David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Garry Coff, who has been involved with health design for over 30 years.
Garry has helped improve the way health scientists are delivered to the community in Adelaide, around Australia and across the globe. Garry's experience covers all aspects of the healthcare system and ranges from design for remote Aboriginal communities to master planning for the Royal Brisbane and Women's Hospital covering emergency medicine, mental health, and age care facilities.
Today we welcome Garry to discuss the importance of design for mental health and how to improve patient care for mental health patients.
Welcome Garry. Thank you for your time.
Garry Coff: Thanks, David. Good to be here.
David Cummins: That is a very extensive CV of hospital projects around Australia and across the globe. I know you've specialised a lot in emergency medicine theaters, age care facilities. Why is mental health so unique in the world of health design, especially when you think about the patient cohort?
Why is, why is mental health something that people get wrong? And why is it so important to get right?
Garry Coff: Yes, good question. The main issues around mental health is to do with the, the cost of providing the services and the focus of dedicating the services to the right areas of where people have need.
Now we've been going through quite radical changes in the mental health system over the last 30 years. And I have to say one of my very first projects, I was involved with the devolution of the Hillcrest Hospital here in the northern suburbs of Adelaide.
And the planning for that was basically working around the principle that the sale of the land that would result from the freeing up of the facilities would generate. Sufficient resources to actually provide appropriate staffing for a community based service.
And therefore the reduction of in-patient facilities would be quite considerable. Now, as it turned out, that wasn't quite accurate in the context of the process. And of course the difficulty retraining people who were working within a mental health facility to be able to then provide a similar type of service out in the community was a hard lesson.
And it was difficult for the system to really respond quickly enough to manage the change in pace.
David Cummins: Just for context, you are referring from the seventies (1970's) when you were starting your career to today, where basically in the seventies mental health patients were pretty much locked away and put sometimes in a padded cell in a straight jacket.
Did that actually exist in Australia or that's more the American.
Garry Coff: Sadly, it was very much in Australia and really the padded cell is actually not quite correct. There weren't very many of those examples in Australia, but nevertheless they were very small cells and they were very robustly built with a lot of stone and cement to keep people from hurting themselves, was the principle, and to contain them.
Now that was a minority of the services, but the thing that was there in those early facilities, this would've been late mid eighties (1980's), I guess was the fact that there was asylum provided at those facilities.
There was a lot of space, there was outdoor areas where people could feel safe. They could generally interact with each other in a civilised way. Given that there was obviously medication being applied and people were able to modify their behaviours to become generally acceptable.
And given time they were going back into the community and generating quite a quality of life. So however, once the asylum factor disappeared there seemed to be a problem with the safety net factor of a place where you could keep people while they re-assimilated their medication profiles and while they went through the rehabilitation exercises.
Of course, the other part of that was there were always a number of people who were old psychogeriatric facilities. They were just a hardened nursing home effectively.
David Cummins: So when did that start to change that model of care from padded cells to isolation rooms to patients going out to the community and understanding as a community, they can offer a lot of benefits to community for many, many reasons. When did it start to change where going to a mental health hospital meant a lifetime of isolation to an a life of in community?
Garry Coff: Medication and treatments were very much the way of achieving that. And it was about modifying people's behaviours and generally reducing stress levels.
And a lot of that is well truly practiced in our industry as well. I think just to keep everybody on in a balanced format. But that was about the late eighties. That really, there was a lot of change and a lot of differences. The community began to realise that this wasn't a humane solution to lock people away and it didn't actually solve anything.
What was good about the devolution process was that a high proportion of people were able to function quite normally and be productive in their life. It did change things a lot in that direction, but the loss of asylum was a shame.
That was something that we still struggle with, not being able to quite provide. Modern facilities are much more live able. They're much more acceptable.
The finishes are all easily cleaned and the materials are robust, but not visibly constraining. Nobody gets chained to the wall anymore. Nobody gets tied to their chair even in a nursing home situation.
There are limits that are very important for people to recognise that they are getting better and that they benefit from the treatment processes that they're in.
David Cummins: Yeah. It certainly has changed a lot. Even when I was a physiotherapist years ago, we did restrain elderly patients or elderly residents because it was deemed safe.
But when you think about it in hindsight, it's actually quite inhumane.
