As part of testing candidates' abilities, patients are used in clinical examinations for professional qualifications throughout all specialties and levels of medicine. However, the patients' views on being used for these purposes have not been investigated. Examiners use the opportunity presented by candidates interviewing patients in an examination setting as part of the test of a candidate's ability in psychiatry. Psychiatric patients' experiences of such examinations may be so different from that of most clinical practice that there may be profound effects on their views of themselves, their illnesses, hospitals and of the profession itself.

Only around 300 cases of the Capgras syndrome have been reported in the medical literature. We report a widely read but scientifically neglected case of a mad scientist who showed this misidentification syndrome with classical and potentially dangerous features. The current literature on the psychopathology and neuropsychology of the Capgras-syndrome is briefly reviewed and discussed in the light of this new case.

The development of ‘community care’ for the elderly, mentally ill, mentally handicapped and physically disabled has been Government policy in Britain since the 1950s. Problems with implementation of this policy led the Audit Commission (1986) to conclude that “the one option that is not tenable is to do nothing about present financial, organisational and staffing arrangements”. Sir Roy Griffiths was commissioned to review “the way funds are used to support community care policy …”. Radical solutions were proposed and subsequently incorporated in the Government White Paper Caring for People (Department of Health, 1989a). However, two very significant measures were not accepted: the ‘ring-fencing’ of community care monies and the creation of a ministerial post within the Department of Health with specific responsibility for community care.

The escalating cost of medical care in most industrial countries has given impetus to several different strategies designed to impose limitations on cost and introduce efficiency into health care systems. In the United States of America, legislation was passed in 1983 to introduce a system of prospective payment for Medicare hospital expenditures. This change was a departure from the previous cost based reimbursement method and was based upon a categorisation of medical conditions into discrete groups termed diagnosis-related groups (DRGs). The intention of the American Congress in passing the legislation was to encourage hospitals to reduce cost without sacrificing quality of care.

Although referral by general hospital doctors is a major pathway to specialist psychiatric care, and there is known to be much clinically unrecognised psychiatric morbidity among general hospital patients, consultation and liaison services have received much less emphasis than community care. A 1984 survey found that consultation liaison services were haphazard (Mayou & Lloyd, 1985). Despite recent evidence of increasing clinical and academic interest, few local strategic plans refer to consultation and liaison services; even when mentioned they are given a lower priority than community developments (Kingdon, 1989).

The decision of the Law Lords in May 1989 that allowed the sterilisation of a woman with serious mental handicap (F. v. W. Berkshire H.A., 1989) is arguably the single most important legal development in relation to psychiatry in the last 30 years. It has far-reaching implications beyond the field of mental handicap and will affect the practice of all psychiatrists. The Law Lords used the appeal to consider “the startling fact that there is no English Authority on the question whether as a matter of common law (and if so in what circumstances) medical treatment can lawfully be given to a person who is disabled by mental incapacity from consenting to it” (Lord Goff). Quite clearly this encompasses a large part of psychiatric practice and promised to clarify much of the controversy surrounding consent and the incompetent patient. The decision that they reached has now been incorporated into the Code of Practice of the Mental Health Act 1983 which was approved by Parliament in December 1989. The effects of this are of huge importance, and it has extensive consequences for all psychiatrists and their patients by simplifying the legal aspects of treatment. The most surprising aspect of this whole issue, therefore, is the silence that has surrounded both the original decision by the Law Lords and the subsequent publication of the Code of Practice. The only reference to these in The British Journal of Psychiatry, or its sister journal, Psychiatric Bulletin, has been a brief letter outlining some implications of the Lords' decision (Lovett, 1989). This is doubly surprising as the Royal College of Psychiatrists has shown considerable interest in this debate, not least by publishing a book about it! (Hirsch & Harris, 1988). The purpose of this paper is to provide a background to the Code of Practice and to clarify certain issues surrounding the Common Law.

