Old age psychiatry has been steadily developing as a specialty in the United Kingdom. In 1978 the Royal College of Psychiatrists established a specialist section for old age psychiatry, and since October 1989 it has been formally recognised as a sub-specialty of psychiatry. In 1989 the Royal College of Physicians and the Royal College of Psychiatrists published a joint report entitled ‘Care of Elderly People with Mental Illness’ in which recommendations were made about both postgraduate and undergraduate training.

For a variety of reasons evidence-based medicine is currently in vogue. The evidence most commonly appealed to comes from randomised controlled trials (RCTs), even though the creator of the RCT, Austin Bradford Hill, argued in the 1960s that while it was good to see some swing toward using RCTs, if we ever ended up thinking that RCTs were the only method to evaluate a treatment the pendulum would not only have swung too far, it would have come off its hook (Hill, 1966).

Service development is guided by outcome measures that inform service commissioners and providers. Those in liaison psychiatry should be encouraged to develop a positive approach that integrates the collection of outcome measures into everyday clinical practice. The Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) is a very useful tool to measure service quality and clinical effectiveness, using a combination of clinician-rated and patient-rated outcome measures and patient-rated experience measures. However, it does not include measures of cost-effectiveness or training activities. The FROM-LP is a significant step towards developing nationally unified outcome measures.

People affected by health conditions bring insights and wisdom to transform healthcare – ‘jewels from the caves of suffering'. Yet traditional patient and public engagement relies on (child–parent) feedback or (adolescent–parent) ‘representative' approaches that fail to value this expertise and buffers patients' influence. This editorial outlines the emergence of ‘patient leadership' and work in the Sussex Musculoskeletal Partnership, its patient director (the first such role in the National Health Service) and a group of patient/carer partners, who are becoming equal partners in decision-making helping to reframe problems, generate insight, shift dynamics and change practice within improvement and governance work.

This paper will outline some of the long-standing problems and new challenges facing acute in-patient care, some of the recommendations for change and various difficulties encountered in trying to improve the situation. It will describe how a collaborative approach (led by the Northern Centre for Mental Health, the Centre for Best Practice in Leicester and both the Northern and Yorkshire and the Trent regional offices) can bring about tangible and measurable change for the better and what lessons there may be for the management and delivery of mental health care in the future.

Respite needs for carers of persons with severe mental illness were assessed using a semi-structured inverview. Very few carers were currently using respite facilities. The need for respite was widespread, although largely unmet. Carers shared clear and definite ideas concerning the layout of a good respite service.

The Care Act 2014 represents a significant change in legislation in England. For the first time it brings together various aspects of adult social care into a single statute succeeding earlier acts and policy. Given its importance to the lives of service users and carers, clinicians need to have a clear understanding of its implications. We provide an overview of why it was developed, its underlying principles and international comparisons, as well as implications for assessments, interventions and outcomes. The impact on the lives of patients and carers is discussed, as well as dilemmas and challenges the Act presents. While it addresses other important aspects of social care, including safeguarding, Mental Health Act section 117 aftercare and duty of candour, we focus on personalisation because of the opportunities it provides to enhance management plans for people experiencing mental health problems.

The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

This paper describes the development of a community orientated mental health service including the introduction of a community-based admission unit. The catchment area is a compact conurbation with a population of 56,000 in a deprived part of North Tyneside. Most people come from social classes IV and V and less than 1 % are from ethnic minorities. The male unemployment rate varies from 16–24% and the area is ranked 58th (out of 192) on the Jarman deprivation indices. The primary health care services suffer from many of the problems of inner-city general practices, with the Family Practitioners Committee being the highest prescriber in the country.

This study compared the mean change in the total Health of the Nation Outcome Scales (HoNOS) with the general practitioners' (GPs) assessment of clinical improvement and satisfaction, in a shifted psychiatric out-patient clinic. The total HoNOS fell significantly between the first and last appointment, suggesting that it was sensitive to change even in patients with a lower level of morbidity. There was a weak association between change in the total HoNOS and the GPs' assessment of clinical improvement (r=0.4; P=0.06), and a trend towards a greater HoNOS fall in patients that the GPs assessed as having improved clinically (5.3) compared with those the GP thought had not changed (2.5), but this difference was not significant (95% Cl, 6.6 to −1.1). There was no evidence of a relationship between change in HoNOS and GP satisfaction, and no trend towards a greater fall in the HoNOS in cases where the GP was satisfied, despite a lack of improvement being the commonest reason given by GPs for dissatisfaction. The results suggest that the fall in total HoNOS relates to some degree with GPs' own assessment of clinical improvement in their patients, and that the HoNOS may be regarded as useful by GP fundholders.

Many typical antipsychotic drugs may be manufactured as alcohols, which react with carboxylic acids to form esters (organic salts). These compounds are highly oil-soluble, but are only sparingly soluble in aqueous fluids such as blood. Thus, an oily solution of an antipsychotic can be injected into a muscle, where it forms a reservoir or ‘depot’ of drug that is slowly dissolved in the surrounding blood. Once released into the blood, drug esters are rapidly hydrolysed by endogenous esterase enzymes to produce the parent antipsychotic. Stable serum concentrations of antipsychotics are usually engendered (although this is not always observed in practice (Tuninger & Levander, 1996)), and administration need only take place every few weeks or so. Adherence can be assured and relapse rates are reduced (Groves & Mandel, 1975: Davis et al, 1994).

Elderly patients constitute nearly two thirds of resident hospital patients (DHSS, 1988): 60,280 people were resident in mental illness beds at the end of 1986, and 34,340 were aged over 65 years; 21,500 had been resident for more than a year and 11,300 for more than five years. This represents a 15.7% fall in numbers of resident elderly patients over a decade, while numbers of younger resident patients fell by 40%. Mental hospitals are increasingly dominated by their population of elderly patients. Some patients have grown old in the hospitals, but more are admitted in late life and remain in care, usually because they are suffering from severe dementia.