The proposals outlined in the White Paper, Caring for People, are now law and were little affected by the wave of protest which greeted them when they were first published. So the time has probably come to see what can be made of them and how they might be turned to advantage, rather than continuing to worry about the politics of whether change was necessary at all.

Recent reports show that continuing problems are being experienced by the returned hostages and their families. The Department of Health advised at the time of the hostages return that, apart from those who needed immediate emergency treatment, the initial point of referral ought to be the persons general practitioner. General practitioners in many cases now employ their own staff who are able to offer support and counselling. In some cases the general practitioner may, however, decide that the most appropriate response is referral to the psychiatric service. All local psychiatric services should be able to respond to the needs of people suffering continuing stress as a result of traumatic experience.

Lithium therapy for affective disorders has been estimated to result in savings of hospital beds in the National Health Service of £23 million each year. In order to maintain and justify this saving we must invest to provide careful monitoring of serum lithium concentrations in patients living in the community. In recent years the advent of lithium clinics has done much to improve the compliance and safety of lithium therapy (Masterton et al, 1988), but we believe that there may be scope for further improvement both in the service to the patient and in encouragement of the patient to comply.

Patients discharged after acute psychiatric admission are vulnerable, and need continuing care in the community. For these people and their families, the first two weeks after discharge is a critical time. This is when problems arise, support is needed, drugs run out, and default most likely. Care may be shared between psychiatrist, community psychiatric nurse, general practitioner and other health personnel. It is therefore essential to identify the roles and responsibilities of all involved in follow-up care. Studies have shown that information needed by general practitioners includes differential diagnosis, management, treatment on discharge, prognosis, what patient and relatives were told, future plans which specify the roles and responsibilities of all involved, as well as the date of any follow-up appointment. Moreover this information is needed within two weeks of discharge. Without this information effective follow-up is unlikely to occur. The early discharge summary provides this vital information in the immediate post-discharge period. This is quite distinct from the final report which usually takes a few weeks to be sent. It is therefore important to identify current psychiatric practice relating to the initial discharge summary.

The MRCPsych Part II examination takes place twice a year at a number of centres in Britain and Ireland. It comprises five components. Three are written exercises and the other two, a viva voce and a clinical examination, are practical assessments characterised by face-to-face interaction with the examiners.

Despite the brevity of the Gulf war, there is still the strong possibility that it will leave long-term problems for psychiatric services within the NHS. The low incidence of acute psychiatric problems in the Falklands conflict does not obviate long-term problems. Surgeon-Commander O'Connell of the Royal Navy, reported informally in the newspapers (Guardian, 7 May 1990) that up to 30% of the 28,000 Falklands veterans are still suffering from post-traumatic stress disorder (PTSD). Hughes (1990), medical officer with 2nd Paratroop Regiment at Goose Green, described his realisation that he had PTSD, his subsequent treatment by the NHS and transfer to a military hospital. The Royal Navy still has a counselling service, set up in 1987, but it is clear that military services cannot deal with all the current problems, let alone those to come. The advice of the Ministry of Defence is that the initial onus to recognise a problem lies with the family and that sufferers should seek treatment through their GP.

As general practitioners (GPs) are clinically responsible for the majority of recognised psychiatric morbidity in the community, they have an important role to play in deciding the shape of new community psychiatric services. This paper reports the results of a self-completion postal questionnaire survey of Harlow GPs' views on how community psychiatric services should be developed. Harlow is a mature new town (population 79,521: 1981 census) north east of London, served by a typical DGH department of psychiatry with in-patient wards and a day hospital, outreach services being provided largely by community psychiatric nurses (CPNs). GPs work in group practices in purpose-built health centres.

The Marital and Sexual Difficulties Clinic at Sheffield offers out-patient treatment that is usually based on a modified Masters & Johnson method. This consists of behavioural techniques, notably sensate focus, used within a psychoanalytic background.

