The sudden collapse of the communist order in Czechoslovakia and the formal installation of the new government in June 1990 has led, inter alia, to a fundamental reappraisal of mental health care. On a visit to Prague in September 1990 the system under the 40-year-old communist regime was still largely intact but clearly about to undergo major changes. Among the reform proposals made by a working group of the Ministry of Health and Social Affairs of the Czech republic are practices familiar to western psychiatrists: mental health care and specialist liaison in primary care settings; formal specialisation within psychiatry into general adult psychiatry, psychogeriatrics, child and adolescent psychiatry, psychotherapy; psychiatric units in general hospitals; community care with restructuring of funding away from the mental hospital budget and devolution to districts. More “humanisation” of psychiatry is envisaged, with choice of consultant, increased competition between doctors and legal definitions of involuntary treatment (Potucek et al, 1990). Voluntary organisations, existing until recently only underground, will be encouraged as also will be counselling services. Dementia, and drugs and alcohol misuse, are seen more as social service than medical issues. Of particular interest is a proposal to separate mental health funding from the rest of the health care budget.

Despite the recommendations of the Health Advisory Service report Bridges over Troubled Waters (1986), there has not been any dramatic growth in adolescent psychiatry as a sub-speciality. The HAS report highlighted the largely unmet special needs of this age group, the rising risk for mental illness with increasing age in adolescence, and the need for effective liaison between professional disciplines working with this age group. Nevertheless adolescent services increasingly perceive themselves as under threat from political initiatives and continue to fight their corner (e.g. Wells, 1989).

In 1990 I saw every member of the Child and Family Guidance Service within the Swindon Health Authority to discuss children from their last (unselected) six or 12 families in relation to child protection issues. All 19 professionals were part-time workers, some only doing three, two, or one sessions per week of child and family guidance work. They were seven psychiatrists (consultants and a senior registrar), two psychologists, six psychiatric social workers (including family therapists), and four specialised therapists (family, child psychotherapy, nurture-group and art). There were 14 female and five male professionals.

There is now an extensive literature describing the value of work for people with a psychiatric disability (Shepherd, 1989; Bennett, 1970; Wing & Brown, 1970; Pilling, 1988). Apart from financial gain the benefits of work can include social contacts and support; social status and identity; ‘normal’ non-patient roles; a means of structuring and occupying one's time; a sense of personal achievement and mastery and a criterion of recovery from illness (Shepherd, 1984). However, for many people with a long-term psychiatric disability the range of opportunity for work is often very limited, usually consisting of subcontract packing or assembly work. The provision of this repetitive and simple work satisfies a basic occupational need. However to a large extent it neglects the fulfilment of broader psychological and social needs. People with a vulnerability to experience periods of major mental disorder usually have more than just an occupational need; they also need to be in an environment which can provide the conditions that will actively assist in the promotion of a state of positive mental health.

In spite of the somewhat disordered development of day care for the mentally ill, the Psychiatric Day Hospital (PDH) has become accepted as an essential element in the mental health services. Several recent studies have defined a role for the PDH in the management of more acute psychiatric disorders (Creed et al, 1989), and this is likely to become increasingly important with the continuing reduction in the availability of in-patient facilities.

Large mental hospitals are gradually being emptied. Patients return to the community. But often their prospective carers have little idea of what to expect when they arrive. Hospital staff often cannot give information regarding how disturbed patients might be.

Discussion of psychiatric casualty figures in military personnel tends not to distinguish between acute and chronic conditions. Combat-related stress (CRS) responds well to immediate, short-term intervention. Overall psychiatric casualties are approximately 30%. Contemplating the future in 1982, Romo & Schneider suggested casualty figures might be higher. This article considers factors contributing to the incidence of psychiatric casualties.

The College has described the White Paper, Working for Patients (Department of Health, 1989a), as “an artist's impression” (Royal College of Psychiatrists, 1989) with the lack of detail obscuring the full implications of the proposals. Some of this detail is now available in the form of a series of working papers. In fact these papers may raise more questions than they answer, and in some cases would seem to be inconsistent with pre-existing Government policy – especially that concerned with the care of the mentally ill in the community.

Tardive dyskinesia (TD) is an involuntary movement disorder associated with long term neuroleptic exposure. Gerlach & Casey (1988) reported a 15% prevalence rate of TD among patients on neuroleptics, the rate increasing to 54% in patients over 60 years old.

In-patient psychotherapy at the Cassel Hospital will continue at least for the time being. Early last year, however, its future was in doubt. In January, the managing health authority, Riverside, faced an annual spending deficit of £6.7 million. The hospital costs £1.25 million to run each year; in February, district management recommended closure of the 70 year old Cassel as the top item on their proposed shortlist of economy measures.

