For 10 years, staff and patients at a crumbling psychiatric hospital in a bleak cliff-top location wondered if they would ever move to a proposed new unit. Now, with their full involvement, they have. Anna Barnes reports

Queen Charlotte's is a dilapidated Victorian hospital with a grim and forbidding aspect. Its three linked buildings on three floors stand at the edge of a cliff.

When it was recommissioned as a temporary site for patients decanted as part of a long-stay hospital closure programme, no-one thought they would still be there more than a decade later.

Hastings and Rother trust in East Sussex had moved patients to Queen Charlotte's in 1986, in preparation for the planned closure of the 2,000-bed county asylum in Hellingly. The old hospital had been recommissioned, pending funds from the regional capital programme for a new unit. It was recognised right from the start that it was totally unsuitable as a long-term proposition.

In 1989, South Thames regional health authority agreed in principle to fund a 52-bed hospital as part of a complete service development strategy in Hastings and Rother. This would include a rehabilitation hostel, a longer-stay unit and a specialist case-management service.

But much changed between 1989 and 1999, and we are now opening a 33-bed hospital on the back of an agreed service development strategy that was fully implemented between 1993 and 1998.The local HA reorganised three times during this period, as did the RHA, putting the capital and revenue for these developments in severe jeopardy. The new unit dropped off the capital programme more than once as personnel changed, and commitments could not be maintained because of the fall in land sales.

Meanwhile, Queen Charlotte's deteriorated year after year, leaving the Mental Health Act Commission to describe it in 1995 as one of the worst inpatient units it had seen.

Needy population Hastings is a seaside town with little indigenous industry save fishing and tourism. One area of growth in the past 20 years has been care homes.There are more than 200 homes registered for the care of people with mental health problems. Hastings has become known as an area where London boroughs can resettle people who require care and support. Rother has fewer of these types of problems and is more affluent, although problems of transport and access to services predominate.

Hastings and Rother (although Hastings in particular) are recognised as areas of high psychiatric morbidity, scoring 107 under the mental illness needs index, against a national norm of 100.Some electoral wards score over 120 on this index. Other factors, such as high unemployment, many houses in multiple occupation and a high level of poverty indicate that the need for mental health services is great. Hastings is also notorious for its high suicide rate - 14.6 per 100,000, compared with the national rate of 11 per 100,000.This reflects the high number of people living without family support, and the transient population associated with seaside towns.

No new unit?

In 1995 we were greatly relieved to hear that East Sussex, Brighton and Hove HA was going to honour the RHA's commitment and invest£1.2m in developing the local community service which could support a new acute unit.

But we still faced the challenge of having to undergo the private finance initiative process in order to raise the capital. This was pursued with great effort, and a private partner was secured. But the investor pulled out at the last minute.

At the end of 1997, the mental health strategy was being implemented around the promise of a new unit, with fewer beds, but a greater infrastructure to support it. Yet there was still no capital for a new building, and the existing one was growing more derelict by the day.

Fortunately, South Thames regional office requested a full business case in order to reconsider the scheme within its own capital programme. This was accepted in early 1998, and the scheme finally got the green light at a cost of£3.5m.

In some ways, the delays were for tunate as mental health commissioning had moved on considerably. Strathdee and Thornicroft's work on bed management gave a clear steer that beds alone were not the answer to providing local mental health services.

They suggested that a comprehensive mental health service should include crisis houses, rehabilitation units, day hospitals and crisis teams to provide alternatives to admission.

The work of the Sainsbury Centre for Mental Health also indicated that the environment and quality of the therapeutic interactions were severely lacking in many hospitals around the country, with up to one-third of patients unable to be discharged for mainly social reasons.

Hastings and Rother trust benefited from these insights and calculated that a smaller number of beds than originally envisaged could meet local needs if they were well managed.

This still left the problem of designing a purpose-built unit based at the local district general hospital. National examples were requested from the region and from the Sainsbury Centre, which had just undertaken its one-day census. None was highly recommended. The Royal College of Psychiatrists' document Not Just Bricks and Mortar was helpful, as was a report from West London Health Estates in 1999.

We relied mainly on the Capital Investment Manual for guidance.

The challenge was to design a building that was warm, friendly, light and airy, with good observation points, while also being secure, extremely durable and with low maintenance. This design process tested the relationships involved.

Involving service users, carers and staff The trust was under increasing pressure from local service users to consult them about the replacement for Queen Charlotte's. The abortive work undertaken for the PFI project meant that a project user group, including service users, carers and staff, had been set up. This group was fed by distinct interest groups, such as the psychiatric nurses and the community health council-facilitated mental health service user group.

Many comments had already been received in writing about the sort of building that was wanted. A group of service users and staff had toured local facilities that had good reputations in order to check out which features made a building function well. Service users were keen to have a less custodial and less institutional environment.

