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.

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.

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.

With the implementation of community care and resettlement programmes, the extent, frequency and the management of emergencies in the mentally handicapped population have attracted a good deal of attention. Among the issues of importance are crisis in the community and unnecessary and repeated hospital admission; inappropriate emergency referrals leading to abuse of services; the need for emergency services and the importance of short term admission facilities (Nolan et al, 1992). While the number of psychiatric emergencies in people with mental handicap is not large, the trend towards living in the community has brought the need to monitor such referrals.

The psychiatric emergency service is a major focal point of entry into the mental health system. Depending on the health care policy and other sociocultural factors, the pattern of attendance in a psychiatric emergency unit tends to differ from one country to another (Bassuk et al, 1983).

Recent changes in the provision of health and social care in the UK such as the institution of a purchaser/provider system and regular screening of the elderly by GPs are of importance to the relationship between primary health care teams (PHCT) and psychogeriatricians. These changes have clarified the necessity for sensitivity by psychogeriatric services to the needs of GPs and commissioning authorities.

The last ten years have seen the development of sectorised psychiatric services across many areas of the country. The characteristic feature of such a service is that a given team is responsible for serving a population base defined either on geographical grounds or by general practice (Tyrer, 1985). However there has been little research on the impact of sectorisation (Tyrer et al, 1989).

Non-attendance at new patient clinics is a well-known problem in psychiatry and particularly common in alcohol treatment units. Reported non-attendance rates in this field range from 12.3% (Addenbrooke & Rathod, 1990) to 52% (Wanberg & Jones, 1973). A number of factors may contribute to this failure to attend including a long waiting time, lack of consent to the referral (e.g. by the GP), postal and administrative problems and the nature of the disorder itself. Hyslop & Kershaw (1981) contacted patients who failed to attend an alcoholism referral clinic in an attempt to establish their reasons for non-attendance. Out of the 39 patients contacted 23 appeared to have good reasons for not attending while 16 gave poor reasons and refused the offer of a second appointment. Ways of increasing attendance at new patient clinics have included reduction of waiting time (Hyslop & Kershaw, 1981) and telephone and written prompts prior to the appointment (Bourgoyne et al, 1983; Grover et al, 1983).

Earlier research reported that female undergraduates performed significantly better than their male counterparts in medical school examinations. Such findings were partly explained by biases in admission policies with women (who formed only 25% of the student body) being higher achievers than men prior to entry to medical school. While some recent studies provide evidence of higher achievement levels by women (Norcini et al, 1985), it is increasingly recognised that these differences do not apply to all specialities within medicine (unpublished observation, Ferrier & Scott, 1987).

Although the EEG has been in constant clinical use for over 40 years, there have been surprisingly few systematic studies of the pattern of referral and clinical use of electroencephalography in a NHS psychiatric service. In view of the current concern about medical audit and cost effective use of special investigation facilities, it is an opportune time to audit the use of clinical electroencephalography in psychiatry. The current study examines the clinical use of electroencephalography in a district psychiatric service that provides comprehensive care for the population of Dundee (population 180,000).

On 28 March 1990 a BBC television programme in the ‘QED’ series was broadcast entitled ‘The Last Resort’. It sympathetically showed the life of a woman with a treatment resistant affective disorder and later presented some aspects of her treatment at this unit, including a stereotactic subcaudate tractotomy (SST) operation. As a result of this programme a number of patients wrote to us and this report compares referrals arising in this way with a sample of referrals to the unit through the usual channels.

The presence of a generalised seizure is necessary, although not sufficient, for effective ECT. Awareness of this has led to a widespread practice of documenting not only the occurrence but also the duration of seizures; a minimum duration of 25 seconds has been suggested (Royal College of Psychiatrists, 1989). Yet even the most recent surveys of practice have shown that on most occasions when a seizure is brief or absent the treating doctor does nothing about it (Scott et al, 1989; Pippard, 1992).

There is growing concern about the care received by mentally disordered offenders (MDOs). The prevalence of psychiatric disorder among the remanded group has received considerable attention (Coid, 1988). Some MDOs are remanded in custody following even petty offences on account of their vulnerability or because their homelessness prejudices bail. Where the offence is serious a remand in custody may be inevitable.

Access to a senior registrar post is growing more difficult because of increasing competition. The College Court of Electors and Joint Committee for High Psychiatric Training have agreed only two criteria for appointment as SR in Psychiatry (possession of MRCPsych and at least three years of general professional training), but, despite heavy workloads, busy timetables, and the need to prepare for the membership examination, clinical skills and dedication to patients will not ensure career progress if they are not accompanied by other aspects of training, sometimes with insufficient facilities and supervision. Indeed, Lewis (1991), after reviewing a group of applications for SR posts, found that the only variable which predicted likelihood of being shortlisted was having published: “Trainers generally believe that evidence of completed research and publications say more about a trainee than a good reference ever can”.

This paper by Gray & Fenn (1993) represents the first systematic attempt to put a cost on Alzheimer's disease (AD) in England. At a time when a large proportion of research effort in AD is directed towards the basic biology, it is an interesting and novel avenue for investigation. There are those who would say it is long overdue. The authors introduce the burden of illness analysis which is essentially a comprehensive attempt to cost the impact of a disorder. The analysis takes into consideration differences in the expression of disease – chronic, non life-threatening disorders rank relatively highly in loss of earning and health service costs but relatively low as a contribution to mortality. A number of concepts are explained which will be of interest to the non-expert, such as the difference between real resource costs, (e.g. payment for a service such as Attendance Allowance to a carer) and transfer payment (e.g. paying Income Support to an AD sufferer). Mortality rates (which give an equal weighting to a death independent of the age at which it occurs) are replaced by potential years of life lost – the loss of economic contribution to society being greater the younger the age of death.

Section 57 of the Mental Health Act 1983 relates to certain forms of medical treatments for mental disorder which require both consent and a second opinion. It applies to any surgical operation for destroying brain tissue or for destroying the functioning of brain tissue; it also applies to the surgical implantation of hormones for the suppression of male sexual drive. These treatments cannot be given unless the patient has consented and three independent people, including a medical practitioner, certify that the patient is capable of understanding the nature of the treatment proposed, has consented to it, and the appointed registered medical practitioner has certified that the treatment is appropriate. This paper examines whether Section 57 is indeed justifiable and whether the current procedure needs amendment.