Garry Coff: Yes, I agree. It's a hard concept to grasp. And although at the time it was what was being done and there wasn't the same quantities or options with drug therapies and counselling and the other factors.
One of the big issues that I came across in another location. Was the secure units, medium and high secure units where people are actually in a prison sentence. Within a mental health facility. They have been convicted of a crime and sent to a place where they will get rehabilitation.
The problem there is they have to actually serve a term of their sentence before they can actually see any likelihood of progressing a pathway out into the community again.
So that's one of the big difficulties that I see in the system is there are still a few of those which don't allow patients to actually re return to the community.
David Cummins: And is there any certain particular community groups in Australia that are more marginalised in reference to mental health and imprisonment? Or is it just generally the younger age group, more drug takers, the older age group? What groups are you generally thinking about or talking about?
Garry Coff: Well, the Aboriginal populations are one of the groupings where the numbers are disproportionate for the rest of the community. And a lot of those situations are difficult because there are several issues that become quite complicated. And for instance, the exercise of earning credibility within the community seems to be with young people that they have to go through a process of finding their way.
And in that process then can be accused of doing things that are antisocial and can be very difficult for them to get back into the community.
It's quite interesting that someone who has offended or created an offence perhaps in a remote community, for instance, for them to get released from a secure mental health institution, the community where the offence was occurred has to give approval for that person to go back to that community, and because of the family situations that occur, the separations between families and groups.
It can be very difficult to get approval to actually return to your country. And that makes it very hard because the pathways into a community where there is a strong, a large mental health facility that will generally be a small city or a metropolitan area.
To actually come from a remote area into the secure mental health unit and then be released into the suburban area is not necessarily gonna work anyway. It's not a good solution. It's not where he came from. It's not his lifestyle. The difficulties are that they'll re-offend and find themselves back in the situation.
So facilities are important in this because you really have to design a pathway from coming into the facility as a person who's done something wrong. You need to be educated to understand what it was that you did wrong in the first place. Then you have to be given a pathway to, and hopefully that pathway to release is something that gets you to appreciate your health and fitness.
It helps you to understand other people's feelings and rights and all of the things that they're associated with, with living in a free community. And of course that can mean flats and things in the community where they can still return to the facility for regular day activities and outpatient, if you like, sort of focuses.
Now that's difficult in a secure environment because there are issues about the fact that these facilities might be run by corrections rather than run by health practitioners. So corrections have a different view of their role than perhaps doctors and psychiatrists who really want people to get better.
David Cummins: It is interesting and if anyone's worked in the prison system or in mental health wards there's plenty of examples of not ideal pathways towards discharge, that's for sure.
Garry Coff: It's very easy to find the wrong direction to go, and it's quite complicated and difficult to find the right direction.
So you're absolutely right. And as much as we try, the full mental health package, it's a lifestyle. It's a life's work basically and special people are needed to be able to do that job. It's not everybody's skill set to be able to manage and gain the confidence of people who are frightened and who are unsettled in their environment.
David Cummins: Yeah. So how does health design. Change with mental health facilities. What are key things people need to be looking for? Understanding the sensitivity and the variance of patients who may be within a health, mental health facility.
Garry Coff: There's a big conflict in the process here, and that is that the facilities are designed, not to look secure, but to just be generally fairly stable and structurally sound.
And they cost money. And the big issue with mental health is, people need space and they need spaces where they can be on their own or they need spaces where they can do things quietly and separately and not be influenced by other people who may have a sense of aggression, or whose medication might not be working properly. There's a whole bunch of things that go on within the environment.
So ultimately the facility needs to offer some form of asylum, even if it's just a little courtyard here and there, or small nooks along the way where an individual can actually sit and read. There's a bunch of spaces that are not taken up with people who aren't feeling well or people who aren't happy.
It's difficult because that is where the cost comes into providing sufficient areas where people can actually feel good, feel they're worth, feel value to their community.
David Cummins: I think extreme credit towards the mental health nurses because they deal with such variance of, of patients in and outside of the community.
And I do know that the design of the nurses station have changed dramatically over the years where it's now smaller. So the nurses have to spend more time with the patients where little things like the doors cannot be in line with each other. Because patients have more privacy because they're active than another person might be an award.
So I do think that design of mental health is extremely important. What do you think? Something that we keep on getting wrong with the design of mental health?
