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People with mental health problems are subject to a variety of prejudices and inequalities affecting everything from promotion opportunities to social lives. Awareness campaigns in England have been hampered by a lack of funding while better-funded initiatives in Scotland and New Zealand have enjoyed wider success. Tackling stigma will only be effective if backed by legislation.

Ten mental health trusts will this year become four as the sector moves towards the 'super trust' model. The move is designed to help trusts compete with others, move towards foundation status and protect improvements after funding stops going up in 2008. With the new trusts to control budgets in the region of pounds sterling 290m, there are fears that their size could distance them from commissioners and service users.

There are over 1 million people currently claiming incapacity benefit because of mental health problems. Statistically, those that have been signed off work because of mental health problems are unlikely to return. South West London and St George's Mental Health trust is working on strategies to employ service users and improve their employment prospects.

Four out of five prisoners suffer mental health problems. There are 139 liaison teams responsible for ensuring offenders are directed to hospitals where appropriate, but they are under-resourced and stretched to capacity. Mental health teams are working to reduce inappropriate referrals.

In 2004, Worcestershire Mental Health Partnership trust got zero stars and a damning report from the then Commission for Health Improvement. The resultant improvement strategy focused on promoting group ownership of organisational performance and ensuring that high-calibre leaders were in place to drive changes. In the final round of star-ratings, Worcestershire became the only mental health trust in the country to go from zero to three stars.

Lack of an alternative has trapped many users in undemanding day-service environments. New models are being developed to increase work opportunities. Extensive training will be needed.

There is a belief in the mental health sector that poor commissioning is slowing modernisation. A problem has been identified in the balance of power, with large trusts providing services for several PCTs. The difficulty in measuring outcomes is key. Strong commissioning needs the involvement of carers and service users.

Infection control is increasingly in the media spotlight. NHS Estates is closing, causing confusion over cleanliness responsibilities. The Matron's Charter and the introduction of patient environment inspections will help clarify this. There are doubts over the assertion that one person could be held responsible for death caused by infection.

Almost 80 per cent of inpatient mental health nurses have witnessed violence or aggression. Inpatient units have been starved of resources to pay for community mental health teams. There are calls to make inpatient care a specialty as inpatients are by necessity the most needy.

A parliamentary pre-legislative scrutiny committee on the Mental Health Bill recommended separate legislation to deal with dangerous and severe personality disorder. There are concerns that policies place protection of the public above the therapeutic needs of the patient. Four pilot services have been set up to address blurred boundaries between custodial and therapeutic concerns, but evidence of their effectiveness remains inconclusive.

Black and minority ethnic patients are more likely to be diagnosed with schizophrenia and detained, more likely to receive high doses of medication and less likely to have access to talking therapies. Input from voluntary organisations and monitoring staff attitudes are crucial factors in tackling the problem.

Professor Louis Appleby's review sets out progress on mental healthcare reform, and future priorities. Spending is higher than ever, but there is still a lack of transparency around funding. More must be done to meet the needs of black and minority ethnic communities.

With the official toll from the Boxing Day tsunami now standing at 300,000, Alexis Nolan and Emma Forrest talk to health service managers who gave more than money to the relief effort--they travelled to the disaster area and gave their time and expertise. The impact on their professional and personal lives was considerable. As Mathi Chandrakumar, clinical director of Kent Health Protection Unit, puts it: 'My heart is there, I feel very sad. I will probably go back.'

Of 12 three-star rated trusts, eight are in contention to join the first wave of mental health foundations. Applicant trusts believe it will be an opportunity to raise the profile of mental health and remove stigma. Some observers believe the financial uncertainty associated with foundation status could endanger trusts.

Over 1 million under-18s would benefit from specialist mental health services, but they are lacking. There is also a shortage of mental health inpatient beds for young people, and need is rising. Comprehensive CAMHS is expected throughout the NHS by 2006, but there are fears this will be impossible.

The concept of choice in health provision is not applied to mental health as much as other areas. A framework for patient choice in various aspects of mental health service is scheduled for spring 2005. The nature of mental health problems make patient choice a prerequisite for effective services.

--Improving knowledge and understanding of diabetes among primary care professionals and patients has triggered service improvements in one PCT. --Diabetes care once given in hospital is now provided in primary care. --Referrals to hospital have halved and waiting time reduces.

A zero-starred mental health trust is battling to turn around its reputation. The trust believes it is reversing its history of vexed relations with other trusts and agencies. The trust is expecting a pounds sterling 29m boost for accommodation.

The Royal Liverpool Children's trust is determined to move on after the organ retention scandal. New forums for parents, staff, carers and children have been set up. A newly formed communications team stresses openness and transparency.

An inner London mental health trust wanted to improve services for Muslim patients. Staff at the trust attended workshops on the religion and a cross-cultural nurse was appointed. Inpatient service users are feeling increasingly able to discuss their beliefs.

Early intervention and crisis teams aim to prevent admission to inpatient services. Early intervention is often far removed from the traditional mental health model--accessibility is key. Crisis teams should be mobile, multidisciplinary and remain in contact with users until the crisis is resolved.