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NSW Health can confirm two people with how to get viagra without a doctor Japanese encephalitis viagra (JEV) are currently being treated in hospital and is continuing to urge the public to be vigilant https://blog.printpapa.com/buy-viagra-with-prescription and safeguard themselves against mosquito bites. Both people are residents of the NSW-Victoria border region – a man from the Corowa area and a child from the Wentworth area in the far south west of NSW. They are both how to get viagra without a doctor currently being treated in hospitals in Victoria. The man remains in a serious condition in ICU.

The child has been discharged from ICU but continues to receive how to get viagra without a doctor hospital care due to the serious nature of their illness. Several more people in NSW are undergoing further testing, and more cases are expected to be confirmed over the coming days and weeks. JEV is a viral illness spread by how to get viagra without a doctor mosquitoes. It can infect animals and humans and has been confirmed in samples from a number of pig farms in regional NSW.

The viagra cannot be transmitted between humans, and it cannot be caught by eating pork or pig how to get viagra without a doctor products. Locally acquired cases of JEV have never previously been identified in NSW in animals or humans. Mosquito control activities are being carried out in the vicinity of farms where pigs are confirmed to have been infected by JEV and NSW Health is arranging vaccination of workers on affected farms. There is no specific treatment for JEV, which can cause severe neurological illness with headache, convulsions and reduced consciousness how to get viagra without a doctor in some cases.

Dr Marianne Gale, NSW Health Acting Chief Health Officer, said the best thing people throughout the state can do to protect themselves and their families against JEV is to take steps to avoid mosquito bites. €œWe are working closely with the NSW Department of Primary Industries and how to get viagra without a doctor other states and territories to determine the extent to which the viagra is circulating,” Dr Gale said. €˜Unfortunately, our recent wet weather has led to very high mosquito numbers, so we need the community to be particularly vigilant and take steps to avoid mosquito bites. €œWe know mosquitoes are most active between dusk and dawn, and we need people planning activities near waterways or where mosquitoes are present to be especially cautious, particularly those in the vicinity of the Murray River and its branches.” Simple actions how to get viagra without a doctor you can take to avoid mosquito bites include.

Avoid going outdoors during peak mosquito times, especially at dawn and dusk. Wear long how to get viagra without a doctor sleeves and pants outdoors (reduce skin exposure). Also wear shoes and socks where possible. There are insecticides (e.g.

Permethrin) available for treating clothing for those spending extended periods outdoors.Apply repellent to how to get viagra without a doctor all areas of exposed skin, especially those that contain DEET, picaridin, or oil of lemon eucalyptus which are the most effective against mosquitoes. The strength of a repellent determines the duration of protection with the higher concentrations providing longer periods of protection. Always check the label how to get viagra without a doctor for reapplication times.Reapply repellent after swimming. The duration of protection from repellent is also reduced with perspiration, such as during strenuous activity or hot weather so it may need to be reapplied more frequently.Apply the sunscreen first and then apply the repellent.

Be aware that DEET-containing repellents may decrease the sun protection factor (SPF) of sunscreens so you may need to re-apply the sunscreen more frequently.For children in particular - most skin repellents are safe for use on children aged three months and older when used according to directions, although some formulations are only recommended for children aged 12 months and older - always how to get viagra without a doctor check the product. Infants aged less than three months can be protected from mosquitoes by using an infant carrier draped with mosquito netting that is secured along the edges.Be aware of the peak risk times for mosquito bites. Avoid the outdoors or take preventive actions (such as appropriate clothing and skin repellent) between dawn and dusk when most mosquitoes become active, especially close to wetland and bushland areas.If camping, ensure the tent how to get viagra without a doctor has fly screens to prevent mosquitoes entering.Mosquito coils and other devices that release insecticides can assist reducing mosquito bites but should be used in combination with topical insect repellents.Reduce all water holding containers around the home where mosquitoes could breed. Mosquitoes only need a small amount of liquid to breed.For further information on mosquito-borne disease and ways to protect yourself go to our website.

Fact sheets on specific mosquito-borne diseases, including Japanese encephalitis Ross River viagra and Barmah Forest viagra, are available on our website..

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Artificial intelligence (AI) software can improve patient care, but a key market failure is preventing its effective development and diffusion.Well-developed and how much viagra should i take the first time validated AI software systems built outside of electronic health record (EHR) systems that could truly advance patient care have had limited adoption. Only a small number of health systems have developed successful and integrated AI software, and broad adoption of these validated tools is essentially nonexistent. In comparison, poorly developed and minimally validated AI software built and deployed within EHRs are how much viagra should i take the first time widely adopted despite serious quality concerns. Unlock this article by subscribing to STAT+ and enjoy your first 30 days free!. GET STARTEDComing out as a queer teenager.

Fostering a child how much viagra should i take the first time to adopt. Grappling with transracial adoption. Examining how addiction and body image affect how much viagra should i take the first time behavior. Coming to terms with dementia, depression, and anxiety. Taking stock of mental health across time.“This Is Us” showed all of this and more during six outrageously successful seasons.This NBC series explored the lives of three children — twins Kevin and Kate, whose parents adopted a third baby, Randall, whose father had abandoned him at a fire station.

As avid fans, we debriefed weekly to discuss the twists, turns, and tears how much viagra should i take the first time of the Pearson family saga, which wraps up on May 24. From our public health and ethnic studies perspectives, the series accomplished a rarity for a fictional TV show. It showed the ways the conditions in which people live, work, and play can how much viagra should i take the first time influence their health.advertisement The series’ subtle approach to sexual orientation and gender identity did its part to try to help normalize them in the real world. The show casually revealed that Randall’s long-lost birth father was bisexual when his lover showed up at a family gathering. And when a middle-school daughter came out as queer, it created only a relatively minor family drama.

Related how much viagra should i take the first time. Giving gender-affirming care. €˜gender dysphoria’ how much viagra should i take the first time diagnosis should not be required The fact that neither storyline was a big deal is actually a big deal. The U.S. Has come a long way as a society since Ellen DeGeneres came out as gay in 1997 on her ABC sitcom “Ellen.” Advertisers boycotted the show and the Rev.

Jerry Falwell called her “Ellen Degenerate.” The final episodes of that season of “Ellen” were criticized for focusing too narrowly on gay issues, and the show was canceled the next year.advertisement “This Is Us,” through its nuanced how much viagra should i take the first time and sensitive approach to sexual orientation and gender identity, held a mirror up to the real world and tried to model an ideal — that many people are moving toward the idea that being openly LGBTQ is only one of the many characteristics that make up complex human beings.Far more front and center in “This Is Us” is the thread of mental health, which plays out across many characters. The family matriarch is diagnosed with dementia, and as the show hops back and forth in time, viewers witness her decline even as they are reminded of what a vibrant young mother she was.Across the seasons, the show highlighted post-traumatic stress disorder related to military service, first in Vietnam and then Afghanistan. Major characters struggled with depression, debilitating anxiety, addiction, disordered eating, and weight and body how much viagra should i take the first time image. Each storyline explores the ways mental health affects day-to-day experience and how access to mental health care affects the quality of life. Related.

Hopelessness around youth how much viagra should i take the first time mental health is creating a ‘nihilistic contagion’ Perhaps one of the best illustrations of this is how the series portrayed battles with substance addiction by the Black birth parents of Randall, compared to his white brother Kevin. Randall’s parents, William and Laurel, lose their child, their relationship, and years of their lives as they each attempt to get sober. But when Kevin — the rich how much viagra should i take the first time celebrity with a family support system — grapples with addiction, it is invariably treated as an illness rather than a crime. His access to intensive rehabilitation, followed by a transitional stay at his mother’s, helps him secure his sobriety.Though this story line may have been fictional, it shows how race and access to resources and support systems dramatically impact the outcomes of this disease for countless Americans today and specifically how addiction among the economically struggling Black parents leads to criminalization by the justice system.One of the ways that structural factors concretely affect peoples’ lives plays out repeatedly through Randall’s storyline, from the events that lead to his adoption by white parents to the adoption years later of an adolescent named Deja by Randall and his wife Beth. Deja is shown to have a loving relationship with her birth mother Shauna, but it is not enough.

Her lack of financial privilege and family support are shown, but “This Is Us” ultimately suggests that how much viagra should i take the first time her risky decisions and personal irresponsibility cost her the loss of her housing and her child. In this case, the storyline missed the mark, minimizing the structural barriers Black mothers face and a foster care system that disproportionately removes Black children from their birth homes. Related how much viagra should i take the first time. A new index measures the extent and depth of addiction stigma The show’s approach to these structural barriers was more nuanced as Randall worked through his trauma from transracial adoption. Viewers learned about his birth mother who, like so many Black mothers, was incarcerated instead of being treated for substance addiction, a pattern documented in real life by legal scholar Dorothy Roberts.

Rather than judging his birth mother harshly — as he had initially judged Deja’s mom — Randall finally comes to terms with his birth mother’s inability to raise him.Randall’s growing realization of the structural barriers that disadvantage marginalized groups is evident after he confronts a man who breaks into his home. When he realizes the intruder is desperate and ill, Randall — in his role as a city councilman — develops programs for people experiencing substance addiction. This shows a deepening realization that “crime” is often rooted in unmet needs that, rather than punishment, should be met with resources and support.We will remember “This is Us” for showing us how people are the same in what affects our lives — love, family, grief, joy — without ignoring the factors that make our lives so different.Sarah MacCarthy is the inaugural holder of the LGBTQ health studies endowed professorship at the University of Alabama, Birmingham. Jalondra A. Davis is a presidential postdoctoral fellow in the Department of Ethnic Studies at the University of California, San Diego..

