The escalating cost of medical care in most industrial countries has given impetus to several different strategies designed to impose limitations on cost and introduce efficiency into health care systems. In the United States of America, legislation was passed in 1983 to introduce a system of prospective payment for Medicare hospital expenditures. This change was a departure from the previous cost based reimbursement method and was based upon a categorisation of medical conditions into discrete groups termed diagnosis-related groups (DRGs). The intention of the American Congress in passing the legislation was to encourage hospitals to reduce cost without sacrificing quality of care.

It is unclear how much the profound changes which have occurred in mental handicap hospitals in the last decade have improved the lot of the profoundly handicapped, since Baker & Urquhart (1987), in a national survey of Scottish Mental Handicap Hospitals, found that 45% of all hospital residents had no set occupation and that there was a relationship between occupation and ability level. Between 14% and 32% of all patients were without occupation and unable, or not allowed, to leave the ward without a member of staff.

In 1988, the Cambridge Health Authority commissioned a working party of clinicians and NHS managers to visit a variety of different treatment services which cater for the psychiatric needs of mentally handicapped adults in England and Wales. This survey – part of an ongoing planning exercise – is now complete, new services are being planned in the light of the findings, and the experience may be of general interest to other clinicians and service planners throughout England and Wales.

The psychotherapist as consultant to in-patient psychiatric units may undertake any one of a number of specific tasks. Central to, and common to these, is his support of the effective work of the psychiatric unit's staff. The consultant's contribution is directed primarily towards enabling the staff to utilise themselves, i.e. their selves, to the full in their treatment of the patients.

Drug and alcohol misuse during pregnancy poses a threat to the health of both the developing foetus and the mother yet this complex clinical problem often falls between different stools within the health services. A mother would first have to recognise herself as a drug or alcohol misuser needing help before she came within the ambit of the addiction services. On the other hand, the obstetric agencies, even when they identify a drug problem, usually do not regard themselves as having a role. General practitioners are most likely to have an overall view and therefore to be in the best position to manage the problem. However, many misusers do not register with GPs and, despite calls to the contrary, GPs have not become more widely involved in the management of addiction.

Child psychiatrists are often requested to contribute to the formal special educational assessments of children for which the 1981 Education Act laid down a new procedure. Some of the evident aims were to enable some handicapped children to remain in ordinary school, to stress ‘needs’ rather than categories, to involve parents more closely in the procedures, and to emphasise the importance of the effect of the handicap on the learning process. The first year of this procedure was reviewed by Wardle (1986) who noted a number of advantages and disadvantages, and subsequently the College (1988) recommended that the working of the Act should be reviewed, particularly because of delays and the cumbersomeness of the procedures.

It was with a feeling of taking a step into only vaguely charted territory that in May 19881 agreed to be the psychiatric member of a pilot multidisciplinary community mental health team to be set up in the South-West sector of Cardiff.

The Mental Health Commissioners recommend that whenever possible two doctors should be involved in the decision to admit a patient to hospital under the Mental Health Act (1983). That is, Sections 2 and 3 of the Act should always be used in preference to Section 4, where only one doctor is required. It further recommends that the use of Section 4 should be confined to emergencies when it is only possible to secure the attendance of one doctor.

I was requested at short notice by Christian Solidarity International, a Swiss-based human rights group, to attend a court hearing in Czechoslovakia concerning a married couple who were being compulsorily detained in a psychiatric hospital. CSI had been alerted by a local Catholic activist, himself a former patient of the same hospital. The Czech authorities facilitated my attendance at the court hearing along with an English solicitor and provided an interpreter.

Depressed patients and their families can benefit enormously from being given appropriate information about their illness, their treatment and the steps that they and their families can take to cope with and overcome the problem. All too frequently, the doctor or psychiatrist, through lack of time, may pay too little attention to this aspect of treatment. Self-help books provide a useful solution to the problem, and not surprisingly the market has been flooded with books which cover, with varying degrees of success, the many facets of depression and its treatment.

Community leadership for mental health is of increasing importance in developing areas of the world. As changes such as urbanisation and indus trialisation affect these areas, their mental health problems are becoming more apparent. These include conditions requiring either curative or cus todial care in an often distant hospital, but probably most others are more appropriately managed by inte grating mental health into primary health care, closer to patients' homes (Giel & Harding, 1976; Harding, 1980; WHO, 1984a).

We decided to evaluate the recommended reading for US consultation liaison fellowships (Mohl & Cohen Cole, 1985). Our group was open to interested doctors who had either passed Part I or who had relevant previous experience. The seminar group met in the evenings every two weeks for six months and all members shared the synopsis and presentation.