General practice fund-holders purchase secondary care for their patients directly, encouraging competition between providers. The scheme now includes almost all community mental health services. Practice counsellors may now be funded from secondary care budgets. Fund-holders may use their purchasing power to influence out-patient policies, have consultant sessions in their surgeries, gain direct referral to community psychiatric nurses, resist sectorisation, or change to a different provider altogether. The implications for mental health teams and their patients are discussed. Mental health workers must define their roles very dearly, and get involved in negotiating contracts now, to influence future service provision.

Psychiatric services delivered outside agreed contracts between purchasers and providers will not be paid for. Reduced income will then mean reduced services. This article describes how psychiatrists might understand and address the contracting issues for their service, so that they effectively involve themselves in the contracting process in their locality, and so maintain the services for their patients.

A 45-year-old woman with a long history of schizoaffective symptoms associated with disruptive and antisocial behaviour refused to cooperate with out-patient treatment and particularly medication, having developed a strong distrust of psychiatrists. After discussions with the multidisciplinary team, the psychiatrist agreed to share treatment decisions with the patient and accepted her refusal of medication. This course of action is not always comfortable for professionals, especially when a patient challenges clinical judgement. However, this case illustrates how, by adopting a less paternalistic approach, the therapeutic alliance developed and, most importantly, the patient's health improved. The scenario described raises similar issues to those explored in the play Whose Life Is It Anyway?

This study assessed, by postal questionnaire, how the role of the psychiatrist in learning disability is perceived by general practitioners. One hundred and forty-six GPs were questioned on various aspects of assessment and management that the psychiatrist in learning disability might be involved with; 43.5% of questionnaires were returned. The results indicated that confusion continues. The psychiatrist was perceived as having a global role in the care of this group of patients with lack of knowledge of community teams for learning disability being evident. Further education at a primary care level is indicated.

The aim of this study was to determine the extent to which general practitioners are informed of and involved in their psychiatric patients' discharge plans, their satisfaction with the present level and methods for improvement. Postal questionnaires were sent to 100 GPs from different practices in England. They reported a high level of dissatisfaction with the present frequency with which they are informed of and involved in discharge plans before the event. They report being informed and involved too infrequently or randomly, or both. This dissatisfaction could generally be resolved by pre-discharge telephone discussion with a member (preferably medical) of the multidisciplinary team.

A retrospective investigation of case-notes compared 54 incidents of informal psychiatric in-patients being detained in hospital on an emergency basis with 66 incidents of discharge against medical advice (AMA). The characteristics of the two groups were compared. Detained patients were more likely to have been detained previously, to be suffering from a psychotic illness, and to have threats of violence or self-harm mentioned in their case-notes. AMA patients were more likely to have a history of substance abuse but were no more likely than the detained group to have been discharged AMA in the past. The results suggest that psychiatrists in this hospital are using current legislation on detention appropriately.

There are advantages to be gained from a knowledge of the patient casemix that psychiatric hospitals, and community services, are likely to encounter. In particular the efficient allocation of resources would be better achieved if individuals could be ‘placed’ into groups. These groups would need to be clinically distinct and contain similar members. Previous methods of defining casemix have focused upon clinical diagnosis. However, the effectiveness of diagnosis in predicting resource utilisation is limited. A range of other factors could be used, including comorbidity, severity of illness, and previous hospital contact.

A one day census of patients on the acute wards at a psychiatric hospital revealed that approximately 40% of in-patients were holders of driving licences and that the majority of them would be affected by the current regulations regarding fitness for driving. Despite this, few patients could recall being given medical advice regarding their driving. In only one case was any advice documented in the case-notes. Psychiatrists' responsibility for ensuring that patients are given appropriate information regarding the effects of their illness or medication on their driving performance is discussed.

A reason sometimes given for not applying a section off the Mental Health Act 1983 to patients for the first time is that this may stigmatise them in some way. A practical example off stigmatisation is that patients who have previously been ‘sectioned’ may be refused tourist or immigration visas to other countries. Since no information on this subject is available in the psychiatric literature this paper attempts to clarify the policy of diplomatic missions in the UK in relation to visa applicants who report a history of mental illness and compulsory hospital treatment.

The experience of detoxification and satisfaction of patients with their treatment in a community-based alcohol recovery unit established by a voluntary organisation and in a psychiatric unit in a general hospital were assessed with the help of a structured questionnaire. Patients admitted to the two units were satisfactorily matched on most, although not all, variables. The types of withdrawal symptoms and lengths of stay were similar. No patient was transferred to hospital from the community facility. Patient satisfaction was greater in the detoxification unit where the cost of treatment was about a third of that in the psychiatric unit.

The three special hospitals of England and Wales are provided for patients subject to detention on account of their dangerous, violent or criminal properties. Special hospital psychiatrists cannot admit patients directly to hospital – the psychiatrist's recommendations can be overturned by a local admissions panel. A two year retrospective study in Rampton Hospital compared the outcomes of the psychiatrists' recommendations to admit or not to admit, with the decisions of the local admissions panel. There was complete agreement in over 90% of cases. This survey lends support to the view that special hospital psychiatrists could admit patients directly to hospital.

Continuing medical education (CME), or continuing professional development, will now receive special attention in the Psychiatric Bulletin (Kerr, 1994). A report from the Special Committee (of Council) on CME examining consultant psychiatrists' experiences and opinions on CME has already been published (Sensky, 1994). Two further aspects of the work of the Committee are now reported.

Higher trainees in child and adolescent psychiatry and their consultant trainers reported high levels of compliance with existing JCHPT guidelines on the structure of direct supervision. There was a consensus about the ideal content of supervision sessions but disparity about whether this is achieved in practice and over issues of responsibility for raising certain topic areas. These findings are discussed and some questions to be addressed by trainee and trainer at the outset of the supervision process are suggested.