Artificial intelligence (AI) software can improve patient care, but a viagra pills online key market failure is preventing its effective development and diffusion.Well-developed and how to get viagra without a doctor validated AI software systems built outside of electronic health record (EHR) systems that could truly advance patient care have had limited adoption. Only a small number of health systems have developed successful and integrated AI software, and broad adoption of these validated tools is essentially nonexistent. In comparison, poorly developed and minimally validated AI software how to get viagra without a doctor built and deployed within EHRs are widely adopted despite serious quality concerns. Unlock this article by subscribing to STAT+ and enjoy your first 30 days free!. GET STARTEDComing out as a queer teenager.

Fostering a child to how to get viagra without a doctor adopt. Grappling with transracial adoption. Examining how how to get viagra without a doctor addiction and body image affect behavior. Coming to terms with dementia, depression, and anxiety. Taking stock of mental health across time.“This Is Us” showed all of this and more during six outrageously successful seasons.This NBC series explored the lives of three children — twins Kevin and Kate, whose parents adopted a third baby, Randall, whose father had abandoned him at a fire station.

As avid fans, we debriefed weekly to discuss how to get viagra without a doctor the twists, turns, and tears of the Pearson family saga, which wraps up on May 24. From our public health and ethnic studies perspectives, the series accomplished a rarity for a fictional TV show. It showed the ways the how to get viagra without a doctor conditions in which people live, work, and play can influence their health.advertisement The series’ subtle approach to sexual orientation and gender identity did its part to try to help normalize them in the real world. The show casually revealed that Randall’s long-lost birth father was bisexual when his lover showed up at a family gathering. And when a middle-school daughter came out as queer, it created only a relatively minor family drama.

Related how to get viagra without a doctor. Giving gender-affirming care. €˜gender dysphoria’ diagnosis should not be required The fact that neither storyline was a big deal is actually a how to get viagra without a doctor big deal. The U.S. Has come a long way as a society since Ellen DeGeneres came out as gay in 1997 on her ABC sitcom “Ellen.” Advertisers boycotted the show and the Rev.

Jerry Falwell called her “Ellen Degenerate.” The final episodes of that season of “Ellen” were criticized for focusing too narrowly http://www.abfischfest.at/ on gay issues, and the show was canceled the next year.advertisement “This Is Us,” through its nuanced and sensitive approach to sexual orientation and gender identity, held a mirror up to the real world and tried to model an ideal — that many people are moving toward the idea that being openly LGBTQ is only one of the many characteristics that make up complex human beings.Far more front how to get viagra without a doctor and center in “This Is Us” is the thread of mental health, which plays out across many characters. The family matriarch is diagnosed with dementia, and as the show hops back and forth in time, viewers witness her decline even as they are reminded of what a vibrant young mother she was.Across the seasons, the show highlighted post-traumatic stress disorder related to military service, first in Vietnam and then Afghanistan. Major characters struggled with depression, debilitating anxiety, addiction, disordered eating, how to get viagra without a doctor and weight and body image. Each storyline explores the ways mental health affects day-to-day experience and how access to mental health care affects the quality of life. Related.

Hopelessness around youth mental health is creating a ‘nihilistic contagion’ Perhaps one of the best illustrations how to get viagra without a doctor of this is how the series portrayed battles with substance addiction by the Black birth parents of Randall, compared to his white brother Kevin. Randall’s parents, William and Laurel, lose their child, their relationship, and years of their lives as they each attempt to get sober. But when how to get viagra without a doctor Kevin — the rich celebrity with a family support system — grapples with addiction, it is invariably treated as an illness rather than a crime. His access to intensive rehabilitation, followed by a transitional stay at his mother’s, helps him secure his sobriety.Though this story line may have been fictional, it shows how race and access to resources and support systems dramatically impact the outcomes of this disease for countless Americans today and specifically how addiction among the economically struggling Black parents leads to criminalization by the justice system.One of the ways that structural factors concretely affect peoples’ lives plays out repeatedly through Randall’s storyline, from the events that lead to his adoption by white parents to the adoption years later of an adolescent named Deja by Randall and his wife Beth. Deja is shown to have a loving relationship with her birth mother Shauna, but it is not enough.

Her lack of financial privilege and family support are shown, but “This Is Us” ultimately suggests that her risky decisions and personal irresponsibility cost her the loss of how to get viagra without a doctor her housing and her child. In this case, the storyline missed the mark, minimizing the structural barriers Black mothers face and a foster care system that disproportionately removes Black children from their birth homes. Related how to get viagra without a doctor. A new index measures the extent and depth of addiction stigma The show’s approach to these structural barriers was more nuanced as Randall worked through his trauma from transracial adoption. Viewers learned about his birth mother who, like so many Black mothers, was incarcerated instead of being treated for substance addiction, a pattern documented in real life by legal scholar Dorothy Roberts.

Rather than judging his birth mother harshly — as he had initially judged Deja’s mom — Randall finally comes to terms with his birth mother’s inability to raise him.Randall’s growing realization of the structural barriers that disadvantage marginalized groups is evident after he confronts a man who breaks into his home. When he realizes the intruder is desperate and ill, Randall — in his role as a city councilman — develops programs for people experiencing substance addiction. This shows a deepening realization that “crime” is often rooted in unmet needs that, rather than punishment, should be met with resources and support.We will remember “This is Us” for showing us how people are the same in what affects our lives — love, family, grief, joy — without ignoring the factors that make our lives so different.Sarah MacCarthy is the inaugural holder of the LGBTQ health studies endowed professorship at the University of Alabama, Birmingham. Jalondra A. Davis is a presidential postdoctoral fellow in the Department of Ethnic Studies at the University of California, San Diego..

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Generic Viagra is used to treat male Impotence also known as Erectile Dysfunction. Also, it has been approved by US FDA for treating pulmonary arterial hypertension.

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What mental health benefits and substance viagra uses use disorder benefits does Medicare http://jeffreymetcalfe.com/contact-us/ cover?. Medicare covers a range of mental health and substance use disorder services, both inpatient and outpatient, and covers outpatient prescription drugs used to treat these conditions. Medicare Advantage plans are required to cover benefits covered under traditional Medicare and most cover Part D prescription drugs as well, but out-of-pocket costs may differ between traditional Medicare and Medicare Advantage plans, and vary from one Medicare Advantage plan to another. (See below section “How are mental health benefits and substance use disorder benefits covered under viagra uses Medicare Advantage plans?. € for more detail.) Inpatient Services Medicare Part A covers inpatient care for beneficiaries who need mental health treatment in either a general hospital or a psychiatric hospital.

Outpatient Services Medicare Part B covers one depression screening per year, a one-time “welcome to Medicare” visit, which includes a review of risk factors for depression, and an annual “wellness” visit, where beneficiaries can discuss their mental health status. Part B viagra uses also covers individual and group psychotherapy with doctors (or with certain other licensed professionals, depending on state rules), family counseling (if the main purpose is to help with treatment), psychiatric evaluation, medication management, and partial hospitalization. Partial hospitalization is a more structured program of individualized and multidisciplinary outpatient psychiatric treatments that is more intensive than in a doctor or therapists’ office, as an alternative to an inpatient stay. Partial hospitalization programs are designed for patients with mental health conditions who do not require 24-hour inpatient care, but have not benefitted from a less intensive outpatient program. Part B also covers outpatient services related to substance use disorders including opioid use disorder treatment services, which include medication, counseling, drug testing, viagra uses and individual and group therapy.

Medicare covers one alcohol misuse screening per year, and for beneficiaries determined to be misusing alcohol, four counseling sessions per year. Medicare also covers up to 8 tobacco cessation counseling sessions in a 12-month period. Prescription Drugs The Medicare Part D program provides an viagra uses outpatient prescription drug benefit to people on Medicare who enroll in private plans, including stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PDs). Medicare Part D prescription drug plans cover retail prescription drugs related to mental health and are required to cover all or substantially all antidepressants, antipsychotics, and anticonvulsants (such as benzodiazepines), as each is one of the six protected classes of drugs in Part D. Part D plans are permitted to impose prior authorization and step therapy requirements for beneficiaries initiating therapy (i.e., new starts) for each of these protected classes of drugs.

Coverage of other prescription drugs is based on an individual plan’s formulary, and depending on a plan’s formulary, beneficiaries can also be subject to prior authorization, step viagra uses therapy, and quantity limits. How much do Medicare beneficiaries pay for mental health benefits and substance use disorder benefits?. Inpatient Services Beneficiaries who are admitted to a hospital for inpatient mental health treatment would be subject to the Medicare Part A deductible of $1,556 per benefit period in 2022. Part A also requires daily copayments for extended viagra uses inpatient hospital stays. For extended hospital stays, beneficiaries would pay a $389 copayment per day (days 61-90) and $778 per day for lifetime reserve days.

For inpatient stays in a psychiatric hospital, Medicare coverage is limited to up to 190 days of hospital services in a lifetime. Most beneficiaries viagra uses in traditional Medicare have supplemental insurance that may pay some or all of the cost sharing for covered Part A and B services. Outpatient Services For most outpatient services covered under Part B, there is a $233 deductible (in 2022) and 20 percent coinsurance that applies to most services, including physician visits. However, some specific Part B services have different cost-sharing amounts (Table 1). Prescription Drugs Those with Part D coverage face cost-sharing amounts for covered drugs and may pay an annual deductible ($480 viagra uses in 2022) and a monthly premium.

