The present paper reviews the restructuring of the NHS that has taken place since 1991, with particular reference to the introduction of self-governing NHS trusts. Established to strengthen the financial management of NHS assets and to contain costs, NHS trusts represent a political solution to the problem of health service funding. Despite the speed of the reforms, there is no evidence yet of any improvement in the cost-effectiveness of resource deployment, and it is too soon to say what effect trusts will have on mental health services. Concern remains that the present reforms will ultimately lead to fragmentation of the NHS.

The Department of Health has published proposals for new legislation, which it hopes will provide a legal basis for effective community care of mentally ill people. Consultant psychiatrists and approved social workers were surveyed to determine attitudes towards the proposals. Despite the impression that new powers are provided, respondents saw little in the way of new powers, and could not see how the proposals would improve community care. Not all of the proposals were fully understood, and wider consultation with those who would be using any new legislation is recommended.

There has been much recent government legislation affecting mental health services. Some relates to the delivery of general health and social services, of which mental health care forms only a part, and some specifically to the delivery of mental health care. The complex interplay of the legislation is explored and there are suggestions for the further involvement of psychiatrists.

This paper gives an overview of the first year of a project in which a psychoanalytic psychotherapist worked with the staff of the ophthalmic department of a general hospital to study some psychological aspects of disorders of the eye. The purpose was to see whether semi-structured interviews based on psychoanalytic insights could increase our understanding of the disorder and, if so, how this understanding might be used to help the patient.

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 survey of mental health professionals in a Bristol NHS trust found that most had experience of therapeutic work with sexually abused patients and over half were currently engaged in such work. Supervision was variable and often considered inadequate. Few responders routinely enquired about historical abuse in the course of psychiatric assessment. The findings indicate a need for agreed strategy involving training, supervision and inter-agency co-operation to deal with this increasingly common problem.

The aim of this article is to promote a clearer understanding of the Mental Health Commission's development, structure and function. Over recent years, mental health professionals and patients have become more aware of the organisation and its work, although some may remain uncertain about its function and how it fits into the overall care of detained patients. The Commission's fundamental job is to safeguard the well-being and interests of patients detained under the Act. Its remit does not extend to informal patients. Unless otherwise indicated, all statutory references are to the 1983 Mental Health Act.

A survey of the prescribing practice of a group of psychiatrists working in a Bristol NHS trust found that their preferred choice of antidepressants was surprisingly similar, but reported doses of antidepressants often fell below generally accepted minimum levels. Clinicians used mainly newer antidepressants rather than tricyclics. The choice of antidepressant was based on side effect profile, overdose danger, training and personal experience of efficacy. Cost and drug company advertising had little effect on choice. Difficulties in involving depressed patients in treatment decisions are discussed.

Perceived difficulty in obtaining hospital admission for acute psychiatric patients was investigated in one health region using a self-reporting method. Over 17 months both inner city and rural districts reported a total of 327 episodes of difficulty in finding a bed. One hundred and six (32%) of reported cases could not be admitted, the remainder being admitted to a ‘leave’ bed, a bed booked for another patient, or elsewhere, solutions likely to compromise care. Attempts to locate a vacant bed required numerous telephone calls and led to considerable delays. Thirty-nine (12%) of the patients were described as particularly ill, but five of them absconded during the prolonged search for a bed, and a further 17 had to remain in the community, pending a vacant bed, including two aggressive and eight suicidal patients. Considerable under-reporting was confirmed. Possible consequences of the situation are discussed.

As part of a project designed to assess the impact of the NHS and Community Care Act 1990 upon the care of patients discharged from special hospitals, an attempt was made to obtain local authority community care plans. The difficulties encountered during this exercise and the level of planning obtained for the mentally disordered offender as identified in those plans, may be a cause for concern to all those working in this field.

In a retrospective study, referrals to a community old age psychiatry service were obtained for local practices a year before and a year subsequent to the introduction of prospective general practitioner (GP) fund-holding. Although overall patterns of referral were the same, there was a significant reduction in domiciliary consultations requested by fund-holding GPs which was not balanced by a rise in other referrals. The findings suggest a shortfall in the number of referrals to old age psychiatry services in the light of GP fund-holding, prompting speculation as to the fate of those who would otherwise have been referred.

To date, there are few reports on the extent of elder abuse among patients referred to old age psychiatry services. This study examined suspected cases of abuse among new referrals to a community psychiatric team for the elderly, at a time when guidelines and procedures for the detection and management of elder abuse were about to be introduced. of 74 cases assessed, seven (almost 10%) were probably being abused. Several types of abuse were described, with no single pattern, and the professional responses therefore needed to be flexible. The impact of introducing the guidelines win be assessed later.

A case report is presented which highlights two important, but rarely evoked, aspects of mental health law. In this case, the mentally ill person's nearest relative did not wish to act as such and rescinded his responsibility in favour of another. This other person objected to the use of section 3 of the Mental Health Act 1983 and displacement of her as nearest relative was considered. Some cases from the literature are cited to help clarify the meaning of “unreasonable objection” as used in the Mental Health Act 1983.

In the currant climate of the implications of the Community Care Act and health service reforms, defining the role and function of the psychogeriatric day hospital is crucial, particularly its distinction from day centre care. This paper describes this role and key issues in day hospital planning. It was presented to the Wessex Specialists in Old Age Psychiatry and accepted by them as a consensus document.

A sample of 49 ‘elderly graduate’ residents of a hospital designated for closure were surveyed in 1987 and followed up five years later. Twenty-two patients (45%) had died: the mortality rate was much lower than that predicted by the regional health authority and approximated to that of the general population. All but one of the survivors was living in supported accommodation at the time of follow-up. The majority were satisfied with the move and were receiving an appropriate level of care. However there was significant unmet need for structured activities and companionship. During the follow-up period the survivors had declined in functioning.

The concept of computer diagnosis in medicine is not new. As early as 1971, a computer program was demonstrated to be more accurate than a senior clinician at diagnosing acute abdominal pain before surgery. In psychiatry, however, the problems surrounding diagnosis and classification are more complex than in other branches of medicine, depending as they do on the clinical interview and some agreed classificatory system in the absence of external validating criteria. Reliability has been improved by the application of standardised interview techniques and by the use of operationalised diagnostic criteria but such tools are lengthy and their use requires specialist training. Consequently they tend to be reserved for research purposes rather than routine clinical use. The potential contribution of computer technology to the vexed question of psychiatric diagnosis is here evaluated.