Environmental health


A mental health building by Medical Architecture in north London took a simple, ‘first-principles’ design approach to providing access to external space and daylit interiors, as well as greater independence and wellness for users. James Parker reports

Blossom Court is a new acute mental health inpatient facility at St Ann’s Hospital, north London, which has been designed by Medical Architecture for Barnet, Enfield and Haringey Mental Health NHS Trust as a ‘therapeutic environment.’ That primarily means giving patients a variety of good quality indoor and outdoor space, to promote wellbeing and recovery, but also to improve the experience for staff.

The 74-bed facility comprises three adult acute wards and an eating disorders ward, tackling a different range of user needs. Shared accommodation includes visiting space, staff rest areas, and a multi-faith room. The building, opened in summer 2020, is part of a wider development of the site masterplanned by Medical Architecture, to create a cohesive, ‘people-focused’ healthcare campus.

Site context
The context of this scheme is familiar from many similar NHS projects, with the site having been ‘rationalised’ over many years, with some services moved to other locations. So much so, that by the project’s inception, almost half of the buildings were vacant. However, at the same time, maintaining this surplus estate was diverting funds away from healthcare.

The Care Quality Commission reported on the trust’s existing 1930s-built inpatient facilities, finding them outdated and inappropriate. The existing provision was lacking in several ways, explains project architect at Medical Architecture, Ruairi Reeves: “Corridors had no views out and there was no meaningful outdoor space. This created very internalised space; not good for anyone’s mental health.” He adds: “Wards on the upper storey were isolated from gardens on the ground floor, and gardens outside bedrooms on the ground floor meant these bedrooms had little sense of privacy.”

The trust sold its surplus land to the Mayor of London to be redeveloped for housing, to fund a widespread improvement in the healthcare facilities. With at least half of the new homes being designated as affordable, including dedicated units for key workers that staff might use, the resulting development will be an important way of serving local housing demand.

Reeves explains how the practice had worked with the trust on a design for a smaller inpatient building as part of a previous ‘consolidation’ of the site, but this never got off the ground. “The project was dormant for a number of years. During this time, we invested some of own time to develop a ‘what-if?’ sketch design to provide a vision for the consolidated hospital and prompt a conversation with key stakeholders.” The project was finally relaunched in 2017, and the architects were appointed through the NHS Procure22 framework as part of the team of the Principal Supply Chain Partner, Integrated Health Projects – a joint venture between contractors Sir Robert McAlpine and Vinci.

The architects report that a member of the clinical team commented early on that patients “commonly left mental health wards in worse physical health than when they arrived.” A key driver of this project therefore was to support the physical as well as mental wellbeing of users where possible, throughout the scheme.

People-focused masterplan
Medical Architecture worked closely with the trust to develop plans for a new two-storey building which would form the initial phase of a new healthcare campus. Reeves explains that the architects ran a series of workshops where clinicians were able to describe a typical day. “This helped inform the brief on what could be shared and where rooms needed to be. We talked through a number of concerns, particularly around visibility and observation.”

The ‘focus on people’ is manifested in several ways in the masterplan, including distributing roads and parking around the edge of the site, to keep cars away from users. The buildings are organised along a ‘boulevard,’ allowing activities to spill out and create an “activated street scene” – without adding risk.

To help create a connection with the local community, the original high perimeter wall was partly demolished, thereby creating a new opening connecting the boulevard with the local streets. The new building has also been designed to integrate aesthetically with the adjoining residential development, “adopting an architectural language that will complement high quality housing,” say its designers, while providing the appropriate security and privacy required for inpatient mental health services.

The facade has what the architects describe as a “simple” material palette of brickwork that has been specified to help the building blend with the local vernacular and retained buildings on the site, but also to be a robust solution that will age well. “We wanted to create a normalised environment,” says Reeves, helping explain the choice of a single, familiar cladding material. When addressing all the challenges of designing for mental health, he says

“The very environment can appear distorted, so the design has to integrate anti-ligature and anti-vandal features that are not conspicuous, so it doesn’t shout ‘mental health.’”

The hit and miss brick relief pattern around the windows draws attention to, and enhances, their generous size, while “creating a sense of play along the elevation,” say the architects. This required careful detailing and included building mock-ups to test whether it could be easily climbed. As well as bringing a “subtle play” to the elevations, it also “unifies elements such as the varying heights of doors and windows.”

The windows – ‘Safevent’ by Britplas – are some of the largest the supplier has ever installed, at 2.1 metres high. These address the ligature risks present while being able to be opened wide, behind a fine perforated steel mesh. This design allows good ventilation whilst providing security, including preventing the passing of any prohibited items. The architects also worked with the manufacturer to integrate a fine screen within the window that directs views at a controlled angle so that mutual privacy is maintained between users and those in a nearby housing development. The solution offers patients a view out to “something real,” say the architects – i.e. the sky and surrounding landscaping – that would not have been possible by simply using a translucent film.

Therapeutic design
Mental health services – and therefore the design of mental health wards – have a complex set of demands, but the architects resolved to tackle these with “a simple solution and an integrated approach.” The building isn’t designated as ‘secure,’ but the architects were required to design to ‘medium secure’ robustness standards due to the “growing acuity of patients being admitted,” says Reeves.