For example, most Part D enrollees pay less than $10 for generic drugs, but many pay $40-$100 (or coinsurance of 40%-50%) for brand-name drugs. Beneficiaries with low incomes and modest assets are eligible for assistance with Part D plan premiums and cost sharing. Which health providers can bill Medicare directly for mental health viagra uses and substance use disorder services, and how much does Medicare pay for these services?. Medicare provides coverage and reimbursement for mental health services provided by psychiatrists or other doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. Medicare does not provide coverage or reimbursement for mental health services provided by licensed professional counselors and licensed marriage and family therapists.

Medicare fees vary viagra uses by type of provider, according to the Medicare Physician Fee Schedule (Table 2). Are psychiatrists accessible to Medicare beneficiaries?. The majority of physicians, both primary care and specialists, report taking new Medicare patients, similar to the share who take new privately insured patients. Psychiatrists, however, are less likely than other viagra uses specialists to take new Medicare (or private insurance) patients. According to a recent KFF analysis, 60% of psychiatrists are accepting new Medicare patients, which is just over 20 percentage points lower than the share of physicians in general/family practice accepting new patients (81%).

However, the survey used to conduct the analysis does not distinguish among physicians seeing new patients covered under traditional Medicare or Medicare Advantage, so it is not clear whether physicians are more inclined to accept new Medicare patients in either Medicare Advantage plans or traditional Medicare.Further, psychiatrists are more likely than other specialists to “opt out” of Medicare altogether. Providers who opt out of Medicare do not participate in the Medicare program and instead enter into private contracts with their Medicare patients, allowing viagra uses them to bill their Medicare patients any amount they determine is appropriate. Overall, 1% of all non-pediatric physicians have formally opted-out of the Medicare program, with opt-out rates highest among psychiatrists. 7.5% of psychiatrists opted out in 2022. In fact, psychiatrists account viagra uses for 42% of the 10,105 physicians opting out of Medicare in 2022.

The relatively high rate of psychiatrists not taking new Medicare patients, combined with relatively high opt out rates, could pose access issues for Medicare beneficiaries needing treatment for mental health needs. (For additional information on access to providers in Medicare Advantage plans, see “Provider Networks” in the section below. €œHow are mental health benefits and substance use viagra uses disorder benefits covered under Medicare Advantage plans?. €) How has expanded telehealth coverage affected access to mental health benefits and substance use disorder benefits during the erectile dysfunction treatment viagra?. Prior to the erectile dysfunction treatment viagra, Medicare coverage of telehealth services was very limited.

Before the erectile dysfunction treatment public health emergency, telehealth viagra uses services were generally available only to beneficiaries in rural areas originating from a health care setting, such as a clinic or doctor’s office. One exception, however, was the removal of the geographic and originating site (i.e., the health care setting where the beneficiary is located) restrictions for individuals diagnosed with a substance use disorder for the purposes of treatment of such disorder or co-occurring mental health disorder, as of July 1, 2019, based on changes included in the SUPPORT Act.During the erectile dysfunction treatment public health emergency, beneficiaries in any geographic area can receive telehealth services, and can receive these services in their own home, rather than needing to travel to an originating site. During the first year of the viagra, 28 million Medicare beneficiaries used telehealth services, a substantial increase from the 341,000 who used these services the prior year. Beneficiaries used telehealth for 43% of all behavioral health services they received during the first year of the viagra, including individual therapy, group therapy, and substance use disorder treatment, compared to 13% of all office visits. Behavioral health represented 12.4% of all telehealth services received during the first year http://bigthompsoncreekhoa.org/?p=222 of the viagra uses viagra.

These telehealth flexibilities under Medicare have been extended by the Consolidated Appropriations Act of 2022 for 151 days beginning on the first day after the end of the public health emergency, which was most recently renewed in April 2022 and is expected to be renewed again in July 2022. Beneficiary cost sharing for telehealth services has not changed during the public health emergency. Medicare covers telehealth services under Part B, so beneficiaries in traditional Medicare who use these benefits are subject to the Part B deductible of $223 in viagra uses 2022 and 20% coinsurance. The HHS Office of Inspector General has provided flexibility for providers to reduce or waive cost sharing for telehealth visits during the erectile dysfunction treatment public health emergency, although there are no publicly-available data to indicate the extent to which providers may have done so. Some Medicare Advantage plans have reduced or waived cost sharing during the public health emergency, though these waivers may no longer be in effect. What Medicare-covered telehealth mental health and substance use disorder benefits have been extended beyond the public health emergency?.

Medicare viagra uses has made permanent some changes to telehealth coverage related to mental health services. Based on changes in the Consolidated Appropriations Act of 2021, as implemented under the CY 2022 Medicare Physician Fee Schedule Final Rule, Medicare has permanently removed geographic restrictions for telehealth mental health services and permanently allows beneficiaries to receive those services at home. Also under the Physician Fee Schedule final rule, Medicare now permanently covers audio-only visits for mental health and substance use disorder services when the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology. There are some in-person requirements to receive these mental health services through telehealth, viagra uses but they have been delayed for 151 days beginning on the first day after the end of the public health emergency. Once in effect, in order for a beneficiary to receive telehealth mental health services, there must be an in-person, non-telehealth service with a physician within six months prior to the initial telehealth service, and an in-person, non-telehealth visit must be furnished at least every 12 months for these services, though exceptions can be made due to beneficiaries’ circumstances.

These requirements for periodic in-person visits (in conjunction with telehealth services) apply to treatment of mental health disorders other than treatment of a diagnosed substance use disorder. Recently, a group of Senators on the Senate Finance Committee has released a discussion draft that includes a proposal to remove viagra uses the requirement for an in-person visit prior to the initial telehealth service. How are mental health benefits and substance use disorder benefits covered under Medicare Advantage plans?. Medicare Advantage plans are required to cover all Medicare Part A and Part B services, but cost-sharing requirements for beneficiaries in Medicare Advantage plans vary across plans. Medicare Advantage plans can require provider referrals viagra uses and/or impose prior authorization for Part A and B services, including mental health and substance use disorder services.

Medicare Advantage plans also typically have networks of providers that can restrict beneficiary choice of in-network physicians and other providers, although plans must meet network requirements for the number of providers and facilities that are available to beneficiaries. Medicare Advantage plans also have different flexibilities for telehealth benefits. Cost Sharing viagra uses for Medicare-Covered Mental Health Benefits Medicare Advantage plans have the flexibility to modify cost sharing for most Part A and B services, subject to some limitations. For example, Medicare Advantage plans often charge daily copayments for inpatient hospital stays starting on day 1, in contrast to traditional Medicare, where there is a deductible and no copayments until day 60 of a hospital stay. Medicare Advantage enrollees can be expected to face varying costs for a hospital stay depending on the length of stay and their plan’s cost-sharing requirements.

Prior Authorization and Referrals In contrast to most services under traditional Medicare, Medicare Advantage plans can require referrals and/or prior authorization for Part A viagra uses and B services, including mental health and substance use disorder services. In 2021, virtually all enrollees (99%) are in plans that require prior authorization for some services, including opioid treatment services (87%) and mental health specialty services (84%). Provider Networks Unlike in traditional Medicare, where Medicare beneficiaries can see any provider who accepts Medicare, beneficiaries enrolled in Medicare Advantage plans are limited to receiving care from providers in their network or in most cases, must pay more to see out-of-network providers. In order viagra uses to ensure enrollees have adequate access to providers, Medicare Advantage plans are required to meet network adequacy standards, which include a specified number of physicians and other providers, along with hospitals, within a particular driving time and distance of enrollees. However, prior KFF analysis showed that access to psychiatrists has been more restricted than for any other physician specialty.

On average, plans included less than one-quarter (23%) of the psychiatrists in a county, and more than one-third (36%) of the Medicare Advantage plans included less than 10 percent of the psychiatrists in their county. Telehealth As of 2020, Medicare Advantage plans have been permitted to include costs associated with telehealth benefits (beyond what traditional Medicare covers) in their bids for basic viagra uses benefits. The above-mentioned geographic and originating site limitations do not apply in Medicare Advantage plans, which have had flexibility to offer additional telehealth benefits outside of the public health emergency, including telehealth visits provided to enrollees in their own homes and services provided to beneficiaries residing outside of rural areas. In 2021, 94% of Medicare Advantage enrollees in individual plans had a telehealth benefit. During the first year of the erectile dysfunction treatment viagra, 49% of Medicare Advantage enrollees viagra uses used telehealth services.

Do mental health and substance use disorder parity laws apply to Medicare?. Prior to 2010, Medicare beneficiaries paid a higher coinsurance rate (50%) for outpatient mental health services than for other outpatient services covered under Part B (20%). The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) phased in parity viagra uses for cost sharing for all outpatient services covered under Part B between 2010 and 2014, so that as of 2014, cost sharing for outpatient mental health services is the same as for other Part B services. Federal parity laws, including the Mental Health Parity Act of 1996 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), do not apply to Medicare, however. The Mental Health Parity Act of 1996 requires parity in annual and aggregate lifetime dollar limits for mental health benefits and medical or surgical benefits in large groups plans, but not Medicare.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which expanded on the viagra uses 1996 law, extends parity to substance use disorder treatments, and prevents certain health plans from making mental health and substance use disorder coverage more restrictive than medical or surgical benefits, also does not apply to Medicare. In 2016, some of these parity rules were applied to Medicaid Managed Care Organizations (MCOs) but not to Medicare benefits that are provided by Medicaid MCOs to beneficiaries dually enrolled in Medicare and Medicaid. Because MHPAEA does not apply to Medicare, some mental health benefits can be more restricted than other health services. Some stakeholders viagra uses have asserted that this lack of parity can be seen in the lifetime limit of 190 days on inpatient hospitalizations in psychiatric hospitals, because Medicare does not have any other lifetime limits on comparable inpatient services. What policy approaches have been proposed related to coverage of mental health benefits and substance use disorder benefits under Medicare?.

