Policy for mental health services in England is based on two straightforward principles. These are, first that care should be provided as locally to where a person lives as is reasonably possible, and secondly that treatment should be available in the least restrictive conditions that are compatible with the safety of the patient, of those looking after him and of the public at large. I make no apology for reviewing the history of policy and practice; it is not possible to understand the mental health services that we are trying to achieve for the future without understanding how the service has developed over the years. I shall use the mental illness service as an example – similar considerations apply to the mental handicap services.

In an earlier report (Dolan & Norton, 1990) we commented upon the potential vulnerability of specialist psychiatric units following the implementation of Working for Patients and the NHS Bill. Specialist units provide a valuable resource, not only in terms of treatment, but as sources of practical training, education, development of new therapies and of research. Many such units previously enjoyed financial protection at the regional health authority level. Downloading financial responsibilities to DHAs or NHS trusts will complicate the issue of funding since contracts will now need to be entered with each relevant DHA or NHS trust. This more cumbersome system is inevitably more costly for a specialist unit to operate. Users of such units (customers and consumers) will find referral problematic since funding must be identified in advance. Difficulty in negotiating the new, more complicated contracting system, may lead to a decline in specialist referrals. This will in turn lead to questioning of how necessary such ‘regional’ or (as in the case of Henderson Hospital) ‘national’ specialities really are. Managers may tend to argue that referral patterns will reflect (eventually) the true needs for treatment of particular client groups.

The provision of care for patients with chronic mental illness is changing with the gradual closure of mental hospitals and the expectation that this group will be largely cared for in the community. In Scotland the process is only beginning. A recent Scottish survey examined the demographic, social and clinical characteristics of 2605 “old long-stay” in-patients, defined as those in hospital more than six years and under 65 years of age at the time of last admission (McCreadie et al, 1991). Patients in 18 psychiatric hospitals serving 83% of the Scottish population were studied. Results showed the population was elderly, 70% being over 60 years of age, and nearly 40% over 70 years. The aim of the present study was to look at the physical health of the old long-stay population in one hospital, namely Crichton Royal, Dumfries, because of the implications of physical health care needs for the management of this group in the community.

This paper draws upon over 30 years experience of Tribunals as RMO, medical member and independent psychiatrist.

My paper deals with the provision of psychotherapy services for forensic patients and the training available to the would-be forensic psychotherapist. Psychotherapy in the context of this paper refers to psycho-analytically based psychotherapy, either individual or group, and not to behavioural or cognitive models. In addition, two aspects of psychotherapy should be borne in mind: supportive psychotherapy in the context of ongoing therapeutic relationships (e.g. patients suffering from chronic mental illness) and mutative psychotherapy, which aims to change some aspect of the person. Both aspects are important in the practice of forensic psychiatry, perhaps especially the latter.

The dangers of cigarette smoking are well recognised, and a number of public health measures designed to reduce the level of smoking have been introduced over the past 20 years. These measures have been fairly successful, and there has been a steady decline in the prevalence of cigarette smoking in the UK over the period 1972–1988 (Office of Population Censuses and Surveys, 1990). A number of studies have shown a higher prevalence of cigarette smoking among psychiatric patients (Hughes et al, 1986); however, the majority of these have been of highly selected populations, or have failed to control for factors such as age, sex, socioeconomic status and alcohol abuse, all of which are known to affect the prevalence of smoking. This study compared the prevalence of cigarette smoking among a heterogeneous group of psychiatric out-patients with that of the general population with control for these confounding variables.

The multidisciplinary team approach is considered by the Royal College of Psychiatrists to be a valuable instrument in modern psychiatric practice (Rawnsley, 1984). In addition, it is assumed by the 1983 Mental Health Act in Section 117 concerning joint Health and Social Service responsibility for statutory aftercare and in Sections 57 and 58 where consultation with other disciplines by the second opinion doctor is required. The benefits of this way of working include a broader perspective in care provision, consistency of approach, continuity of care, and improved communication between disciplines (Pollock, 1986).

Charles Shaw, in a number of articles and his Hospital Handbook (Shaw, 1989, 1990) has played a key role in outlining the principles of medical audit. He arbitrarily divides the process of medical audit into four phases. The philosophical phase which seems to have been negotiated, is whether the medical profession should be involved; the organisational phase; who should lead the process, and the resources required; the practical phase, what should be audited and the methods used; and the invasive phase, how the general concepts and the details of audit are communicated through publication. He goes on to describe a variety of methods of audit including the review of adverse events and general statistics, the assessment of randomly selected records, and finally the review of a topic (which includes medical record review). Another approach in planning audit is through understanding of the organisation itself (Donabedian, 1966) and evaluating quality of care in terms of the structure of the organisation (bricks and mortar, staffing, beds, technology etc.), the process of care, and this may include length of stay, broad out-patients statistics, and perhaps more controversially, face to face contact, group interaction, home visits, day hospital attendance and so on. Finally, and most complex, is outcome.

