The starting point to receiving mental healthcare support, can sometimes begin at a crisis point, with a police officer, working in partnership with the local health network, taking a person to a place of safety or 136 suite where they are assessed by a healthcare professional, within a 24-hour period to decide on next steps for treatment.
The Kings Fund reported that unfortunately, in the UK, people are not getting healthcare support early enough to prevent detention, despite national aims for interventions. This has led to a 45% increase in reported detention cases since 2017.1
The Royal College of Psychiatrists (RCPSYCH) document2 describes how there is a shortage of appropriate facilities and that more are needed to prevent inappropriate use of police custody and A&E departments and goes on to describe the need for enough rooms within the place of safety to meet the local need.
The law keeps evolving to try to protect patients and the public when moving people to places of safety, but the environment of the destination itself is only briefly mentioned in the Health Building Note3 and the RCPSYCH document2 with reference to some environmental factors, safety, robustness and observation. It appears the facility is seen as a place to contain, detain and assess rather than a place to potentially aid the recovery process.
The patient experience
It is noted by the RCPSYCH2 that more research is needed on the patient and carer experience in the UK in relation to 136 suites. What we have learnt in some cases is that this can be an extremely traumatising journey. Imagine being at a very low point in your life, being taken unwillingly into an unfamiliar environment?
Involuntary admission to a mental health patient in the UK is highly sensitive and has common issues with other countries relating to perceived coercion, dignity, and human rights. Since being taken to a place of safety is sometimes the gateway to people’s admission, this has potential to set the tone for their patient experience, severely impacting overall speed of recovery and duration of stay if committed into a mental health ward. Patient outcomes can vary with patients also going straight home after assessment.
Due to concern over safety features and lack of research on the benefits of providing a more therapeutic place of safety, it is often very basic in nature with bright lighting, reverberating due to the use of durable surfaces and often bland with very little in the sense of visual interest for fear of creating a triggering environment. There is also no evidence to support that an environment devoid of art, visual interest, high quality furniture and biophilic design is in anyway beneficial for 136 suites4. In fact, the opposite can be said for aiding recovery for general health and wellbeing.
How can we improve this experience and give people the best chance to de-escalate, enabling a rapid assessment? As designers, we should be looking for opportunities to humanise this journey from the point of entry to the facility.
Investing in Places of Safety
Although it might seem inappropriate to compare a Maggie’s Centre or a Macmillan Centre to a place of safety due to the nature of their use, there are still valuable comparisons to be made. These well-known charities afford an uplifted patient user experience by investing in high quality building materials, furniture, art and biophilic design, creating a welcoming and therapeutic experience for patients and relatives of those affected by cancer.
Imagine if a charity invested 30% of the construction value to uplift places of safety? What could be the possibilities and the impact on health benefits? What impact would this have on staff wellbeing and wider patient users? These are high stress and extremely emotional places accessed by the police, health workers, care givers and family. Arcadis’s emotional mapping tool has highlighted the critical moments as patients access these areas which would benefit from high investment.
Humanising Places of Safety
Arcadis Mental Health Experts have been working with NHS Trusts designing such facilities for over ten years gaining valuable experience co-designing with Experts by Experience. Hearing first-hand accounts from several perspectives of both patients and staff has enabled us to gain valuable insights into their lived experiences. Together with evidence-based design and human centric considerations such as neurodiversity, the senses, proxemics and biophilia we are discussing what the possibilities are to humanise and enhance the place of safety.
By focussing on the patient user experience and the senses, we look to infuse it with nature, art, visual interest, and choice, giving patient some control and autonomy over their environment which has also been associated with a reduced aggression. We will discuss what the benefits could be, such as achieving a more rapid de-escalation and an overall less traumatic experience for all.
‘Halcyon’ Meaning - Peaceful, gentle, calm and tranquil. Deriving from the Greek mythological bird called the Halcyon that had the power to calm rough ocean waves in order to nest.
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The private yet visually permeable building is aimed at reassuring patient users over their care upon the point of arrival. Manicured landscaping on arrival not only provides biophilic visual interest but also promotes a sense of care and quality.
Dual, symmetrical, pitched roofs are domestic in scale giving a less institutional feel. Horizontal lines in design have been known to promote calm, tranquility and trust which is reflected throughout. The limited architectural palette is simple to understand visually with natural finishes such as wood and natural stone pattern. Wood in particular is an important material providing an organic tactile experience, the grains and organic patterns in wood reflect back to our evolutionary past having a soothing effect on our wellbeing whilst providing a mindful experience of the present moment5. Real wood panelling in areas such as the public spaces and robust wood effect panelling in patient bedrooms could provide sanctuary, fostering psychological comfort.