As part of the President’s FY 2023 budget, the Administration has made a number of recommendations to support mental health, including but not limited to Medicare enhancements. These include, viagra uses for example. Applying the Mental Health Parity and Addiction Equity Act to Medicare. Requiring Medicare to cover three behavioral health visits without cost sharing. And authorizing viagra uses licensed professional counselors and marriage and family therapists to bill Medicare directly.

Policymakers have also introduced legislation to improve mental health access in Medicare, including the Medicare Mental Health Inpatient Equity Act of 2021, which would remove the 190-day lifetime limit on inpatient psychiatric hospital services under Medicare, and the Mental Health Access Improvement Act of 2021, which would allow marriage and family therapists and licensed professional counselors to be reimbursed under Medicare.While many of these proposals would increase access to mental health and substance use disorder treatment, there would likely be an increase in costs for the Medicare program. For example, eliminating the 190-day lifetime limit on psychiatric hospital services would be expected to increase Medicare Part A spending by $3 billion over 10 years, according to CBO. Other changes, such as requiring Medicare to cover three behavioral health visits without cost sharing would increase Part B spending by $1.4 billion over 10 years.

The erectile dysfunction treatment viagra has taken a heavy physical and mental health toll on all ages, including older adults, heightening interest in strategies to improve access to mental health how to get viagra without a doctor and substance use disorder (SUD) services generally, and in Medicare. In April 2022 – more than two years into the viagra – one in six adults 65 and older (16%) reported anxiety and depression, according to KFF analysis of the Household Pulse Survey, somewhat lower than the quarter of older adults (24%) who reported anxiety and depression in August 2020, when the country was in still the midst of widespread lockdowns in the early stage of the viagra. (Both estimates would likely be higher among the entire Medicare population because Medicare beneficiaries under age 65 with long-term disabilities report higher rates of anxiety and depression than older beneficiaries, according to unpublished KFF analysis of the Medicare Beneficiary Survey from 2019.) Additionally, nearly a third of adults 65 and older (32%) say that worry or stress related to erectile dysfunction has had a negative impact on their mental health, according to KFF polling, a somewhat lower rate than reported among younger adults. These FAQs review mental health and substance use disorder coverage and out-of-pocket costs in Medicare and discuss policy proposals related to coverage how to get viagra without a doctor of mental health and substance use disorder treatments.

What mental health benefits and substance use disorder benefits does Medicare cover?. Medicare covers a range of mental health and substance use disorder services, both inpatient and outpatient, and covers outpatient prescription drugs used to treat these conditions. Medicare Advantage plans are how to get viagra without a doctor required to cover benefits covered under traditional Medicare and most cover Part D prescription drugs as well, but out-of-pocket costs may differ between traditional Medicare and Medicare Advantage plans, and vary from one Medicare Advantage plan to another. (See below section “How are mental health benefits and substance use disorder benefits covered under Medicare Advantage plans?.

€ for more detail.) Inpatient Services Medicare Part A covers inpatient care for beneficiaries who need mental health treatment in either a general hospital or a psychiatric hospital. Outpatient Services Medicare Part B covers one depression how to get viagra without a doctor screening per year, a one-time “welcome to Medicare” visit, which includes a review of risk factors for depression, and an annual “wellness” visit, where beneficiaries can discuss their mental health status. Part B also covers individual and group psychotherapy with doctors (or with certain other licensed professionals, depending on state rules), family counseling (if the main purpose is to help with treatment), psychiatric evaluation, medication management, and partial hospitalization. Partial hospitalization is a more structured program of individualized and multidisciplinary outpatient psychiatric treatments that is more intensive than in a doctor or therapists’ office, as an alternative to an inpatient stay.

Partial hospitalization programs are designed for patients with mental health conditions who do not require 24-hour inpatient care, but have how to get viagra without a doctor not benefitted from a less intensive outpatient program. Part B also covers outpatient services related to substance use disorders including opioid use disorder treatment services, which include medication, counseling, drug testing, and individual and group therapy. Medicare covers one alcohol misuse screening per year, and for beneficiaries determined to be misusing alcohol, four counseling sessions per year. Medicare also covers up to 8 tobacco cessation counseling how to get viagra without a doctor sessions in a 12-month period.

Prescription Drugs The Medicare Part D program provides an outpatient prescription drug benefit to people on Medicare who enroll in private plans, including stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PDs). Medicare Part D prescription drug plans cover retail prescription drugs related to mental health and are required to cover all or substantially all antidepressants, antipsychotics, and anticonvulsants (such as benzodiazepines), as each is one of the six protected classes of drugs in Part D. Part D plans are permitted to impose prior authorization and step therapy requirements for beneficiaries initiating therapy (i.e., new starts) for each of these protected classes of how to get viagra without a doctor drugs. Coverage of other prescription drugs is based on an individual plan’s formulary, and depending on a plan’s formulary, beneficiaries can also be subject to prior authorization, step therapy, and quantity limits.

How much do Medicare beneficiaries pay for mental health benefits and substance use disorder benefits?. Inpatient Services how to get viagra without a doctor Beneficiaries who are admitted to a hospital for inpatient mental health treatment would be subject to the Medicare Part A deductible of $1,556 per benefit period in 2022. Part A also requires daily copayments for extended inpatient hospital stays. For extended hospital stays, beneficiaries would pay a $389 copayment per day (days 61-90) and $778 per day for lifetime reserve days.

For inpatient stays in a psychiatric how to get viagra without a doctor hospital, Medicare coverage is limited to up to 190 days of hospital services in a lifetime. Most beneficiaries in traditional Medicare have supplemental insurance that may pay some or all of the cost sharing for covered Part A and B services. Outpatient Services For most outpatient services covered under Part B, there is a $233 deductible (in 2022) and 20 percent coinsurance that applies to most services, including physician visits. However, some specific Part how to get viagra without a doctor B services have different cost-sharing amounts (Table 1).

Prescription Drugs Those with Part D coverage face cost-sharing amounts for covered drugs and may pay an annual deductible ($480 in 2022) and a monthly premium. For example, most Part D enrollees pay less than $10 for generic drugs, but many pay $40-$100 (or coinsurance of 40%-50%) for brand-name drugs. Beneficiaries with low incomes and modest assets are eligible how to get viagra without a doctor for assistance with Part D plan premiums and cost sharing. Which health providers can bill Medicare directly for mental health and substance use disorder services, and how much does Medicare pay for these services?.

Medicare provides coverage and reimbursement for mental health services provided by psychiatrists or other doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. Medicare does not provide coverage or reimbursement for mental health services provided how to get viagra without a doctor by licensed professional counselors and licensed marriage and family therapists. Medicare fees vary by type of provider, according to the Medicare Physician Fee Schedule (Table 2). Are psychiatrists accessible to Medicare beneficiaries?.

The majority of physicians, both primary care and specialists, report taking how to get viagra without a doctor new Medicare patients, similar to the share who take new privately insured patients. Psychiatrists, however, are less likely than other specialists to take new Medicare (or private insurance) patients. According to a recent KFF analysis, 60% of psychiatrists are accepting new Medicare patients, which is just over 20 percentage points lower than the share of physicians in general/family practice accepting new patients (81%). However, the survey used to conduct the analysis does not distinguish among physicians seeing new patients covered under traditional Medicare or Medicare Advantage, so it is not clear whether physicians are more inclined to accept new Medicare patients in either Medicare Advantage plans or traditional Medicare.Further, how to get viagra without a doctor psychiatrists are more likely than other specialists to “opt out” of Medicare altogether.

Providers who opt out of Medicare do not participate in the Medicare program and instead enter into private contracts with their Medicare patients, allowing them to bill their Medicare patients any amount they determine is appropriate. Overall, 1% of all non-pediatric physicians have formally opted-out of the Medicare program, with opt-out rates highest among psychiatrists. 7.5% of how to get viagra without a doctor psychiatrists opted out in 2022. In fact, psychiatrists account for 42% of the 10,105 physicians opting out of Medicare in 2022.

The relatively high rate of psychiatrists not taking new Medicare patients, combined with relatively high opt out rates, could pose access issues for Medicare beneficiaries needing treatment for mental health needs. (For additional information on access to providers in Medicare Advantage plans, see “Provider Networks” how to get viagra without a doctor in the section below. €œHow are mental health benefits and substance use disorder benefits covered under Medicare Advantage plans?. €) How has expanded telehealth coverage affected access to mental health benefits and substance use disorder benefits during the erectile dysfunction treatment viagra?.

Prior to the erectile dysfunction treatment viagra, Medicare coverage of telehealth services was very limited. Before the erectile dysfunction treatment public health emergency, telehealth services were generally available only to beneficiaries in rural areas originating from a health care setting, how to get viagra without a doctor such as a clinic or doctor’s office. One exception, however, was the removal of the geographic and originating site (i.e., the health care setting where the beneficiary is located) restrictions for individuals diagnosed with a substance use disorder for the purposes of treatment of such disorder or co-occurring mental health disorder, as of July 1, 2019, based on changes included in the SUPPORT Act.During the erectile dysfunction treatment public health emergency, beneficiaries in any geographic area can receive telehealth services, and can receive these services in their own home, rather than needing to travel to an originating site. During the first year of the viagra, 28 million Medicare beneficiaries used telehealth services, a substantial increase from the 341,000 who used these services the prior year.

