This is the first in a series of articles to be published serially in the Psychiatric Bulletin on recent government policy and legislation. Each article will describe a different piece of legislation and place it in its international perspective, highlighting how it will affect individual psychiatric practice, users of mental health services and the working relationship with purchasers and managers. The articles are aimed at all practising psychiatrists and those in training who wish to familiarise themselves with the important recent legislation that is having a profound effect on the practice of psychiatry in the UK. The legislation that will be covered includes the NHS and Community Care Act, The Health of the Nation community care plans and mental illness specific grant, the care programme approach, discharge and aftercare planning procedures, NHS trusts, fundholding and commissioning general practitioners and the purchaser provider split. There will be a summarising article to reflect common themes and trends. The series was commissioned by Dr Sara Davies and Dr Jeanette Smith, Trainee Editors at the Psychiatric Bulletin.

The National Health Service and Community Care Act, 1990, enacts some provisions contained in the Working for Patients and Caring for People White Papers. The former measures were introduced immediately in 1990 and contain, for example, the legal basis for NHS trusts and fund-holding GPs. Most of the community care sections of the Act were delayed in their implementation until April 1993. The key element is allocating the main coordinating responsibility as ‘lead agency’ to local social service authorities; they are charged with conducting ‘needs assessments’ on clients presenting with problems. Whether, however, there is a legal obligation upon social services departments to provide care for people with unmet needs to not yet dear.

This paper describes the experience of a general practitioner employed to provide physical care to 12 highly dependent residents of a group home. In the first year after their discharge from hospital the residents required a mean of 15 contacts each, 90% of which occurred during regular twice-weekly visits to the home. Previously unmet needs for physical care were identified on screening, including visual, dental and footcare problems which were usually correctable. Smoking and obesity were common and resistant to intervention. Shared care policies are described which were developed together with the nursing staff and visiting mental health professionals.

The aggressive, acutely psychotic patient may present in many medical settings. Drugs are usually necessary to avert or abort a crisis yet specific guidance on such management is lacking from standard psychiatric texts. Consultant psychiatrists have a crucial advisory role in these situations but information on their prescribing habits has not been published. This study aims to determine whether there is any consensus on the drug management of the aggressive, acutely psychotic patient by consultant psychiatrists.

Learning disability services care for the needs of patients whose autonomy of thought and action is impaired by processes that often cannot be reversed. Their autonomy may also be limited by external influences such as carers' attitudes, both positive and negative. Others may therefore find themselves making decisions for such patients. The case presented in this paper illustrates how these factors can condemn a wealthy woman to a life of relative poverty, lacking in pleasures she could so easily afford, because she lacks competence in some areas of decision making. A possible solution is proposed.

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?

There has been little published on the application of the Mental Health Act (1983) in the elderly. We therefore surveyed its use in a district old age psychiatry service covering a mixed rural and urban population with about 60,000 people over 65 years. The MHA was applied 36 times to 32 patients over a two year period. The primary diagnosis was a functional psychiatric illness in 64% patients (usually depression) and dementia in 36%. Functionally ill patients were most frequently detained on a treatment section (S3) and demented patients on an assessment section (S2). Only one patient with dementia was placed on a guardianship order. The outcome of treatment is described.

The psychiatric discharge summary is an important means of communication between general practitioners (GPs) and psychiatrists and invaluable in the continuity of patient care. The early discharge summary therefore needs to provide relevant information for GPs during this vulnerable period. We surveyed GPs in the Grampian area in order to obtain information felt to be most relevant and the results were incorporated into a new semi-structured format which is now currently being used in the Grampian area.

Views of the elderly were obtained from a cross-section of the public using 12 semi-structured interviews in the form of stratified group discussions. As a group, the elderly were generally thought of in negative terms. Furthermore, they were held partly responsible (or their perceived status, in particular by falling to keep physically active and to avoid mental deterioration and depression which were not considered conditions requiring treatment. In contrast, Alzheimer's disease was recognised as a disease, and sympathy was expressed for patient and carer. It was expected that responsibility for caring for the elderly mentally ill should pass to the State once the burden on carers became intolerable.

