The decision of the Law Lords in May 1989 that allowed the sterilisation of a woman with serious mental handicap (F. v. W. Berkshire H.A., 1989) is arguably the single most important legal development in relation to psychiatry in the last 30 years. It has far-reaching implications beyond the field of mental handicap and will affect the practice of all psychiatrists. The Law Lords used the appeal to consider “the startling fact that there is no English Authority on the question whether as a matter of common law (and if so in what circumstances) medical treatment can lawfully be given to a person who is disabled by mental incapacity from consenting to it” (Lord Goff). Quite clearly this encompasses a large part of psychiatric practice and promised to clarify much of the controversy surrounding consent and the incompetent patient. The decision that they reached has now been incorporated into the Code of Practice of the Mental Health Act 1983 which was approved by Parliament in December 1989. The effects of this are of huge importance, and it has extensive consequences for all psychiatrists and their patients by simplifying the legal aspects of treatment. The most surprising aspect of this whole issue, therefore, is the silence that has surrounded both the original decision by the Law Lords and the subsequent publication of the Code of Practice. The only reference to these in The British Journal of Psychiatry, or its sister journal, Psychiatric Bulletin, has been a brief letter outlining some implications of the Lords' decision (Lovett, 1989). This is doubly surprising as the Royal College of Psychiatrists has shown considerable interest in this debate, not least by publishing a book about it! (Hirsch & Harris, 1988). The purpose of this paper is to provide a background to the Code of Practice and to clarify certain issues surrounding the Common Law.

Last year I was unfortunate enough to suffer a major depressive episode which required in-patient care and extensive physical treatment. I have now progressed far enough from the experience to be able to look at it more objectively, and to think about the implications it will have for my own practice of psychiatry in the future. I hope that what I have observed, reflected upon and learnt will make me a better psychiatrist, more in touch with the needs and fears of my patients, and that my view of ward dynamics “from the other side” will give me more insight into why things happen as they do. The thoughts that follow are offered not as a critique of my care, which was excellent and for which I am very grateful, but merely as a view of the practice of psychiatry from an alternative standpoint. Hopefully they may encapsulate some of the difficulties faced by the depressed in-patient, although of course they cannot presume to speak for those suffering from other forms of psychiatric illness.

Psychiatric day care has expanded considerably over the past 20 years. Day hospitals may serve as alternatives to short-stay in-patient units or speed discharge from them. Day services are also necessary to ensure appropriate support for patients with chronic disability, especially chronic functional psychosis, if they are to remain in a community setting (these are often called day hospitals to ensure NHS support). The present paper focuses on this latter group and describes the characteristics of day attenders in a service that has developed a multi-facility approach to community support.

Exactly two years after a large survey of substance use among secondary school adolescents in London in 1987 (Swadi, 1988), a similar survey among a sub-sample using the same questionnaire was carried out. Of 242 second- and third-year pupils from one of the six schools in the original sample, 219 were available for the follow-up. In 1989 they were in the fourth and fifth years; the sexes were equally represented. The follow-up survey aimed to investigate the trends with respect to the prevalence of use of various drugs and to investigate the effect of the absence of a specific drug-prevention programme on such trends. Comparisons are also made with survey results from the fourth and fifth year at the same school in 1987.

“Welcome to ‘Lillian’. This is all about schizophrenia. Schizophrenia is an illness, a serious mental illness which affects one person in a hundred. It is an illness which causes strange thoughts and strange feelings. It leads to emotional disturbances and a withdrawal from the reality of the external world. Those who suffer from it withdraw into their own world, into an unreal world of fantasy. Often they are tormented by strange and frightening experiences. Some develop strange ideas and fear that they are persecuted. Others hear voices, see and feel things that are not there, though they are real to them. Sometimes it is difficult to understand them because their thoughts are jumbled. They may even feel that someone else is interfering with their minds. In time, some lose their ability to do their everyday activities and lose their drive and initiative but this is not laziness. They often become very anxious and have periods of depression. For many the ability to express their emotions is blunted and in others their behaviour is unusual. These experiences are all very real to them and sadly some never realise what is happening to them. Most do recover with treatment, understanding and support but often under stress, relapses occur. We ask for your understanding and support”.

This advice to a traveller could be offered to those moving resources from institutional care of the elderly to true care in the home. While present plans concern the destination and mode of travel, less attention is paid to differences in the starting point. Health districts vary greatly in terms of numbers, movements and placements of their elderly populations. Numerical increases or decreases may be caused by migration of elderly people to traditional seaside retirement areas. A further attraction is the availability of nursing and residential homes in these belts. Such homes tend to multiply in a given area and draw in new residents from other districts leading to a disproportionately elderly population.

It is one of the failures of contemporary psychiatry that many patients who respond well to neuroleptic medication given to them when they are in-patients relapse after discharge due to not taking any further medication. Those working closely with the acute psychiatric patient in the community are often forced to stand by powerlessly as a patient deteriorates, causing damage to himself and his social milieu until such a point is reached when he is again ill enough to warrant compulsory admission and treatment. This process is, of course, devastating for a patient's family and also disheartening for professionals involved, and is perhaps partly responsible for the high turnover of staff involved in front line services. Even if assertive outreach methods are employed such as those involved in a number of comprehensive community-based programmes (Stein & Test, 1980; Borland et al, 1989) so that contact with the patient is not lost, it is not possible without the necessary legislation to enforce treatment in the community.

