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Asylum seekers with a difference

With mental health care high on the NHS agenda, the approaches not just of the old asylums but of much more recent care programmes are being rethought.

Barrie Evans reports from last week's 'With Design in Mind' conference at the RIBA

Mental health is now one of the NHS's four care priorities, alongside heart disease, cancer and care of older people. This is a significant change for what architect John Wells-Thorpe said has been the 'Cinderella of the health service'. It has been felt that 'there are no votes in mental healthcare', yet, currently, one in three referrals to surgeries and local health centres relates to mental health or distress.

Louis Appleby, national director for mental health in England at the Department of Health, told delegates at last week's 'With Design in Mind' conference at the RIBA that change is on the way. He said the strategic planning phase was over and that mental health had designated funding. Money had started to flow for refurbishment - many facilities were constructed before 1947 and 10 per cent of beds are still provided in asylum-type buildings. As with other areas of the health service, there is a move towards care in the community where possible. But with this transition comes the need for therapeutic day care and more acute residential facilities of varying levels of security, which may all be provided in adjacent buildings.

So what should the service offered in these buildings be like?

The core issue is to help build people's self-esteem, according to Robin Ford, for many years a 'service user' (what used to be called a 'patient').

Dignity and support are needed, a service that says that you are still a valued member of society. People in residential care also need something to do, and Ford praised the growing range of therapeutic arts and other activities often available.

As architect Mike Nightingale pointed out, the Victorian asylums got two things right, albeit for the wrong reasons - they often offered people contact with attractive landscapes, and also gave them things to do. He suggested current trends in activities could be more ambitious, not just therapeutic but sometimes more vocational.

Nightingale noted that today's building norms are very different from those of the Victorian era - units for about 45 people, in single, en suite rooms, hotel style, local, rather than remote. Even 10 years ago it seems we were still getting it very wrong. In a 2000 user survey by mental health charity MIND, which included recent buildings, 45 per cent said service buildings were depressing and bleak, and 30 per cent found them frightening.

The survey also found 68 per cent of people believed that visits from friends and family was the most important factor in their recovery, hence the value of the smaller, local, hotel-style approach. The wish list of those in residence, in addition to visits and activities, included interaction with staff, privacy, access to outside information (the internet, for example), security and gender separation (wanted especially by women). This latter wish, plus a desire for groupings on the grounds of ethnicity or other causes, and the need for different levels of care and secure segregation, all put a very high premium on designing flexibility into these buildings. We got it wrong even 10 years ago. Beyond today's more civilised approach, who can predict the exact care regimes in these buildings in 10 years' time?

For now, Ford cautioned architects to avoid big architectural statements. Some of the stigma of the 'loony bin' still exists, on which the not-in-my-back-yard tendency thrives.

In procuring these buildings, increasing emphasis is being put on user involvement in briefing, sometimes with specific local groups, sometimes with people who have developed more of an overview, such as Brian Ford. As Richard Brook of MIND pointed out, if you want anyone to give their time to working at shaping a building brief, you should be paying them for that time, that design input.

From the NHS side, chief executive Nigel Crisp admitted that the NHS 'needs to get better at being a customer'. As part of learning from experience, something he sees the NHS as being poor at, he is considering the approach of having strategic partnerships with a smaller number of suppliers, including designers.

Two case study schemes featured - Sevenacres on the Isle of Wight by Nightingale Associates and an old hospital site redevelopment under way in Birmingham by MAAP Architects. Sevenacres is on the St Mary's Hospital site on the Isle of Wight - though separate from the main buildings - surrounded by its own gardens and with some longer views.

It demonstrates clear legibility, small areas to meet and eat, it is single storey with relatively high ceilings and rooflighting, while having effective but not dominant surveillance, including a central staff station.

MAAP's Birmingham site comprises large grounds in an urban setting.

Much of the land has been sold off for housing. 'We took the best bits and gave the rest to the developer, ' said MAAP's Mungo Smith. By putting care units on the site perimeter, location in the community is achieved at a stroke.

As Susan Francis of the Medical Architecture Research Unit wrote of Sevenacres, it is 'not just about making new buildings with less obtrusive surveillance, it is about bringing normal life into the building'. Of mental health service users, think tank director Julia Neuberger suggested 'the esteem in which we hold them is a test of a civilised society'.

The MIND survey, 'Creating Accepting Communities', is at www. mind. org. uk/information (click on About Government Policy and scroll down to the Social Inclusion sub-head). The NHS plan is at www. nhs. uk/thenhsexplained/priorities. asp

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