The limits of the role of psychiatrists are becoming increasingly vague as a consequence of the confusion on the theoretical model, the excessive size of the field and the managed care movement that is deeply altering the way psychiatric services are delivered. A thorough reflection has to be made about the need to strengthen the professional identity of future psychiatrists in the course of their training. Theoretical orientation of psychiatrists depends, to a large extent, on the training that they received during residency and the type of practice they undertake. It is necessary, therefore, to consider that the institutional path and expected activities in the program of training postgraduates is particularly important for the development of the identity of the resident as a psychiatrist. The criteria for elaborating these programs have to take into account, not only the opinion of the teachers and of the residents, but also many other parameters, one of which is the description of what makes a true psychiatrist in his or her clinical practice, so as to adapt the content of programs to the realization of inherent objectives to the activities described.

There are extrinsic as well as intrinsic limits to the resources available for health care. Therefore, economic factors have become an essential part of medical activity, leading to a disruption of the traditional doctor-patient relationships. A new economic approach of health care (ie, through managed care) and ethical attitude (to overcome the limits of managed care) are essential, especially in psychiatric practice.

Aim: To investigate the characteristics of Australian organisations providing case management to individuals who have acquired brain injury, and to determine the methods of case management service delivery including professional development and evaluation of outcomes.

Method: An anonymous 23-item web-based survey was used. Respondents were case managers who deliver services to adults and/or children with brain injuries. A snowball sampling method was used to recruit respondents from around Australia.

Findings: Fifty-one case managers completed the survey. Respondents were from a wide range of professions, the largest group being occupational therapy. The majority of respondents were based in metropolitan areas, were employed within the public health system and were based in the community. Respondents reported that the main determinant for clients receiving case management was the severity of the brain injury followed by complex family needs. Variations in practice and a lack of consistency in outcome measurement, goal setting and professional development were noted.

Discussion: This study provides an overview of characteristics of case management practices for people with acquired brain injury (ABI). Identifying roles and responsibilities of case managers is the first step to developing future research designs, which determine the effectiveness of case management.

The paper discusses the role of actuaries within the NHS. Actuaries have applied the concept of Geographic Information Systems to health data on patient traffic flows, transportation studies and specialty specific information on NHS providers (such as hospitals, ambulance stations and GP practices). Actuaries have been working with NHS Trusts to generate private patient income. Actuarial modelling developments, as part of a multi-disciplinary approach, have been used to interpret health data and to assist with the reconfiguration of NHS services. Actuaries have also been involved in long-term health services planning and in the financial planning of services for chronically ill patients.

The paper outlines a series of case studies involving actuaries working in the NHS, highlighting their unique contributions. The case studies include advising on emergency health services planning, acute hospital service planning, NHS Trust private patient unit income generation, comparative peer group ranking studies, long-term population projections, health needs assessment and a feasibility study for a provider unit to care for the chronically ill. Finally, we discuss the role of the actuary in the NHS and his or her ability to build a communication bridge between NHS purchasers and providers, in the public interest.