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.

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.

The 1975 White Paper Better Services for the Mentally Ill recognises different roles for day hospitals, day centres and the voluntary sector in the provision of psychiatric day care. Two broad client groups, needing short-term support or long-term care, are described. However, Vaughn (1983 and 1985) and Wilkinson (1984) have reviewed lack of co-ordinated planning in the provision of services and the placement of clients. Carter (1981) in a major survey of day care, showed that in many cases it was difficult to differentiate between day hospital and day centre services or client groups.

In order to plan a comprehensive psychiatric service for County Clare, it was necessary to divide the county into four sectors, North, East, South and West. The area I am discussing is the West Sector, which covers 800 square kilometres and has a population of 20, 000. Kilrush town is the capital of the West Sector situated 50 kilometres from the main hospital in Ennis. Psychiatric morbidity was noted to be high in this rural area. Prior to opening a Day Hospital in Kilrush (May 1986) we were using 15 beds in the acute unit. Now we are using, on average, five beds at any given time.

It is common knowledge that psychiatric patients sometimes need to have compulsory measures applied to them for the safety of themselves and of others.

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.

In the form of economic evaluation known as cost-utility analysis, the consequences of health programmes are measured in time units adjusted by health utility weights (i.e., states of health valued relative to one another in terms of notional quality). The outcome of health programmes can then be expressed in terms of increased (or decreased) life expectancy and increased (or decreased) quality-of-life. This provides a device for evaluating health programmes that extend life at the expense of undesirable effects, or, that produce reduced morbidity rather than reduced mortality.

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.

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 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.

Community support teams are an important component of services for the chronically mentally ill who do not need to remain in hospital. In the autumn of 1989 the Department of Psychiatry in Central Manchester established a small team with a remit to develop such a service. The team is made up of four nursing staff (a charge nurse, staff nurse, SEN and a nursing auxiliary) with additional support provided by two occupational therapists, a clinical psychologist, consultant psychiatrist and senior registrar in rehabilitation psychiatry. This paper will briefly describe some of the experiences and problems that the service has encountered so far and some of the solutions that have been explored.

Psychiatry is unique in already being subject to statutory external audit through regular visits to psychiatric hospitals and units by the Hospital Advisory Services and Mental Health and Mental Welfare Commissions. These organisations do comment on aspects of the standard and quality of care. Reports of their findings undoubtedly facilitate change. By their programme of repeated visits they are in a position to observe the implementation and outcome of altered patterns of practice brought about by their reports. The Codes of Practice being prepared by the Mental Health Commission (England and Wales) and Mental Welfare Commission (Scotland) is another step that will significantly influence clinical practice. Finally, the Royal College of Psychiatrists' postgraduate training scheme accreditation exercise, like those of the other Royal Colleges and Faculties, has had an impact on quality of clinical care through its policy of gradually increasing the standard of postgraduate clinical training requirements. Locally based audit clearly complements these external exercises and local psychiatric services are now expected to organise systems of regular internal audit as are the other clinical disciplines (Department of Health, 1989).

From November 1987 until March 1990 I worked as a researcher with the TAPS project. So far this project's task has been to evaluate the reprovision of hospital services for the long-term mentally ill from two hospitals in the North East Thames Region (Team for the Assessment of Psychiatric Services, 1988). My work involved gathering clinical and social data from over 250 patients and their carers after they had spent a year out of hospital. Most of these patients were suffering from schizophrenia. The design and first results (Team for the Assessment of Psychiatric Services, 1990) provide an objective account of this research. In contrast, this paper intends to put forth a subjective view of some of the problems encountered while obtaining these data in the community. This situation faced the researcher with unique and challenging circumstances that are not normally discussed in the scientific presentation of follow-up data. Its aim is to pre-empt similar difficulties for other community reserarch by providing guidelines. I am going to cover three areas: arranging interviews, conducting them safely, and handling situations that necessitate stepping out of the interviewer role.

There has been little economic evaluation of the costs of closing long-stay institutions. Studies that have been undertaken have rarely had the opportunity to study the before and after effects of complete closure. Most attention has focused on the mentally ill not the mentally handicapped. This study followed a sample of residents leaving Darenth Park Hospital which was closed in 1988.

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.

Professor R. G. Priest and Dr K. A. Day have prepared a discussion document on the future of mental hospital sites on behalf of the Public Policy Committee (Psychiatric Bulletin, April 1990, 14, 245–248), and may be complimented for stating their views in such detail.

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.