Beneficiaries used telehealth for 43% of all behavioral health services they received during the first year of the viagra, including individual therapy, how to get viagra without a doctor group therapy, and substance use disorder treatment, compared to 13% of all office visits. Behavioral health represented 12.4% of all telehealth services received during the first year of the viagra. These telehealth flexibilities under Medicare have been extended by the Consolidated Appropriations Act of 2022 for 151 days beginning on the first day after the end of the public health emergency, which was most recently renewed in April 2022 and is expected to be renewed again in July 2022. Beneficiary cost sharing for telehealth services has not changed during the public health emergency how to get viagra without a doctor.

Medicare covers telehealth services under Part B, so beneficiaries in traditional Medicare who use these benefits are subject to the Part B deductible of $223 in 2022 and 20% coinsurance. The HHS Office of Inspector General has provided flexibility for providers to reduce or waive cost sharing for telehealth visits during the erectile dysfunction treatment public health emergency, although there are no publicly-available data to indicate the extent to which providers may have done so. Some Medicare Advantage plans have reduced or waived cost sharing during the public health emergency, though these waivers may no longer be in effect. What Medicare-covered telehealth mental health and substance use how to get viagra without a doctor disorder benefits have been extended beyond the public health emergency?. Medicare has made permanent some changes to telehealth coverage related to mental health services.

Based on changes in the Consolidated Appropriations Act of 2021, as implemented under the CY 2022 Medicare Physician Fee Schedule Final Rule, Medicare has permanently removed geographic restrictions for telehealth mental health services and permanently allows beneficiaries to receive those services at home. Also under the Physician Fee Schedule final rule, Medicare now permanently covers audio-only visits for mental health how to get viagra without a doctor and substance use disorder services when the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology. There are some in-person requirements to receive these mental health services through telehealth, but they have been delayed for 151 days beginning on the first day after the end of the public health emergency. Once in effect, in order for a beneficiary to receive telehealth mental health services, there must be an in-person, non-telehealth service with a physician within six months prior to the initial telehealth service, and an in-person, non-telehealth visit must be furnished at least every 12 months for these services, though exceptions can be made due to beneficiaries’ circumstances.

These requirements for periodic in-person visits (in conjunction with telehealth services) apply how to get viagra without a doctor to treatment of mental health disorders other than treatment of a diagnosed substance use disorder. Recently, a group of Senators on the Senate Finance Committee has released a discussion draft that includes a proposal to remove the requirement for an in-person visit prior to the initial telehealth service. How are mental health benefits and substance use disorder benefits covered under Medicare Advantage plans?. Medicare Advantage plans are required how to get viagra without a doctor to cover all Medicare Part A and Part B services, but cost-sharing requirements for beneficiaries in Medicare Advantage plans vary across plans.

Medicare Advantage plans can require provider referrals and/or impose prior authorization for Part A and B services, including mental health and substance use disorder services. Medicare Advantage plans also typically have networks of providers that can restrict beneficiary choice of in-network physicians and other providers, although plans must meet network requirements for the number of providers and facilities that are available to beneficiaries. Medicare Advantage plans also how to get viagra without a doctor have different flexibilities for telehealth benefits. Cost Sharing for Medicare-Covered Mental Health Benefits Medicare Advantage plans have the flexibility to modify cost sharing for most Part A and B services, subject to some limitations.

For example, Medicare Advantage plans often charge daily copayments for inpatient hospital stays starting on day 1, in contrast to traditional Medicare, where there is a deductible and no copayments until day 60 of a hospital stay. Medicare Advantage enrollees can be expected to face varying costs for a hospital stay depending on the length of stay and their plan’s how to get viagra without a doctor cost-sharing requirements. Prior Authorization and Referrals In contrast to most services under traditional Medicare, Medicare Advantage plans can require referrals and/or prior authorization for Part A and B services, including mental health and substance use disorder services. In 2021, virtually all enrollees (99%) are in plans that require prior authorization for some services, including opioid treatment services (87%) and mental health specialty services (84%).

Provider Networks Unlike in traditional Medicare, where Medicare beneficiaries can see any how to get viagra without a doctor provider who accepts Medicare, beneficiaries enrolled in Medicare Advantage plans are limited to receiving care from providers in their network or in most cases, must pay more to see out-of-network providers. In order to ensure enrollees have adequate access to providers, Medicare Advantage plans are required to meet network adequacy standards, which include a specified number of physicians and other providers, along with hospitals, within a particular driving time and distance of enrollees. However, prior KFF analysis showed that access to psychiatrists has been more restricted than for any other physician specialty. On average, plans included less than one-quarter (23%) of the psychiatrists in a county, and more than one-third (36%) of the Medicare Advantage plans included less than how to get viagra without a doctor 10 percent of the psychiatrists in their county.

Telehealth As of 2020, Medicare Advantage plans have been permitted to include costs associated with telehealth benefits (beyond what traditional Medicare covers) in their bids for basic benefits. The above-mentioned geographic and originating site limitations do not apply in Medicare Advantage plans, which have had flexibility to offer additional telehealth benefits outside of the public health emergency, including telehealth visits provided to enrollees in their own homes and services provided to beneficiaries residing outside of rural areas. In 2021, 94% of Medicare Advantage enrollees in how to get viagra without a doctor individual plans had a telehealth benefit. During the first year of the erectile dysfunction treatment viagra, 49% of Medicare Advantage enrollees used telehealth services.

Do mental health and substance use disorder parity laws apply to Medicare?. Prior to 2010, Medicare beneficiaries paid a higher coinsurance rate (50%) for outpatient how to get viagra without a doctor mental health services than for other outpatient services covered under Part B (20%). The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) phased in parity for cost sharing for all outpatient services covered under Part B between 2010 and 2014, so that as of 2014, cost sharing for outpatient mental health services is the same as for other Part B services. Federal parity laws, including the Mental Health Parity Act of 1996 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), do not apply to Medicare, however.

The Mental Health Parity Act of 1996 requires parity in annual and aggregate lifetime dollar how to get viagra without a doctor limits for mental health benefits and medical or surgical benefits in large groups plans, but not Medicare. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which expanded on the 1996 law, extends parity to substance use disorder treatments, and prevents certain health plans from making mental health and substance use disorder coverage more restrictive than medical or surgical benefits, also does not apply to Medicare. In 2016, some of these parity rules were applied to Medicaid Managed Care Organizations (MCOs) but not to Medicare benefits that are provided by Medicaid MCOs to beneficiaries dually enrolled in Medicare and Medicaid. Because MHPAEA does not apply how to get viagra without a doctor to Medicare, some mental health benefits can be more restricted than other health services.

Some stakeholders have asserted that this lack of parity can be seen in the lifetime limit of 190 days on inpatient hospitalizations in psychiatric hospitals, because Medicare does not have any other lifetime limits on comparable inpatient services. What policy approaches have been proposed related to coverage of mental health benefits and substance use disorder benefits under Medicare?. As part of the President’s FY 2023 how to get viagra without a doctor budget, the Administration has made a number of recommendations to support mental health, including but not limited to Medicare enhancements. These include, for example.

Applying the Mental Health Parity and Addiction Equity Act to Medicare. Requiring Medicare to cover three behavioral health visits without cost sharing.

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The course can be delivered for teams or individuals and can be used to underpin workplace projects does viagra make your penis bigger. It delivers, in detail, and with worked examples, how to understand laboratory processes, identify problem areas, gather data, use problem analysis tools and data to test different solution scenarios, evaluate improvement and implement project management tools to the improvement process. There are two course options. Asynchronous - study at your own pace, utilising 10 hours does viagra make your penis bigger of on-demand videos Cohort - join a cohort group where a facilitated course is run over 8 weeks For further details, download and view the course prospectus. Asynchronous - Study at your own pace IBMS members The course is discounted for IBMS members who can access it via the IBMS members website.

Log into your MyIBMS and visit the Laboratory Transformation and Improvement Program page, this directs to the LabVine website where the course cost is £410. Non-members Non-members can join the course by selecting the link below, this directs to the LabVine website where does viagra make your penis bigger the course cost is £510. Non-IBMS members will then be invited to become IBMS members free for one year, at a membership grade appropriate to qualifications. Sign up to access the course>>. Cohort - Join a facilitated cohort The cohort program will run annually over 8 weeks starting on the 30th January 2023 and will feature weekly facilitated sessions to assist individuals progress with their does viagra make your penis bigger project.

As with the asynchronous program, IBMS members will receive a discount through the link on the members page, non-IBMS members can access the course through the IBMS website and will be invited to receive IBMS membership, free for one year at a membership grade appropriate to qualifications. Course enrolment will be available from 1st November – 23rd Dec 2022. Organisations wishing to arrange a cohort within their own does viagra make your penis bigger networks should contact the IBMS, Donna Torrance, donnatorrance@ibms.org16 August 2022 We are holding two virtual webinars in September to train eligible members to become verifiers and examiners Training and refresher training for registration verifiers and specialist portfolio examiners will be taking place online on the 22nd September 2022 (click to register) and 29th September 2022 (click to register).The days will be split into two sessions. Mornings for Registration Verifiers and afternoons for Specialist Examiners. IBMS members can attend either one or both sessions but will need to register for each session individually.

