With mental ill health rising and models of care evolving, we need new facilities that fulfil modern mental healthcare requirements. Jonathan Puddle of Aecom and Wendy de Silva of IBI Group explain the design considerations and cost drivers and break down the costs of an example facility
01 / Introduction
One in four people will experience a diagnosable mental health problem in any given year. This means most people will be either personally affected or close to someone affected by mental health issues. The Mental Health Foundation has said that if urgent action is not taken, depression will be the leading cause of disease burden globally by 2030.
The human and societal costs of those affected are immeasurable – and the economic costs are startling. All are equally unsustainable. Mental health problems represent the largest single cause of disability in the UK, with an estimated cost to the economy of £105bn a year.
NHS England analysis has found the national cost of dedicated mental health support and services across government departments in England totals £34bn a year, excluding dementia and substance abuse. Some £19bn of this is government spending, with the balance provided by unpaid carers and the private and voluntary sectors.
For centuries stigma, discrimination and the marginalisation of people with mental health problems have been rife. However, the past 50 years have seen significant transformation, with new models of care, the development of new drugs and a move away from acute hospital care to community-based care.
More recently, growing awareness and a more positive attitude towards mental health has stimulated further change. High-profile support from politicians including the prime minister, Theresa May, and the Heads Together Campaign fronted by some of the younger members of the Royal Family has raised awareness of the nation’s widespread mental health issues.
The growing understanding that people with mental health conditions benefit enormously from early intervention and timely support, and that this support is most effectively delivered in the home or in community settings, is changing the model of care. More care will be delivered in the community and less in acute inpatient settings.
This is better not only for the service user, their carers and families but also for the taxpayer. According to NHS benchmarking data reported by the commission to review provision of acute inpatient psychiatric care for adults, it is it is anything from 18 to 44 times cheaper to provide care in an outpatient setting than it is in an inpatient one, depending on the particular mental health condition.
02 / Government policy
Simon Stevens, chief executive of NHS England, commissioned a report by the independent Mental Health Taskforce which resulted in the publication in February 2016 of the Five Year Forward View for Mental Health.
The report identified the need for a step change to deliver improved access to high-quality care, more integrated services and a focus on prevention coupled with earlier interventions. It said that mental health should achieve parity with physical health, meaning that problems are prevented and treated with the same commitment as is given to tackling physical health issues. Priorities include reshaping care delivery, improving access to the right care at the right time, addressing imbalances in care quality and improving outcomes.
The Five Year Forward View set out a challenging 10-year plan to deliver improvement, with an ambitious aim to close the care gap through ensuring a million more people with mental health problems are able to access high-quality care by 2020/21. It also identified a need to invest an additional £1bn at the end of the 10 years to generate significant savings.
The report also urged provision of an integrated mental and physical health approach whereby people with physical health problems can be offered advice and support to ensure their mental wellbeing is catered for to ensure the best chances of recovery. Equally, people with mental health problems should also be able to access advice on physical wellbeing.
Mental health services have been promised disproportionately more of the NHS budget over the next few years. Estates directors from several mental health trusts have said that they have not yet had sight of this promised additional funding. However, they are cautiously optimistic that, as promised in the NHS Long Term Plan published this January, it will arrive over the next few spending rounds.
The report emphasised that significant human and economic value could be gained from earlier intervention, investment in improved and equal access to effective and quality evidence-based care and integrating the care of people’s mental and physical health and wellbeing.
The report also underlined that improved outcomes cannot be achieved by the NHS alone. This can only be done in partnership with NHS organisations working with local authorities, the education sector, housing providers, the voluntary sector and other supporting organisations.
A Consistent and Cohesive Approach
The implementation of NHS England’s Five Year Forward View for Mental Health requires a co-ordinated and cohesive local approach. Local plans are developed by Sustainability and Transformation Partnerships (STP) that were formed between local councils and the NHS across England in 2016 to develop integrated proposals to improve health and care. Common principles to achieve the aims and objectives set out by the independent Mental Health Taskforce include:
- Co-production of plans with people who have real experience of services alongside their families and carers
- Working in partnership with other organisations.
