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.

Defaulting from out-patient surveillance constitutes a major problem among neuropsychiatric patients globally. In an extensive review of default studies (Baekeland & Lundwall, 1975), it was concluded that between 20–50% of psychiatric patients fail to return after their first visit and 31–56% attend not more than four times before defaulting.

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.

In 1973 a survey was carried out of male schizophrenic patients who had become long-stay residents in Leverndale Hospital, Glasgow, ‘long-stay’ being defined as having been continuously in hospital for more than three years (Todd et al, 1976). The patients were recruited from a four year cohort of admissions in the years 1967 to 1970 inclusive. In the following years there have been many changes in the provision of facilities and in clinical practice. In some countries, such as Italy, the USA and England, there has been a strong drive to reduce long-stay populations along with the closure of some mental hospitals. In Scotland the process has been much more gradual, possibly reflecting the differences in preexisting provisions and patterns of care.

We were members of a support group for women psychiatrists which we found rewarding and which stimulated us to question many assumptions. We describe our experiences in the hope that trainees and consultants alike will consider the potential of similar groups in their own working lives.

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.

In 1979 a survey of Hackney's psychiatric in-patients revealed that many were resident simply because there was nowhere else for them to go. (Lomas, 1979). As a response to this, the Community Psychiatry Research Unit (CPRU) was set up, and a team of support workers appointed (from nursing, social work and occupational therapy backgrounds) to assist in re-housing and to provide continuing care. Developing projects have meant that the role and job description of this support team have constantly changed. To review their present role, we decided to assess the day-to-day activities of three workers so as to improve our understanding of their function, training needs and work load. Details of the assessment criteria for taking on patients have been outlined by Rich et al (1989).

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.

In daily clinical practice, out-patient non-attendances are, unfortunately, regular occurrences. With the current trend towards community based care, out-patient facilities have become increasingly important, and the failure of patients to attend is both disruptive and worrying for professionals in this area. It is difficult to predict which of the non-attenders will progress to join the ranks of those “lost to follow-up”. This study was conceived in an attempt to clarify this question, in the setting of adult general psychiatric out-patient services.

The problems of diagnosis in transcultural psychiatry and the ideological and anthropological questions raised have received much attention in the psychiatric literature over the last 15 years. Even when the diagnosis is not in dispute, specific problems are encountered in the delivery of psychiatric care to patients from ethnic minorities (Littlewood & Lipsedge, 1989; Rack, 1982). Different explanatory models of illness and treatment, linguistic and cultural misunderstandings and numerous, apparently minor, practical difficulties bedevil treatment. Contributions to the psychiatric literature of practical use in management and service designs have been sparse.

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.

Mental hospital closure and the resultant discharge of patients with chronic psychiatric disabilities into the community has led to public concern (Wallace, 1989). Currently it would seem important to collect as much pertinent data as possible on all aspects of mental hospital closure and the resultant effects on patients and communities. This study focuses on a relatively neglected area in the research literature on community psychiatry and mental health planning, i.e. the opinions of the consumers.

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.

This paper is based on experiences over the past three years in North Devon (population 140, 000), a predominantly rural district that until 1986 based most of its psychiatric facilities in a large mental hospital in Exeter, nearly 40 miles away. When Exeter went ‘Italian’, services were devolved to local districts, and North Devon was given the responsibility for providing comprehensive psychiatric care based on a DGH unit, a Day Centre, two hostels and a small multidisciplinary team. No formal psychotherapy services were included in this plan. This is a familiar enough pattern, one that can be found throughout Europe and North America. I shall try to chart the movement from the heady days of decarceration to current uncertainties about community care, a state which might be called post-deinstitutionalism.

Liaison psychiatry in general practice has been recognised as an increasingly important part of the development of community psychiatry. Collaborative working between general practitioners (GPs) and psychiatrists has become commonplace in most parts of the country (Strathdee & Williams, 1984). Different models of liaison have been proposed and a variety of advantages claimed for such work (Mitchell, 1985).

The growing realisation that health care resources are limited has led to increasing concern about the wastage caused by the failure of patients to keep their psychiatric appointments. Generally, non-attendance following psychiatric referral is particularly high (e.g. Baekland & Lundwall, 1975), although in the north-east of Scotland the rate is roughly similar to those reported by other specialties (Alexander & Hillis, 1989). However, little effort has been made to elicit the views of non-attenders themselves or to consider what aspects of the referral system may contribute to this failure to attend.

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.