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.

Since 1959, the responsibility to detain a patient in hospital compulsorily has been given to doctors, social workers and hospital managers. The 1983 Mental Health Act stipulates that medical recommendations are made by two medical practitioners (one an “approved” doctor) for compulsory admission for assessment (Section 2) and compulsory admission for treatment (Section 3). When this was debated in Parliament, the importance of the independence of the two doctors making medical recommendations was stressed. This was to avoid collusion, influence or interference with clinical judgement (Bluglass, 1983).

There is currently considerable debate in the UK as to the preferred model of services for adults with an acute mental health problem. Most of this debate has focused on the apparent benefits of the various models. Little research has been undertaken, however, on the financial costs of the models. This paper attempts to present some initial costs for both innovative and standard models of service. It is intended to generate thought about the scale and nature of the financial costs entailed in different models of service.

This brief article reports the results of a questionnaire survey of Academic Departments of Psychiatry in the UK in August 1992 initiated by the Association of University Teachers of Psychiatry (AUTP). The survey was undertaken in an effort to gauge more objectively a growing sense of anxiety within academic psychiatry, whose key functions – education, training, clinical research – seemed to many to be threatened by changes in the logistics of funding within universities and the NHS. These changes include the introduction of the internal market in the NHS, changes in the funding from the Universities Funding Council (UFC) and the service increment for teaching and research (SIFTR), ever stiffer competition for research grants, changing funding patterns for clinical research with the Peckham initiative, and, for the ten London departments, the Tomlinson report.

In 1992, Pippard reported a comprehensive audit of electroconvulsive treatment, (ECT), in two NHS regions. He found deficiencies in most aspects of ECT administration (Pippard, 1992), particularly the training and supervision of the administering doctor, usually an SHO or registrar. Regrettably, the competence of a trainee to administer ECT appeared to have improved but little in the 11 years since the same author first reported on the subject (Pippard & Ellam, 1981). In particular, it failed to meet the guidelines issued by the Royal College of Psychiatrists in 1989. This was reflected in inadequate administration of ECT as assessed by direct observation and by determining the provision made for teaching and supervision of ECT by senior staff. Pippard concluded that the overall standard of training was inadequate and that “The responsibility for this mediocrity rests squarely on the consultants as a whole and not just on those whose nomination to be in charge appears to absolve the rest…”.

The number of psychiatric beds in Friern Hospital in North London was steadily reduced in line with plans to close the hospital in 1993. Meanwhile some discharged patients deteriorate, most of whom have schizophrenia, with significant and multiple disabilities of a chronic nature and are service dependent as described in the recent report of the Royal College of Psychiatrists (1993). Return to their accommodation may be prejudiced by their relapse and the attendant disturbed behaviour. The poor employment prospects too are unhelpful in rehabilitation, particularly since we are running down and closing probably one of the best industrial rehabilitation facilities in the world. The combined effects generate great pressures on the remaining beds and there are increasing numbers in prison.

Mental health policies and the focus of psychiatric services have shifted over the last three decades from hospital to community care. Greater care in the community and reduced psychiatric bed numbers have contributed to the discharge or non-admission of many patients with severe and persistent disorders who formerly would have been cared for in hospital. Increasing numbers of the chronically ill in the community will necessitate the development of systems to provide continuous and integrated services for such people.

Much of the medical care of the long-term mentally ill falls to the general practitioner (Wilkinson et al, 1985) and, for example, a survey in Buckinghamshire showed that these patients consult their general practitioner (GP) twice as often as mental health services. Lodging house dwellers are known to show an increased prevalence of major mental illness and to suffer much secondary social handicap, presenting a challenge to helping services of all disciplines. For this reason we chose a lodging house in which to explore further the relationships between mental illness and residents' present contact with their GP, mental health services and other local sources of help.

Personal experience shows that discrepancies are common when out-patient psychiatric medication records are checked with the information held by a patient's GP. This could lead to duplicated or conflicting treatment regimes, dangerous drug interactions, abuse of prescribed drugs, and failure to monitor therapeutic drug levels.

Background of the study

Rationale for monitoring carbamazepine levels

Carbamazepine fulfils some of the criteria required in order to render a drug suitable for serum level monitoring in that there is poor inter-individual reproducibility of the serum levels achieved with fixed dosage regimes, interbrand differences in bioavailability are known to occur and serum levels can be raised significantly by several commonly prescribed drugs; dextropropoxyphene (a constituent of coprozamol), erythromycin, isoniazid and cimetidine.

