These notes explore how people in the health and welfare services are tackling the problems of developing comprehensive mental health services, in situations where these services are currently based on large institutions serving two or more health districts. Attention has been focussed on the question of how the psychiatric services should be organised and managed so as to encourage high standards of care within the institution; foster the development of community-based services and integrate institutional and local provision. Some key issues staff face in confronting this question are identified, and an attempt made to provide a basis from which groups of staff can work towards relevant responses to the particular dilemmas of their own local situation.