Psychiatric clinics see 4% of all hospital referrals by general practitioners (GPs), but the literature contains surprisingly little about the referral behaviour of, and the patients referred by, GPs to psychiatrists (Wilkinson, 1989). We describe an analysis of the Royal Liverpool Hospital psychiatric out-patient clinic which serves a deprived inner city population of 125,000 people and its GPs.

In a recent study we compared writing to the patient with writing to the general practitioner after an initial psychiatric out-patient consultation. One of us (R.A.) interviewed the patients at home about two weeks after the consultation, and compared the two groups on satisfaction with the consultation, comprehension of information given by the psychiatrist, and compliance with advice. We felt that the comments of the patients might be of interest, particularly to those who might have considered (or done) something similar.

When planning new service initiatives it is important to review the role and functioning of existing services. As more patients are discharged from long-stay beds, there is increasing concern regarding the quality of community care and the accessibility of urgent psychiatric help. The Department of Health has recently expressed concern over the level of such services provided (DoH, 1989). In Edinburgh, alternative methods of delivering psychiatric emergency care are currently being considered. Community-orientated crisis intervention teams may be useful, but only a small proportion of people presenting to general psychiatric services fit into the stereotyped model of crisis. Centres with short-term admission facilities have been developed in other countries and within the United Kingdom many general hospital casualty departments have a psychiatrist available on call. Walk-in or self-referral psychiatric clinics provide an easily accessible service but few have been systematically reported (Lim, 1983; Haw, 1987). Such clinics have been described as seeing mainly chronic patients of the hospital who are already in current contact and who present with less severe psychiatric disorders than GP-referred cases. In a climate of NHS financial restraint it is pertinent to ask whether such clinics are needed.

Because of the problem of diagnostic unreliability in psychiatry, there has been a trend over recent years to create explicit diagnostic criteria, such as the Research Diagnostic Criteria and DSM–III. This movement has been called neo-Kraepelinian (Klerman, 1978) as it promotes many of the ideas associated with the views of Kraepelin, regarded as the founder of modern psychiatry. It favours a biological approach and arose partially as a response to attacks on the ‘medical model’ in psychiatry.

Idiot-savants are people of low intelligence who have one or two outstanding talents such as calendar calculation, drawing, or musical performance. The syndrome occurs with high frequency among autistic children (autism is about four times commoner in boys), and the male to female ratio is about 6:1 suggesting a sex linked disorder (Hill, 1977). It is estimated to occur in 0.06% of the mentally handicapped population or about 1 in 2,000 of those living in institutions (Treffert, 1988). The gift starts apparently spontaneously between age 5 and 8 years. Frequently the parents claim that they themselves do not have the talent and know of no one in the family who has, but there is a tendency for savant skills to run in families, suggesting that genetic factors play a role.

Mental health problems in primary care settings have received wider attention in recent years (Wilkinson, 1985). In India, the National Mental Health Programme (NMHP) was formulated with the purpose of promoting mental health care through primary health care (National Mental Health Programme, 1982). As part of the implementation of NMHP, training programmes for medical officers and health workers have been initiated in a number of centres in the country (National Mental Health Programme for India, Progress Report, 1988). At the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, a monthly training programme for doctors and health workers of primary health centres has been carried out since 1982. In order to evaluate the gain in knowledge and clinical skills, a multiple-choice questionnaire and case vignettes have been standardised (Sriram et al, in press). The doctors are also evaluated through a structured clinical examination which is carried out on the last training day. The focus of the present report is to evaluate the clinical skills of medical officers using the structured clinical examination.

It is recognised that the consultants of the future will have a greater management role than those of the past. The Griffiths report (1983) regarded doctors as ‘natural managers’, although this has been challenged by some authors. They suggest that medical training, with its emphasis on the individual case and rapid decision-making (Higgins, 1989), leads to a very different perspective from the manager considering the often competing long-term needs of many individuals.

The guidelines on criteria necessary for promotion to senior registrar grade in psychiatry may be found in The Handbook for Inceptors and Trainees 1987. The criteria are essentially those in the 1980 edition, namely the need for possession of MRCPsych status and completion of at least three years general professional training approved by the College. Yet it is undeniable that in recent years eligible candidates have experienced much more difficulty in achieving appointment as a senior registrar. Indeed Holden (1988) comments that “dedicated clinical service and the qualification of MRCPsych is insufficient to guarantee a registrar success in his or her application for a senior registrar post”. In the increasingly competitive job market research experience, possession of publications, and management training have become valuable assets for prospective candidates. Our concern at the lack of pertinent career guidance for trainee psychiatrists prompted us to look at trainees' perceptions of requirements and at the provisions which exist in their training to enhance their career prospects.

Your two correspondents are psychiatrists in their mid-30s working at two publicly-funded mental health centres in Navarra. We share the responsibility for co-ordinating the eight mental health centres, two day hospitals and two psychiatric units in general hospitals in the province. Each of us takes care of half these resources, grouped in a ‘mental health area’.

The 40th anniversary celebrations at Keele are proving to be a lively acknowledgement that the University is now firmly back on its feet and has a renewed confidence in its baptismal vows. There has indeed been a recovery of Keele's raison d'être to provide multi-faculty education (all students study an arts and science subject), to pioneer a Foundation Year to allow more informed choice of Honours courses, and to accommodate undergraduates as well as many staff on its leafy 18th century estate. The Vice Chancellor has succeeded in putting Keele back in the black, and on the map, and now plans to increase the number of students to 6,000 in the next decade.