Child and adolescent psychiatric services receive referrals from a variety of sources in addition to traditional medical channels. It is unknown whether this practice has implications in patterns of usage of time. Our hypothesis was that referrals from non-medical sources were likely to be more time-consuming than those from medical colleagues.

Since developing an interest in the use of electroconvulsive therapy (ECT) in late life, I have received correspondence from psychiatrists describing difficulties in obtaining anaesthetics for elderly patients who are perceived as frail or physically unwell. Nevertheless, Pippard & Ellam (1981) found in their survey of the use of ECT in 1980 that 37% of courses were given to people aged 60 years and over. I decided to survey old age psychiatrists' views on ECT, and to look at difficulties encountered in obtaining anaesthetics. Old age psychiatrists specialise in the care of mentally ill elderly people and are dealing with patients who are particularly likely to have physical problems in addition to mental illnesses. Their experience of ECT is therefore of wider relevance to all who prescribe ECT for elderly or physically ill people.

Policy for mental health services in England is based on two straightforward principles. These are, first that care should be provided as locally to where a person lives as is reasonably possible, and secondly that treatment should be available in the least restrictive conditions that are compatible with the safety of the patient, of those looking after him and of the public at large. I make no apology for reviewing the history of policy and practice; it is not possible to understand the mental health services that we are trying to achieve for the future without understanding how the service has developed over the years. I shall use the mental illness service as an example – similar considerations apply to the mental handicap services.

Lithium is a drug used extensively in psychiatry for the treatment of depression, acute mania, and the prophylaxis of recurrent affective disorders. Lithium also has a place in the management of schizoaffective disorders and has been suggested for aggression and alcoholism. The side-effects, dangers of toxicity, and need for monitoring are well documented and should be considered before starting anyone on lithium. Likewise patients should be adequately informed of the benefits and hazards of treatment.

“Quality of life” (QOL) appears intrinsically important but difficult to measure. As a mental health professional, one might wish to know whether patients moving from the security of hospital to “the community” improve their QOL, or to evaluate their QOL against that of other groups in society. Simply looking at symptom change or economic cost-benefit misses much of the point behind innovations in psychiatric services. From previous QOL assessments (e.g. Lehman, 1983) one would focus upon positive aspects such as living situation, personal relationships, and general health and on negative aspects such as lack of money or being a victim of crime. Literature from the 1950s and 60s attests to the adverse effects of institutional care but more recently writers such as Kathleen Jones (Jones et al, 1986) have drawn attention to the benefits of living in such an environment. Also, various well-publicised “scandals” have suggested the pitfalls of inadequately thought-out discharge into the community.

In an earlier report (Dolan & Norton, 1990) we commented upon the potential vulnerability of specialist psychiatric units following the implementation of Working for Patients and the NHS Bill. Specialist units provide a valuable resource, not only in terms of treatment, but as sources of practical training, education, development of new therapies and of research. Many such units previously enjoyed financial protection at the regional health authority level. Downloading financial responsibilities to DHAs or NHS trusts will complicate the issue of funding since contracts will now need to be entered with each relevant DHA or NHS trust. This more cumbersome system is inevitably more costly for a specialist unit to operate. Users of such units (customers and consumers) will find referral problematic since funding must be identified in advance. Difficulty in negotiating the new, more complicated contracting system, may lead to a decline in specialist referrals. This will in turn lead to questioning of how necessary such ‘regional’ or (as in the case of Henderson Hospital) ‘national’ specialities really are. Managers may tend to argue that referral patterns will reflect (eventually) the true needs for treatment of particular client groups.

There is now an increasing emphasis on the views of the consumers of health care, but little is known of psychiatric patients' opinions on their care and treatment. This may be due to an assumption that their reports are unreliable. Much of the research in this area has been carried out in the USA, although there have been reports from the UK and elsewhere (Freeman & Kendall, Hansson et al, 1985; Lazare et al, 1975; McIntyre et al, 1989; Weinstein, 1981).

Recent reports show that continuing problems are being experienced by the returned hostages and their families. The Department of Health advised at the time of the hostages return that, apart from those who needed immediate emergency treatment, the initial point of referral ought to be the persons general practitioner. General practitioners in many cases now employ their own staff who are able to offer support and counselling. In some cases the general practitioner may, however, decide that the most appropriate response is referral to the psychiatric service. All local psychiatric services should be able to respond to the needs of people suffering continuing stress as a result of traumatic experience.