Vienna, a city with a population of 1.5 million, as well as being the capital of Austria is also one of its nine provinces. Care for the mentally ill in Vienna, as elsewhere, was for decades either misguided or poor. The large mental hospitals in the city were seriously overcrowded and understaffed. In the extramural sector, there was an enormous deficit in out-patient and complementary facilities.

Rigorous studies of community alternatives to hospitalisation show that they are feasible and effective but have spawned considerable debate about their methodology, replicability, and appropriateness for normal clinical practice. In Britain, many demonstration projects have been centrally funded and evaluated initially by the Personal Social Services Research Unit at the University of Kent and latterly by Good Practices in Mental Health (Renshaw et al, 1988). Such community-based projects have attempted to avoid the problems of community mental health centres in the United States which have, with some important exceptions, failed to offer a comprehensive service that would allow closure or a significant drop in bed numbers at state hospitals (Dowell & Ciarlo, 1983). In practice, the design of community services is very dependent on local circumstances, including the demography of the population, existing service provision and attitudes. For this reason, planners and practitioners need to be aware of many practical options for service delivery.

It is well recognised that there is an increased psychiatric morbidity, in particular psychosis, personality disorder and substance abuse, among the single homeless (Lodge Patch et al, 1971). The reasons for this are complex. There is evidence that these people are mentally ill before becoming homeless and that their illness may be a cause of their homelessness. In a study of newly presenting patients at the DHSS Reception Centre in Camberwell, London, Tidmarsh & Wood found that 87% of those with mental illness had been staying recently with their families just before their first hospital admission, suggesting that mental illness may have led to homelessness in these patients (Tidmarsh & Wood, 1972). Although direct evidence is scant in the UK, it is felt that the closure of long-stay psychiatric hospitals could lead to some of their in-patients becoming homeless.

NHS out-patient clinics remain a major point of contact between psychiatrists and their patients. There are several advantages to this setting for consultation: it is time efficient, there is usually easy access to case records and contact with other disciplines and services is often available. With the current trend towards community care, increasing use of out-patient facilities is likely as home visiting becomes impractical and, moreover, may be undesirable for some patients.

The best form of psychiatric audit would probably entail carrying out detailed structured interviews of mental state throughout treatment programmes in order to measure clinical effectiveness. In practice this is clearly impossible for busy routine services and will probably be confined to research initiatives. A number of units have attempted to carry out clinical audits subjectively but that clearly has the limitation of bias.

Day care has been called one of psychiatry's gifts to medicine. The British psychiatric day hospital movement began in the post war years and its philosophy continues to flourish with the decline of institutional care.

Rampton Hospital is one of four Special Hospitals in England and Wales. Along with the other Special Hospitals, it usually has a small number of deaf patients. I had developed a special interest in the particular problems of psychiatrically ill deaf patients and it seemed fortuitous that I should spend a year of my senior registrar training at Rampton Hospital.

The presence of the Official Secrets Acts of 1911 and 1920 precludes comment from doctors working within Her Majesty's prisons on the state of remand prisons in Britain. Her Majesty's Chief Inspector of Prisons, Judge Tumin, has described them as “intolerable, and representing much human misery”. In an article entitled ‘Under the prison outrage: a quieter scandal’, Kilroy-Silk (1989) refers to a report implying that, at any one time, one third of remand prisoners suffer from mental illness.

Music and medicine have been closely associated for centuries. Indeed, Pythagoras believed that if music were used in daily life in a prescribed manner it would make a salutary contribution to one's health, a concept which led him to investigate the physics of sound and to develop the fundamentals of today's tonal system (Munro & Mount, 1978). During medieval times, music was imbued with significant therapeutic properties and used as a mood altering medium, an aid to digestion, an antidote to poison and as a wound healing stimulant. The idea of using a pure sinusoidal tone at a low frequency has been known for centuries, and in primitive cultures instruments and sounds were used to treat psychosomatic disorders (Skille et al, 1989). Today, music is acknowledged as a therapeutic modality, with scientific evidence attesting to its psychological and physiological effects.

Some of the proposals in Achieving a Balance (DHSS, 1987) seem to have developed with little regard for postgraduate training in psychiatry. In psychiatry it has become common practice for SHO posts to be incorporated in training schemes with registrar posts, allowing several years of overall basic specialist training in preparation for obtaining the MRCPsych. This is in accord with the GMC Education Committee's position (GMC, 1987a) that specialist training can, on the ‘fast track’, follow on immediately from satisfactory completion of pre-registration posts (general clinical training) and full registration. Achieving a Balance states clearly that specialist training begins at registrar level and that any doctors in SHO posts should be receiving further general training. There are few guidelines concerning the necessary nature of such general training.

A majority of psychiatrists embark on their careers by entering an SHO/registrar rotation where they can expect to receive a broad based training in the principles and practice of their chosen specialty. These posts should provide the trainee with an opportunity to observe and emulate high standards of clinical care as well as fostering academic interests and research skills. The Royal College of Psychiatrists recognises the importance of these years by monitoring the standard of posts and by examining trainees at the end of this period.

The process of psychiatric research, as distinct from its content, has been the subject of little comment. Central to present-day techniques are the use of questionnaires and more or less structured interviews. Pre-coded data are preferred, and even if there are few cases in any one study, the quantity of data collected for each usually compensates for this and justifies computer analysis, using statistical packages such as SPSS∗. The days of punched cards have passed (only in the last eight years in one centre of excellence), so at least one of the error-prone steps (transfer of data from paper schedules by card-puncher) has been abolished, but the major chore is still this process, albeit direct to magnetic media (floppy or hard disk).

It is a common assumption throughout the world that people may be put in one of two categories, male or female, and that members of each group share common attitudes, beliefs and behaviours. However, variations in how male and female behaviour are defined in the different groups may be numerous.

The cost effectiveness of treatment has to be a major consideration in any well managed service. It is, therefore, the job of management to ensure that effective treatment is delivered efficiently.