Garry Coff: Yeah. No, you're absolutely right. The things that appear in a mental health environment undoubtedly. It's not possible to hang yourself on them, for instance.
That's the sort of starting point that says, okay, no tapware that has a handle, or that you can strap something onto no door handle, or no coat hooks, no curtain tracks that you can take down and use as a weapon. All that sort of stuff takes away from the ability to look around and not see anything that's gonna be a problem and not do any harm to yourself because of it.
So that they become a practical factor. But they don't look as good or they don't have a, domestic feel about them. They don't make you feel that you are at home.
You're definitely somewhere different. Stainless toilet bowls and hand basins and stainless steel mirrors are just a horrible thing. But that's something that becomes a driver of the planning. And needs to be offset by a lot of other things, things that can provide some sort of comfort and things that bring fond memories back to people who are undergoing fairly strong medications.
You need to really take all of those factors into account and the important factor of unobtrusive observation. You must allow that people are constantly observed, but you can't just stick cameras around the place and you can't have big glass sections around that don't provide them with any privacy or a quiet space for themselves is difficult.
So there's a lot of confliction information involved in how to do this, but daylight, greenery courtyard spaces, activity spaces within the courtyards that are safe but provide exercise, provide shading, generally, keep the environment friendly and warm.
So that people are actually feeling as though they are at home as well as that you can observe them.
Mental health nurses work really hard. It's a difficult job and the challenges are huge. They are the, the biggest ally that a designer in the mental health facility can have because they'll explain in real terms as to what it's about and why you shouldn't do something.
You've really gotta listen to that. That's where it becomes a real key issue to understand and be able to put yourself into their position and understand that they are at risk, so they need to be protected.
But the clients are at risk too, because they can hurt each other. They can be hurt by others as well. So yeah, there's a lot of factors in there that require more consideration. Not just a nice hospital bedroom.
It's got to be interesting and it's gotta be safe. And passive colors, things like that, they make a difference.
David Cummins: Yeah, certainly the user group what if questions are more predominant in mental health design than in normal hospital design, because there is so many what ifs for such a diverse range of patients at certain levels with their mental state.
So their body of questions are something that a designer has to listen to. Otherwise, it can have serious consequences.
Garry Coff: Absolutely. The things that can be used as weapons, incredibly surprising and challenging but yeah, you're absolutely right. It is all about safety, but then you have to try and make it look nice and feel good.
So yeah, life and space and plantings and things like that are important. Maintaining good sterile conditions can be a problem, can be a challenge. And as I was saying, the ab pollution areas are tricky because they're generally over designed for robustness and underdesigned for comfort.
You can struggle a bit with that one but really the important thing is the staff and the way they interact with the clients and given the opportunity to provide encouragement and support that goes a long way. The overprotectiveness of staff can actually send all the wrong messages.
So you've gotta be pretty careful about that sort of thing. You have to be very careful about televisions and media factors in the environment. The wrong music can set people off in the wrong direction. And there's a lot of issues around the management of clothes and storage are clothes and things like that.
That are not normal, but need to be taken into account because people can hurt themselves with the wrong sort of clothing and the wrong sort of materials at their fingertips, available to them, they can do bad things with them. So yes, it's a challenge.
There are some good solutions out there and they often lie in having grounds around the space, around the buildings, so that you've got outdoor spaces that are visible from inside where the clients might be during most of the night and that sort of thing.
There are night spaces where they can go, where there's light. At night if they do need to get out and they do need to move around. And there are pathways again, it's all about providing something that leads people to somewhere better.
People will fall off those. Pathways will actually not always work, but if you've got them built into your thinking, they do actually provide a structure that eventually will get people through the process of rehabilitation and back into the community.
So that's really the best thing I can offer to it. We need to spend more obviously but we need to be cautious about how we do it too, and not just build prisons.
David Cummins: Yeah. I think there's some very, very good lessons for everyone there. And I think from your last 30 plus years of design in that space, you would've seen dramatic changes and have no doubt being part of that force to be a change for improving patient and client care in mental health.
So thank you for all your hard work with that.
Garry Coff: Oh, thanks David. I hope there's something in there for people to take with them, take a message from and yes, look forward to chatting later.
David Cummins: Thank you.
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