Summary and conclusions: Implications for the future

The text reflects a general systemic change in the structure and orientation of inpatient child psychiatry: from units that are relatively closed systems to ones that are relatively open. A sign of this is the time now devoted to communication with external structures and the emphasis on collaborative therapeutic work with family and referring agencies. Such developments are essential although they put extra demands on staff organisation (there has rarely been any increase in staff provision to accommodate such increased roles). But taken to the extreme, the move towards open boundaries can end up threatening a basic raison d’être of in-patient units: the provision of a boundaried residential treatment milieu. In the USA for instance, some units have become no more than holding environments pending triage or crisis resolution. Such developments raise urgent questions; firstly about the nature and effectiveness of the internal treatment environment that units should be providing-and for whom? Secondly there is the question of the relationship of this treatment environment to the external world-whether family, referrer or purchaser. These two broad areas will be addressed in turn.