- Identifying needs and intervening at the earliest possible opportunity
- Designing and delivering person-centred care, underpinned by evidence.
- Underpinning commitments through outcome-focused, intelligent and data-driven commissioning.
03 / An evolving landscape
Children and young people
Today the NHS is challenged to care for people with complex issues across the age spectrum, from young children through to older people.
The Five Year Forward View for Mental Health states one in 10 children between the ages of five and 16 has a diagnosable mental health problem and 50% of all mental health problems have been established by the age of 14, rising to 75% by age 24. In response to such alarming statistics, in July 2018 the government published a green paper, Transforming Children and Young People’s Mental Health Provision.
One initiative that has emerged as a result of the green paper is the creation of designated senior leads for mental health in schools and colleges. Another is ensuring teachers have access to appropriate training as they are often one of the first to recognise and support school children’s mental health needs.
An ageing population
At the other end of the age spectrum, dementia is now the leading cause of death in England and Wales. There are around 850,000 sufferers in total across the whole of the UK.
The considerable economic cost associated with the disease is estimated at £23bn a year, and this is predicted to triple by 2040. The Alzheimer’s Society reports that two-thirds of people with dementia live in the community in their own homes, while one-third live in a care home.
Leading mental health academic researchers and clinicians are coming together to collaborate on solving the mental health challenges faced by the UK. In 2018, the UK’s top mental health researchers and clinicians joined forces across hospitals and universities to form a new National Institute for Health Research Mental Health Translational Research Collaboration, which works with industry and charity partners to find new treatments and therapies.
Other translational collaborations between clinicians and academics – sometimes in formal academic health partnerships, sometimes in more loosely formed groupings – are becoming increasingly common.
Community-based primary care models
A common thread running through the objectives of the Five Year Forward View for Mental Health is around building capacity within community-based services. This approach reduces demand on in-patient beds while moving the model for in-patient beds towards a more place-based approach so that care pathways are better aligned and efficiencies are more likely to be secured.
Recent statistics from the NHS underline the urgent need for people to be treated within their own communities. In 2018 there were 7,655 out-of-area placements made by mental health trusts, of which 96% were considered inappropriate. These out-of-area placements cost the NHS more than £112m, and the inappropriate placements among these accounted for £108m of this figure.
A survey of more than 1,000 GPs by charity Mind in June 2018 found two in five appointments involved mental health, while two in three GPs said the proportion of patients needing help with their mental health had increased in the previous 12 months. NHS England has committed to investing in an extra 3,000 mental health therapists based in primary care facilities, thereby supporting the drive for earlier intervention and offering a broader range of integrated services for patients within their communities.
The Welsh government is funding a £68m network of 19 health and care centres, bringing NHS and community services together. It is anticipated that councils, housing associations and the voluntary sector will be involved in the network, along with NHS services, in an effort to improve the care people receive closer to their homes by 2021.
The next section of this analysis and the cost model itself are based on adult mental health in-patient facilities
04 / Design guidance and technical standards
NHS design and technical guidance for the construction of health buildings is set out in Department of Health publications such as health building notes (HBN) and health technical memoranda (HTM). These explain the principles behind the design of different types of accommodation for people with a range of mental health conditions. While they do not dictate detailed building design, they often include useful guidance on space standards, accommodation requirements and environmental targets.
Mental health design guidance (in the form of HBN 03-01, HBN 03-02 and HBN 08-02) outlines the requirement for in-patient adult acute mental health units, child and adolescent mental health services and dementia-friendly health and social care environments respectively. Outpatient and community mental health guidance is contained within HBN 11-01 (on facilities for primary and community care services and HBN 12 (on outpatients departments).
