FORENSIC MENTAL HEALTH
your doorstep, and you were effectively ‘invisible’. If a patient walked out the front gate there they could be anybody, whereas it’s difficult to do that out in the country at the new hospital in Portrane.” Prof. Kennedy said when the discussions about a redevelopment or new hospital began, his team was told that the 34-acre Dundrum site was valued at between €300 and 600 m. He added: “We were told it was impossible to use it for healthcare, and we’d have to get out. We were then allocated to a plan to be co-located with a ‘super-prison’ near Dublin’s airport.”
‘Sympathetic’ Minister Fortunately, Prof. Kennedy explained, in 2013 a ‘sympathetic’ Minister for Health, James Reilly, offered the Portrane site where the new hospital has been built. Another Minister, Kathleen Lynch, was key to getting to project funded. He said: “The new hospital was built on the site of a closed former asylum, St Ita’s, which had been one of Ireland’s biggest; essentially we were given a corner to build the National Forensic Hospital. The campus sits on about 20 acres on the top of a low hill, and while an essential feature of a modern secure forensic hospital is a five- metre close mesh steel perimeter fence, it’s completely surrounded by 15-metre high trees. It’s a very sympathetic setting; the security vanishes into the greenery.” Prof. Kennedy said ‘one really
fascinating thing for him’ about working with the team at architects, Medical Architecture, had been the involvement of the practice’s founder, Chris Shaw. He explained: “Chris was really interesting to work with; one of his first questions to me was: ‘What’s your model of care?’ Like everybody then, we didn’t have a written one. My 2002 article about stratified therapeutic security was the nearest we had, but like most people, we had a sort of traditional knowledge of what we were doing – a professional understanding. Writing it down, however, was a challenge”. Prof. Kennedy explained that the current structure, the four chapters he had mentioned – ‘Goals not principles’, ‘Pathways and processes’, ‘Treatments,’ which includes a logic model that relates resources to outputs and health gains, and ‘Evaluation’, had grown out of this.
Goals for new hospital I asked him what he and his colleagues’ key goals for the new hospital were. He answered on a tangent, focusing on physical security, and the apparent lack of understanding of the need for it among some with non-clinical backgrounds. “A big problem in psychiatry today, and particularly in forensic psychiatry, is that the budget-holders – those with the real power, generally have no clinical background, and have very simplistic ideas about popular concepts of health,” he explained. “Nor do they have any personal experience of dealing with the profoundly ill, deluded, hallucinating, angry, and
THE NETWORK | NOVEMBER 2023
The welcoming café and dining space at the new National Forensic Mental Health Service Hospital.
violent, or any idea about how it is we help people by treating them – often without their consent in the early stages, or indeed that we have a huge responsibility to prevent violence.” “So, when you explain that we have
a locked door, and five-metre fences, it takes a long time for them to get this. We were however, very lucky with Kathleen Lynch, who had impeccable progressive credentials, and so once she understood our aims, was a particularly strong ally. Non-clinical managers, with no clinical background, wonder why they should have anything to do with a service where there’s always the possibility that, from time to time, people get severely injured, just working in the hospital.
A lengthy process “Getting such individuals to understand that there is a safe, scientifically valid, professional way of minimising risks and running a safe service to produce health gains and recovery takes time, and the model of care is one of the key ways of communicating this, so it has to be quite short and crisp,” he added. “When I’m lecturing about this today, I always explain that our written Model of Care is 13,000 words; you can read it in an hour with a cup of coffee, but by then you’ll have a much better idea of what we’re doing here and why.” Knowing Prof. Kennedy had contributed
substantially to the architecture, design, and layout of the new National Forensic Mental Health Service Hospital, I asked him about this. He said: “It’s the work of many hands, and a beautiful building. Walking around it is really inspiring. Lots of people I know either do or do not ‘get’ the uplifting elements of good architecture. In
my holidays, I quite often walk around a cathedral somewhere. I often find myself telling managers – and particularly those from consultancy firms, that a clinic is not a shop; it’s something different, and a hospital is not a factory. So, yes, you’ve got inputs and outputs, resources in and health gains out, but it’s not like running a conveyor belt in a car factory, and nor is customer satisfaction the correct way to think about people coming along to a clinic, or therapeutic interaction. It’s sadly a popular delusion.”
The Griffiths reforms Recalling that he had spent a large part of his career in the NHS, Professor Kennedy said he remembered the Griffiths reforms. (In February 1983, the government asked Roy Griffiths, a Director of J Sainsbury’s plc, to lead an inquiry into the effective use and management of manpower and resources. The report was delivered in October 1983, and Griffiths’ recommendations saw the introduction of general management in the NHS.) He said: “I was a registrar at the time, and was new in psychiatry, when actually it was quite fashionable to say you had no idea what you were doing at a hospital. One of the lines I heard was: ‘Isn’t this just like running Ford in Dagenham?’ The answer is categorically ‘no’. Here we are in 2023, and it is still sadly necessary to say that quite often.” I asked the Professor whether he feels
there have been significant improvements in mental health architecture and design generally, but particularly in forensic mental health. He said: “I do, yes. For instance, the questions Chris Shaw and Ruairi Reeves (of Medical Architecture) put to us were really helpful, as was their
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Paul Tierney
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