engagement and we approached this is numerous ways. POE from previous CAMHS clients, reaching out to MH charities, advocates and champions in the field, and approaching leading figures in Autism centred services. This included The Caudwell Children’s charity who we have worked with collaboratively in developing the brief and even taking part in their Family fun day event meeting/engaging with young people, families, ambassadors and clinical practitioners to understand the key issues/drivers/triggers. Same experts then helped refine the initial concepts into a working design.

Designs were then developed with an assembled group of innovative suppliers (Kingsway Group, Britplas, Pineapple, Thorlux etc) to help create actual 1 to 1 mock up located either end of the country and with a view to engaging with key stakeholders over time to help evolve the understanding/stimulate the conversation. A chance to challenge the norm, go beyond the P23 repeatable room model, and promote design aspiration and expectations on MH build projects across all pathways.

Patients with mental health disorders could find themselves in the emergency department in their most vulnerable state. However, CQC research has identified that these patients have a poorer perceived experience than other patient groups.

Increasingly, the physical needs for patients with mental health disorder in the emergency pathway have been addressed and dedicated places of safety are provided in the department. However, what have we put in place to safeguard a patient's psychological well-being in these environments?

As an architect and a service user, I would like to share personal experience of using these spaces in the emergency departments and the subsequent design project I undertook to redesign a mental health patient assessment room. This research project included testimonies from service users, families and ward staff.

This talk will highlight the benefits of broad collaboration, the importance of a strong relationship with stakeholders and securing post-occupancy feedback. It reflects on the rewards and difficulties of applying a Grounded Theory research methodology as opposed to a conventional building process.

Ty Llidiard: 15-bed Child/Adolescent Mental Health (CAMHS) regional admission hospital unit in Bridgend.

• 2019: went into level 4 enhanced monitoring (‘special measures’ highest level) over quality, safety, leadership and culture concerns.
• Undertook intensive 4Cs work programme to change the unit’s culture and physical environment to address concerns and improve staff and young people’s (YP) mental health and wellbeing.
• 2023: de-escalated to level 0 care group monitoring.

Challenges

• Meaningful engagement with demoralised and demotivated staff, following intense scrutiny/investigation for 4 years, and Covid-19.
• Coproducing with YP aged 12-17 with wide range of behavioural/emotional/health needs.
• Very large, hexagon-shaped building with mostly white, cold-looking, segmented clinical spaces.
• Funding - no models/precedent for similar transformation programme in health board.

Ingredients for success

• Unit lead trusted by health board, able to define and communicate vision and commission specialist delivery team. Worked with Scarlet Design creating visual identity and 4Cs philosophy: Caring, Compassionate, Calm, Confident.
• Genuinely coproduced - engagement events, including on-site event with 65+ people, extensive consultation with past and present service-users, carers, staff and stakeholders, collecting 300+ survey responses.
• Unit lead understood the amount/type of physical environment change required to achieve aims.
• Building transformation plan created at start, delivered in stages to evidence impact, build trust and source funding.
• Visual identity that could extend across large unit.

Impact

4Cs identity, rainbow tree with birds logo and woodland scene applied across unit:
• Giant 4Cs scenes in connecting corridors, waiting spaces, meeting rooms
• External/internal entrances redesigned, providing welcoming environment, improving ‘first impressions’.
• Staffroom and outdoor spaces redesigned
• Ward office relocated to building centre creating a central square, improving interaction and observation for staff and YP - graffiti wall requested by YP.
• on YP door name-plates, office/lift doors, staff uniforms/lockers.

Staff feel valued, with improved retention and sickness reduction; YP feeling listened to and empowered, with improved outcomes.

- Outlining the vision to create an outstanding environment for healthcare, research, innovation, and education, achieved with true co production.

The presentation will focus on how we have started a complex journey in realising a shared vision and ambitious plans driven by a unique collaboration between an NHS Foundation Trust, the oldest university in the English speaking work, and a philanthropist.
To create a mental health hospital, offering the best therapies, care, and a therapeutic environment that provides the best opportunity for recovery, co-located with global brain health research facilities and a new post-graduate college that educates future generations of clinicians and researchers.
Demonstrate how we have worked with a number of interested parties across the partnership and how we have sought to engage and achieve true co production.
Sought to achieve leading design and innovation within the built environment of a site that will not only meld Healthcare, research and education but also span 200 years of architecture.
How we have endeavoured to do that sympathetically while also learning important lessons from the past and enhancing the knowledge base for the future. An environment that is ambitious in its aim to vastly improve patient and staff experience and one that will truly promote mental health and wellbeing.
How we are using clinically driven design based on the input from our staff and experts by experience in our plan to develop a new hospital that, if approved, will deliver world-leading care for patients in Oxfordshire and beyond.

Laura will be presenting the findings from two systematic literature reviews that she has led and delivered to inform the development of the mental healthcare built environment (mHBE) Quality Assessment Tool produced by NHS Scotland Assure and the Scottish Government. The systematic literature reviews identified, critically assessed and synthetised existing research on the factors of the facility design that (1^st literature review) act as a therapeutic intervention for service users, and (2^nd literature review) impact or are important to staff. The focus of both reviews is on adult mental health inpatient settings.

In this session, Raf Hamaizia, Lived Experience Lead for Cygnet Healthcare, will explore the importance of Co-production within the built environment. Using Cygnet’s coproduction toolkit as a basis, he will give examples of how it can be used to improve environments, patient safety as well as peoples experiences and their well-being.