In addition, the ProCure 22 NHS Framework’s principal supply chain partners have developed a number of repeatable room arrangements and standard components for use in mental health facilities, and all of these are compliant with HBNs and HTMs.
05 / Form
The majority of in-patient mental health facilities are single-storey buildings that provide direct access to outside spaces. However, achieving this preferred format sometimes proves difficult to achieve in city-centre locations, and consequently inventive work-arounds have to be found, such as by delivering multi-storey facilities with external space provided at upper levels.
The design of the buildings should create a comfortable and therapeutic environment for the patients, which includes maximising natural light and ventilation. This also means providing appropriate levels of safety and security.
Ward accommodation is normally designed to allow for between 15 and 18 service users per ward for adult accommodation and 10-12 service users per ward for child and adolescent accommodation.
Generic ward designs are becoming more common place as mental health trusts recognise that models of care change relatively frequently. Designing flexible accommodation that can meet changing demand, patient groups and models of care over the lifespan of a building makes good therapeutic and investment sense.
06 / Physical environment: design considerations
The environment provided by acute mental health services is a crucial element in the delivery of positive outcomes, patient safety and the safety of staff and the wider community. Key design criteria include:
Privacy and dignity
The design needs to strike the right balance between nursing observation of patients and the patients’ own privacy. Furthermore, consideration must be given to allow patient service users and their families their own space outside the bedroom or ward.
Access to external space
Invariably at the top of on any service user wish list is easy access to external space, which is very important for therapeutic mental health environments. Views out onto this space – which ideally would be landscaped – are also therapeutically important, along with good daylighting levels to day spaces and bedrooms.
When new external amenities and multi-use games areas for exercise were introduced at a facility in the Midlands, both obesity and anxiety levels fell dramatically among service users. Some of the best mental health units provide two distinctly different types of external space, accessible directly from the ward: one designed for activity and conviviality and the other for therapy and quiet contemplation.
External space is also particularly important in facilities for older people. Because senses play a large part in the lives of dementia patients, as memory is waning, making connections to a past life is more possible through the senses – the sense of smell when passing a rose garden or hearing birds on a table. For older men, “man sheds” have been very successful additions.
The right environment for sleep
Most people with mental health issues do not sleep well. Consequently, observation points from outside the bedroom, lighting levels and arrangements and noise levels need to be carefully considered to promote comfortable and uninterrupted sleep. Some facilities have started to introduce technology such as infra-red illuminators and optical sensors that monitor patients as they sleep and allow vital signs to be taken without disturbing them. Further innovative digital solutions will inevitably be incorporated into facilities over the next few years.
Where trusts have commissioned art programmes in parallel with new buildings, there have been some very positive results.
At Woodland View, NHS Ayrshire and Arran’s new 206-bedroom integrated acute mental health facility and community hospital at Ayrshire Central hospital, two arts co-ordinators worked closely with the trust to employ 14 different artists to engage with local community and service users from the various existing units to produce a number of different types of artwork – some sculptures in the woods, some changing displays of art in the main corridor spaces.
Workshops were undertaken with service users and local community users, enabling effective engagement before and during the building’s construction as well as on a routine basis after occupation. Art is seen as a key component to augment the delivery of services and inform design rather than something that happened after the completion of the building.
Ligature and robustness
A ligature point is anything that could be used to attach a cord, rope or other material for the purpose of self-harm. Therefore anti-ligature products are essential for the safety and wellbeing of patients. Everything in an inpatient unit should be risk-assessed.
Typically anti-ligature components include anti-climb drainpipes, security windows, doors and ironmongery of all types. Robustness also has to be built in. This usually includes a plywood backing to plasterboard walls and ceilings, bespoke extra-sturdy fixtures and fittings, specialist sanitary ware and light fittings.
A well-designed mental health unit, however, bears no visible sign of such measures, as specialist manufacturers have made significant strides forward to create products that are robust but also non-clinical in appearance.
