Studies have shown that significant physical morbidity exist within psychiatric units (Honig et al, 1989), yet general medical care is often left in the hands of psychiatrists who may not always be the most appropriate people to deliver it (Colenda et al, 1988). The new general practice contract places certain obligations on the general practitioner (GP) with regard to his or her patients, especially the elderly, yet these provisions do not extend to many of our patients. Our study looks at four areas of health care and examines how they are delivered to long-stay patients in a district pyschiatric unit with no GP input.

A series of papers looking at the work of the walk-in psychiatric emergency service based at the Maudsley Hospital have been reported in the literature (Lim, 1983; Mindham et al, 1973; Brothwood, 1965). This clinic was established in 1952 and is one of the oldest in Europe. A similar clinic the Emergency Assessment Clinic (EAC) was introduced to Whitchurch Hospital, Cardiff in 1970.

The new general practitioners' contract requires the primary health care team to perform a yearly assessment of their patients of 75 and over. This includes an assessment of the ‘mental condition’. In a list size of 2,000, typically 130 fall within this age group. Screening does not have to be carried out by the doctor and as 90% are already seen at least once a year, there is scope for opportunistic screening. Nonetheless, screening increases the general practitioner's workload and while it improves the morale of elderly people, it may have little impact on medical and functional problems.

Psychiatric patients have had the right to see their notes from 1 November 1991. The ‘Access to Health Records Act (1990)’ makes provision for certain parts of the record to be exempt, including information which may cause serious mental or physical harm to the patient or anyone else. In addition, patients should not have access to information given by third party informants unless appropriate consent has been obtained. The legislation only applies to records made after 1 November 1991. It does not cover informal arrangements where written application for access is not made.

With the move towards community care, the problem of wandering behaviour in psychogeriatric patients may pose a barrier to their placement in residential homes. The prevailing wisdom that this behaviour increased around twilight was looked at by Evans (1983) whose study showed increased restlessness in the late afternoon in a nursing home population. Cohen-Mansfield et al (1989), however, did not find any clear pattern of behaviour related to sundown. This study examines only wandering behaviour and controls for seasonal change in twilight times.

Descriptions of psychiatric morbidity among the homeless have generally been carried out in community settings (Marshall, 1990) or among those who have come into contact with psychiatric services.

There are many kinds of crisis service. Most are open only to people who have been diagnosed as mentally ill. They facilitate rapid admission to short-stay in-patient services with the back-up of multidisciplinary teams working in the community. Others attempt to keep patients out of hospital by providing support to patients and their families in the community. Several have demonstrated striking reductions in the rate and duration of hospital admissions without detriment to the subsequent health or social adjustment of the patient.

It is acknowledged that assessing ‘consumer satisfaction’ is an important part of medical audit (The Royal College of Psychiatrists, 1991). For the mentally handicapped, it can be argued that ‘carer satisfaction’ is particularly relevant. This is particularly so at a time when the ‘community’ is being advocated as the preferred setting for the long-term care of the mentally handicapped, the families and neighbours of the handicapped being the main providers of this ‘community care’ (Griffiths, 1988).

The Stoke Park Hospital Group in Bristol has been providing a service to mentally handicapped people and their families since 1909. The nature and extent of the service has changed significantly between then and now, largely due to changes in Government policy, first laid out in the 1971 white paper Better Services for the Mentally Handicapped. The changing nature of the service was highlighted in Carter's paper in 1984, in which he examined all admissions to the Group over ten years. He found an increasing use of the hospitals for short-term care, particularly for those patients with a superimposed psychiatric disorder, and a continuing, albeit reducing, demand for long-term care for some patients. He concluded that the hospital would continue to have an important role to play in the evolving pattern of care.

Consent for operation/treatment of a mentally handicapped person has been an issue stimulating much discussion. Generally, in the past, relatives or consultants responsible for their care have given ‘consent’ for treatment when mentally handicapped people were unable to do so. It was appreciated that legally this was not valid once the person was over the age of 16 and so we felt that the ‘consent’ procedure operating at our hospital should be reviewed. We were unsure of the practices in other areas, apart from Lothian Area where we knew new ‘consent’ forms had been devised, and felt that a good starting point would be to contact mental handicap hospitals in Scotland to gather information regarding the present ‘consent’ practices overall.