Why choose to become does viagra make your penis bigger a verifier?. Becoming a verifier provides an opportunity for you to. Refresh your knowledge Become aware of new methodologies Stimulate new ideas Develop new skills in peer review and assessment Connect with other laboratories and training officers, and grow your network Schedule Registration training portfolio assessor training Start - 9:45am Finish - 12.00 Specialist portfolio assessor training Start -1.45pm Close - 4pm In order to become an IBMS verifier or examiner you must meet the following criteria. · IBMS Member or Fellow · Health and Care Professions Council (HCPC) registered · A minimum of three years post registration experience · Currently working in an IBMS-approved training laboratory · Actively participating in CPD for at least the last two years.Further information Click below to read Mike Carter's reflection on becoming a verifier.

The course can be delivered for teams or http://www.em-holtzheim.site.ac-strasbourg.fr/2021/09/01/rentree-de-septembre-2021-cadre-sanitaire/ individuals and can be used to how to get viagra without a doctor underpin workplace projects. It delivers, in detail, and with worked examples, how to understand laboratory processes, identify problem areas, gather data, use problem analysis tools and data to test different solution scenarios, evaluate improvement and implement project management tools to the improvement process. There are two course options. Asynchronous - how to get viagra without a doctor study at your own pace, utilising 10 hours of on-demand videos Cohort - join a cohort group where a facilitated course is run over 8 weeks For further details, download and view the course prospectus.

Asynchronous - Study at your own pace IBMS members The course is discounted for IBMS members who can access it via the IBMS members website. Log into your MyIBMS and visit the Laboratory Transformation and Improvement Program page, this directs to the LabVine website where the course cost is £410. Non-members Non-members can join the course by selecting the link below, this directs to the LabVine website where the course how to get viagra without a doctor cost is £510. Non-IBMS members will then be invited to become IBMS members free for one year, at a membership grade appropriate to qualifications.

Sign up to access the course>>. Cohort - Join a facilitated cohort The cohort program how to get viagra without a doctor will run annually over 8 weeks starting on the 30th January 2023 and will feature weekly facilitated sessions to assist individuals progress with their project. As with the asynchronous program, IBMS members will receive a discount through the link on the members page, non-IBMS members can access the course through the IBMS website and will be invited to receive IBMS membership, free for one year at a membership grade appropriate to qualifications. Course enrolment will be available from 1st November – 23rd Dec 2022.

Organisations wishing to arrange a cohort within their own networks should contact the IBMS, Donna Torrance, donnatorrance@ibms.org16 August 2022 We are holding two virtual webinars in September to train eligible members to become verifiers and examiners Training and refresher training for registration verifiers and specialist portfolio examiners will be taking place online on the 22nd September 2022 (click to register) and 29th September 2022 (click to register).The days will be split into two sessions how to get viagra without a doctor. Mornings for Registration Verifiers and afternoons for Specialist Examiners. IBMS members can attend either one or both sessions but will need to register for each session individually. Why choose to become a how to get viagra without a doctor verifier?.

Becoming a verifier provides an opportunity for you to. Refresh your knowledge Become aware of new methodologies Stimulate new ideas Develop new skills in peer review and assessment Connect with other laboratories and training officers, and grow your network Schedule Registration training portfolio assessor training Start - 9:45am Finish - 12.00 Specialist portfolio assessor training Start -1.45pm Close - 4pm In order to become an IBMS verifier or examiner you must meet the following criteria. · IBMS Member or Fellow · Health and Care Professions Council (HCPC) registered · A minimum of three years post registration experience · Currently working in an IBMS-approved training laboratory · Actively participating in CPD for at least the last two years.Further information Click below to read Mike Carter's reflection on becoming a verifier.

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Notes1 http://rlalebanon.org/how-do-i-get-cipro/ viagra over the counter walmart. R. C Keller (2006) viagra over the counter walmart. "Geographies of power, legacies of mistrust. Colonial medicine in the global present." Historical Geography no.

34:26-48.2. Bridget Pratt et al. (2018). "Exploring the ethics of global health research priority-setting." BMC Medical Ethics no. 19 (94).

Doi. 10.1186/s12910-018-0333-y3. Richard Horton (2013). "Offline. Is global health neocolonialist?.

" The Lancet no. 382 (9906):1690. Doi. 10.1016/S0140-6736(13)62379-X4. Anonymous (2019).

"Editorial. Break with tradition. The World Health Organization’s decision about traditional Chinese medicine could backfire." Nature no. 570:5.5. S.

S Amrith (2006). Decolonizing international health. India and Southeast Asia, 1930–65. London. Palgrave Macmillan.6.

Arturo Escobar and A Escobar (1984). "Discourse and power in development. Michel Foucault and the relevance of his work to the third world." Alternatives no. 10 (3):377-400. Doi.

10.1177/0304375484010003047. UNDG (2013). A million voices. The world we want. A sustainable future with dignity for all.

New York, NY. United Nations Development Group.8. WHO (2019). Speech by the Director-General. Transforming for impact 2019 (cited 10 March 2019).

Available from. Https://www.who.int/dg/speeches/detail/transforming-for-impact.9. R. C Keller (2006). Geographies of power, legacies of mistrust.

Colonial medicine in the global present.10. Mishal S Khan et al. (2019). Durrance-Bagale, H. Legido-Quigley "‘LMICs as reservoirs of AMR’.

A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan." Health Policy and Planning no. 34 (3):178–187. Doi. 10.1093/heapol/czz02211. Clare I R Chandler (2019).

"Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure." Palgrave Communications no. 5 (1):53. Doi. 10.1057/s41599-019-0263-412.

In the area of antimicrobial use for human health, other problem areas include, for example, public hygiene and disease prevention, regulated access to medicines, disease diagnosis, or market conditions for the development of new antimicrobials. The Review on Antimicrobial Resistance (2016). Tackling drug-resistant s globally. Final report and recommendations. London.

The UK Prime Minister, WHO (2015b). Global action plan on antimicrobial resistance. Geneva. World Health Organization, Conan MacDougall and Ron E Polk (2005). "Antimicrobial stewardship programs in health care systems." Clinical Microbiology Reviews no.

18 (4):638-656. Doi. 10.1128/CMR.18.4.638-656.2005.13. The Review on Antimicrobial Resistance. Tackling drug-resistant s globally.

Final report and recommendations.14. WHO, Global action plan on antimicrobial resistance.15. Maria R Gualano et al. (2015). "General population's knowledge and attitudes about antibiotics.

A systematic review and meta-analysis." Pharmacoepidemiology and Drug Safety no. 24 (1):2-10. Doi. 10.1002/pds.371616. H Haak and A.

Radyowijati (2010). "Determinants of antimicrobial use. Poorly understood, poorly researched." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 283-300. New York, NY. Springer.17.

These problems persist despite encouraging trends. For example, the field is becoming increasingly multidisciplinary through the involvement of several United Nations agencies alongside WHO in governing AMR, and AMR policy narratives are slowly broadening the hitherto hyper-individualised and behaviour change focus of global action plans. Connor Rochford et al. (2018). "Global governance of antimicrobial resistance." The Lancet no.

391 (10134):1976-1978. Doi. 10.1016/S0140-6736(18)31117-6, WHO, FAO, and OIE (2018). Monitoring global progress on addressing antimicrobial resistance. Analysis report of the second round of results of AMR country self-assessment survey 2018.

Geneva. World Health Organization, Food and Agriculture Organization of the United Nations and World Organisation for Animal Health (OIE), WHO (2017). Antimicrobial Resistance Behaviour Change first informal technical consultation, 6-7 November, 2017 Château de Penthes, Geneva. Meeting Report. Geneva.

World Health Organization, Elise Klein and China Mills (2017). "Psy-expertise, therapeutic culture and the politics of the personal in development." Third World Quarterly no. 38 (9):1990-2008. Doi. 10.1080/01436597.2017.131927718.

Emma R M Cohen et al. (2008). "Public engagement on global health challenges." BMC Public Health no. 8 (168). Doi.

10.1186/1471-2458-8-16819. B Hamlyn et al. (2015).Factors affecting public engagement by researchers. A study on behalf of a consortium of UK public research funders. London.

TNS20. Research Councils UK (2011) Concordat for engaging the public with research. Research Councils UK. Swindon.21. C Wilson, P.

Manners, and S. Duncan (2014). Building an engaged future for UK higher education. Full report from the Engaged Futures consultation. Bristol.

National Co-ordinating Centre for Public Engagement.22. Also referred to as ‘community engagement’, ‘patient and public involvement’ (PPI) in research, or in some instances also as participatory research. S. Staniszewska et al. (2017).

"GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research." Research Involvement and Engagement no. 3 (13). Doi. 10.1186/s40900-017-0062-2, Jo Brett et al.

(2014). "Mapping the impact of patient and public involvement on health and social care research. A systematic review." Health Expectations no. 17 (5):637-650. Doi.

10.1111/j.1369-7625.2012.00795.x, Paulina O Tindana et al. (2007). "Grand challenges in global health. Community engagement in research in developing countries." PLOS Medicine no. 4 (e273).

Doi. 10.1371/journal.pmed.0040273, F Darroch and A. Giles (2014). "Decolonizing health research. Community-based participatory research and postcolonial feminist theory." Canadian Journal of Action Research no.

15 (3):22-36.23. J Redfern et al. (2018). "Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event." FEMS Microbiology Letters no.

365 (16). Doi. 10.1093/femsle/fny17524. Victoria Jane Hume et al. (2018).