The audience will be left to explore different and innovative ways of working such as harnessing talents and abilities of the workforce and people with lived experience in dedicated roles such as the Co-production Artist at Cygnet Health Care.

This presentation will involve: input from a CAMHS Consultant Psychiatrist and Medical Architecture.

The theme will be the journey of developing the case for and the design of a CAMHS PICU in Poole, Dorset. The presenters will bring together the patient experience, the clinical need, the operational drivers, and the design piece.

The recognised shortage of CAMHS PICU beds nationally, makes this a live issue. The proposed new-build PICU will have a number of state-of-the art therapeutic spaces. The focus of the sessions will be about relating design, to the PICU clinical model and patient experience.

An audit of mental health patients carried out by Lewisham & Greenwich NHS Trust in August 2019 found that more than half of the people who went to emergency departments (EDs) for help because of their mental health waited more than four hours to get the right care. One in seven spent more than 12 hours in ED, exposing patients, NHS staff and visitors to additional stress. This figure is probably far greater now.
The project involves collaborative working between the Queen Elizabeth Hospital (QEH) and Oxleas NHS Foundation Trust, to improve the collaboration and partnership between mental health departments and ED teams. The new area will allow mental health patients to receive higher quality care by providing them with a specialised area for their specific needs, staffed by specialist nurses from Oxleas.
The new Mental Health Assessment Area (MHAA) at QEH will offer the local population a suitable and safe environment for patients who present in crisis, in which to be assessed and treated whilst awaiting next steps in their care pathway or whilst awaiting transfer into a clinically appropriate environment. This will give a better patient experience by removing patients from the overly stimulating ED environment and by allowing patients to access therapeutic intervention.
The presentation will focus on the collaboration and partnership of the MH and EDs teams and in specific on two of the biggest challenges which were:
• To find and agree on a location within the existing and busy hospital to host the new MHAA, considering the importance of the relationship with the EDs and mental health teams, and
• The consultation with all the different groups of stakeholders to build strong ERs and to deliver a mental health friendly and functional environment which can work for all the stakeholders.

We are all the experts on ourselves. Ideally, we need to stay within our homes and communities. However, if a facility is needed it needs to feel comfortable and the person needs the space and opportunity to learn who they are. Let’s be open to the idea that western psychiatry is not necessarily the right answer for some and maybe multi-cultural approaches can be beneficial.

Several studies departing from the experiential worlds of patients and staff have explored the links between the architectural design of forensic psychiatric buildings and the patient recovery process. Others have proposed models of how psychiatric wards may be designed to reduce stress and aggression. Nevertheless, one of the most prominent recommendations in the literature concerning psychiatric hospital design is to minimize the institutional atmosphere and instead promote a more homelike environment. Even though current literature has affirmed the importance of the physical environment in supporting better outcomes in mental health services, more rigorous research is needed to establish the link between structural surroundings and mental health outcomes.
In November 2018, the psychiatric Aarhus University Hospital (AUH), dating back to 1852, relocated to a new modern purpose-built psychiatric hospital. The relocation presents a unique opportunity to examine the effect of structural surroundings on aggression and how the physical environment may impact recovery.

Aim of study
To explore how inpatients and staff in medium secure forensic psychiatric wards experience the structural environment, focusing on homeliness and how the structural surroundings may impact recovery and aggression.

Methods
The study design is mixed-method. We perform semi-structured interviews with staff and patients, collect structural data from official blueprints and building databases on the old and new forensic wards. Interview data will be coded in Nivivo12 and analyzed using thematic analysis inspired by the literature on patient recovery. We depart from a model of how architecture may support the reduction of aggression in wards and evaluate what kind/if critical architectural features are recognized as essential to minimize the risk of aggression.

Results
Will be presented and discussed at the conference.

In 2020, The NHS declared its journey to net zero vision. This ambitious vision includes mile-stone targets for an 80% reduction in the carbon footprint by 2028-2032 and a 100% reduction in the carbon footprint by 2040 (net zero carbon performance). Achieving these targets demands that we collaborate, acting now, acting decisively, and acting correctly.

This is a great ambition, and it must be delivered whilst maintaining a patient first approach to health care. Based on feedback from service users given in the 2021 Designing in Mental Health Conference, the environmental condition within rooms has a pronounced effect on patient well-being, health and recovery.

Following the successful response to our presentation at last year's conference we would like to come back and present further findings over the year and how current net zero carbon thinking is affecting service user experience.

Architecture is a discipline that helps organise environments to suit the user's requirements and needs. This is fundamental to our design philosophy, none more so than when we work on mental health projects. We believe that creating autism friendly environments is central to any scheme and that, no more, should people with autism have to fight for their rights.
In many cases we see that surrounding environments contribute to a person's disablement. The same person set in the right environment could then be seen as an able person.
The main design principles, which we apply to all our projects, have evolved through consultation and engagement with trustees, clinical staff, facility managers and, more importantly, in talking with and respecting people with autism and other learning difficulties and their families.
The presentation will focus on
• How to engage with people with Autism at the design stage
• Autism friendly colour palette research with Hilary Dalke at Kingston University
• Proxemics and sensory space perception
• Specific challenges: finding the right balance between a building that will resist challenging behaviour and the need of sensory stimulation to avoid self harming

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.

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.

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.

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.