Between 1983 and 1991 mental health services in Buckinghamshire, as in many other parts of the country, underwent a radical restructuring. Facilities previously dominated by the mental hospital (St John's, near Aylesbury in the centre of the county), were devolved to the three health districts, Milton Keynes, Aylesbury Vale and Wycombe. These changes culminated in the closure of the hospital in September 1991.

As part of the shift towards community care, a number of the large mental hospitals throughout the United Kingdom have now closed and many more are due for closure. In a review of deinstitutionalisation, Thornicroft & Bebbington (1989) concluded that the run-down of hospitals was outstripping the provision of new community facilities. Between 1974 and 1984 the mental hospital population fell by 25,000. However, the increase in residential places provided by local authorities and by the private and voluntary sectors totalled only 3,000. Inadequate planning and provision could give rise to discharged patients facing the prospect of isolated, segregated and impoverished lives with a high likelihood of homelessness and recurrent admission.

Recognition of the problem

Sir Bernard Tomlinson's Report of the Enquiry into London's Health Service, Medical Education and Research (1992) starts with an excellent analysis of the particular problems associated with providing health care in the capital with its high density and turnover of population and disproportionate burden of severe deprivation. He emphasises the particular problems that arise because of the flow into London of vulnerable people with mental illness, drug addiction problems and alcoholism, many of whom are homeless. The consequent difficulties are compounded by the fact that primary health care and community services are poorly developed in comparison with elsewhere in the country and may not be easily accessible to those who need them most. Inadequacies in comprehensive service provision contribute to the high usage of accident and emergency departments as providers of primary health care, where community nursing services are expensive because of higher staff costs and where the characteristics of the patient population referred to above, make maintaining effective contact very difficult.

The populations in the large mental handicap hospitals are known to be diverse, ranging from elderly non-psychiatric residential groups to acutely psychotic and behaviourally disturbed patients. At present demographic variables, medical and psychiatric characteristics of populations in these hospitals are changing in parallel with implementation of community care and resettlement programmes. In resettlement programmes, discharge priorities have been given to the easy to manage and less dependent residents while new challenging behavioural units and admission assessment wards are being opened to care for the multi-handicapped population.

Effective participation in the work of Mental Health Review Tribunals (hereafter the “Tribunal(s)”) held under the Mental Health Act 1983 (MHA) requires a knowledge and understanding of detailed points of law, and practice. This summary and commentary may be of assistance to new or infrequent participants.

Withdrawal of chronic day-time users from benzodiazepines is rarely attempted in general practice because patients are considered more dependent on their medication than analogous night-time users. Our aim was to evaluate two forms of brief intervention by general practitioners to reduce intake of benzodiazepines in chronic day-time users. A subsidiary aim was the development of a booklet to help patients with benzodiazepine withdrawal.

Over the last four decades there has been a substantial reduction in the number of psychiatric hospital beds. Alternative residential facilities in the community have been developed. These include staffed hostels, group homes and supportive lodgings providing bed and breakfast. While hostels and group homes are often integrated with psychiatric services and run by experienced staff, this may not be the case with the small privately run homes. Anstee (1978, 1985) described two supportive lodging schemes and suggested that such facilities were particularly helpful for people with schizophrenia. However, there has been little further research in this area even though supportive lodgings may constitute a significant proportion of long-stay residential facilities. We know little about the landladies, their background, training, experience and particularly the rewards and frustrations of their work. The extent of psychiatric morbidity and the overall burden of care for these landladies is also unknown.

The aim of the present study was to gather information about the carers, the residents and the level of care provided in these facilities.

We followed up 33 cases over three months where psychiatrists recommended the compulsory detention in hospital of mentally ill men and women but social workers disagreed. Seventeen of the cases were detained a mean of 25 days after the index date of assessment by social workers, but the group as a whole spent fewer days in hospital than a “control” set of patients whose detention had been agreed (P = 0.02). The terms of reference of the Mental Health Act Commission should be extended to cover such cases.

It is well known that there is a high prevalence of psychiatric disorder among residents in hostels for the homeless (Timms & Fry, 1989), and staff in these hostels are looking after the mental health needs of these people sometimes with little help from the institutional services. Recent studies have emphasised the plight of schizophrenia sufferers (Marshall, 1993) while other subgroups of mentally disordered homeless people have received less attention.

This study was undertaken to analyse training needs and to formulate a training plan to meet the needs of psychiatrists in non-training posts.

Over the last few years, there has been a considerable increase in public awareness of the sexual abuse of children and the incidence of violence, often with sexual aspects, to women in their homes and elsewhere. Questions about such occurrences are now frequently asked as part of the psychiatric assessment of women patients (Palmer et al, 1992). However, only comparatively recently has the issue of sexual assault within psychiatric provision begun to be raised (Gath, 1989; Subotsky, 1991; Tonks, 1992).

Few psychiatrists have had much experience of guardianship (Section 7, Mental Health Act, 1983). The two cases described have been successful and suggest wider use of this section. It seems apposite in view of the Royal College of Psychiatrists' advice on discharge of patients from hospital, and discussion on a community treatment order; the continuing drive to community care, as codified in the ‘Care Programme Approach’; and the need in the future to treat increasingly disturbed individuals in the community as envisaged in the Reed report.

Concern is increasingly being expressed about the lack of provision for mentally disordered offenders, who by default end up within the penal system. Gunn et al (1991) in a study of sentenced prisoners identified a significant number who were mentally disordered to be in need of psychiatric treatment. Among these, 0.4% were considered to be mentally handicapped. Recent reports have emphasised the importance of diverting these individuals from the criminal justice system (Woolf & Tumin, 1991; Home Office, 1990; British Medical Association, 1990). However, the majority of such offenders do not fulfil the criteria for admission to hospital under the Mental Health Act 1983. Most are not overtly mentally ill and do not require treatment in conditions of medium security such as exist in regional secure units. However, it is not clear what provision there should be for such individuals. Smith (1988) described an open forensic unit for mildly mentally handicapped offenders (the Leander Unit). She concluded that there was a need for a specialised service to cater for these patients, who were neither appropriately nor adequately provided for by the general psychiatric services, the mentally handicapped services, regional secure units or special hospitals. Unfortunately, in practice there are very few facilities for this group of patients.

Research into delivery of psychiatric care has shown that the chronic mentally ill (CMI) patients continue to pose major difficulties not only in terms of economic cost to patients, their families and the state but also in the ability of authorities to provide adequate facilities in the community. The latter is especially important now because of rapid discharge of patients into the community from long-stay wards of mental hospitals, often with little rehabilitative preparation and even less consideration of the effects of the environment into which they are relocated. Although follow-up in some cases has been of exceptionally high quality, a majority have filtered through the network into inadequate residence; this surely is unacceptable. The high prevalence of mental illness among the homeless and the difficulties of providing care for them by an inflexible health service have been highlighted by a recent report of the Royal College of Psychiatrists (Bhugra et al, 1991). This paper attempts to define the possible adverse consequences of the recent reorganisation of National Health Service (NHS) on the care of the chronic mentally ill.

Just as the management of individual patients requires specific and timely information upon which clinical decisions can be based, so managers and clinicians, responsible for service planning, require appropriate information on the activity levels and functions of their services. This is true at all levels, from individual clinicians and teams who wish to audit their activities, through clinical directors and managers of departments and units, to those who plan for Districts and Regions. Casemix is an attempt to facilitate this process by developing a meaningful language, to describe and measure clinical activity.