The Department of Health's 1971 Circular (HM (71) 97) and the White Paper, Better Services for the Mentally Ill (1975), had recommended the guideline of 0.5 acute beds per 1,000 population as an average for District General Hospital units. Patients with stays of more than one year, the elderly severely mentally infirm (ESMI), children, adolescents, and certain specialized units were not included. Unfortunately, planners have tended to stick to this figure, despite the fact that the recommendation was only meant as a general guideline based on known bed usage up to 1974, and some more recent downward trends in newer smaller community-based units. The suggestion that bed requirements should be modified according to local circumstances had largely been ignored, and this is not surprising as there is little information which can help planners determine the factors or their weighting which any local authority should take into account to adapt the norm for ‘local circumstances'. This led to the setting up of a working party of the College's Social and Community Psychiatry Section to make recommendations on bed norms for acute psychiatric units.

Do consultant psychiatrists believe that psychotherapy supervision should be an integral part of the training of the junior doctors? If they do, when, where, for how long and by whom do they feel that supervision should be done? In the South West Thames Region we circulated a questionnaire to all general psychiatric consultants in an attempt to answer these questions. We report on some results of our survey and raise important immediate issues which would seem a subject for debate. The major issue is the debate about specialist psychotherapists versus psychodynamic psychiatrists. Although the College seems to favour strongly that psychotherapy teaching for general psychiatrists should be done by psychotherapy specialists, the ‘consumer’ appears to have a conflicting view, at least in our region.

An examination of the changes to be introduced by the Mental Health (Amendment) Act 1982 suggests that they might have a significant effect on the fate of many patients who are currently admitted on compulsory orders. There are potentialities for improvement, but for these to be fruitful a firm commitment will be required from the professionals involved to attend to these patients' needs. The tide generated by the new legislation is more likely, however, to carry the professionals away from these patients for the main thrust of the new Act is to make treatment more difficult.

In April 1983 I went on a medical tour of China, travelling around the People's Republic in three weeks, with compulsory stops at the Friendship Stores, and flying visits to commune hospitals, clinics, a Chinese Medicine hospital, and a Chinese Medicine factory. The psychiatrists on the tour were interested in visits to the Shanghai Psychiatric Hospital, the Neuropsychiatric Department of the Beijing Capital Hospital and the Hangzhau Railway Workers' Sanitarium.

Since central government allocated capital and revenue money for the regional secure units (RSU) programme, following the 1975 Butler Report, the planning and building programme has been gathering momentum. It was felt it would be useful to review the present complicated and varied picture and to look ahead to the future. This seems a particularly apt moment to look around the regions as the climate of opinion, both within the clinical professions and in the various NHS administrative levels, is changing. Reference will mostly be made to the provisions for Mental Illness rather than for Mental Impairment and Adolescents.

The continued existence of ‘psychopathic disorder’ in the Mental Health Act of 1983 ensures that well into the next century individuals thus categorized will be detained in Special Hospitals and elsewhere. In this paper I want to consider the problem of ‘psychopaths' in the Special Hospitals, as I see them, both for the patients and the institutions, and I will pay special attention to the way such patients are detained. More specifically, I will argue that greater use should be made of treatment orders during the course of a prison sentence, rather than at the time of conviction. In other words, let there be more use of Section 72 of the 1959 Act (to become Section 47 of the new Act), as opposed to Sections 60 and 60(65), which in the new Act become Sections 37 and 41 respectively. At the end of 1982 only seven out of about 150 ‘psychopathic disorder’ patients in Broadmoor were detained under Section 72. The great majority were held on Section 60(65).

The Salford Psychiatric Case Register was started in its present form in 1968 and collected data on all persons coming into contact with the psychiatric services who were residents of the old County Borough which had a population of around 130,000 people. Since the reorganization of local authority boundaries, Salford has become a Metropolitan District, with twice the population and the Register has collected data on this new area since 1976.

