Public health has traditionally been concerned with the primary prevention of disease, either by eliminating its causes or by enhancing host resistance. Clean water supplies, efficient sewage and rubbish disposal, and refrigeration of food have largely eliminated the micro-organisms responsible for a wide range of infectious diseases, while anti-smoking campaigns have reduced mortality from cancer of the lung and coronary heart disease. Immunisation programmes have had a similarly dramatic effect on the incidence of many bacterial and viral diseases. Indeed, they have completely eliminated smallpox, and the polio virus seems likely to follow it into oblivion.

Sexual offences account for just under 1% of all notifiable offences and have been increasing over the past decade (Home Office, 1993). However, the official statistics on rape prevalence grossly underestimate the extent of the problem; many cases of non-consensual intercourse are not reported or prosecuted; about one-third of reported serious sexual offences are ‘no crimed’ by the police, and many rape offences are reduced to lesser charges through the practice of plea bargaining. Only a small minority of alleged rapists are eventually convicted and receive a custodial sentence (Gregory & Lees, 1996).

The proportion of children affected by chronic illness is relatively high, approximately 10–12%. For these children, there is no available cure and the best that medical care can currently offer is relief from symptoms and the opportunity to participate in normal life as far as possible. Epidemiological work suggests that many of the children experience relatively few restrictions on everyday life, but about 1–2% of the total population of sick children have more severe conditions (Gortmaker & Sappenfield, 1984).

The purpose of this review is to outline current knowledge on the life expectation of people suffering from organic brain disease, the techniques available for describing and comparing life expectation in populations, factors which are associated with longer and shorter life expectation, and the causes of death among patients with this condition.

The role of the general practitioner (GP) in the care of individuals with mental health problems has long been recognised. Goldberg & Huxleys' (1980) pioneering work on the pathways to mental health care demonstrated that only a fraction of identified mental health problems are referred on to psychiatrists. Goldberg & Bridges (1987) estimated that between 20 and 25% of a GP's workload concerns mental health, with only about 5% referred on to psychiatrists. Shepherd (1991) insisted that the only real hope for significant improvement in mental health care lay in the improvement of GP provision – there will simply never be enough psychiatrists.

The Government White Paper ‘Working for Patients' (1989) incorporated the idea of general practitioners (GPs) managing funds in order to purchase health services for the patients under their care. The aim was for decisions about purchasing and providing health care to be taken as close to the patient as possible, by their own GP. It has meant that two forms of purchasing have grown side by side – health authority and GP fundholding. Subsequent policy changes have made fundholding accessible to more practices, and have extended the fundholders' areas of purchasing. More than 50% of the population in England are now covered by fundholding GPs. The proportion of GPs who are fundholders varies enormously geographically, with high levels in the West Midlands, Trent, South Thames, Oxford and Anglia regions, where the collective purchasing function of GP fundholders is now very considerable.

Clinical management of patients across cultures challenges the clinician's familiar tried and tested strategies. The relationship between the patient and the psychiatrist is often examined in isolation from a number of premises which both patient and professional bring to the encounter: previous experience of other cultures, contact with less familiar cultures, past experiences and socioeconomic status are some of the determinant influences. There are a number of ways in which the clinician can facilitate therapeutic effectiveness. However, a trusting relationship must first emerge such that the patient has faith in the treatment recommendations. Special difficulties can arise in the context of pharmacological, social, psychotherapeutic and psychological interventions. Community, out-patient, in-patient and emergency settings each require that consideration be given to the context of the assessment and treatment process, as well as the content and immediate outcome. The clinician must plan the assessment and intervention carefully. The rationale and goals of treatment should be discussed and agreed by participants in the therapeutic interaction. Special groups have unique cultural and historical obstacles to receiving health care. Potential problems are highlighted in this paper and suggestions made for managing conflicts when they arise.

In 1979 Archie Cochrane, a British epidemiologist, stated that: