In the last year or so the future of mental health services in this country has been intensively discussed. COHSE, MIND, and the Richmond Fellowship have produced their ‘blueprints', outlining details of the way they see services being organized. All variety of professional organizations have been busy presenting evidence to the House of Commons Social Services Committee which is specifically examining community care. The DHSS has committed more joint finance to ‘care in the community’ projects and Regional Health Authorities are examining the strategies to close large psychiatric hospitals. Consequently, District Health Authorities, in many cases, are planning the shape of a new mental health service which places increasingly less reliance on the large institution. The phrase ‘community care’ has now become so hackneyed in planning circles that for many it has lost whatever meaning it may have once had. However, despite all the rhetoric, and indeed all the planning activity, psychiatric nurses themselves have still to voice coherently their thoughts and fears about the shape of things to come.

‘Violence viewing and aggressive behaviour clearly are positively related, not just in our culture but in other western cultures as well. The weight of evidence strongly suggests that observational learning and attitude change induced by television violence are contributing to the positive relation’.

We are familiar with the idea that the distribution of consultants should be guided by ‘norms' supported by the College. Current norms have been derived from what is (or rather was at the time), not from knowledge of how consultants spend their time, still less on the basis of estimates of morbidity or demand. As Russell noted, a norm of one consultant for 70,000 people was developed using simple arithmetic when there were 700 consultants available to forty-nine million people. From this starting point, one consultant to 60,000 or 40,000 or 25,000 people suggests the possibility of an improved service, but it cannot be assumed that the service is better simply because more people are providing it. Evaluation of the consultant's contribution to a service requires, among other things, knowledge of what the consultant actually does with his time.

The move towards community care essentially aims at the provision of a comprehensive psychiatric service in each District with facilities for the chronically disabled based outside the hospital for the greater part. Parallel with this move runs the aim to close all large mental hospitals. The present debate centres around the extent to which we can move towards a system of comprehensive District psychiatric services alone at this stage in time and the question of whether it is desirable to abandon totally the large psychiatric hospital style of care. The brief of this paper is to summarize the reasons for concern about a wholesale move towards District-based services from the large mental hospital from the psychiatrists' view-point. Unfortunately, much of the debate is based on speculation because of the experimental nature of this move and the fact that objective research is lacking on any changes already made in this country.

The recent formation of a Liaison Psychiatry Group within the College reflects the growing integration of psychiatry with other medical specialties in the general hospital. The Group was established to foster the development of psychiatry in relation to medical and surgical patients, including its clinical, teaching and research components. The title, Liaison Psychiatry, is not an ideal term but has become firmly established in other countries to denote that area of psychiatry where the psychiatrist has particular skills to contribute to the care of the physically ill, and to those in whom psychiatric disorder presents in somatic terms.1

Late one October afternoon in 1984, I left the grey London drizzle behind and took off on a flight bound for Aarhus, major city on the east coast of Jutland, Denmark.

Within twenty minutes the jet, appropriately called a Viking, had climbed above the turbulence of the clouds and was cruising through a serene dimension poised somewhere between the night sky, the sunset, and the purple rainclouds far below. Such a passage from turbulence into even stability is. I reflected, a familiar experience to the hundreds of thousands of people who have now benefited from tithium all over the world. But the introduction and acceptance of lithium therapy have been far from smooth, and would perhaps not have been possible at all were it not for the commitment and persistence of a few dedicated individuals.

‘Procrustes was a robber of Attica, who placed all who fell into his hands upon an iron bed. If they were longer than the bed, he cut off the redundant part; if shorter, he stretched them till they fitted it. [Any attempt to reduce men to one standard, one way of thinking, or one way of acting, is called placing them on Procrustes' bed, and the person who makes the attempt is called Procrustes].’

I am grateful for the opportunity of commenting on a recent article by Dr Paul Bridges, ‘Psychosurgery and the Mental Health Act Commission’ (Bulletin, August 1984, 8, 146–48). It may be useful to clarify the areas where we agree with him and to put into context matters in which he is critical. In the latter case I wish to consider whether his criticism is accurately directed at the Commission's policies.

The Court of Protection, in carrying out its task of managing and administering the property and affairs of those who are incapable of managing for themselves, normally works by appointing a receiver to stand in the patient's shoes. The application for appointment of a receiver may be made through a firm of solicitors or by personal application to the Court. In either case, it needs to be supported by medical evidence, which is usually given on Form CP3. The Court is always conscious that its jurisdiction only extends to people who are incapable of managing their affairs by reason of mental disorder, so medical evidence there must be. (In rare cases, in an emergency, the Court is empowered to act even before receiving formal medical evidence, provided it has reason to believe that the person in question is suffering from mental disorder, but this power is exercised sparingly and only when its use is essential for the patient's protection.) It is an extreme step to deprive a person of his financial liberty and it must be reserved for cases where it is really necessary.

These departmental guidelines at last revise advice of the 1968 vintage—that all parasuicides should be admitted to hospital and assessed by a psychiatrist. Of course this was never achieved, nor even attempted in many areas. It is a welcome set of new recommendations, therefore, which will help ensure that what actually happens is done well. It is great credit to undergraduate medical teachers that such confidence can now be expressed in newly qualified doctors carrying out these psychosocial assessments. It recognizes that suitably trained nurses and social workers can assess and manage aftercare of these patients quite competently.

The task of summarizing the experience of public mental hospitals in the USA is perhaps impossible and unrewarding as far as UK-based psychiatry is concerned. The complex governmental and insurance intrastructure, the heterogeneity of approaches and the disappointing rhetorical stance one observes in learned journals make it difficult to translate American practice to our own. This task is even more difficult when one only has written communications to fall back on, and readers will have to take this into account in this brief article.

For the fortunate few who participate in College study tours abroad, an added bonus—and a not inconsiderable one at that—is the opportunity to abdicate all responsibility. From the moment of take-off on the way out to the moment of touch-down on the way back, the tour leader takes over as a sort of surrogate father. On this occasion our father, ironically enough, may not have been the youngest among us chronologically speaking, but he was nevertheless the youngest in heart. He was irrepressible, imperturbable and ebullient, and on his, admittedly, broad shoulders fell the onus of caring for a mixed bag of psychiatrists and their spouses, mixed, that is, in terms of age, sex and, in particular, temperament. We, with little respect for his status, chose to call him ‘Cyril’, whereas our Chinese colleagues with their traditional sense of propriety and respect for parental status, gave him his due and saw fit to address him reverentially as, ‘The Honourable Dr Cyril Davies’.

Section 58 of the Mental Health Act 1983 provides for statutory control of certain treatments given to detained patients through an obligation to obtain their consent or secure the approval of a doctor called as a second opinion through the Regional Office of the Mental Health Act Commission.

Following the publication of correspondence between the then Minister for Health, Mr Kenneth Clarke, and the National Schizophrenia Fellowship (Bulletin, March 1985, 9, 49–55), we are now publishing the concluding letters in this exchange of correspondence. (Mrs Joyce Major has been succeeded by Mr R. N. Lines as Chairman of the NSF.)

We use the expression ‘long-term patient’ to describe one who, whether in hospital or elsewhere, needs a great deal of supervision and/or nursing care. We use ‘long-stay patient’ for the smaller category in hospital or equivalent health service institution. The great majority of long-term who are not long-stay are at present cared for by relatives, if at all; a small fraction are in staffed homes provided by the voluntary sector, or are in local authority hostels.