Viewpoint: Shock Corridors

Shock

Corridors:

Bipolar mental healthcare planning and passive-aggressive design in the NHS

A review of the Architects for Health seminar ‘Context, Challenge and Creativity : Designing for Acute Mental Healthcare’ on 21 September 2006 at the King’s Fund, London.

Context

Current developments in British mental healthcare still show traces of their medieval origins. Scrolling through the Mental Health Timeline 1 reveals a saga of myths, beliefs, theories, investigations, Royal Commissions, legislation and, more recently, government guidance. Its a 700-year story of protecting of normalcy and segregation of the afflicted so they can be properly cared for, treated and, perhaps, cured. The route taken has been paved with good intentions, but the navigation has been by trial and error. Who went on trial and who made the errors are obviously matters for the Royal Colleges, not Architects for Health (AfH).

New developments in acute (inpatient) mental healthcare have been largely overshadowed by the 100-hospital building boom, so this seminar was organized to bring AfH members up to date. Broadly speaking the trend is towards smaller less ‘institutional’ projects within the community. MHU treatment is non-invasive, and there are no surgical, imaging, laboratory and sterile supply departments. The parameters for good MHU design were presented by Andrew Simpson 2, one of that rare breed of end-user client who takes the game out of the box, confident that the beancounters won’t value-engineer William Morris down to Laura Ashley. His criteria, coincidentally elaborated in Mind’s recent publication entitled ‘Building Solutions’ 11 include the need for safety, privacy, comfort, dignity, and the importance of gradients of intimacy (as propounded by Christopher Alexander 3 sixties Design Methods guru). There are, of course, detailed complications arising from the ergonomics of suicide – hooks are a no no. On the other hand, surveillance and safety are simplified by cctv and electronic gizmos. The consensus is that MHU;s are more like hotels than hospitals. This is not quite true: the balance between privacy and observation means they are like hotels in East Germany!


Springfield Village Regeneration Master Plan. MAAP

Queen Mary’s Hospital MHU, Roehampton. Devereux Architects

Woodhaven MHU, New Forest, Hampshire. Broadway Malyan


Ward concepts by Devereux


En-suite room concepts by Broadway Malyan

Challenges

Three schemes were presented:

  1. Springfield Village, a phased campus of inward focussed square donuts by Mungo Smith and MAAP 4,7
  2. Queen Mary’s Hospital MHU, a 2-storey rooftop addition to a general hospital, by Nic Allen and Devereux Architects 5,8
  3. Woodhaven MHU, a single-storey pavilion in a park by Doug Attrill and Broadway Malyan. 6,9

Springfield is a fascinating regeneration plan to weave new mental healthcare, commercial and residential building into a new urban fabric. Nonetheless, If we accept that smaller, less institutional and community settings are the overarching parameters, these schemes present unmistakeable signs of systemic bipolarity. Having raised our expectations, Mr Simpson owes it to his architects to explain to us why:

  • If smaller really is better, why will Springfield’s modest Phase A eventually be surrounded on three sides by a complete mental health campus, big and, inevitably institutional?
  • If less institutional is better, isn’t Queen Mary’s a lame duck from the start?

And Simpson’s counterparts should explain why, if being in the community is critical to recovery regimes, how can they achieve this in the green and pleasant lands at Woodhaven?

Trusts are in a hell of a bind. Struggling to stay afloat in the new internal healthcare market, praying that patient choice doesn’t mean patient flight, torn between tariffs and targets. And however adept Trusts may be at resource planning and facility planning – and these are not now nor have they ever been the same thing – Trusts simply don’t have the muscle or agility to buy into town centres or the overheated residential property markets. As an agent told me, ‘If they’re afraid of the big dogs they’ll have to stay on the veranda!’ The veranda is, inevitably, a Trust’s own property, usually the grounds of the asylum that is to be replaced.

Shifting healthcare of all kinds into the community is one of Secretary Hewitt’s main rally cries these days. CABE thinks it jolly important too. And I think it is too. every time I walk past the brand new retail units near the bus stops, on my way to my GP who hides in the obscurity of the side street. Getting GP’s to offer more. Stay open, and appear hygienic let alone into locations that positively contribute to the officially desired vibrant high street still seems beyond our reach. Unless and until our borough planning departments can find the staff to draw up town centre and neighbourhood plans and design briefs, the fate of community healthcare will be in the hands of property developers. They would love to have healthcare tenants – great covenant, planning gain and a great match with retail because they have different and therefore non-competitive parking peaks. We need less rhetoric, joined-up procedures and some clout to make this real. But if they were to try, my guess is that we would not only get mental healthcare closer to the community, but it would have to be smaller and less institutional too.

