In the form of economic evaluation known as cost-utility analysis, the consequences of health programmes are measured in time units adjusted by health utility weights (i.e., states of health valued relative to one another in terms of notional quality). The outcome of health programmes can then be expressed in terms of increased (or decreased) life expectancy and increased (or decreased) quality-of-life. This provides a device for evaluating health programmes that extend life at the expense of undesirable effects, or, that produce reduced morbidity rather than reduced mortality.

Enoch Powell's famous ‘Water Tower’ speech, in which he described mental hospitals as, “Majestic, imperious, brooding institutions… rising unmistak ably and daunting out of the countryside”, inaugur ated the policy of successive governments to close the large mental hospitals and care for the chronically mentally ill “in the community”.

The White Paper (CM 555) Working for Patients DoH, 1989 and its associated Working Paper 7 recommended Regional Health Authorities to devolve everyday management of consultant contracts to Districts, with instructions that, by April 1991, hospital consultants must have job plans which reflect their main duties and responsibilities within the service. Health Circular HC(90)16 represents, in four pages, the outcome of the year-long negotiation between the Ministry and the medical profession's negotiators on the Central Consultants and Specialists Committee (CCSC). Honours are even. Government can claim that the profession's traditional autonomy, already weakened by the Griffiths NHS enquiry in 1983, has been brought further under its iron fist; on the other hand CCSC can justifiably pride itself on the preservation of a flexible professional contract (Havard, 1990). It has succeeded too in modifying the original proposals by winning rights to an appeals mechanism, and, of great importance to those involved in College activities, in preserving the opportunity for consultants to contribute to national and local professional committees within NHS time. The CCSC has also negotiated amendments to Terms and Conditions of Service for Consultants which allow those involved in management activities (UMRs, Clinical Directors, Resource Management Leaders and Audit Co-ordinators) either payment for up to two additional notional half days a week or relinquishment of equivalent clinical work, in which case a colleague may be paid to take this on. These are important concessions and will be welcomed by all consultants.

Liaison psychiatry in general practice has been recognised as an increasingly important part of the development of community psychiatry. Collaborative working between general practitioners (GPs) and psychiatrists has become commonplace in most parts of the country (Strathdee & Williams, 1984). Different models of liaison have been proposed and a variety of advantages claimed for such work (Mitchell, 1985).

For the past three years I have been involved in a study of the effects of depot neuroleptic therapy on the social functioning of chronic schizophrenics with Dr D. A. W. Johnson. Having had to screen the bulk of the depot patients of two Area Health Authorities (South and Central Manchester) in the search for possible study entrants, and then monitor a large group of patients for two years who were under the clinical control of a range of Consultant Units, I have been in a good position to make observations about depot management. These are generalisations and may not apply equally to other psychiatric services, but I suspect they will have some relevance.

Until the mid 1950s, the management of persons suffering from chronic mental illness in Australia was the responsibility of the large mental hospital. With the advent of psychotropic drugs and concern about the ‘negative’ influence of the institutional environment on patients there was a shift to shorter but more frequent periods of hospital admission. As the pattern of shorter admissions increased, community services for the mentally ill were expanded in the early 1970s. Between 1950 and 1985 in the state of New South Wales, the numbers of patients in large mental hospitals decreased from 256 to 55 per 100 000 population. However, no special arrangements for accommodation, as distinct from treatment, were made for these ex-mental hospital patients. The decline in hospital numbers can be attributed to a general reduction in the length of hospital stays. Initially, there seemed to be no pressing need for extra accommodation in the community as the provision of social security benefits was adequate to allow patients without homes to afford basic accommodation, a situation different to that in the United States (Lamb, 1984).

John is a 30-year-old man suffering from severe mental handicap (IQ:30) and epilepsy, without other physical deformities or illness. He is sociable, would initiate social interaction (physical), enjoys a cuddle and going out on trips. He has no communication skills but is able to understand basic commands like ‘open your mouth’, ‘sit down’ and so on. He has been a long-term in-patient in a mental handicap hospital for the past 15 years. He is from an affluent family and had been admitted because of his family's inability to cope. He has visits from his mother once a month, and from his father less frequently. A few months ago his mother left a verbal instruction to the ward staff to make arrangements to donate his organs and to ask me, as responsible medical officer, to leave written instructions to inform the local Organ Transplant Team before his death, whenever it becomes imminent, so that the Organ Transplant Team can remove the necessary organs on his death.