Working with the architect

When the contract was tendered, interviews were arranged with the shortlisted candidates. The successful architects - local firm AJK - were chosen for their sensitive approach to the concept design and their ability to encourage the participation of service users and staff.

The firm selected an in-house experienced community architect to run the project. The development of the design became an active and enjoyable process for users.

Meetings were organised to develop the conceptual design, and a working model was made of the whole building, together with a large-scale mock-up of a typical bedroom and shower room.

Questionnaires, the models, plans and suggested finishes were displayed in a mobile trailer which toured sites accompanied by the project architect and trust staff. The completed questionnaires were then analysed and fed back to the design team, resulting in changes to the design.

Users requested that the large day room should be given over to smokers, asked for a separate entrance for the admission of severely ill patients, and requested that long corridors should not be included: 'Long corridors give the feeling of prison, ' they said.

It is perfectly possible to involve all the key stakeholders in the design process. This does not cause delay or provoke unreasonable demands.

The key lessons of our experience are as follows:

Set up a structure, such as a project board and project user group, which has support and commitment right up to board level.

Provide a central contact point for information to flow in and out.

Accept information in any way it is given, whether through a focus group, a letter, a chat in the corridor or a one-to-one meeting.

Be flexible about the way you operate so that people who have difficulty with formal meetings can still feed in their views.

Be responsive to criticism.

At an early stage in the design process, the architect initiated discussions with the Art in Hospital project.

Support for the initiative among service users and the design team was unanimous, and the trust agreed to allocate a significant 1 per cent of the total project budget towards art in communal areas of the development. This sum was later increased.

Key areas of the unit were identified where works of art could help minimise any institutional feel. An arts steering group was set up with representatives from the staff, users, the League of Friends and a local community mental health organisation. A strategy and brief for the individual artists were agreed, artists selected and the design process set up.The process of liaison and debate between this group and the hospital community was a lively and useful one for both the artists and the staff and patients.

Many service users, local artists and staff became involved, working alongside the artists who designed and installed the selected features. This group also helped choose the colour scheme and furnishings for the unit.

The League of Friends agreed to sponsor two further commissions, and in total£70,000 has been invested in this programme.

Photographer Gina Glover was appointed to undertake a scheme which would help patients with the move. She took photographs of the old unit and patients' possessions and completed a series of seascapes which now hang in the new unit.

However unsuitable the old building was, there was still pain in the upheaval and displacement of moving. Ms Glover's work with patients and staff provided a welcome creative stimulus.

Building begins In November 1998, responsibility for detailed design and delivery of the building was transferred to the main contractor, Dove Brothers, under a design and build package. A few design changes resulted, but none that significantly compromised the specification that was submitted for tender.

Service users and staff were also part of a specific subgroup set up to choose a name. 'Woodlands' was finally chosen because of the wooded nature of the site, and because of its calming and therapeutic connotations. The service users also wanted the address to be part of the district general hospital site to do awaywith the stigma that had been associated with Queen Charlotte's being a separate unit.

Woodlands opened in December 1999.Staff and service users have expressed satisfaction about the way the difficult tensions in designing this building have been resolved. It looks warm and friendly, and the use of colour within the outdoor frame, and natural wood throughout, means that it is not forbidding and intimidating in the way that hospitals can be.

Staff are happy about the good observation and natural light throughout the building, and the wide corridors give it the luxurious feel of the private sector. Patients enjoy the feeling of space that is so important when you are feeling paranoid or confined against your will.

'We continued to empty the buckets that collected leaks on the veranda' ' When I started working at Queen Charlotte's in 1991, I was astounded by the building that acutely ill patients were being treated in. It felt enormous and was on three floors. But within days I realised the nursing staff were extremely skilled at nursing and maintaining safety despite the environment.

There was constant talk about a new purpose-built unit and eventually a plan was circulated of a design, but no-one dared believe that the vision might become a reality. We continued with our routine of walking three flights of stairs to remind patients of mealtimes, emptying the buckets that collected leaks on the veranda, and receiving visitors' criticism about the environment with professionalism. Our optimism about a new unit was heightened and then dashed when the private finance initiative process started and then failed. The feeling was one of cynical acceptance - we still felt it would happen, but it became 'one day' again.

After another wait, more praise for the nursing care, more criticism of the leaking veranda roof, funding was approved. It was daunting to be asked what we wanted after 'making do' for so long. We were suddenly forced to face the reality and rose to the challenge - the different opinions were thrashed out and the consultation process continued. The users of the service had similar ideas and reinforced the feeling of this being a shared excitement.

As the process continued, opinions among the nurses varied, but one common thought was wanting the new unit to be a new start.

