Of the very large sum of money spent on mental health services, almost all comes from the public directly in the form of central or local government taxation. In 1990, approximately £2 billion was spent in the National Health Service directly on mental health services. That represents 10% of total health service expenditure. In addition, local authority social services departments spend around £50 million annually on residential and day care services for people with mental problems. A further £100 million is spent on supplementary benefit for board and lodgings payments and a considerable amount expended by prisons, courts and the police. These figures omit the growing amount of money spent on supporting elderly people with senile dementia outside mental illness hospitals, in residential and nursing homes. Almost two thirds of all residential care for elderly people provide care for those with mental disorder, adding a further staggering £5–600 million by 1990. The current direct care costs of disabling mental disorder to the public purse is approximately £3,000 million (£3 billion). For all the huge amount of money, resources appear inadequate, ill-directed and uncoordinated. Several actions need to be taken to improve the use of these vast resources.

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.

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.

The proposals outlined in the White Paper, Caring for People, are now law and were little affected by the wave of protest which greeted them when they were first published. So the time has probably come to see what can be made of them and how they might be turned to advantage, rather than continuing to worry about the politics of whether change was necessary at all.

Throughout society there is an increasing tendency to approach the various activities of human existence in a way which eschews blind acceptance, but requires instead thorough examination and analysis of the processes involved in those activities in the belief that the insight gained will improve performance. Treatment is a central activity of the Health Service, and this paper will attempt an analysis of the processes involved in it within the context of the clinical team delivering it.

From 1 January 1990 medical and dental practitioners employed by health authorities were no longer required under the terms of their contracts to subscribe to a medical defence organisation. The health department, however, advised practitioners (DHSS circular) to “maintain their defence body membership in order to ensure they are covered for any work which does not fall within the scope of the indemnity scheme”. The expediency with which the scheme was introduced enabled little discussion on the consequences of such change and surprised medical practitioners and defence organisations alike. This major change in medical indemnity since 1954 will have long-term implications for practitioners, medical defence organisations, local health authorities and most importantly, the quality and quantity of health care which can be delivered. A meeting held on 9 April 1990 at Charter Nightingale Hospital was convened to discuss the implications of the NHS indemnity scheme between senior registrars in psychiatry and representatives from the Medical Defence Union, Medical Protection Society, British Medical Association and the local health authority.

Broadmoor Hospital is one of the three special hospitals covering England and Wales. It provides approximately 500 beds for mentally disordered patients who on account of their dangerous, violent or criminal propensities constitute a grave and immediate danger to the public, requiring treatment in conditions of special security (Section 4, National Health Service Act, 1977). It is generally recognised, however, that there are patients in special hospitals no longer requiring treatment in conditions of maximum security. These patients could probably be more appropriately cared for elsewhere if the facilities existed in general psychiatric hospitals or the community. However, special hospital consultants frequently encounter significant obstacles when attempting to transfer patients to local hospitals. Dell (1980) highlighted this problem, suggesting that 16% of special hospital patients were waiting to leave, following the agreement of the DHSS and the Home Office to their transfer. This delay appeared to be due to hospitals not wanting to accept patients who might prove to be difficult or dangerous. At the time of this current study (March 1990) these difficulties in transferring patients were particularly relevant as two of the special hospitals, Broadmoor and Ashworth (Park Lane and Moss Side) were full for male patients and therefore closed to male admissions, despite a continuing demand for beds.

A pilot study in Bloomsbury established that the majority of patients were dissatisfied with the information given about medication. Consequently a medication group was set up to which all patients were invited to discuss issues about medication. It emerged that many patients believed they had not been adequately informed about the medication they were receiving, or possible side effects, and would have liked to receive written information. It was therefore decided to review professionals' and patients' satisfaction with the information provided and to test whether leaflets improved patients' satisfaction.

More than two decades ago, Aubrey Lewis delivered a visionary Bradshaw lecture to the Royal College of Physicians (Lewis, 1958). The address centred upon the place of scientific method as applied to the art of psychiatry. In his concluding remarks, Lewis emphasised the ardours and perils of guessing. Nowhere is the temptation to guess more clearly illustrated than in multiple choice examinations.

The MCQ has now become firmly established as an integral part of post-graduate psychiatric examinations. In my experience a number of trainees have particular difficulty with MCQ tests such that they find them threatening, and in some cases a repeated stumbling block to the advancement of their careers. A minority within this group may consider the MCQ test to lie in the realm of the arcane and mysterious and find themselves subject to repeated worry and frustration. While advice on techniques for answering is plentiful (sample textbooks and manuals on examination technique) I am not aware that there has been any focus to date on study technique. I would like to suggest a personal approach for MCQ study (based on successful application) which I believe fully integrates MCQ with general psychiatric study and emphasises the potential of ‘MCQ thinking’ in refining ones overall psychiatric knowledge.

The above specimen MRCPsych Part 1 question (Royal College of Psychiatrists, 1989) illustrates well the difficulties facing the examination candidate who is required to make a TRUE/FALSE/DON'T KNOW decision in the knowledge that an incorrect response will result in a negative mark.

The early years of medical students' experience can clearly be important in shaping their attitudes for the future. Typically pre-clinical students are bombarded with basic science subjects and many express the view that it is difficult to see the relevance of much of their academic study to their ambition of working with people. The Behavioural Science Course which is generally held during the students' second year is one of the few courses which is devoted to the functioning of the whole person in society. Typically, this course includes psychology and medical sociology.

Community psychiatry is at present an ill defined specialty. The emphasis is on psychiatry practised in the community, often in the context of a community mental health centre (CMHC), although in-patient facilities are still an important component of most services.

This comment by Diana Brahams, Barrister at Law, is the latest on automatism in her regular series in The Lancet on the Law as it affects medicine. It is a subject to which she has had occasion to return frequently (Brahams, 1983a, 1983b, 1989) as several recent cases have developed the legal concept of automatism to the increasing confusion of many psychiatrists. Automatism has also been thoroughly discussed in a recent monograph in Psychological Medicine by Peter Fenwick (1990) which is to be recommended to anyone having to prepare a report dealing with this problem.

Mark Jones continues this occasional series by taking a look inside Wagner's tetralogy The Ring of the Nibelung which was first performed complete in 1876 at Wagner's own opera house in Bayreuth.