Diffused lighting and a clear pathway leads the way to the front door where a non reflective glazed side panel offers a view inside showing the patient where the next part of their journey will be. The reception and waiting area is protected yet clearly visible, it smells of pine and there are forest, bird and water sounds, there is some evidence to suggest that forest sounds and smells lower anxiety and stress levels67.
There is a sculptural form ahead, organic in shape, made of wood, calming, a place to retreat to, a comfy seat for a few minutes, the texture of the wood feels homely and warm. For all, and especially neurodivergent patient users, (one in seven people are neurodivergent in the UK8), building in organic forms, resembling trees, images of trees or a view of a tree has been evidenced to improve wellbeing.
In addition to feature lighting, diffused lighting within all areas of the building as standard is designed to meet circadian rhythm requirements. Known for its effects on the hypothalamus in controlling melatonin, affecting sleep quality, essential for wellbeing this is embedded into the design. Local controls mean that lighting can also be tailored to suit individual needs. This is particularly important for staff spending extended periods of time in the facility, enabling them to deliver better care. Roof lighting within deeper circulation areas help orientate the time of day and weather outside.
Circulation spaces are generous, more likely to meet the needs of individuals proxemics. Solid acoustic ceiling tiles throughout and timber baffles work together to prevent reverberations.
Private spaces
Upon entry to the private areas patient users are met with an immediate piece of calming biophilic art, proven to consistently reduce stress and blood pressure9 strategically located and bathed in natural light from an overhead roof light. This is also where observation takes place, a spacious area with a window view for staff. Privacy and dignity of patient users is maintained by offset vision panels used for observing patient users by staff.
Upon entering the assessment spaces an immediate garden view is visible. The assessment rooms are generous in size allowing plenty of space for interview and manoeuvring with choices for resting.
A fixed durable bed with soft bedhead cushioning and a fixed robust window seat, cushioned with tough fabric and with dining ledge create a more homelike environment whilst meeting safety standards. Blind spots are reduced due to strategic positioning of the bed assisting with observation.
Patients can control sounds, music, lighting levels and temperature. Evidence grounded theory in healthcare design by Ulrich explores how personalisation and opportunities for control of a patient’s environment may result in stress reduction and diminished aggressive behaviours10. The patient can also contact their family and friends. Further assessment rooms can be used flexibly to provide either a lounge space or sensory room depending on patient user need. All areas have ample views to nature and biophilic art.
Summary
Below is a quotation from Hannan Cadogan, Lecturer in Nursing at Roehampton University and Representative for Lived Experience at the College of Nursing, taken from the CQC ligature guidance overview.
‘As a nurse myself, I know how easy it is to concentrate on the measurable aspects of a risk or difficulty. You can easily create a tick box form to say you have door handles that can't be used as ligature point; in this you feel as a healthcare worker you can demonstrate you have reduced the risk, which feels like a job well done.
However, as a person who has suffered from severe mental illness and used mental health patients, I have learnt from my own lived experience that the interventions that are not so easily measurable, like therapeutic engagement, more often than not were the factors that reduced my risk of using a ligature.’
For the additional upfront capital costs of building in more beautiful spaces, could we see greater value in overall patient wellbeing and self-regulation affecting length of stay and overall recovery?
Might this environment enable staff to deliver better patient centric care form the outset?
What impact could this have on the long-standing issue of attracting staff including caregivers and police officers, increasing staff well-being, thereby reducing staff turnover and stress related illness which impacts revenue costs?
Can we challenge manufacturers to develop and test a more suitable pallet of materials that have the same robust qualities but provide more choice for designers and patient users?
References
1. The Kings Fund – Mental Health 360: Acute Mental Healthcare for Adults
2. Royal College of Psychiatrists – CR519
3. Health Building Note 03-01: Adult acute mental health 8.143
4. DiMH org – The Seclusion Issue
5. Medium – The Psychological impact of Wooden Interior Design
6. Injoon Song, Kwangsik Baek, Choyun Kim, Chorong Song- Effects of nature sounds on the attention and physiological and psychological relaxation
7. DiMH org – The Sound Issue
8. https://www.cuh.nhs.uk/our-people/neurodiversity-at-cuh/what-is-neurodiversity/
9. BMJ Journals - Evidence for the effects of viewing visual artworks on stress outcomes: a scoping review
10. Ulrich, Bogren, & Lundin, 2012– Psychiatric ward design can reduce aggressive behaviour
Further references
Department of Health, Code of Practice, Mental Health Act 1983
NICE – Assessment and Treatment under The Mental Health Act
https://www.brighton.ac.uk/_pdf/research/ssparc/jpmh-s136-paper-20141.pdf
Unsplash photo – credit to Maxim Hopman