Whether a Trust decides it can’t relocate into the community or not, or that it will bring the community closer to it’s MHU’s, which is what Springfield is all about, architects will always be challenged by prior strategic decisions that compromise design options. But like anyone else the architect is only the true hero under fire. But they also have to contend with the medieval dilemma of loyalty to both church and state – today, however, the state bares it’s soul in the church of private finance. Challenge the Hospital Building Note gospels or the 4,500 stone tablets of the Activity Data Base and you can expect the inquisition, Spanish, Swedish or French. It is not only that the money-lenders are back in the temple, but also the fact that planning, briefing and commissioning is now in the hands of tens of thousands of born-again internal market converts.


Springfield ward layout by MAAP

Queen mary’s ward layout by Devereux

Woodhaven ward layout by Broadway Malyan

Table One

Creativity

After a year nibbling at salads AfH has finally got back to the meat and potatoes of real building design. What the three schemes show is that it is possible to run the DoH gauntlet and still produce diverse, indeed opposing, design solutions to roughly the same brief. Table One gives the architects’ answers to a short questionnaire I sent them after the seminar. It is a snapshot only, a handy reference when comparing their plans.

The main elements in these schemes are en-suite single-patient rooms (red), group activity areas (yellow), and a variety of offices and consultation rooms (lavender) and one exam / treatment room built to conform with DoH ADB XO 104 – electric shock treatment. ECT may not be medieval in origin but it is without doubt medieval in effect: no matter how benign the MHU décor may be, with or without William Morris touches. Patients must surely know that, just as uncooperative or hysterical residents are called to a chat with Big Brother, they too can be taken on the long walk to hell. ECT is still current. Statistics show that the administration of ECT is really a matter of psychiatrist preference, not patient condition. The question is whether interior design can ever mitigate incipient terror.

It takes one kind of creativity to win a healthcare project, another to design within the parameters, another again to again to make an environment that maintains the pretence that there is no electric hell. I suspect many MHU designers would counter this by asking what they can possibly do to reduce the anxieties of a resident population with such diverse perceptions, obsessions and compulsions, chilled out or hopped up.

It was interesting to hear John Wells-Thorp stress the importance of environmental cognition theories. This, and Andrew Simpson’s citation of Alexander’s Pattern Language, suggests that interest in the way the built environment is perceived is still strong, despite the rise of evidence-only dogma. This is great news because in the big brash world of PFI general hospitals, design theory has been dumbed down to the wow factor.


Woodhaven by Braodway Malyon

Woodhaven by Braodway Malyon

Queen Mary’s by Devereux

Queen Mary’s by Devereux
Whether anyone comes forward with a design version of the double helix that allows us to analyze and predict design meaning remains to be seen. Meanwhile, there is a growing body of knowledge to dip into. For instance, a couple of speakers at the seminar said that colour is subjective. I refer them to CHER 10 who offer a CD on this subject for $35.00. Another speaker said they tried to stick to natural ventilation throughout their schemes, yet Building Solutions 11 reports that MHU patients’ number one complaint is that it is usually too hot and smell too bad, and they can’t do anything to about it, a chilling reminder that good therapeutic environments depend on good science, not just arts and crafts.

Obviously site conditions have had a huge influence on the way a similar brief, encapsulating a similar concept of care, has been translated into designs. Springfield is the latest version of a quadrangle concept that MAAP has been reinventing in a succession of schemes for around fifteen years.

At Springfield itself the urban density of the masterplan and a sloping site have lead to back-to-back quads further complicated by steps in cross-section. The end product appears to exceed the net-to-gross benchmarks, not by accident but because MAAP have lobbied long and hard about the functional merits and therapeutic benefits of their plans.

Queen Mary’s, Devereux had to add the MHU onto the rooftop of a bigger scheme they were already designing. Fitting it all in has meant a tight squeeze, aggravated by the decision to keep it well inboard from the parapet. As I understand it, it was for reasons of privacy and discretion.

At first glance the plan is a potentially confusing labyrinth – the sort of plan that needs lots of signage – but it is in reality a series of gated communities where wanderers will find access denied.

The plan at Woodhaven, a pavilion on a park, is an essay in angular invention, origami on a grand scale, and it’s two internal courts are incidental to the main aim of maxing the views out.