Research on day care has tended to focus on the day hospitals rather than day centres. A substantial body of work has evaluated the success of the day hospital as an alternative to the acute admission ward (Herz et al, 1971; Creed et al, 1989). But many day hospitals appear to have taken on long-term supports, the role envisaged for the day centres, as their principal function, rather than short-term treatment (Pryce, 1982; McGrath & Tantam, 1987): for example, Pryce draws attention to the accumulation of long-stay psychiatric day patients in a day hospital in South Glamorgan, where 67% of patients have been attending for between two and 17 years.

In recent years there has been increasing interest in long-stay psychogeriatric patients. Hilton et al (1989) and Anderson (1990) have described the profile and characteristics of this population, confirming clinical impressions of the severe degree of cognitive impairment and high dependency levels among such patients. At the same time, there has been a trend towards more active intervention in the type of care provided, moving away from the traditional custodial approach and towards more supportive continuing care models.

When any organisation is exposed to pressure to change, this not only mobilises considerable anxieties within the organisation but calls a variety of defensive operations into play. The work of Jaques (1955) and Menzies Lyth (1959, 1988) has demonstrated that this can result in the central problem ceasing to be the focus of attention, with primitive defensive mechanisms (often of an obssesional or paranoid kind) being mobilised. This process may either lead to energy being devoted to isolated elements of the situation, or staff withdrawing into a state of passivity and hopelessness. Indeed, Jaques has observed that when changes are imposed on an institution in a way which fails to take account of the functions that existing structures serve in relation to the deeper needs and anxieties of those working within the institution, such changes are likely to be resisted, and may even fail.

The Royal College of Psychiatrists' Working Party on Medical Audit has emphasised the multidisciplinary nature of patient care in psychiatry (Royal College of Psychiatrists, 1989). Much has been published on individual audit topics and on definitions of the various aspects of audit such as peer review, performance indicators and quality assurance. The essential element of audit is its systematic nature and little has been written concerning an overall structure for clinical audit within an individual psychiatric setting. It is not sufficient to start with ‘a simple project with minimum of cost in terms of both time and money expended’, as recommended by the Royal College of Psychiatrists' Working Party. What is needed is an overall structure for regular review so that the systematic nature of the process is not lost and that recommendations from audit meetings are reviewed regularly for their usefulness and level of implementation.

The need for severely disabled long-stay general psychiatric in-patients to be resettled within their own districts is likely to arise increasingly as area mental hospitals close. The White Paper, Caring for People, acknowledges that some of these patients will continue to require hospital care. Transfer between hospitals might be considered a major life event for these patients, some of whom will have spent many years in the area mental hospital. Conflicting results have been found in studies of mortality rate following relocation (Morriss et al, 1988). Pryce's (1977) study with long-stay chronic schizophrenic patients and other more recent studies with new long-stay patients yielded data suggesting optimal environmental factors in keeping with Wing & Brown's (1970) observations.

In ‘Leonardo Da Vinci and a memory of his childhood’, Freud (1910) provided an analysis of the artist's personality and sexuality, with a description of his capacity to sublimate his libido into creative works. He discussed the Mona Lisa's ability to command attention and induce differing emotions within the viewer. In his paper he described the distinct elements of her expression, “The contrast between reserve and seduction, and between the most devoted tenderness and a sensuality that is ruthlessly demanding – consuming men as if they were alien beings”.

Occupational therapy as a discipline (Finlay, 1988) has grown and matured with time. It has moved away from an ill-defined, imprecise and informal discipline to one which, while treating the patient as a whole being, nevertheless attempts to identify an individual's unique problems and treats them through purposeful activity. It strives to attain the qualities of a holistic, goal-orientated objective process.

Adolescent psychiatric services differ considerably in terms of the patient groups they seek to address and in their modes of treatment (Health Advisory Service, 1986). The Prestwich Adolescent Unit is a general purpose, seven day, regional service for adolescent psychiatry, based in Salford Health Authority. Serving a population of 4½ million, it offers a mix of in-patient, day-patient, out-patient and consultation/liaison work, specialising in the treatment of mental illness.