"Biomedicine and the humanities. Growing pains." Medical Humanities no. 44 (4):230-238. Doi. 10.1136/medhum-2018-01148125.

Astrid Treffry-Goatley et al. (2018). Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014). "Medicine and the visual arts." In Medicine, health and the arts. Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63.

Abingdon. Routledge.27. Angela Ross Perfetti (2018). "Fate and the clinic. A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no.

44 (1):59-62. Doi. 10.1136/medhum-2017-01131928. Devan Stahl et al. (2016).

"Seeing illness in art and medicine. A patient and printmaker collaboration." Ibid. No. 42 (3):155-159. Doi.

10.1136/medhum-2015-01083829. Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid. No.

43 (1):19-23. Doi. 10.1136/medhum-2016-01100230. T. R Cole, N.

S. Carlin, and R. A. Carson (2015). Medical humanities.

An introduction. New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016). "Applying social theory to understand health-related behaviours." Medical Humanities no.

42 (2):143-145. Doi. 10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities. Growing pains.33.

A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65. Edinburgh. Edinburgh University Press.34.

Jordanova, Medicine and the visual arts.35. Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.36. William Viney et al. (2015).

"Critical medical humanities. Embracing entanglement, taking risks." Ibid. No. 41 (1):2-7. Doi.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016). "Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?.

" In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394. Edinburgh. Edinburgh University Press.38. J Macnaughton and H. Carel (2016).

Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39. P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no.

11 (2):147-163.40. Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &. Illness no. 25 (3):41-57.

Doi. 10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018). "Making research and building knowledge with communities.

Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287. Cham. Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019).

"Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no. 5 (1):31. Doi. 10.1057/s41599-019-0239-443.

R Garden (2014). "Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ. Rutgers University Press.44.

Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018). "Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no. 4 (96).

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No. 5 (1):45. Doi. 10.1057/s41599-019-0251-847. Sue Walker (2019).

Ibid."Effective antimicrobial resistance communication. The role of information design." 24. Doi. 10.1057/s41599-019-0231-z48. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.49.

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Stabilisation, individualisation and antibiotics as infrastructure.67. Steve Hinchliffe, Andrea Butcher, and Muhammad Meezanur Rahman (2018). "The AMR problem. Demanding economies, biological margins, and co-producing alternative strategies." Ibid. No.

4 (142). Doi. 10.1057/s41599-018-0195-468. Chuengsatiansup and Limsawart, Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders.69.

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A qualitative study." Journal of Antimicrobial Chemotherapy no. 59 (6):1155-1160. Doi. 10.1093/jac/dkm10372. McCullough, et al.

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Growing pains.88. I Bamforth (2000). "Kafka's uncle. Scenes from a world of trust infected by suspicion." Ibid. No.

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A transdisciplinary approach.96. R. J Hester (2016). "Culture in medicine. An argument against competence." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 541-558.

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R. K Yin (2003). Case study research. Design and methods. Thousand Oaks, CA.

Sage.105. Marco J Haenssgen et al. (2018)106. S. L Gilman (2015).

Illness and image. Case studies in the medical humanities. New York, NY. Taylor &. Francis.107.

HarbarthM Haughton (2018). Staging trauma. Bodies in shadow. London. Palgrave Macmillan.108.

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10.1136/jmh.2006.000256109. Hume, et al. Biomedicine and the humanities. Growing pains.110. Saam Idelji-Tehrani and Muna Al-Jawad (2019).

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10.1136/medhum-2018-011517111. Suze M P J Jans et al. (2012). "A case study of haemoglobinopathy screening in the Netherlands. Witnessing the past, lessons for the future." Ethnicity &.

Health no. 17 (3):217-239. Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 114. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.115. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise. The emergence of the lay expert in medical sociology.117. Gilman, Illness and image.

Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.120. C Teddlie and A. Tashakkori (2009). Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences.

Thousand Oaks, CA. Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122. Gian Luca Barbieri et al.

(2016). "Imagination in narrative medicine." Journal of Child Health Care no. 20 (4):419-427. Doi. 10.1177/1367493515625134123.

Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.124. WHO (2016). World Antibiotic Awareness Week.

2016 campaign toolkit. Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range. 18 to 81 years.

Based on subsequently collected survey data).126. Nutcha Charoenboon et al. (2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128. The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref.

OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &. Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129.

Marco J Haenssgen et al. (2018)130. National Statistical Office (2012). The 2010 population and housing census. Changwat Chiang Rai.

Bangkok. National Statistical Office.131. Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124. Doi. 10.1136/medhum-2013-010466133.

Carusi, Modelling systems biomedicine. Intertwinement and the 'real'.134. Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.135. Emma Sacks et al.

(2018). "Beyond the building blocks. Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384.

Doi. 10.1136/bmjgh-2018-001384136. Sudhinaraset, et al. What is the role of informal healthcare providers in developing countries?. A systematic review.137.

G Bloom et al. (2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton. University of Sussex138.

WHO (2007). Strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva. World Health Organization.139.

Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.141. A Bleakley (2014). Ibid.

"Towards a 'critical medical humanities'." In, 17-26.142. Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al. (2019)144.

Marco Haenssgen et al. (2018)145. WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146. The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue.

Amoxicillin. Red-black. Cloxacillin. White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material).

Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147. The ‘desirability’ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!. € The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148.

Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic. This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149. Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150. Arya Nielsen et al. (2007).

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Nithima Sumpradit et al. (2012). "Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913.

Doi. 10.2471/BLT.12.105445152. C Muksong and K. Chuengsatiansup (2020). Forthcoming.

"Medicine and public health in Thai historiography. From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London. The Wellcome Trust Centre for the History.153.

L Sringernyuang (2000). Availability and use of medicines in rural Thailand. Amsterdam. Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts.

The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al. (2019) and Marco Haenssgen et al. (2018).155.

For example, Redfern, et al., Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018). 2018.

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10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.

While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete. Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice.

With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms.

Communal areas should have movable furniture. Wards should be designed for low social densities. And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?. The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?.

In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?. While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves.

Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care. There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.

The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals).

These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients. Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice.

Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.

This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff.

Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts. Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?. We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare.

The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).

It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed. Architectural decisions related to these values operate across three scales. Context, hospital and individual.

Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site. And how spatial and functional links are set up between those buildings.

This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views. And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings.

What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1).

Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside. Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site.

Two different treatment hub arrangements are in use. €˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1). Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’.

A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.

Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2).

The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape. This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan.

While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2).

Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over. Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’). Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised.

Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size. The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces.

For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience. To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.

But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff.

Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment. In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients.

They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process. Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.

Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients.

History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction. For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold.

To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes. And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.

That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients. The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment.

Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital. Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice.

The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences.

This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband.

At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site. Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.

Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement.

This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital. The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces. A shared kitchen and dining room is provided for each house.

Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.

According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness.

These are arranged in a semicircle, opening onto a large veranda and greenspace. The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital.

Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.

The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care. The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction.

This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones. The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5).

The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria.

Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value.

Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects. History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.

A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace.

MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision. The following people contributed their time and expertise in shaping the research process that enabled this article.

Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria. Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2. 169–80.2.

The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3. B Edginton (1994), “The Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no.

2. 375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no. 4 Pt 4.

425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding. Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2. 232–56.4.

Roger S Ulrich et al. (2008), “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3. 61–125. Jill Maben et al.

(2015), “Evaluating a Major Innovation in Hospital Design. Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3. 1–304. Penny Curtis and Andy Northcott (2017), “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no. 11–12.

1584–96.5. Roger S. Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57. 53–66.6.

Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7. For further examples of this see Jon E. Eggert et al.

(2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &. The Law 32, no. 4. 527–38. C.C.

Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no. 5. 639–44. Gabriela Novotná et al.

(2011), “Client-Centered Design of Residential Addiction and Mental Health Care Facilities. Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11. 1527–38.8. Morgan Andersson et al.

(2013), “New Swedish Forensic Psychiatric Facilities. Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al. (2013), “Stressed Spaces.

Mental Health and Architecture,” HERD. Health Environments Research &. Design Journal 6, no. 4. 127–168.

Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space. Systematic Review,” British Journal of Psychiatry 205, no. 3. 171–6.10.

R. Allen and R.G. Nairn, 1997. Alan Dilani, 2000, “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37. 20–4.

Rebecca McLaughlan (2018), “Psychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2. 151–62.11. Rebecca McLaughlan (2017), “Learning From Evidence-Based Medicine.

Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1. 210–28.12. B Edginton (1997), “Moral Architecture. The Influence of the York Retreat on Asylum Design,” Health &. Place 3, no.

2. 91–9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London. Mansell Publishing Limited).

Anne Digby (1985), Madness, Morality and Medicine. A Study of the York Retreat 1796–1914 (New York. Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.

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Rebecca McLaughlan (2014), “One Dose of Architecture, Taken Daily. Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).14. Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S.

Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no.

2. 39–48.15. M Gibbons (2000), “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27. 161.16. D Seamon, 2000, “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed.

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This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting. Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/. Cannon Design (2014), “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September.

Health Nexus Group, 2017, “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia. W.A.F.

Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock). Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

Eggert et al., “Person-Environment Interaction.”23. Anon (1895), “Review. The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr.

Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin. Springer, 1983),” The Journal of Mental Science 41. 697–703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.

Arthur H. Stockwell Ltd), 64.25. John Galt (1854), “The Farm of St. Anne,” American Journal of Insanity II (1854). 352.26.

Galt, “The Farm of St. Anne,” 352.27. Martin James (1948), “Diagnostic Measures,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London. Buttefwork &.

Co. Ltd), 146. World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28.

