Recent years have seen a steady move from a hospital based psychiatric service into a community orientated one. Mental health carers and psychiatrists need to be trained in order to be able to meet the changing demands placed upon them (Lancet, 1985).

One morning last week, I had said goodbye to my family, and as usual went to feed my chickens. They were excited to see me except for one, which was lying on its back with its feet up in the air, motionless and stiff. My medical training helped me diagnose death, and after I recovered from the initial shock, I had to consider the aetiology. Unfortunately, a few days earlier, I had found some tunnelling into the chicken shed and eggs had gone missing. I thought this was most likely to be rats. Can rats kill chickens? I was able to clarify the position later in the day, from a patient who was a poultry farmer, who informed me that rats do not kill chickens, but only baby chicks and that it was common for chickens at the age of nine months to suffer from sudden death.

It is interesting to observe just how much (or little) psychiatric services adapt to changing circumstances. The progressive move to community care, with the resettlement of seriously ill patients outside hospital and the avoidance of admission for many acutely ill patients, has shifted the focus of the psychiatric team away from its traditional institutional base – or rather the focus should have shifted. Yet it is probable that many psychiatrists, while paying lip service to the needs of patients in the community, have not altered their weekly routine. Hospitals, and the security they represent, retain their magnetic attraction for many staff. But with the growing number of out-patients and chronically disabled patients being supported by team members outside hospital, how should the multidisciplinary team respond?

In 1987 there were 1,428 psychiatrists in Australia, 8.8 per 100,000 population (Burvill, 1988), 55% identified as in private practice and 45% in public sector practice. Let us be clear about terms. Public sector practice means that each week you receive a salary from the public purse whether you have seen one or a hundred patients. Private practice means that you are paid on a piece-work basis, also largely from the public purse (national health insurance or Medicare), but the income (at about $100 per hour) depends exactly on the number of hours spent with patients. On average, private psychiatrists in Australia gross about $150,000 per year, out of which they must pay practice expenses. The pay for public sector psychiatrists probably averages $70,000 to which, for the purposes of our calculation, we will add the cost of rooms, telephone and secretary provided by the hospital which at $30,000 brings the cost of a public sector psychiatrist to about $100,000 per year. If 45% of psychiatrists are in public practice then the averaged cost of a psychiatrist in Australia can be calculated as $127,500 per annum, and as there are 8.8 psychiatrists per 100,000 the cost, calculated on this simple basis, is $1.12 million per 100,000 population (Andrews, 1989).