Christine Lockwood, senior community link nurse

One step forward. . . through the years

1989 South Thames regional health authority agrees in principle to fund a 52-bed hospital.

1995 East Sussex, Brighton and Hove health authority agrees to honour the RHA's commitment and invests£1.2m in new unit. Scheme submitted for PFI.

1996 Private investor pulls out.

1996 Business case for a 25-bed unit submitted to South Thames region.

1997 Mental health strategy implemented without capital for new unit.

1998 South Thames agrees to fund full business case for 33-bed unit at cost of£3.5m.

November 1998 Building work starts.

December 1999 Patients move into new unit.

24 March 2000 Official opening by comedian and former psychiatric nurse Jo Brand.

'I'm glad I live in an area with a progressive trust' Having been a patient in old institutions at Hellingly and Oakwood, and also for a short time in a modern unit at Eastbourne's district general hospital, I knew the difference a new unit makes to morale.

The way the trust sent representatives to consult with users was good. There were many meetings of users, both routine and plenary. Some of the points discussed included standards for a mental health unit and the design and overall layout. We said we wanted a light and airy place where we could be treated with dignity and respect. My attitude to the consultation process was that nothing should hold it up. I am glad that I live in an area with a progressive trust and with brand-new mental health facilities. I hope the new unit lives up to expectations.

Andrew Voyce, former patient 'It was an opportunity for us to be listened to and have our contributions valued' ' For users of mental health services to be involved and asked for our opinions on the design of the new unit was a breakthrough. It was an opportunity to be listened to and have our contributions valued. It was an important learning curve for everyone.

One of the difficulties was how to get as many users as possible involved. To overcome the apathy and negativity that some users had needed a lot of work. We had to be convinced our views were going to be taken seriously, that it was not going to be tokenistic.

It was also difficult to consult a wide variety of users, so representatives from local day centres formed the user group.

Asking opinions often meant a delay in providing feedback.A major problem was that occasionally decisions needed to be made quickly and it was not possible to consult everyone. It was difficult to please everyone and compromises were made, sometimes at the expense of users' requests.

Our main concern was the reduction in the number of beds in the new unit. Although we tried to exert pressure to change this decision, sadly we will have five fewer beds .

The ambience of the unit was very important. We all felt it was important to have a light and airy environment, with specific requests to avoid long dark corridors or a prisonlike building, yet providing a place of safety and security.

Smoking areas proved a major issue. Originally, we were informed there would be one small room. However, after the pressure we put on, a large day room has been allocated for smoking, and other day room areas for non-smokers and quiet space.

We also thought it would be beneficial to have a separate entrance for the admission of severely ill patients, thus avoiding disturbing the other patients, and preventing embarrassment for those being admitted. This was agreed, along with an area for patients with severe needs that can be locked, for their own safety and the safety of fellow patients.

The users wanted the nurses' station in a position where the staff could see the patients and the patients could easily access staff. We are concerned that there are some corridors and day rooms that have a lack of observation. However, the main day room has good observation from staff, without the feeling of being watched and imposing on our privacy.

We were all heavily involved in this group, to the benefit of the design process. We helped the artist who designed the flooring to come up with a design that emphasised our move away from the sea into the woodland site. But we would have liked to have had more say about the choice of chairs and carpets.

To be involved in this process, to have a voice and be listened to, has helped me gain confidence and develop assertiveness and a belief that as service users we can have an influence on how our service is provided. Bricks and mortar alone are not sufficient - to be involved as a user in the delivery and type of service provided is what really matters.

Diana Byrne, former patient What a difference a move makes The patient areas here are excellent. It's a light and modern environment, conducive to making people feel better - so different from the drab Victorian building of Queen Charlotte's. Many staff still miss the fantastic sea views, but not the wind that used to whistle in through the cracks in the window frames.

Norma Luther, lead nurse

Key points

A scheme to reconfigure mental health services took 10 years from agreement in principle to the opening of the new unit.

A plan to finance it under the private finance initiative had to be abandoned when the private investor pulled out.

The original design was substantially altered in response to service users' requests.

The trust allocated 1 per cent of the budget for artworks in the new unit.

REFERENCES

1Thornicroft G, Strathdee G. Commissioning Mental Health Services .HMSO, 1997.

2 Shepherd G, Beadsmore A, Moore C, Muijen M. The relationship between bed use, social deprivation and bed availability in acute psychiatric units and alternative residential options: a cross sectional survey and one-day census.Br Med J 1997; 314: 262 -266.

3 Royal College of Psychiatrists. Not Just Bricks and Mortar: report of the Royal College of Psychiatrists working party on the size, staffing structure, siting and security of new acute adult psychiatric inpatient units. Council report CR62, 1998.

4 Oddi D.Community-Based Mental Health Facilities Including People with a Learning Disability, safety and security by design. West London Health Estates, 1999.