Enoch Powell's famous ‘Water Tower’ speech, in which he described mental hospitals as, “Majestic, imperious, brooding institutions… rising unmistak ably and daunting out of the countryside”, inaugur ated the policy of successive governments to close the large mental hospitals and care for the chronically mentally ill “in the community”.

Having gone to the trouble of organising a day conference on ‘The Psychiatrist in Court’, primarily directed at trainees, we were disappointed to find that on the day the considerable audience was composed mostly of consultants. This seemed a pity, particularly as we knew that this was an area of concern to many young psychiatrists. Kindly colleagues assured us that it is always difficult to get juniors to attend conferences. Nonetheless we were curious to know why trainees seemed more reluctant to take time away from their normal duties than perhaps their ‘more pressed’ consultants.

It is well recognised that there is an increased psychiatric morbidity, in particular psychosis, personality disorder and substance abuse, among the single homeless (Lodge Patch et al, 1971). The reasons for this are complex. There is evidence that these people are mentally ill before becoming homeless and that their illness may be a cause of their homelessness. In a study of newly presenting patients at the DHSS Reception Centre in Camberwell, London, Tidmarsh & Wood found that 87% of those with mental illness had been staying recently with their families just before their first hospital admission, suggesting that mental illness may have led to homelessness in these patients (Tidmarsh & Wood, 1972). Although direct evidence is scant in the UK, it is felt that the closure of long-stay psychiatric hospitals could lead to some of their in-patients becoming homeless.

Regional secure units are a relatively new facility for the treatment of mentally disordered offenders and difficult to manage patients. Their role is still evolving. Previous studies have described details of referrals and admissions to such secure units (Higgins, 1981; Gudjonsson & Mackeith, 1983; Offen & Taylor, 1985; Faulk & Taylor, 1986; Bullard & Bond, 1988). To date, however, no studies have examined changes of practice in RSUs over time. The purpose of the present study is to examine changes in the admission characteristics of patients admitted to the Butler Clinic, regional secure unit for Devon and Cornwall since it opened in 1983 to the present time.

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 publication Caring for People: Community Care in the Next Decade and Beyond (DoH, 1989) sets out the Government's plans for community care and is the much awaited response of Government to Sir Roy Griffiths' report on community care. Many health districts have been doing all, if not more, than is recommended in the White Paper but this has been rather costly as far as the DSS funding is concerned. It should be remembered that the high cost of community care to the DSS was one major reason for Sir Roy being asked to investigate and report on such care.

Units to admit psychiatrically ill mothers with their babies to psychiatric hospitals were pioneered follow ing Main's description (1958) of the treatment of mothers with their children at the Cassel Hospital. Particular interest in puerperal psychosis and dis orders of bonding and attachment led to units usually providing for babies below six or 12months. Suggesting older infants should also be admitted, Main referred to the benefits in admitting parents to paediatric wards with ill children, and described how toddlers had been admitted with their mothers at the Cassel. Another early unit at Banstead Hospital cared for schizophrenic mothers with their babies and found that joint admissions lead to faster recovery, lower relapse rates and more babies continuing to live with their mothers (Baker et al, 1961).

The psychotherapist as consultant to in-patient psychiatric units may undertake any one of a number of specific tasks. Central to, and common to these, is his support of the effective work of the psychiatric unit's staff. The consultant's contribution is directed primarily towards enabling the staff to utilise themselves, i.e. their selves, to the full in their treatment of the patients.

As well as the more spectacular 999 calls to urgent road traffic accidents and myocardial infarction victims, the ambulance service provides a background care which allows people with chronic and recurring disabilities to remain in their own homes.

“Welcome to ‘Lillian’. This is all about schizophrenia. Schizophrenia is an illness, a serious mental illness which affects one person in a hundred. It is an illness which causes strange thoughts and strange feelings. It leads to emotional disturbances and a withdrawal from the reality of the external world. Those who suffer from it withdraw into their own world, into an unreal world of fantasy. Often they are tormented by strange and frightening experiences. Some develop strange ideas and fear that they are persecuted. Others hear voices, see and feel things that are not there, though they are real to them. Sometimes it is difficult to understand them because their thoughts are jumbled. They may even feel that someone else is interfering with their minds. In time, some lose their ability to do their everyday activities and lose their drive and initiative but this is not laziness. They often become very anxious and have periods of depression. For many the ability to express their emotions is blunted and in others their behaviour is unusual. These experiences are all very real to them and sadly some never realise what is happening to them. Most do recover with treatment, understanding and support but often under stress, relapses occur. We ask for your understanding and support”.

NHS out-patient clinics remain a major point of contact between psychiatrists and their patients. There are several advantages to this setting for consultation: it is time efficient, there is usually easy access to case records and contact with other disciplines and services is often available. With the current trend towards community care, increasing use of out-patient facilities is likely as home visiting becomes impractical and, moreover, may be undesirable for some patients.