Designing for dementia
A key principle when designing facilities for dementia sufferers is to mitigate the effects of confusion and create a sense of familiarity. Clear sightlines and way markers need to be provided in wards and subtle measures incorporated elsewhere.
Examples include: specifying cupboards with see-through doors; lit pathways from beds to bathrooms to minimise falls; wandering routes and destination points in wards; and clear identification of doors for general use while painting out FM doorways. Floor finishes need to be carefully specified because differences in tone can be perceived as holes that might stop patients from leaving their rooms.
The use of light to reinforce natural circadian rhythms is important for dementia sufferers, so attention must be paid to both natural light and the artificial lighting scheme. Touch often remains an acute faculty when other senses have diminished, so the finishes and textures within a room must be considered carefully to provide optimum level of stimulation to residents.
Technology-driven design firm IBI has been working with Kingsway, specialist manufacturer of mental health products, to develop an innovative “dementia doorway”, a customisable product that supports people living with dementia in multiple ways. It is being piloted in a new care home development at present, and, along with many other innovative products developed specially for the mental health market, will be on display at the Design in Mental Health Conference in Coventry on 21-22 May.
Embracing biophilic design – actively incorporating natural materials, natural light, vegetation, nature views and other experiences of the natural world into the modern built environment – is important for mental health facilities. This is particularly important in urban settings, where land and external space are at a premium.
Studies have shown that incorporating elements of nature into buildings can lessen stress and anxiety, reducing medication needs while enhancing wellbeing.
Wherever possible, the design intent should be for a naturally ventilated building featuring openable security windows with vents. Underfloor heating or ceiling-mounted radiant panels are usually provided to heat the building with localised, zoned controls to provide the patient with some control over their environment. For localised areas of high heat gain that require cooling, individual refrigerant-based systems are likely to be appropriate. Dedicated mechanical extraction is often required for kitchens, bathrooms and dirty utility areas.
All pipes, ventilation ducts and cabling in patient areas should be enclosed and designed to be accessible, where possible, from non-patient areas. Fire detectors, light fittings and ventilation grilles should be located out of reach of patients and appropriate tamper-proof fittings should be installed in patient areas.
Security systems such as staff attack alarms, CCTV and door access control will also be in use. In addition, staff should be able to control and isolate electrical power, lighting heating and water services to each patient bedroom and en-suite in case of emergency.
William Lauder, senior manager for inpatient (mental health) and forensic services at Ayrshire Central hospital, has observed the benefits of building design and functionality experienced at Woodland View, an integrated acute mental health facility and community hospital.
He says: “The building design and functionality of Woodland View has had a number of significant benefits – a reduction in staff running costs as the environment supports the delivery of high quality person-centred care in an appropriate environment; ready access to safe outside space reducing frustration among service users who may have restrictions to time off of the ward; no requirement to source out-of-area beds since opening due to flexibility of single room accommodation; reduction in adverse events with serious harm due to safer environment; sustained reduction in requirement for enhanced 1:1 observations resulting in reduction of 16.3 whole-time-equivalent staff compared with previous accommodation; being able to swing beds between wards with no material changes as care needs have developed.
“Service user feedback has also been very positive as to the new environment – describing feeling valued and that the new accommodation is ‘night and day’ in comparison with the previous environment, greatly enhancing their inpatient experience.”
07 / Stakeholder engagement
Stakeholder engagement is an essential pillar in the planning and implementation of a new mental health service and associated facility. Many stakeholder engagement sessions include clinicians, designers and NHS commissioners. More recently they have included service users, their families, carers and the organisations that represent them.
Engagement and co-production of plans with a wider group of stakeholders has produced tangible improvements to the therapeutic environment and in some instances has led to improved staff and service user engagement in care planning. Service users bring to the design perspectives of which clinicians and designers are often unaware and that prove to be beneficial all round.