Electroconvulsive therapy (ECT) involves the close collaboration of psychiatrists and anaesthetists (Freeman et al, 1987). The Royal College of Psychiatrists' audits of ECT in 1980 (Pippard & Ellam, 1981) and 1991 (Pippard, 1992a, 1992b) relied on psychiatrists rating the facilities and performance of staff in ECT clinics. In contrast we are unaware of any research assessing anaesthetists' views of ECT clinics. Considering their different roles and expectations, opinions may well differ. To investigate this possibility we conducted a survey between November 1990 and February 1991.

Several studies in the United Kingdom have highlighted the lack of knowledge that patients show about electroconvulsive therapy (ECT), both before treatment starts (Malcolm, 1989) and after it is completed (Freeman & Kendell, 1980; Hughes et al, 1981), with only 10 to 15% of patients having a full understanding of the treatment. In an American study (Baxter et al, 1986) patients seemed slightly better informed; this might be because they were given written information. However, subjects who watched a videotape of someone having the treatment did not score higher on a knowledge questionnaire than a control group and the authors postulated a ‘ceiling effect’. Bird (1979) demonstrated that access to media coverage about ECT improved patients' knowledge without increasing anxiety about the treatment.

It is well established that there is a strong relationship between psychiatric admission rates and socioeconomic deprivation; the more deprived the area, the more admissions may be expected (Hirsch, 1988). In the development of community resources for the mentally ill, therefore, an aim might be to site the majority of facilities in areas of greatest social deprivation, as that is where the majority of patients will live. It might also be expected that areas of greater deprivation would have more professional NHS staff. The present survey examines the siting of rehabilitation and support services in the catchment areas of Scottish psychiatric hospitals in relation to measures to socioeconomic deprivation. It also examines the relationship between deprivation and numbers of professional NHS staff in the different catchment areas.

This paper aims to give a very brief outline of the vast subject of hypnosis in the context of psychiatry. The word hypnosis, which was derived from Hypnos meaning the God of sleep, has long been associated with magical practices, superstition, witchcraft, occult and many other esoteric practices. The forerunner of hypnosis was the theory of animal magnetism proposed by Franz Anton Mesmer in the 1770s. He began to experiment with magnetic metals and gradually elaborated the theory of animal magnetism. According to Mesmer, a magnetic fluid spread throughout the entire universe and its disturbed balance in the human body resulted in illness. He claimed that a beneficial magnetic fluid could be transmitted from one subject to another by ‘passes’. Braid (1843) refuted the fluidist theory, since according to him hypnosis could be induced by visual fixation. He believed the condition to be a form of sleep and called the technique neurypnology, later to become hypnology and hypnosis. Liebeault (1866) for the first time used verbal suggestion to induce hypnosis. Bernheim stated that “There is no such thing as hypnotism, there is only suggestibility”, and concluded that suggestibility was the process by which the brain “accepts the idea and transforms it into action”.

It has been claimed (Abbati et al, 1987) that patients benefit from continuity of professional involvement sustained over a long period. Schizophrenia sufferers in particular find it harder than non-sufferers to articulate their difficulties and concerns, and may adjust poorly to change, only building up trust in professionals over an extended period. In their turn, professionals need time to get to know such individuals and to recognise ‘early signs’ (Birchwood et al, 1989) of possible relapse. Management of potential decompensation involves a knowledge of how the individual has responded to changes in medication in the past and what psychosocial factors may be relevant. Working with such patients refines the clinician's skills in interacting with them, obtaining their compliance with a particular regime, and pre-empting potential problems. Without this background of knowledge and experience, the management of sufferers may be crude with adverse results for the patient.

The asylum movement was developed in the 19th century to provide care and cure for people with mental disorders. In the 20th century the old vision of asylum was abandoned, but no new alternative vision of community mental health care has taken its place. A divide between acute psychiatric services and provision for the social aspects of care has been described by Murphy (1991).

The Island of Jersey is a separate country from the United Kingdom and has its own laws. In the Jersey Mental Health Law, 1969, there is a community treatment order in which the guardian appointed has the powers of a father over a child (under 16). This law was implemented on 1 January 1972 and in this paper we look at the way in which it has been used in the 18 years between 1 January 1972 and 31 August 1990. We are not suggesting that the way in which we have used it has been the right or only way. We are engaged in description not prescription.