Careers in academic psychiatry can follow various paths but usually are aimed at achieving a university appointment at consultant grade; i.e. senior lecturer, reader, or professor.

Trainees in psychiatry are encouraged to become involved in research during their training (Sims, 1988). As Crisp (1990) points out, research skills are basic to a number of attributes such as problem solving abilities, consultation skills, self-audit, and the audit of others. Both the College and senior registrar appointment committees seem to value some research experience as it demands persistence, as well as the ability to think both creatively and logically. The College does provide a research option for the MRCPsych Part II, but this is only chosen by a minority of candidates. In addition the College runs its own course. Nevertheless, many trainees find it very difficult to know how to set about research unless they have previous experience or their job specifically involves research.

This article deals with the organisation and evaluation of a pilot series of seminars at the Institute of Psychiatry on the relevance of social anthropology to psychiatry. Despite increasing interest in the relationship of culture to psychiatry, trainees have few opportunities to learn about anthropological issues in psychiatric theory, practice and research. The present authors, all with higher degrees in social anthropology, believe that this is one of the first seminar series of its kind in the country specifically for mental health trainees. Some further possibilities for developing and applying this teaching are also considered.

With the closure of large mental hospitals there is increasing emphasis on community psychiatry (Thornicroft & Bebbington, 1989) and a need for experience and training at all grades in this speciality. Some training aspects of an area of community psychiatry as experienced by a senior registrar are detailed.

By 1841, advances in communication and education, coupled with an increasing number of medical staff attached to mental asylums, made the idea of a formal grouping of such asylum staff a viable proposition. Although, as the following paragraphs indicate, such a group took many years to become established, the body whose early years are described briefly here, is the direct ancestor of the Royal College of Psychiatrists.

The British Journal of Psychiatry, the title it has enjoyed since 1963, can claim descent in direct line from three earlier journals, entitled in chronological order, The Asylum Journal from 1853; The Asylum Journal of Mental Science from 1855; and The Journal of Mental Science from 1858.

The Greek origin of the word psyche (breath) is well-known but psyche also referred to life as action or as soul, some special force or spirit which entered living creatures. It was as soul or spirit that psyche was adopted into the English words psychology and psychiatry but its exact semantic status is a knotty affair.

Sir Robert Armstrong-Jones was President of the Medico-Psychological Association in 1906.

The relocation of chronic psychiatric patients in the community may be of unexpected benefit to town planners. Many Victorian mental hospitals, largely redundant in terms of medical use, are high quality buildings – some are listed or otherwise of architectural merit – and they are often set in mature landscaped grounds. Architect John Burrell has developed the idea of using former psychiatric hospital sites on the edges of cities as a basis for establishing a new urban core to outer suburban areas. His plans for the Woodford Green site won him the top prize in a national competition ‘Tomorrow's New Communities’, which was organised earlier this year by the Town and Country Planning Association and the Joseph Rowntree Trust, with the backing of the Prince of Wales.

Once upon a time there were clear-cut career pathways for ambitious doctors, what are now called ‘inside tracks’. Forward-looking people in the UK, for example, realised early that in order to become a consultant or professor in a teaching hospital, it was essential to be well qualified and published. In psychiatry, this meant proof of being truly renaissance with qualifications in medicine, psychiatry and research. How this was achieved was up to the individual. At places like the Maudsley Hospital people often arrived bristling with degrees. About half the entrants had passed College exams or had research doctorates. During psychiatric training the others went for the extra qualifications. They had to; otherwise they would not make it to senior registrar. Some characters practised brinkmanship and passed the MRCP on the umpteenth occasion. Thereafter things varied, with some moving into personal analysis (no degree) and others into wet and dry laboratory research. Many eschewed both and headed for clinical work. There was a period, perhaps between 1945 and 1975, although the limits are arguable, which was halcyon. Medical trainees were actually committed to research. There were twin pathways; the scholarly going to the MRC unit or the Chair and the entrepreneurial to the teaching hospital consultant job and Harley Street practice. The teaching hospital wallahs needed about ten papers to be acceptable. An engaging feature of the system was that the pay was not particularly discrepant between researchers and clinicians. The somewhat subfusc role of researchers was, in any case, redressed in the mid 1960s and parity achieved. Amazingly, then, it was possible to have a career in research without losing money. To what did it all add up? In modern parlance, was it cost-effective and efficient? Did the clinicians with their ten papers or the MRC medical scientists give value for money? After all, with what can they be compared?