M I C A	The many point contacts with the professional secondary service did not hear schizophrenia. People with that illness do not see their change as illness.Their inner lives are not disclosed - not seen as illness - sometimes because of what might follow if they do. The Consultant at the medium Secure Unit said that he could not complete a diagnosis without stopping the medication and allowing the illness to show itself conclusively. He felt that was unsafe in view of what had happened. But that leaves an unsatisfactory uncertainty of provision hanging over any attempt at resettlement. A secure unit is a suitable place to try without medication. Close observation in a serial way is available there. Remediable steps are in place. Failure to accept medication after community reinstatement will not be so safe. A substantiated diagnosis will be the right basis upon which the aftercare conditions can be imposed. Over a long mental illness - where there is neither expressive signs of illness nor movement to recovery - the diagnosis and treatment do have to be reviewed at the top level of experience, as the Inquiry indicates. A way of obtaining more information is to be pursued. Here the aunt might have heard about oddities from the mother. Here this extended illness was left to inexperienced doctors in training. The Consultant under whose care he was eventually and ultimately seen whilst he was living at home recognised this and attempted clarity by reducing the challenge medication to one preparation. Service provision and the working arrangements in the community mental health service did not obtain the circumstances in which a continuous contact with observation could anticipate and respond to florid or covert indications pointing to a recrudescence of illness. Again and again the Inquiries confirm that illness criteria are not revealed at the point professional interview but people living close to the person observe behaviour which gives the diagnosis. The family were not brought into the picture in these working arrangements. The social services and the community nurses were not in this team working practice for this person. It is the close carers who have the advantage of a long base line familiarity which enables them when to recognise a crossing of the 'boundary line' of illness against the usual normality for the person being watched over. They will not know the diagnosis but they will report the change - if asked to do so, and if drawn into the thinking within the team that is giving the professional intervention. Guidelines about the care programme approach are just a map - the actual treatment scene has to work within the relationships that are in place on the ground Here a continuing illness which disabled this person was never subjected to the rigor and direction coming from a diagnosis, and that allowed him to be seen as of lesser need. He did not get the full service that was required - even if it was there to be used. The old ways would have seen a request to a community nurse or a social worker to keep in touch with a significant observer, to be sure that either a steady state of adequacy was in place or if there was uncertainty, then they would seek significant observations from an appropriate witness, establish a fail safe expedient and then they would regularly maintain support. In hindsight. Maybe Something is made of the consultant work load In the good old bad old days a consultant would see two new cases at his outpatient clinic and would normally hold two out-patients per week. He would see four to six after-care patients. His staff assistant might see twelve after-care people at two clinics The current workload as referred to in the Inquiry does not seem overburdensome. What does seem different is the working practices and working relationships. The Raymond Sinclair Inquiry ( ! ) is cogent in this respect and points to what is required - a regular meeting in work relationship - so that trust in professional companionship builds up into a deliverable and reliable oversight of progress - not just point information obtained at structured professional settings. The Inquiry skates over the historical underfunding which has prevented the satisfactory realignment of community services and hospital provision. That has had to go along without the underpinning of generous hospitalisation experience, or fully staffed alternative community sanctuaries for temporary observations and partial relief of service pressure. Successive NHS re-organisations have destroyed the idea of leadership in multi-disciplinary teams, and so undermined the morale and confidence of psychiatric leadership in enough access and control in the community setting, that they will not cooperate with a new Mental Health Bill. They have learnt from experience that provision has been sacrificed in both hospital admission for observation facilities, and in any connected aftercare for domestic settlement with support and occupational structure. Confident clinical oversight is not possible in these conditions. Isolated 'one off 'professional assessments are too open to failure where the patient does not volunteer an accurate history, and generally they fail to acquire the community information necessary for contingent aftercare planning. Inquiry List Links Inquiry Curwen; Leane