Carla Yanni (2007), The Architecture of Madness. Insane Asylums in the United States. Minneapolis (London. University of Minnesota Press).29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30.

Taylor, Hospital and Asylum Architecture in England.31. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. O. Jenkins, S. Dye and C.

Foy (2015) (Oliver Jenkins et al., 2015), “A Study of Agitation, Conflict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01. 27–35. M. Daffern, M.M.

Mayer, and T. Martin (2004), “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no. 1. 105–114. Kathryn L.

Brooks et al. (1994), “Patient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2. 133–44.

T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no. 12. 1237–40.32. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57.

Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33. Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

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J. Enser and D. Maclnnes (1999), “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3. 170–4.

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Leslie Topp (2007), “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria. Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed. Leslie Topp, James Moran and Jonathan Andrews (London and New York. Routledge), 244.36.

McLaughlan, “One Dose of Architecture, Taken Daily,” 35. Digby, Madness, Morality and Medicine.37. Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410. 728–9.38.

Anon, “Proposed New Hospital for Mental Diseases.”39. McLaughlan, “One Dose of Architecture, Taken Daily.”40. Samuel Tuke (1964), “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London. Dawsons of Paul Mall). Scull, Museums of Madness.

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66–71. David Clark (1965), “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111. 947–54.42. Jolanda Maas et al. (2009), “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health &.

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Growing pains." Medical Humanities no. 44 (4):230-238. Doi.

10.1136/medhum-2018-01148125. Astrid Treffry-Goatley et al. (2018).

Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014).

"Medicine and the visual arts." In Medicine, health and the arts. Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63. Abingdon.

Routledge.27. Angela Ross Perfetti (2018). "Fate and the clinic.

A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no. 44 (1):59-62. Doi.

10.1136/medhum-2017-01131928. Devan Stahl et al. (2016).

"Seeing illness in art and medicine. A patient and printmaker collaboration." Ibid. No.

42 (3):155-159. Doi. 10.1136/medhum-2015-01083829.

Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid.

Carson (2015). Medical humanities. An introduction.

New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016).

"Applying social theory to understand health-related behaviours." Medical Humanities no. 42 (2):143-145. Doi.

10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities. Growing pains.33.

A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65.

Edinburgh. Edinburgh University Press.34. Jordanova, Medicine and the visual arts.35.

Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.36. William Viney et al.

(2015). "Critical medical humanities. Embracing entanglement, taking risks." Ibid.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016).

"Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. " In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394.

Edinburgh. Edinburgh University Press.38. J Macnaughton and H.

Carel (2016). Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39.

P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no.

11 (2):147-163.40. Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &.

10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018).

"Making research and building knowledge with communities. Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287.

Cham. Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019).

"Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no. 5 (1):31.

Doi. 10.1057/s41599-019-0239-443. R Garden (2014).

"Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ.

Rutgers University Press.44. Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018).

"Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no. 4 (96).

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"Antimicrobials before antibiotics. War, peace, and disinfectants." Ibid. No.

Sue Walker (2019). Ibid."Effective antimicrobial resistance communication. The role of information design." 24.

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A systematic review." PLoS ONE no. 8 (2):e54978. Doi.

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A systematic review and meta-analysis.54. Edward A Belongia et al. (2002).

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I Bamforth (2000). "Kafka's uncle. Scenes from a world of trust infected by suspicion." Ibid.

10.1136/mh.26.2.8589. Wistrand, When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians.90.

Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.91. A Harpin (2016).

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Edinburgh University Press.92. Jordanova, Medicine and the visual arts.93. Stahl and Stahl, Seeing illness in art and medicine.

A patient and printmaker collaboration.94. K G Sweeney et al. (2001).

"A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. " Ibid.

10.1136/mh.27.1.2095. Treffry-Goatley, et al., Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.96.

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L Jerke, M. Prendergast, and W. Dobson (2018).

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A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. 99.

S Switzer (2018). "What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods." In Creating social change through creativity.

Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 189-207. Cham. Springer.100.

Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. , 378.101.

Cole, et al. Medical humanities. An introduction.102.

J Herman (2001). "Medicine. The science and the art." Medical Humanities no.

[Viney, et al. Critical medical humanities. Embracing entanglement, taking risks.104.

Design and methods. Thousand Oaks, CA. Sage.105.

L Gilman (2015). Illness and image. Case studies in the medical humanities.

HarbarthM Haughton (2018). Staging trauma. Bodies in shadow.

London. Palgrave Macmillan.108. S Hodge, J Robinson, and P Davis (2007).

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Biomedicine and the humanities. Growing pains.110. Saam Idelji-Tehrani and Muna Al-Jawad (2019).

"Exploring gendered leadership stereotypes in a shared leadership model in healthcare. A case study." Ibid. No.

45:388-398. Doi. 10.1136/medhum-2018-011517111.

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Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?.

114. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.115.

Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise. The emergence of the lay expert in medical sociology.117.

Gilman, Illness and image. Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience.

Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.120. C Teddlie and A. Tashakkori (2009).

Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences. Thousand Oaks, CA.

Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122.

Gian Luca Barbieri et al. (2016). "Imagination in narrative medicine." Journal of Child Health Care no.

20 (4):419-427. Doi. 10.1177/1367493515625134123.

Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.124.

WHO (2016). World Antibiotic Awareness Week. 2016 campaign toolkit.

Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range.

18 to 81 years. Based on subsequently collected survey data).126. Nutcha Charoenboon et al.

(2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128. The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref.

OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &.

Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129. Marco J Haenssgen et al.

(2018)130. National Statistical Office (2012). The 2010 population and housing census.

Changwat Chiang Rai. Bangkok. National Statistical Office.131.

Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124.

Doi. 10.1136/medhum-2013-010466133. Carusi, Modelling systems biomedicine.

Intertwinement and the 'real'.134. Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.135.

Emma Sacks et al. (2018). "Beyond the building blocks.

Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384.

Doi. 10.1136/bmjgh-2018-001384136. Sudhinaraset, et al.

What is the role of informal healthcare providers in developing countries?. A systematic review.137. G Bloom et al.

(2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton.

University of Sussex138. WHO (2007). Strengthening health systems to improve health outcomes.

WHO’s framework for action. Geneva. World Health Organization.139.

Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.141.

A Bleakley (2014). Ibid. "Towards a 'critical medical humanities'." In, 17-26.142.

Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al.

(2019)144. Marco Haenssgen et al. (2018)145.

WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146. The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue.

White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material). Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147.

The ‘desirability’ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!.

€ The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148. Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic. This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149.

Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150.

Arya Nielsen et al. (2007). "The effect of gua sha treatment on the microcirculation of surface tissue.

A pilot study in healthy subjects." EXPLORE no. 3 (5):456-466. Doi.

10.1016/j.explore.2007.06.001151. Nithima Sumpradit et al. (2012).

"Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913.

Doi. 10.2471/BLT.12.105445152. C Muksong and K.

Chuengsatiansup (2020). Forthcoming. "Medicine and public health in Thai historiography.

From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London.

The Wellcome Trust Centre for the History.153. L Sringernyuang (2000). Availability and use of medicines in rural Thailand.

Amsterdam. Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts.

The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al.

(2019) and Marco Haenssgen et al. (2018).155. For example, Redfern, et al., Spreading the message of antimicrobial resistance.

A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018).

2018. "Patient and public engagement in research and health system decision making. A systematic review of evaluation tools (epub ahead of print)." Health Expectations.

Doi. 10.1111/hex.12804157. Staniszewska, et al.

GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al.

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Towards a critical and interdisciplinary reading of participatory visual methods.160. R. C Barfield and L.

Selman (2014). "Health and humanities. Spirituality and religion." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 376-386.

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Doi. 10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers.

This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.

While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete.

Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities.

This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited.

An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms. Communal areas should have movable furniture. Wards should be designed for low social densities.

And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?.

The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?. In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?.

While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into.

It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care.

There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.

The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type.

Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals). These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1).

Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients.

Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals.

Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.

This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project.

While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts.

Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?.

We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare. The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value.

Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).

It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed.

Architectural decisions related to these values operate across three scales. Context, hospital and individual. Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs.

Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site.

And how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology.

The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views.

And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings. What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence.

Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards.

Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside.

Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views.

Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site. Two different treatment hub arrangements are in use.

€˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1).

Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges.

Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.

Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions.

The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape.

This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations.

(1) Peninsula. Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor).

(2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped).

Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort.

However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden.

However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2). Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over.

Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’).

Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised. Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size.

The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together.

More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience.

To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.

But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question.

Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff. Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others.

A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment.

In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process.

Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.

Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity.

Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction.

For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses.

The aspirations were threefold. To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes.

And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.

That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients.

The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated.

The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital.

Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis.

By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace.

Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals.

In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security.

Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site.

Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.

Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma.

Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement. This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital.

The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces.

A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces.

This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.

According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom.

Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace.

The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness.

The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital. Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls.

At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.

The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care.

The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement.

While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones.

The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5). The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey.

These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one.

Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines.

Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects.

History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.

A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches.

The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace. MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat.

In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision.

The following people contributed their time and expertise in shaping the research process that enabled this article. Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria.

Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2. 169–80.2.

The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3.

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375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no.

4 Pt 4. 425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding.

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61–125. Jill Maben et al. (2015), “Evaluating a Major Innovation in Hospital Design.

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Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7.

For further examples of this see Jon E. Eggert et al. (2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &.

C.C. Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no.

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1527–38.8. Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities.

Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al.

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Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space. Systematic Review,” British Journal of Psychiatry 205, no.

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91–9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London.

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Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S.

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