The Introduction of the new contract and budget-holding practices hat given general practitioners more say in the care given to their patients by secondary care units and other providers of health core. It is therefore important that the views of GPs be taken into account when service requirements are determined. This study compares the treatment choices of GPs with those of consultant child psychiatrists in the management of childhood psychological disorder. The doctors were also asked to indicate treatments they thought were harmful or ineffective. To the best of my knowledge this is the first UK study to compare child psychiatrists' and GPs' treatment priorities.

A representative sample of 307 consultant psychiatrists was canvassed regarding experiences and views of continuing medical education (CME). Full responses were received from 73%. The results indicated that most respondents already participated in a range of CME activities, inducing attendance at local and other educational meetings, and teaching. Those respondents who had few consultant peers, or who did not teach psychiatric trainees or medical students, also participated in fewer CME activities. Nearly half the sample funded their CME activities wholly or in part from their own pockets. The majority of respondents supported some form of specialist accediation based on participation in CME.

Fifty-two mental health workers in South Manchester were asked to complete a survey to try to identify patients with chronic mental health problems who would benefit from home-based rehabilitation. These patients were known to the services but were unwilling to attend activities in the day hospital or day centre or come into hospital for in-patient rehabilitation. Seventy per cent of the mental health workers who comprised psychiatrists, social workers and community psychiatric nurses completed the survey. Overall 68 patients were identified. Negative symptoms or defect state were the most frequently reported problems with difficulties with engaging or poor compliance being the next most frequently reported problem. There were some differences in the ranking of the order of problems by different professional groups.

The law in England and Wales regarding consent to treatment is of some complexity, but it remains true that hospital patients have two basic rights: to refuse treatment of any kind, and to leave hospital. Two hundred and seven teaching hospital in-patients were asked about their care, and what would happen if they exercised these rights. Informal psychiatric patients were the most likely to disagree with their treatment in hospital, while almost half of all patients did not know that they had the right to refuse it. Many anticipated coercive responses from staff. Patients in hospital should be better informed of their rights.

Forensic psychiatrists have particular ethical duties in relation to the protection of the public, which few other doctors have. Part of the fulfillment of that duty is the assessment of risk, upon which many ethical decisions rest. But comprehensive risk assessment may require information which is not available, leaving the forensic psychiatrist in a dilemma between her duty to the patient and to the public. This case history is based on a real case.

A postal questionnaire was sent to a random sample of 300 fund-holding general practices. Respondents were asked to indicate if they had links with a psychiatrist, community psychiatric nurse or psychologist; 210 (70%) general practitioners returned completed questionnaires. Out of 210 practices 161 (77%) had links with at least one specialist mental health professional. Community psychiatric nurses had links with more practices than psychiatrists or psychologists. Problems with time or space made it difficult for practices to form links.

When introduced into the NHS in 1991, the internal market world off purchasers and providers was greeted with considerable cynicism by many working in the mental health field. Three years on, this cynicism has to a large extent been supplemented by either support or hostility about the changes dependent upon individual experiences. However a more detached analysis suggests a more balanced picture of the impact off the internal market beginning to emerge.

Although the process of psychiatric reform is taking place across Europe, national political, economic and historical factors determine to a large extent the manner and pace of its implementation as well as its final shape. The degree of centralisation of health care systems and the degree of prominence of primary care affect how efficiently change can be achieved. Various forms of professional resistance may, in different degrees in European countries, hamper the implementation of community care. The widely varying contexts in which psychiatric reform takes place throughout Europe, should provide a fertile area for future comparative research.

This study involved a case-note review of referrals to community psychiatric services in a university town in New Zealand. About one third of all 163 patients referred were taking antidepressants for depression; of these one third were taking therapeutic doses, with the remainder taking inadequate doses. This tends to confirm the findings of other studies that have identified problems relating to GP prescribing of antidepressants.

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.