The recent Eighth World Congress of the World Psychiatric Association (WPA), held between 12 and 19 October 1989 in Athens, was reminiscent of the previous World Congress in 1983 in Vienna, and the one before that in 1977 in Honolulu. Once again the issue of the Soviet political misuse of psychiatry reared its ugly head, and dominated the Association's proceedings. In 1977 the critical debate revolved around what position the WPA should adopt concerning the abuse. In a cliff-hanger vote, the WPA passed a resolution condemning the political misuse of psychiatry but explicitly citing the Soviet case (Bloch & Reddaway, 1984). In the absence of any improvement in the situation by the time of Vienna and in the virtual certainty that the Russians would have been expelled from the organisation, the Soviet Psychiatric Society resigned from its membership in January 1983. In order to forestall a precipitous and premature readmission, the Royal College of Psychiatrists proposed at the Vienna Congress that the Soviets would be welcomed back into the fold but only when they had demonstrated “sincere co-operation”, and when there had been concrete evidence of “amelioration” of the abuse.

In ancient Japan, written characters and religions were largely based on Chinese cultures. The first foreign physician was invited from Korea to Japan during the Shiragi Dynasty, when an Emperor became ill at the beginning of the 5th century. Since then, Chinese medicine dominated in Japan until Western medicine was introduced in the middle of the 19th century.

Schizophrenia is an expensive disease. In the USA, it affects approximately 1% of the population but patients occupy 25% of all hospital beds. In Australia, schizophrenia was found to affect less than 10% of the number experiencing a myocardial infarction and yet the costs of medical services for treating schizophrenia are 75% of those for myocardial infarction.

In October, public attention focused on psychiatrists gathering for the Eighth World Congress in Athens. Was psychiatry still being abused for political purposes in the Soviet Union (Bloch, 1990)? And were mental patients elsewhere being mistreated? At the Stadium of Peace and Friendship overlooking the Aegean Sea, delegates had the chance to meet and talk about these important issues concerning human rights and human dignity.

The needs of people with mental health problems transcend agency boundaries. Service-planning, however, has often been carried out within the confines of individual agencies. Although inter-agency collaboration has been an integral part of official policy since 1974 (DHSS, 1974), joint planning has often been limited to the allocation of centrally-earmarked joint finance (DHSS, 1976). In the ten years following the introduction of joint planning, few authorities prepared, let alone attempted to implement, any broader joint strategies.

For the purpose of this article, a specialist psychiatric unit refers to any community project, out-patient clinic, hospital ward or, as in the case of Henderson, a whole hospital which specialises in providing a specific type of treatment or treatment to a particular patient group(s). Specialist psychiatric units may be particularly vulnerable at this time when, because of the implications of Working for Patients, many psychiatrists' minds are focused on the need to justify and define their ‘core services’. Many specialist psychiatric units are directly funded by their hosting Region. If Regional Health Authorities do not maintain special psychiatric units directly then a high financial risk will be put on any District Health Authority or self-governing hospital which hosts them. If the latter fail to accept the financial risk, or take the risk and then suffer financially, there is the possibility that both a wealth of specialist expertise will be lost from the psychiatric profession as a whole and that certain patients will receive substandard or no treatment. It may be, therefore, that there is now a need specifically to justify the continued existence of specialist psychiatric units. Henderson Hospital, a therapeutic community specialising in the treatment of severely personality disordered young adults, is a case in point.

The recent prominence of medical audit in psychiatry is due in large measure to the place given to the subject in the government's White Paper Working for Patients (DoH, 1989a). However, medical audit existed before the White Paper and covers a broader scope than the White Paper proposes. Thus in considering the introduction of audit into the mental health services it is important not to allow the White Paper to narrow the field of view.

It is unclear how much the profound changes which have occurred in mental handicap hospitals in the last decade have improved the lot of the profoundly handicapped, since Baker & Urquhart (1987), in a national survey of Scottish Mental Handicap Hospitals, found that 45% of all hospital residents had no set occupation and that there was a relationship between occupation and ability level. Between 14% and 32% of all patients were without occupation and unable, or not allowed, to leave the ward without a member of staff.

In the psycho-geriatric field there is great concern that as the number of elderly people in the population rises so the number of those suffering from dementia will increase. Services are already stretched and innovatory changes are needed to ensure that this large group of people receive adequate care.