That adults with mental handicap∗ are particularly vulnerable to sexual exploitation is not new, although relatively unacknowledged or investigated. Indeed successive acts under the mental health legislation have sought to protect them, particularly those with severe mental handicap. With the growing awareness and identification of sexual abuse of children, and the growing knowledge of the long-term psychological effects (Jehu, 1989), which may be even more severe for people who have disabilities (Kennedy, 1990; Sinason, 1989), it has been acknowledged that not only are the mentally handicapped particularly vulnerable to abuse (Benedict et al, 1990), but the problem may well be seriously underestimated by those working in management positions (Brown & Craft, 1989). While it is recognised that the mentally handicapped have rights and need to express their sexuality, they also have the right not to be exploited or abused. We therefore need to know more about the numbers, indicators and circumstances where this group may be sexually abused and to develop policies, systems and training to protect them (Brown & Craft, 1989). This pilot study was a step in this process.

The run-down of the psychiatric institutions has led to innovative and novel methods of treatment of the mentally ill in the community. In New Zealand, as in other countries, deinstitutionalisation of the more traditional psychiatric services is proceeding rapidly and the statutory and non-statutory community services are straining under the burden. Amid the turmoil of change and the crying out for alternative provisions, a pilot scheme was proposed to serve the mentally ill in the population of West Auckland. In early 1988 the Extended Hours Team (EHT) was born. It is based on the model used in North Sydney, Australia (Hoult, 1986) and Madison, Wisconsin (Stein & Test, 1980). At the time of conception of the EHT, cost cutting was the rule which led to a difficult gestation but a surprisingly easy delivery and subsequent development over the first year.

Mentally handicapped people have the same rights in terms of good quality and range of care as other members of society. This has been highlighted by the recent emphasis on community care for psychiatric patients irrespective of their disability.

It is known that in most traditional psychiatric hospitals a significant minority of patients can have a better quality of life in hospital-hostels. With ample hospital-hostel places it was decided to interview and/or review the notes of all the non-demented Gloucestershire patients under 75 years whose stay in psychiatric hospitals exceeded one year on a census date of 26 September 1990. The characteristics of these long stay or residual patients are described.

The compulsory treatment of addicts has always attracted controversy and even generates strong emotional responses from workers in the field. But the few projects which have been mounted have yielded results no less encouraging than voluntary approaches and in some instances report greater success. These schemes have already been subject to an international comparison (Webster, 1986).

Throughout society there is an increasing tendency to approach the various activities of human existence in a way which eschews blind acceptance, but requires instead thorough examination and analysis of the processes involved in those activities in the belief that the insight gained will improve performance. Treatment is a central activity of the Health Service, and this paper will attempt an analysis of the processes involved in it within the context of the clinical team delivering it.

In the peripheries of excellence, providing a service is the main task. Professor Nichol says that describing a child psychiatry service to managers is easy (Third Section Newsletter). I say it is and it is not. The way he does it follows the traditional bioscientific medical pattern and logic - number and range of cases and diagnoses etc. Health managers at a first glance may be quite happy with this ‘biomedical’-looking picture. But I believe that in their second glance they can tell that these expensive child psychiatrists, who just sit in rooms talking, are not dealing with the same thing as surgeons and physicians.

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.

The year 1991 will be emblazoned on our minds as the year of the Middle East War. Saddam Hussein gave more than a clue to his own psychopathology when he named this conflict “The Mother of All Wars”. All nations which actively participate in battle will lose troops and civilians. Physical damage, terror and distress are the immediate accompaniments of battle. Starvation, sub-standard living conditions and infectious disease often follow. Modern weapons and terrorism are capable of inflicting major damage on populations which are far away from the centre of the war.

Although childhood psychiatric disorders are commonly seen in general practice, only a few children in the community gain access to professional help. Whether a child is referred or not depends on various factors to do with the child and family and others, such as what the GP expects from the referral. Severity per se is not the only referral determinant. Whether GPs know what the child psychiatric services in the area have to offer could also be expected to affect referral (Markantonakis & Mathai, 1990). We are aware of the need for general practitioners to be made more aware of the services that we have to offer.

There is an increasing momentum for the provision of care for people with chronic mental illness to be made in settings other than mental hospitals. One concern arising from this shift in emphasis is with those patients who may find it particularly difficult to live in the community.