A legal finding of unfitness to plead results in automatic committal of the accused to a mental hospital. In Scotland, if criminal proceedings are under solemn jurisdiction, there is a mandatory order restricting discharge without limit of time and the hospital must be a state hospital unless for special reasons an alternative hospital is appropriate (Section 174 of the Criminal Procedure [Scotland] Act 1975). The mental condition of a person found unfit to plead may subsequently improve such that he may become fit to be tried in the normal way. In England and Wales the Home Secretary has power, under Section 5(4) of the Criminal Procedure (Insanity) Act 1964, to remit to prison for trial a person found unfit to plead who subsequently recovers. On arrival of such a person in prison the hospital and restriction orders cease to have effect. The Criminal Procedure (Insanity) Act 1964 does not apply to Scotland; authority to reprosecute unfit defendants in sheriff courts and the High Court rests exclusively with procurators fiscal and the Crown Office respectively. The status of the original hospital and restriction orders in reprosecuted cases is unclear.

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.

A need for improved communication between the social sciences and psychiatry is being expressed from many quarters. Interest in social and cultural issues is not, of course, new to psychiatry, but collaboration between the two approaches has not always been easy. Recently one social science in particular has become popular with psychiatry. This is social anthropology, and many psychiatrists consider that the inclusion of anthropological data and methods, particularly in cross-cultural research, can be useful and informative to psychiatry. What then is the relationship between anthropology and psychiatry and what are the problems which professionals face in attempting interdisciplinary research?

Drug and alcohol misuse during pregnancy poses a threat to the health of both the developing foetus and the mother yet this complex clinical problem often falls between different stools within the health services. A mother would first have to recognise herself as a drug or alcohol misuser needing help before she came within the ambit of the addiction services. On the other hand, the obstetric agencies, even when they identify a drug problem, usually do not regard themselves as having a role. General practitioners are most likely to have an overall view and therefore to be in the best position to manage the problem. However, many misusers do not register with GPs and, despite calls to the contrary, GPs have not become more widely involved in the management of addiction.

The White Paper (CM 555) Working for Patients DoH, 1989 and its associated Working Paper 7 recommended Regional Health Authorities to devolve everyday management of consultant contracts to Districts, with instructions that, by April 1991, hospital consultants must have job plans which reflect their main duties and responsibilities within the service. Health Circular HC(90)16 represents, in four pages, the outcome of the year-long negotiation between the Ministry and the medical profession's negotiators on the Central Consultants and Specialists Committee (CCSC). Honours are even. Government can claim that the profession's traditional autonomy, already weakened by the Griffiths NHS enquiry in 1983, has been brought further under its iron fist; on the other hand CCSC can justifiably pride itself on the preservation of a flexible professional contract (Havard, 1990). It has succeeded too in modifying the original proposals by winning rights to an appeals mechanism, and, of great importance to those involved in College activities, in preserving the opportunity for consultants to contribute to national and local professional committees within NHS time. The CCSC has also negotiated amendments to Terms and Conditions of Service for Consultants which allow those involved in management activities (UMRs, Clinical Directors, Resource Management Leaders and Audit Co-ordinators) either payment for up to two additional notional half days a week or relinquishment of equivalent clinical work, in which case a colleague may be paid to take this on. These are important concessions and will be welcomed by all consultants.

While research into the effectiveness of neuroleptic medication consistently demonstrates its value in improving psychotic symptoms, and in the prevention of relapse, the treatment continues to generate controversy. Indeed, McClelland (1989) has recently asserted that this treatment of choice is “an indispensable evil”; “indispensable” by virtue of its clinical effectiveness, and “evil” because of the wide range of adverse and distressing side effects experienced by patients.

In this issue of the Psychiatric Bulletin (pp 72–76), Dolan & Norton discuss the need to protect specialist psychiatric units such as the Henderson Hospital. They describe a variety of functions of these units, but only make brief reference to training. I would like to describe my six months in psychiatry spent as a registrar at the Henderson Hospital. My enjoyment of the placement may not be synonymous with the Henderson serving an important training function, but I hope that I can explain why the two may be linked.

The main aim of this pilot study was to identify factors influencing acute psychiatry bed use. The reasons for occupying a bed vary with time, so patients in the study were assessed on a weekly basis to monitor the changes in the factors thought to be responsible for continued stay. The reasons for bed occupancy also are often only known to those professionals directly involved in day to day care of patients, and it is suspected that the reasons often have little to do with manifest psychiatric illness. The reason for this study was to investigate this question.

Experience of being resident on-call is common to all practitioners who have worked through the training grades. Other professions have their lean years while in training, for example the apprentice years in the law profession or the junior financial executive's commitment to his company, but being resident on-call in a place of work, ready to deal with any emergency for a significant fraction of one's waking and sleeping life, is peculiar to the junior grades in the medical profession. Judging by the opinions expressed by my colleagues, all registered practitioners are united in having experience of being on-call and finding it to some extent irksome. Part of the problem lies in having to do long periods of overtime for reduced rates of pay, often in delapidated surroundings when one could be more enjoyably occupied elsewhere. Most people decide that the benefits of serving the prescribed training period in the junior grades to become vocationally trained general practitioners or members of one of the Royal Colleges outweighs the short-term discomfort. In this paper I examine the experience of ‘being on-call’, working through the different aspects. I argue that the irksomeness of the experience may derive in part from the echoing of unconscious conflicts.