User centred services as an ideology have not become a reality of everyday clinical practice. In this paper we introduce a series of articles which describe user centred practice in a south London community-based rehabilitation service for the severely mentally ill. We emphasise the medical consultation style adopted, the service management style and specific initiatives allowing users to influence our practice and shape functional and structural components of the service.

Because of the nature of some mental illness, care and compulsion in psychiatry are not always antithetical. However, it is no longer acceptable to link compulsory treatment almost exclusively to compulsory hospitalisation. Treatment should occur in the least restrictive environment possible. This paper looks at experience of extended leave of absence in Scotland, and in England and Wales before 1986, at the recent evidence for an increased risk of violence and homicide in schizophrenia and the danger of a backlash against community care if it is perceived as unsafe, and makes suggestions in relation to research and to provision for treatment in the community in the absence of consent.

A questionnaire on attitudes to the supervision register, about one year after its introduction, was sent to all consultant psychiatrists identified as working in the National Health Service South Thames Region. A response rate of 72.3% was obtained. Half of the respondents felt that the supervision register was not likely to reduce the risk of violence to the public by mentally disordered people and a quarter was unsure. Just over half felt confident in predicting violence, and over half felt that they had been reasonably trained to do so. Most had not changed their practice in admitting or discharging patients, or in the use of the Mental Health Act. There were criticisms of the register, for example: lack of resources needed to implement it, increased paperwork, stigmatisation of patients and the lack of a formal appeal mechanism. Fifty per cent felt the register should be abolished, only 25.5% felt it should not be.

The effects of service expansion and change (including Joint working with social services) following the provision of a community mental health centre and the introduction of care management were examined by auditing service activity. Data were collected on service provision to 20 randomly selected patients who met the local criteria for care management, and also on the general level of service activity as judged by service contacts for all disciplines. Compared to the baseline period, face to face contact with care-managed patients increased six-fold. There were more home contacts, a wider range of professional contacts occurred, and a greater variety of types of treatment provided. A substantial (though not statistically significant) reduction in day hospital attendance was seen over the period studied. The number of service contacts for non-care-managed patients also rose. The introduction of care management was simplified by changes in service organisation. Increased resources were needed to both implement care management and provide an adequate service to the remainder of patients. Both aspects of the service functioned efficiently in parallel.

Dissatisfaction with current psychiatric services provided for women in secure health environments is described. Mention is made of recent improvements in the special hospitals. A set of key criteria is suggested to judge the effectiveness of services wherever provided.

This first of a series of articles intended to guide clinicians through the evidence-based process assesses the published evidence for drug therapy in Alzheimer's disease. A Medline search identified a randomised, controlled trial of donepezil. Although this trial appeared to have a reasonably sound methodology, we had some doubts about the treatment effect and applicability of the results.

A postal questionnaire concerning the management of cognitive impairment of vascular origin was completed by 88 psychogeriatricians and 100 geriatricians. Aspirin was considered an important part of management, and clinically indicated with: a history, or clinical signs of stroke; computerised tomography (CT) scan changes suggestive of cerebrovascular disease; and atrial fibrillation. Advanced dementia was seen as a contraindication for treatment. Eighty per cent of responders indicated they would institute antihypertensive therapy in an elderly patient with a history of raised blood pressure and cognitive impairment. The median lower limit of systolic blood pressure requiring treatment was 160 mmHg, with a treatment target blood pressure of 150 mmHg.

A sample of 19 consultant psychiatrists and 28 keyworkers were interviewed to determine their views on using the supervision register and to see whether it was affecting their practice. The majority felt that the supervision register was politically motivated and had little effect on direct clinical practice. However, there was a slight increase in indirect patient activities such as administration and meetings and some keyworkers were more vigorous in their outreach work. Most patients did not challenge their registration and the use of advocates in Care Programme Approach meetings may be needed. There was also a need for improved training and supervision for keyworkers.

The reduction in psychiatric beds over the past few decades has coincided with burgeoning homelessness in the UK. What effect has this had on the provision of in-patient care to this neglected section of the population? Admissions of people of ‘no fixed abode’ in Birmingham were compared for the years 1961–1964 and 1995–1996. Both the number of admissions and duration of in-patient episodes had decreased and many patients continued to receive no aftercare. Solutions to the problem of homelessness among the severely mentally ill must address failings in hospital as well as community services.

There has been an increasing move to involve consumers in the assessment of health services. Needs assessment and consumer satisfaction of a recently setup community mental health team is described.

We live in an era in which debates on the need for mental health reform are over-focused on single issues (like how to ‘get people who live in the community to keep taking their medication’) or, even worse, single cases (how to prevent another tragedy like the killing by Jason Mitchell). This prevents rational policy-making. Unusual cases make bad law. Narrow proposals for risk reduction ignore many of the most pertinent risks: that service users will be victims of attack, but have no access to justice because they are not seen as ‘credible witnesses’; or that they will be detained for fear of violence when in fact they would not have been violent (Sayce, 1995). The recent statement on prime time British TV by Dr Deahl that he would rather detain nine people unnecessarily than discharge one who went on to harm a member of the public, shows how ‘single issue’ risk analysis can lead straight to breaches of natural justice (‘Panorama’, 13 October 1997, British Broadcasting Corporation).

The views of general practitioners (GPs) on the priorities for a new old age psychiatry service were obtained. Most GPs identified dementia patients with behavioural or psychiatric disturbance as being the greatest priority for an old age psychiatry service. There was less consensus on the priorities for delivery of the service, but hospital-based services such as in-patient and day hospital facilities remain high on the GPs' priority list. There was a widely-based desire for results of assessments to be communicated by telephone, followed later by letter. These findings have been taken into account in the development of our new service.

This prospective, sequential study compared the costs of using haloperidol or zuclopenthixol acetate for rapid tranquillisation. In the first phase, all 16 patients admitted to our psychiatric intensive care unit requiring rapid tranquillisation received haloperidol; in the second phase, all 26 such patients received zuclopenthixol acetate. Mean overall costs per patient were substantially lower in the zuclopenthixol acetate group than the haloperidol group, mainly because special nursing was used much less in the zuclopenthixol acetate group. All nursing staff preferred to use zuclopenthixol acetate rather than haloperidol. Zuclopenthixol acetate could potentially reduce the need for special nursing and produce valuable cost savings.

This paper presents the literature on compliance as an ideology and then examines strategies to improve patient outcomes if non-compliance is identified as undermining the treatment regimen. We present strategies used by our team in a south London rehabilitation service for the severely mentally ill.

This study addresses the perception among senior trainees that the lot of a consultant general psychiatrist is currently not a happy one and that transition from training to consultant grade can be difficult. Reasons for this are explored and alternatives suggested that might make the move from senior/ specialist registrar to consultant general psychiatrist a more rewarding and attractive proposition.