Taking a lead from service user consultations, this type of methodology for sharing and gathering information has informed the design of many mental health facilities. The Design in Mental Health Network is shortly to publish guidance on this which will be launched at their conference on 21-22 May.
One example of this engagement is “emotional mapping”. This is an evidence-based technique, developed by design firm IBI’s TH!NK research division, used to better understand how people feel in certain spaces. The process helps understand the positive and negative aspects of a service or facility from a user viewpoint – for instance, the fact that a blue colour in a room can make the apparent temperature 4º colder than a warm colour in the same space.
An example of putting such findings into practice can be found in the process used in the design of a 123-bed unit in the north-west of England. At key points throughout the design process, meetings were set up with service users to explore ideas and understand their preferences. IBI designed activities that engaged the service users in a variety of ways, producing evidence that has informed the design of the building and the interiors. In addition to emotional mapping, these included sessions on users’ views on the external and internal environments and sensory responses to the design strategy.
08 / Lifecycle
Given the ongoing pressures on revenue budgets as well as capital budgets, operational costs continue to be scrutinised across all healthcare facilities. Where mental health facilities differ from other health facilities is the additional premium cost (including work disruption and security costs) of carrying out maintenance programmes of work within live, operational facilities.
Consequently, it is imperative during the planning and design phases that whole life cost analysis of solutions, systems and products are made including “spend to save” initiatives, which offset the initial capital costs through reduced operational and running costs. For example, in secure mental health units M&E plant maintenance must be designed to be undertaken outside clinical areas, and robust materials must be specified from the outset. In addition, the on-site workmanship must be to the highest standards in order to make sure the facility is handed over with zero defects and is easy to maintain.
09 / Key cost drivers
Generally, the more area that a building contains, the greater the capital cost. However, designing solely to HBN guidance can affect the therapeutic environment. Careful consideration must be given to incorporating daylighting, natural ventilation and single-loaded corridors that provide good levels of natural light and views out to external spaces.
Deviating from HBN guidance has both positive and negative revenue and operational effects. This was demonstrated by a mental health trust that decided to increase all its bedrooms with en-suites from 15m2 (as per HBN guidance) to 23.5m2. This enabled the trust to admit patients of all levels of mobility, resulting in never having to turn away a patient who required a larger room.
This decision resulted in the trust achieving the optimum 85% occupancy rate, with a positive effect on revenue. Conversely, other trusts have deviated from HBN guidance and driven areas too low, resulting in a loss of occupancy and higher levels of staffing and operational costs to provide more inpatient beds.
As stated above, where possible, the design intent should be a naturally ventilated building. Additional mechanical systems and cooling with associated BMS installations can have an impact on plant space and capital cost.
Consideration must also be given to the HTMs that have been developed for acute hospitals. Well-informed derogations can lead to considerable cost savings on mental health facilities if the client and design team has the expertise and confidence to consider this.
The robustness of products and the need for appropriate design solutions in line with statutory design guidance for mental health facilities all increase as the facility security levels rise from adult acute through medium to high security environments.
Higher security levels require significant increases in capital expenditure, on items such as anti-ligature products and specifications, security installations including nurse call and staff attack systems and CCTV along with security fencing solutions.
10 / About the cost model
The cost model is based on a new-build 49-bed adult acute mental health facility in the south-east of England. The building has a gross internal floor area of 4,258m2 and is aiming to achieve BREEAM “excellent”.
The following assumptions have been made in drawing up the cost model:
- No abnormal site or ground conditions
- Fixed bedroom furniture, loose fittings and equipment are not included
- Professional fees, statutory fees, other client non-construction contract costs and VAT are not included
- The costs reflect a two-stage competitive tender with a design and build contract and include for the contractor’s pre-construction stage services
- All costs in the model – materials and labour – are current at first quarter 2019 and based on an outer London location
- The rates in the cost model may need to be adjusted to account for specification, site conditions and constraints, procurement route and programme.
Download the cost model using the link below
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