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Mental health and the NHS estate: putting it right

With toilets falling apart, poor soundproofing, and uncomfortably hard flooring, mental health facilities can often feel more like prisons than actual hospitals. Andy Bell, deputy chief executive at the Centre for Mental Health, outlines the three steps that must be taken to renew the currently unfit-for-purpose mental health estate.

In December 2018, the Independent Review of the Mental Health Act made a clear and unequivocal statement about the need for far-reaching improvements to the inpatient environments the NHS offers to people who are in hospital for mental health assessment and treatment.

It concluded that “people are often placed in some of the worst estate that the NHS has, just when they need the best,” and it called for major capital investment in renewing the mental health NHS estate to put this right.

The review noted that “the physical environment of wards… can create the kind of institutional atmosphere that psychiatry has been trying to move away from for the last half century because of its negative impact on patient experience. For example, rimless toilets, heavy wipe-clean armchairs, hard flooring, and bare walls that are easier to clean, but absorb little sound, make buildings oppressively noisy.

The review noted: “Poorly designed and maintained buildings obstruct recovery by making it difficult to engage in basic therapeutic activities (getting outdoors or social interaction with others) and contributing to a sense of containment and control.

Wards are experienced as cold and impersonal places that some say are more similar to a prison than a hospital – making a return to the community, with all its everyday stimuli and risks, more challenging.”

The review acknowledged that creating a safe, therapeutic, and effective environment is about much more than the physical fabric of an inpatient ward, or indeed any other place in which mental health care is provided. It exaplained: “Wards become people’s home, often for many months, and so should offer a positive community for the patient where they can build new relationships.”

“They should also support patients to keep connected to their communities and relationships outside of the hospital where that is appropriate. Ward culture should promote therapeutic benefit and minimise institutionalisation. Recruitment and retention of permanent staff at the right grades needs to be improved, and with ratios identified to ensure safety, a positive ward culture, and the development of meaningful therapeutic relationships.”

The three priorities

The challenge of renewing the NHS mental health estate is therefore one that requires action on a number of levels. First, we need to look at where services are located. NHS England has already committed to end out-of-area acute hospital admissions; and there is a growing acknowledgement that ‘locked rehabilitation’ wards (where people can spend many months and years far from home) and secure services also need to change fundamentally. We need to ensure the right balance of inpatient and community services is available locally in all areas to make it unnecessary for anyone to be sent away from home, or a local hospital bed, for anything but the most specialised treatment.

Second, we need to ensure the environments people are in are not just modern and fit-for-purpose, but that they are psychologically informed. This was a key theme in the recent Women’s Mental Health Taskforce report, which emphasised the importance of creating environments and practices within them that acknowledge the traumas many women have experienced and seek to avoid re-traumatising people.

And third, we need sufficient workers with the necessary skills, knowledge, and capabilities to meet people’s needs. Mental health nursing numbers have fallen steadily in recent years as the number of inpatient beds has reduced, while sickness and vacancy rates continue to be a major concern in mental health services (particularly acute inpatient.) We need to address these issues now in order to meet the objectives of the Five Year Forward View for Mental Health, and at the same time plan for the future mental health workforce, bringing in an ever-more diverse range of people, experiences, and skills to offer the best possible support in every setting.

Modernising the NHS mental health estate is an enormous challenge that will require attention not just to buildings, fixtures and fittings, but to the workforce, the culture, and the wellbeing of everyone involved. But it is a challenge we cannot ignore if we are to ensure people get the best possible care and support when they most need it.

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