A 'buffer' of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.

This study examined one possible strategy for switching patients to treatment with risperidone involving immediate cessation of current neuroleptics and gradual withdrawal of anticholinergic treatments. All patients received risperidone monotherapy for at least 4 weeks. Side-effects and symptoms were rated and successful switching was defined as completion of the study with no consistent worsening in any rating scales. Of the 41 patients entered, five withdrew for reasons unconnected with the study. Of the remaining 36 patients, 64% (23 patients) were switched successfully. Overall, the rating scales showed significant improvements (mean score on Krawiecka scale, 11.0 to 6.6, P < 0.001), and side-effects decreased (mean score on Simpson & Angus scale, 5.1 to 2.9, P = 0.004). The strategy appeared to be successful for most patients, especially those who had previously received depot medication. However, more gradual withdrawal of previous treatments, including anticholinergics, may be advisable in some cases.

The results are not explained by variations in population need, longer in-patient stay, or poorer aftercare leading to early relapse. The question of whether there is over-provision of services compared with real need in south Southwark, or under-provision (particularly for people with affective disorders) in Hammersmith & Fulham, is considered but left open for discussion following a study of ethnic issues and the reasons for admission.

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 caremanaged 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.

No abstract