It has seemed to me and many others that Britain is now entering a political phase in which the post-war consensus around matters of social welfare is being dissolved in favour of a new set of assumptions which emphasize the individual's recourse to law or to legally-embodied appeal procedures, even at the expense of more collective rights which were previously enshrined (imperfectly, it is true, but still definitely) in State-sponsored welfare provision. As I present it here, the implication is made of a fundamental antagonism, perhaps, and more certainly of a serious and unmistakable competition, between the claims of a legally-inspired and individualistic approach and the aspirations of medicine and psychiatry which are grounded in the availability of collective provisions: collective in a double sense, as being both the product of politically organized popular demand and also the expression of structured interventions by the State and other social agencies aligned with the State. It is this dualism between medicine and law, or at a more rarefied level between an individualism founded on contractual civil relations and a collectivism rooted in the institutions of mass democracy and public spending, which I feel needs most justification in argument, and which clearly lacks such justification in the remarks I shall offer here.

If the Health Service were perfect there would be no suicides among hospital patients. The first aim of all doctors and nurses is to preserve life, and patients are admitted to hospital in part so that they will not harm or kill themselves. Yet every year over 100, perhaps 200 or more people in the UK, deliberately end their lives while receiving in-patient psychiatric care. The exact number is not known, partly because of the way the statistics are collected, and partly because of a pall of secrecy spread over such deaths.

The following is the second part of Brian Barraclough's interview with Max Hamilton. Part I appeared in the March Bulletin.

Psychiatric disorders in the community are very common and most are dealt with by GPs, only a small proportion reaching psychiatrists (Goldberg and Huxley, 1980; Shepherd et al, 1981). It has been suggested that a large proportion of the psychiatric problems seen by GPs are intimately related to adverse life events and difficulties (Ingham, 1981; Tennant et al, 1981).

The Association of University Teachers of Psychiatry recognizes the recommendation of the Royal College of Psychaitrists (1971) that experience in behavioural psycho-therapy should be an integral part of the training of psychiatrists. To help reduce the shortage of trainers in this field the AUTP, with the Institute of Psychiatry, runs a course to increase available training resources. This course is mainly intended for consultants and senior registrars and those of equivalent status, including specialist psycho-therapists, but a limited number of other places may be available.

Following the taking of a psychiatric history and the examination of the mental state, it is standard practice to prepare a formulation (Institute of Psychiatry, 1973; Slater and Roth, 1977; Royal College of Psychiatrists, 1979; Garrick and Stotland, 1982). Indeed, the concept of formulation is central to the psychiatrist's approach.

In November 1982, a conference on the provision of comprehensive, district based, psychiatric services was organized by the Community Psychiatry Research Unit of St Bartholomew's Hospital Medical College. At this conference, Lord Trefgarne, Parliamentary Under Secretary of State at the DHSS, reaffirmed the Department's policy of creating local district psychiatric services and closing those mental illness hospitals which are not well placed to provide a local service.

The concept of crisis intervention and the various types of services available for dealing with crises affecting the individual or the family have been well set out in the publication from Napsbury Hospital. We would agree with Ratna's statement in that publication that crisis intervention is not only a system of delivering emergency psychiatric care, but also a set of techniques which utilizes a crisis to therapeutic advantage. It was with this in mind that a pilot study was launched in April 1979 for a crisis intervention service in Tunbridge Wells, Kent.

When Wilson et al (1978) described ‘The new Aberdeen Medical Record,’ they stated: ‘The bulk and disarray of many hospital medical records make it impossible to review and retrieve information easily, hamper the proper care of patients and cause much time to be wasted … when papers accumulate chaotically in the folders much time is wasted in clumsy attempts to retrieve information; important facts about patients and their problems and drug treatment are obscured.’ The same problems apply to the records of psychiatric patients, and this paper describes the adaptation of the Aberdeen Medical Record for use in psychiatric units and hospitals.

The debate on the place of community psychiatry is conducted as if it were a matter of choosing between service in the community on one hand and hospitals on the other. When expressed as a dichotomy the question, as illustrated by Scull's Dilemma (Jones, 1982), may be unanswerable. Instead, should we not ask what range of co-ordinated services are required to provide a comprehensive service for the mentally disturbed in a geographically-defined community? The key word then becomes comprehensive with community, in the sense of extra-hospital, important but subordinate. The hospital is then seen as part of the service; it is of the community, not alien to it. Other service components need not be anti-hospital, but hospital staff will need to avoid institutionalism and live down prejudice. The debate about what we can afford, although relevant, is separate.