In everyday life we all make choices and decisions with regard to ourselves and our environment. Such decisions may be quite trivial, for example which pair of trousers we should wear, or major, for example to move home. The freedom to make such decisions may be called the right to self-determination or autonomy. For adults, such a right is recognised by the law, either explicitly as in USA or more implicitly as here in the United Kingdom. Such a right is also partially acknowledged in children although if the child or young person is not capable of making a reasoned decision then the parent or guardian may make the decision on their behalf. Some adults through mental disability (mental illness, mental handicap) have a diminished ability to make reasoned decisions. However, it is important to recognise that in any given situation there should be an assessment of the person's ability to make a reasoned decision and assumptions not made for convenience's sake. Even people with substantial intellectual impairment are capable of making some decisions.

In spite of all the publicity in recent years about child abuse, very little mention has been made of another group of people who are also very vulnerable to abuse, namely adults with a mental handicap. Although chronologically adults, and therefore not susceptible to the laws designed to protect children, they may be functioning intellectually and emotionally at a much lower level. Because they are often dependent on other people for many aspects of their care, this makes them vulnerable to physical and sexual abuse and neglect. Difficulties with speech and communication may render them unable to inform anyone of their plight or ask for help, therefore many problems remain hidden. Personal involvement in one such case made me aware of this problem and the current lack of legal protection for this group of people. I therefore undertook a national survey in order to gain more information on the prevalence of abuse, factors associated with it, and possible legal solutions.

In the study of suicide little attention has been paid to the role of life insurance. One might suppose that ‘deliberately accelerating the event insured against’ by homicide or suicide would void a policy. One might also predict that changes in attitude towards suicide, so that it is increasingly regarded as a medico-social problem rather than a criminal act, would be reflected in a softening of attitude among insurers. On the other hand, recent epidemiological changes, such as the increased suicide rate among young males, could make companies reluctant to relax their policy conditions.

Child and adolescent psychiatry is a growing speciality. Significant increases in workload, the reasons for which have been described elsewhere (Black, 1989), have led to an expansion in consultant posts across the UK. Recently the Joint Planning and Advisory Committee (JPAC) reviewed senior registrar numbers and recommended an increase in the establishment by 38 whole-time equivalents in England and Wales, a rise of 38%, to meet the expected shortfall. How existing senior registrars, as well as this large number of new recruits, are trained is clearly a matter of some importance.

Child and adolescent psychiatry training has progressed considerably in recent years. Additional training posts have been created, as well as senior academic appointments, and some pre-existing rotations have coalesced, allowing innovative schemes of high quality to evolve. CAPSAC (Child and Adolescent Psychiatry Specialist Advisory Sub-Committee) has continued to oversee established standards and encourage these changes.

Improving discharge procedures is a topical subject and audit of discharge summaries is an important part of this procedure. In many hospitals the summary compiled following a patient's discharge is used for two purposes: a copy is sent to the general practitioner to provide details of the patient's illness and management, and a copy is filed in the hospital notes as a record of the admission. Discharge summaries often fail to meet the needs of either psychiatrist or GP. Using a questionnaire study, we have recently demonstrated that GPs and psychiatrists have different requirements from discharge summaries (Craddock & Craddock, 1989). The present study, which examines the content of a sample of discharge summaries from a large psychiatric hospital, was conducted to identify potentially important items of information which are consistently poorly covered in psychiatric summaries.

James Tilly Matthews, a paranoid schizophrenic admitted to Bethlem on 28 January 1797, was to become the most colourful and controversial inmate of the hospital in the years up to his death in 1815. Influential relatives and friends campaigned for his release and attempted to demonstrate his sanity, on two occasions, in 1797 and 1809, having him examined before high court judges. The hospital medical staff, in particular John Haslam, the apothecary (in post 1795–1816), were obliged to demonstrate repeatedly Matthews' continued insanity, and to this end his case was published (Haslam, 1810). Bethlem was under political pressure to continue Matthews' detention. His admission followed an attempt to disrupt a sitting of the House of Commons in December 1796, which occurred as the climax of a campaign of deluded lobbying during which he had made threats against the safety of senior politicians, including Lord Liverpool, the Home Secretary (Matthews, 1796). Under in-patient care, Matthews continued to express threats against the lives of the Royal Family, politicians, and the staff of Bethlem (Matthews, 1804). Transferred to the incurable ward in 1798, his continued detention was at the specific request of the Home Secretary, a fact revealed by Haslam at the 1809 hearing (Haslam, 1809). In May 1813, Matthews, having developed a spinal abscess, was transferred to a private madhouse in Hoxton, where it was felt country air might improve his medical condition. He died there in January 1815.