Although referral by general hospital doctors is a major pathway to specialist psychiatric care, and there is known to be much clinically unrecognised psychiatric morbidity among general hospital patients, consultation and liaison services have received much less emphasis than community care. A 1984 survey found that consultation liaison services were haphazard (Mayou & Lloyd, 1985). Despite recent evidence of increasing clinical and academic interest, few local strategic plans refer to consultation and liaison services; even when mentioned they are given a lower priority than community developments (Kingdon, 1989).

The recent prominence of medical audit in psychiatry is due in large measure to the place given to the subject in the government's White Paper Working for Patients (DoH, 1989a). However, medical audit existed before the White Paper and covers a broader scope than the White Paper proposes. Thus in considering the introduction of audit into the mental health services it is important not to allow the White Paper to narrow the field of view.

Although childhood psychiatric disorders are commonly seen in general practice, only a few children in the community eventually gain access to professional help (Rutter, Cox, Tupling et al, 1975; Bailey, Graham & Boniface, 1978). Whether a child is referred or not depends on various factors connected with the child and family (Garralda & Bailey, 1988) and others such as what the GP expects from the referral. Whether GPs know of what the child psychiatric services in the area have to offer might also be expected to effect referral. We know that there is a general dissatisfaction with written communication between general practitioners and specialists in terms of the quality on the communication and usefulness to both groups (Pullen & Yellowlees, 1985; Kentish, Jenkins & Lask, 1987).

In an attempt to provide data for medical audit, to standardise the information on discharge letters and to speed communication, a computerised discharge form was introduced for a catchment area of 20,000 people over 65 years. The programme, based on a surgical audit programme using DBASE II, was developed by one of us to run on an Amstrad PCW. This produced a discharge summary on a standard layout which gave the date of admission, the patient's name, date of birth and address as well as the consultant and GP's name. The patient's diagnosis (according to ICD-9), and a list of disciplines and facilities involved in follow-up preceded brief notes on history and progress. Date of discharge was followed by a list of medication and a space for ‘other information’. All this was contained on one side of A4 paper.

While research into the effectiveness of neuroleptic medication consistently demonstrates its value in improving psychotic symptoms, and in the prevention of relapse, the treatment continues to generate controversy. Indeed, McClelland (1989) has recently asserted that this treatment of choice is “an indispensable evil”; “indispensable” by virtue of its clinical effectiveness, and “evil” because of the wide range of adverse and distressing side effects experienced by patients.

The Working Party on Security in NHS Hospitals (The Glancy Report, DHSS, 1974a) and the interim report of The Butler Committee (DHSS, 1974b) both recommended that secure provision should be made available for the treatment of mentally disordered patients who required greater security than could be provided in a standard hospital setting. They recommended that patients with mild or borderline mental handicap should be treated together with the mentally ill but that “severely subnormal patients” should be treated separately. Later the Royal College of Psychiatrists (1981) largely endorsed this advice proposing that:

1. (a) individuals with borderline and mild mental handicap could be adequately treated in the secure units for mentally ill individuals

2. (b) individuals with moderate mental handicap needed a special secure facility

3. (c) individuals with severe mental handicap did not need high security, and should be managed in high-staffed wards in mental handicap hospitals.

The RMO who is well informed about his patient, and conversant with the law in respect of the particular problems that the case presents, has little to fear from Tribunal proceedings. Nevertheless to have to write reports and insert, into a busy timetable, often at short notice, a sometimes lengthy Tribunal is an irritation which can have an adverse effect on both knowledge of the case and on objectivity.

The objects and purposes of the constitution of the Royal College of Psychiatrists in 1971 included to “advance the science and practice of psychiatry” and “to promote study and research” (Supplemental Charter and Bye-Laws, 1989).