Springfield Design sketches by MAAP


Ospedale Degli Inocenti Florence 1419 by Filippo Brunelleschi

Are the differences alone result in different patient recovery outcomes? One of these days we’ll get some post-occupancy evaluation that may show how one works better than the other. It is a marvellous case study for someone like Roger Ulrich to bring CSI Miami into the MHU. Here and now, however, are some observations on the architecture as it has been presented, and a few questions:

Woodhaven is a great example of expressive composition, achieving a rousing crescendo in volume, in every sense. It is extrovert and unapologetically a building that happens to house an MHU.

By accident of siting and because of striking design Woodhaven is a piece of real estate that could, if circumstances were ever to change, be sold off. Re-use is a serious matter for everyone except DoH.

DoH assume that (a) today’s new hospitals will still be in great nick in thirty years time and (b) they will continue to be used for the same purposes in sixty years from now. They approve plans without exit strategies. What are they thinking?

If Woodhaven expresses it’s function in form, what does Queen Mary’s tell us? The general hospital is in safe British brick with discreet residential windows, while the supposedly less institutional MHU is proto-modem white with glass block and the over sailing flat roof comes with modish retro holes. If anyone still has a copy of ‘Ad-hocism: The Case for Improvisation’ 12 it must be Devereux. Yes, form follows function, but not because they are stapled together.

Finally, back to Springfield: quadrangles are as old as any of our civilizations, but for hospital architects the iconic image must be Brunelleschi’s Ospedale Degli Innocenti. 13 It incorporates a colonnaded single-loaded corridor – a perfect place for a contemplative stroll – which creates the gradient in intimacy between the surrounding building and the central piazzetta. The centre must be different. It should be a delight.

Creating such a space and then filling most of it in, is a victory for the mundane. Winning dispensations on size, and cost, only makes the mundane bigger. Why why why do I start thinking CLASP? Wow may be dumbed-down but it is still something. The point In architecture is spatial foreplay, penetration and climax. That’s why we build courtyards and why we put fountains in them.

Phil Gusack
phil@gusack.com


  1. http://www.mdx.ac.uk – page no longer available
  2. Director of Planning at the South West London and St. George’s Mental Health NHS Trust
  3. http://www.patternlanguage.com
  4. http://www.medicalarchitecture.com
  5. http://www.devereux.co.uk
  6. http://www.broadwaymalyan.com
  7. http://www.swlstg-tr.nhs.uk
  8. http://www.nhs.uk – page no longer available
  9. http://www.hantspt.nhs.uk – page no longer available
  10. http://www.cheresearch.org
  11. http://www.mind.org.uk
  12. Charles Jencks and Nathan Silver, 1972 (ISBN: 0385016174)
  13. http://www.bluffton.edu – page no longer available

Context, Challenges and Creativity

Context, Challenges and Creativity: Designing for Acute Mental Healthcare
Presented by Architects for Health on Thursday 21 September 2006 at the King’s Fund, 11-13 Cavendish Square, London, W1G 0AN

Sponsored by Dräger Medical

AfH are pleased to have a group of speakers to discuss the issues and share their experiences in providing facilities for the Acute Mentally Ill.

They will be presenting two recently completed and a proposed scheme to show how they have responded to their particular context, whilst demonstrating innovation and creativity in responding to the challenges offered in designing for this care group.


L to R: Chairman Mike Barrett, The Panel, Andrew Simpson

Chairman

Mike Barrett, OBE, Non Executive Director of the Trust Board of South London and Maudsley NHS Trust, and Ex- Chief Executive of The Great Britain Sasakawa Foundation

Speakers

Andrew Simpson, Director of Planning at the South West London and St. George’s Mental Health NHS Trust, who will be setting the scene and describing the challenges which new Mental Health facilities need to meet;

Mungo Smith, Director, MAAP architects, who, with Andrew, have been developing proposals for Springfield Village, a scheme to redevelop and provide a new inpatient mental health hospital for the Springfield Hospital in Tooting, Southwest London;

Nic Allen, Director, Devereux Architects, will be talking about the newly completed mental health unit for the same Trust at Queen Mary’s Hospital, Roehampton, an LDSA award winning building and unique facility of it’s type.

Doug Attrill, Director of Healthcare at Broadway Malyan, and
Sarah Leonard, the Modern Matron from Hampshire Partnership NHS Trust will present the Woodhaven Mental Health Unit for Tatchbury Mount Hospital in the New Forest. This scheme was awarded an NHS Building Better healthcare Award in 2004 for best designed Mental Health Facility.


The audience