The spaces we live and work in have profound effects on our mental health. And the environment in which a mental health service operates can have a huge bearing on how it feels (for people receiving care, carers, and staff alike), how safe it is, and how much it helps people to heal and recover. Yet the physical fabric of these services (one of the first aspects of care that people encounter) is often overlooked, under prioritised, and too often absent from broader discussion about quality, outcomes, or investment.
The mental health services estate in the UK is on average older than the rest of the NHS. Despite decades of deinstitutionalisation, mental health inpatient environments are often closed off from their surroundings with little or no outdoor space, while community services are often in run-down buildings or locations that are hard to reach. Many are not conducive to providing trauma-informed care, or even respecting people’s most basic dignity.
Recently, Centre for Mental Health and the Design in Mental Health Network co-hosted a roundtable with a range of participants including experts by experience and practitioners from health, care, design, and the built environment, to explore what kind of physical fabric we should expect from mental health services in the (near) future. We wanted to prompt debate about the environments in which people should expect to be treated, and the kinds of spaces staff need to support their wellbeing. Despite evidence showing us that the built environment influences outcomes, safety and staff retention, good design of the environment is still too often treated as an afterthought. People have come to expect and often accept that healthcare environments will be unpleasant, stressful or dehumanising.
The message from that discussion was loud and clear. We need change. We too readily accept environments that are not good enough. But by bringing together experts by experience with clinical and design professionals, we could reimagine a very different mental health estate that worked for the people it serves and those who work in it. It is possible to create a good environment experience that supports healing, not further harms, in difficult times.
It’s easier to describe what we don’t want from the mental health estate than what we do. As one participant described, ‘buildings carry history’. Hospitals where people have experienced coercion, restraint, seclusion and distress continue to evoke those feelings long after they first happened. Trauma can shape how people perceive, navigate and respond to their environments especially when those spaces are intimidating, disorientating or emotionally cold. Poor design choices can unintentionally reinforce power, hierarchy and loss of control, even when the intention is care and protection.
Environments can heal or harm.
Those histories also live on in communities, where mental health hospitals are feared, stigmatised and misunderstood. Hospital buildings in particular can come with power dynamics wired into their design. They separate children from parents. Poor lighting, repetitive layouts and noisy environments were repeatedly highlighted by roundtable participants as contributors to distress, confusion and escalation. They rely on one-size-fits-all solutions that prioritise containment and physical safety, often at the expense of psychological wellbeing. Hospitalisation is seldom forgotten.
Community services may be less restrictive, but community based care frequently operates in spaces that are dilapidated, inflexible, isolated, still stigmatised and ill-suited for those receiving or delivering care. We undervalue the asset that a well-designed environment brings to improving our mental health.
So what would work better? There may not be a single answer to that, but there is a growing evidence base which clearly articulates the design elements and processes that help to create better mental health environments. Participants spoke about principles of designing spaces that make sense for their community and in their location. They described wanting spaces that can provide respite when it’s needed, located in places people feel comfortable going to and can reach easily, and that look and feel more like home than hospital. And crucially, they spoke about the importance of co-designing spaces with the people they seek to serve. Not consultation or involvement, where power rests solely with the institution, but equal partnership.
The environments we should expect would be welcoming, calm and non-stigmatising. They would embrace and support families. This was felt to be particularly critical in children and young people’s services, where long inpatient stays with limited space for movement, and lack of family inclusion often further negatively affect both mental and physical health. They would reflect and respect people’s cultures, spirituality and identities – something that can only be achieved in partnership with communities at a local level, not imposed from distant corridors of power. They would embrace art and creativity; they would have ready access to green space as an essential element of a therapeutic environment; and they would enable the use of therapeutic technologies, knitting the physical and digital worlds together to create a positive and empowering experience of care. Whether they are community or inpatient or a hybrid of both, the mental health environments of the future need to be spaces for people to recover and thrive in.
None of these aspirations is technically impossible, but they do require capital investment and a commitment to learning from what is already happening in practice. Capital investment in mental health environments is often time limited and tightly defined, meaning models such as mental health emergency departments are at risk of being developed in silos in the absence of all those who have a stake in the design or robust evidence of their safety or efficacy. Codesigning spaces means sharing power and spending money differently.
They also require imagination, humility and trust. Regulatory systems that exist to keep people safe and maintain quality standards sometimes have the opposite effect, of stifling creativity and preventing innovation. Honest discussions about how we can build the estate of the future without compromising on patient safety are going to be needed.
We hope this blog, and the discussion that informed it, marks the beginning of something bigger. We don’t have all the answers and solutions are likely to be different in different places, in any case, but we know the environments where mental health care happens matter a lot. So, we want to begin a conversation and a movement for better mental health care environments that promote compassion, understanding and recovery.
Charlotte Burrows is Chief Executive of Design in Mental Health Network, Andy Bell is Chief Executive of Centre for Mental Health.