The Government's proposals in the White Paper have given rise to exceptional controversy and concern not only among professional groups working in the NHS but also among the general public. It is therefore not surprising that the medical profession has somewhat lost sight of the significance of the radical proposals in the report issued in October 1987. The report Hospital Medical Staff: Achieving a Balance ‘Plan for Action’ (1988) was issued on behalf of the UK Health Departments, the Joint Consultants Committee and the Chairmen of the Regional Health Authorities. The report, after a careful review of the alternatives, formulated proposals for an integrated package of measures to achieve gradual reform of hospital staffing structures in the interests of patients and doctors alike. The results of deliberations identified three principal areas:

1. (1) an increase in the number of consultants to provide leadership and career opportunities

2. (2) sensible planning of the number of doctors in career training grades, taking account of career prospects

3. (3) maintenance of necessary levels of support for consultants particularly in the acute specialities.

Nicaragua is celebrating ten years of revolution since the overthrow of the 45 year long Somoza dictatorship∗. In this time, the Sandinista government has attempted to construct a more democratic society with considerable achievements in the area of health, welfare and education. Indeed, health care has been a priority in spite of severe economic difficulties caused by the United States economic blockade and by the need for defence against the war waged by the counter-revolutionaries (the Contra).

In June 1989, while the Polish people took part in their first free elections for 40 years, I spent a busy day in the company of Dr CY, an English-speaking Polish psychiatrist, visiting state psychiatric facilities in the Gdansk/Gdynia region and sitting in on consultations in Dr Y's private clinic in Gdansk.

As usual, I bought my wife Vogue magazine for Christmas. It always serves well as, in North America parlance, a ‘stocking stuffer’. This year it had further value as it highlighted the brain. A well-known psychiatrist, Nancy Andreasen, set out to inform America about modern psychiatry (Andreasen, 1990). The article is entitled ‘Brave New Brain’ with the subtitle being ‘Modern Psychiatry has Left the Couch for the Laboratory’. She takes the reader through neuro-imaging, molecular genetics and psycho-pharmacology. It is an elegant synopsis and worthy of someone who had a doctorate in English before she took up medicine. Importantly, however, she prefaced her serious material with a mock-comic story about a conversation she had had with someone at a New York hospital recently. She was phoning about the retrieval of a brain for research and the ingenuous person at the hospital just could not put the idea of psychiatry and brains together. Another sad tale of psychiatric breast-beating? Those of us who trained in psychiatry in Britain a generation ago might give a wry smile. After all, biological psychiatry was all that we ever knew. When I entered the Maudsley in 1964, part of the orientation for registrars consisted of going to the laboratories. A mouse was popped into a jar containing liquid nitrogen, it went rock hard and the group was advised that freezing the neurotransmitters in that way was the royal road to solving problems.

It is ironical that of the two greatest Austrian psychiatrists, Freud and Wagner-Jauregg, Freud is now a household name throughout the world, whereas Wagner-Jauregg is hardly known outside German-speaking countries. Yet his work brought him the highest honours not only in his own country and was crowned by the award of the Nobel prize in 1927. The reason for the reversal of their reputations is not far to seek. The Nobel prize was awarded to Wagner-Jauregg for his malaria treatment of general paralysis of the insane (GPI), a severe and fatal form of neurosyphilis, which saved untold thousands of lives. Today GPI is rarely seen because syphilis can now be successfully treated with antibiotics. Wagner-Jauregg also did pioneering work into the relationship between thyroid deficiency and cretinism, which in those days was still in a speculative state, but his name is hardly ever mentioned in this context. He had the misfortune to publish in journals with a more restricted circulation than those in which the results of Schiff's and Kocher's work appeared.

A new centre to study the needs of people with learning difficulties (mental handicap) was opened at the University of Bristol on 1 February 1990.

The 1980s have been a productive decade for the aptly re-named MHS (Managerial Health Services) nationally and locally. And here at District X, 1989 saw us exceed national norms for most of the usual indices of managerial activity, including bulletins and minutes at a staggering 6.2 metric equivalents per person per year of service.