The four wards are arranged on both levels, around two private two-storey courtyards. The building’s two volumes are separated by a central garden, which can be seen through glazing from the main entrance, giving a reassuring glimpse of nature. The courtyards offer patients private views, as well as providing “abundant daylight and a positive focal point.” The ward plan is a straightforward loop, giving users two choices of route; assisting Covid-safe, one-way circulation.

This, say the architects, also “gives staff or patients the opportunity to back away from escalating and challenging situations.” Wards can also be subdivided, in order to separate patient groups if needed. The architects wanted to use generous levels of glazing to aid observation for staff, as well as provide a feeling of openness in areas such as corridors.

The ward corridors run around the perimeter of the courtyards, forming light-filled colonnades of a generous width. Each bedroom has a recessed threshold for privacy, with seating across the colonnade for clinicians or patients; the extra space allowing patients to pass one another with less potential for anxiety or tension.

There was an “involved” discussion between the designers and the clinicians around the location of the ward office, says Reeves – this being an area which tends to attract patients, potentially leading to a “pressure cooker” effect. With the architects seeking to address this “power dynamic between patients and staff,” a solution was arrived at of making it a less central feature.

“The model evolved that staff would be more active on the ward itself rather than based in the office; this allowed it to be located away from the main social area, closer to the ward entrance for direct observation of access to and from the ward.” It also has a “touchdown area” – a seated zone where patients could sit and chat that “gets away from the idea of a formal counter.”

Access to outdoor space
Providing easy access to good quality outdoor space was one of the architects’ fundamental design principles, a factor which has taken on heightened importance during Covid-19. As a result of the design, patients have access to the outside on both levels, and can enjoy the courtyards safely without supervision.

“Both storeys are configured to provide direct access to outdoor space without the need for direct staff supervision, something which was severely lacking in the previous inpatient facilities,” say the architects. Facilitating this new level of autonomy reduces pressure on staff and removes potential sources of conflict and frustration.

The ground floor opens onto the courtyard, with a deep overhang in front of the dining and activity rooms that provides shade as well as shelter. Above, this supports a first floor terrace that is enclosed with a curtain wall, providing a space that feels larger than it is, giving expansive views over the courtyard beyond and below.

Promoting holistic health & wellbeing
As part of a general focus on keeping patients physically active, a variety of appropriately ‘inclusive’ exercise equipment is provided to the courtyards – both on the glazed terrace and on the first floor level. With their greater independence, patients are able to do healthy activity outdoors at a time that suits them.

The layout allows daylight to reach into the core of the building, enabling users to feel a “connection with the hours of the day, the seasons, and the changing weather,” say the architects. The interiors have been designed to provide “calm, organic environments,” with natural oak finishes where feasible.

Futureproofing & sustainability
The building has been designed with efficiency in mind, but also to be as flexible and adaptable as possible for future changes to the trust’s healthcare provision. Wards are designed to a standard template, and stacked to share risers, but that standardisation allows services to “swap or adapt in the future,” say the architects. Medical Architecture’s masterplan also provides a “route for future redevelopment of further inpatient accommodation with an additional three blocks.”

Passive design measures used include “low-tech solutions to control the internal environment,” including tall ceilings, high level window vents, and exposed thermal mass to reduce summer overheating. Substantial amounts of insulation to the envelope are supplemented by air source heat pumps and a roof “covered” with PV panels, but concealed behind the parapet – all contributing to the building’s BREEAM Excellent score.

In addition to the renewable energy measures, and low-energy use design, use of natural materials where possible (such as oak finishes internally) helped contribute to the BREEAM score. However, so did the building’s promotion of physical health, including how the open, prominent stair helps encourage users to use it rather than the lift. Good views, enhanced by increased biodiversity, and access to outdoor space are further contributors. In addition, many windows can be opened safely to provide natural ventilation.

Achieving the balance between safety, security and high-quality environments for users and staff in acute mental health units is never easy. However Medical Architecture deployed their deep knowledge to transform the provision at St Ann’s Hospital, to provide a sense of space, and independence to users and staff. Not only that, a focus on healthy activities alongside wellness meant the unit can offer a different level of support to hopefully ensure that users leave the unit in a better physical state than they arrived in.

Part of the success of this project is down to the “great involvement” of clinicians with the design process, says Reeves, including the architects sharing VR visualisations, and providing a series of room mock-ups during design development, before the contract’s ‘guaranteed maximum price’ was arrived at. “We were able to refine the design, then post-GMP, work with subcontractors, particularly windows and joinery, to get the details just right.”

Testimony from one user shows the power of a simple, ‘first-principles’ approach to better quality environments: “The design of the new wards with ensuite bathrooms, more daylight and views of nature will reduce patient stress, anxiety and pain. This will all help to shorten the time service users need to stay.”

The real proof is that since opening, the project architect says the hospital has had “significantly lower levels” of incidents where patients needed to be secluded or tranquilised,” and physical restraint has “almost entirely stopped.”