Schizophrenia is an expensive disease. In the USA, it affects approximately 1% of the population but patients occupy 25% of all hospital beds. In Australia, schizophrenia was found to affect less than 10% of the number experiencing a myocardial infarction and yet the costs of medical services for treating schizophrenia are 75% of those for myocardial infarction.

In 1983, Dr Newson-Smith wrote an article in the Bulletin on services for the younger brain damaged persons. In particular she described Hamble Ward, which provides care for such people and for which she had medical responsibility. At that time, this type of service was very rare in the UK and the article generated considerable interest. In 1984, Dr Newson-Smith left the hospital and was replaced by one of the authors (CRS).

The way in which doctors practise medically undoubtedly has effects on the ways in which other staff, the nurse, occupational therapist, physiotherapist etc. are able to practise, just as their style affects the doctor. But all share the common aim of providing the best possible care for their patients. Changing service provisions have affected mental handicap services more than most. It is crucial at a time of great change within health service systems that good medical practices evolved over many years experience are not lost or neglected by changing philosophies or care models. Medical aspects of care of the mentally handicapped person which evolved in hospitals should be flexible enough to be used in the settings used by any district. Medical standards of care must be maintained and improved despite changes to the service.

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 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.

In efforts to improve the acceptability of psychiatric services and their ease of access, the issue of how people get psychiatric help when they need it is one of growing concern. There is now increasing evidence that psychiatric services operate differently for black and white people in Britain, and much concern that services may differentially disadvantage blacks (Francis et al, 1989).

Medical care in general hospitals is a collective activity and liaison psychiatrists may become part of this process. Cornerstones of successful management are co-operation with colleagues and ‘teamwork’, although these elusive goals are not always achieved. A shared uniform is one possible solution to improve this teamwork, the white coat being the livery of the hospital doctor. Furthermore, patients may appreciate a uniform. One survey of 200 North American general hospital in-patients showed the white coat to be surprisingly popular (Dunn et al, 1987); 65% of those replying wanted to see their doctor in a white coat. But the white coat is often unpopular with doctors and perhaps a more relevant question is whether it makes any difference to patient behaviour.

Training in psychotherapy for junior registrars is often piecemeal and relegated to an after hours out-patient and supervision. We are fortunate in having had the opportunity for a whole-time psychotherapy placement at the Cassel Hospital, Ham Common, Richmond, itself an internationally renowned clinical and training centre devoted to psychotherapeutic treatment of in-patients and out-patients.

In the medical profession a consultant is a doctor who has attained the capacity for totally independent practice, otherwise known as clinical freedom. Consultants differ from other doctors in the important respect that they have full clinical responsibility (BMA, 1984). The work of the consultant may be audited by his peers, with his full participation, but may not be supervised by one (DoH, 1989a). Thus, whereas the consultant is accountable, administratively, to his employers, in the clinical area, he is not accountable to any other doctors or managers: he is accountable to the General Medical Council for his professional conduct, and, with respect to the diagnosis and treatment of illness, to the patients directly, the patients' relatives, and the law of the land.

The post of Emergency and Liaison Registrar in the Bloomsbury Rotation was created in 1988 to provide a psychiatric service at University College Hospital, London, in the Accident and Emergency (A&E) Department and to the A&E Ward for assessment of deliberate self harm (DSH) cases. It incorporated existing commitments of liaison to the UCH wards and provision of urgent psychiatric assessments. The service had previously been shared among a number of psychiatric staff. The registrar can thus be seen as a ‘central pivot’ within the District Psychiatric Services.

A workshop organised by the Research Committee of the College took place on 20 November 1989, in which 14 invited delegates from nursing, psychiatry and general practice presented and discussed the implications of recent research developments in community psychiatric nursing. Papers were given by Helen Hally, Chairman of the Community Psychiatric Nurses Association, on recent developments in the workload of community psychiatric nurses. Dr Joseph Connolly presented the preliminary findings of the ‘Daily Living Project’ at the Maudsley Hospital in which comprehensive community care is given primarily by community psychiatric nurses. Professor Brandon outlined some of the difficulties in obtaining data on the working practices of community psychiatric nurses arising from a study in Leicester and this was followed by an account by Dr Alastair Wright, a general practitioner in Glenrothes, Fife, of the typical psychiatric workload of a general practitioner and the ways in which community psychiatric nurses may be of value in treating this without the necessity of referral to psychiatric care.

Psychiatric services in Zimbabwe are, by African standards, relatively sophisticated and are modelled on the British system. A new patient is assessed using the Maudsley history-taking format modified to suit local situations, and a mental state examination. A physical examination and routine investigations follow. X-ray facilities and basic laboratory work-up such as haematology and microscopy are available at Provincial level. EEG, ultrasonography, echoencephalography, CT scanning and serum anticonvulsant levels are available in Harare and Bulawayo.

The Centre Hospitalier Specialise de Ville-Evrard is situated 17 kms from the centre of Paris and serves an area of approximately a quarter of the north-eastern outskirts of the city. I visited as one of a multi-disciplinary party of 20. The visit took place over five days and returned their visit to Bexley Hospital, Kent in South East England, which took place in November 1989. English lessons take place in the hospital as part of the hospital's responsibility for continued education for its employees and they had initiated the visit to England to improve the standard of their English.

Some 40 years had passed since the death of Mozart, and Donizetti had made a name for himself with Anna Bolena and L'Elisir d'Amore. His music is certainly more fragile than Mozart's and his originality lies in his use of melody which is masterfully constructed to evoke humour, sentimentality and tragedy. In Lucia his musical canvass is, perhaps, the greatest he ever painted. Based on a story by Sir Walter Scott, it tells of the love of Lucia for Edgar of Ravenswood, who is the last of a rival household. In order that the Lammermoors' fortunes can be retrieved, Lucia's brother, Lord Henry Ashton, arranges for her to marry a politically influential figure, Lord Arturo Bucklaw. Ashton arranges that a forged paper indicating the infidelity of Lucia's lover is passed to her. She believes herself deserted and unwillingly consents to marriage with Bucklaw. On sealing the contract with her signature at the wedding, Edgar appears, having returned from France to claim his Lucia. Convinced that she has betrayed his love he damns her and throws the ring she gave him at her feet. The effect of this is to drive Lucia insane, she slays her husband and dies of her sorrows. Edgar waits to duel with Lord Ashton outside the castle. But Ashton flees, leaving Edgar in solitude. Edgar is then told by a procession of Lucia's death. He kills himself in sorrow.