Whilst a small number of acute psychiatric cases will always need emergency hospitalisation, most people suffering with a serious mental illness will be referred to a psychiatrist in a hospital out-patient department. But, studies have shown, that as a result of intolerable pressures on the system, as many as a quarter of people suffering with schizophrenia only receive treatment from their GPs - leading to what the University of Newcastle's Department of Psychiatry described as an "increasing awareness" of the condition amongst general practitioners.

One such GP is Dr David Pelta. A senior partner in a general practice in Southend, Dr Pelta's surgery is on the frontline of delivery for seriously mentally ill patients in the community. Southend is a seaside town with around 23,000 patients and 10 doctors. His practice is at the centre of town which has its own unique set of problems, including drug users, and a large amount of poor quality B and B provision which can act as a magnet for problem families and people with psychiatric conditions, as well as re-housed asylum seekers experiencing their own unique set of problems.

When the system "collapsed" a couple of years ago - and his practice became "inundated with people experiencing psychiatric problems at short-notice" - Dr Pelta decided it was time to take action. In particular he knew it was time to tackle the "enormous problems" his practice had had with consultant psychiatrists: "There haven't been any."

With nobody substantive in post and at least 10 locums in a period of two years, Dr Pelta's practice was in an "impossible situation" with no long term management for the severely mentally ill. It has been, he says, an "awful situation" for staff and patients alike with no time "to meet the new people before they have gone again".

And with different prescribing patterns and preferences, there was great variation in the quality of the service Dr Pelta's patients were receiving. "Some of the locums did actually seem quite reasonable but others were extremely, to be polite, idiosyncratic in their behaviour - seemingly changing for change's sake drugs we would choose not to use and then every one had to pay for it. Patients would come in, and say, 'I've been changed from x to y.' And nobody knew why and then that person who had changed them had gone."

With no way to establish why things had been done, and around 200 "actively symptomatic" psychotic patients, Dr Pelta and his colleagues decided "to take the bull by the horns and deal with it ourselves. The problem then became how to deal with it without professional help".

Then a GP Fund-Holder, Dr Pelta took the decision to engage a Community Psychiatric Nurse (CPN). "We were extremely fortunate that we managed to find a particularly capable CPN with whom we work very closely."

The local chief of psychiatry, and the health authority, were seemingly unimpressed by the move: "They berated us and said 'you can't do this, be it on your own head if there is any problems'. They were extremely difficult and unpleasant about it, even though they couldn't provide a service. But it now transpires that we are offering the best service in the area."

The CPN and her assistant work in a premises 100 yards away from the main surgery: "So we relate to each other and work together as a team. Most GPs have no idea who the CPNs are, and with rapidly changing consultant staff used only for weeks at a time, nobody knows what is going on. And that is not a functional way of working."

A paperless practice, the Queensway surgery is fully computerised and as a result previous problems involving a lack of communication on treatment choices have been "eradicated". "The CPNs put their notes on the same computer system as we do. We now meet regularly and share a joint plan of action. When you understand each other, you know where each side is coming from, which really transforms the management."

A part of that plan of action was to decide between them on the most sensible way of managing psychiatric patients. The two main problems were medicinal: "With the traditional drugs you have got the side effect difficulties - for instance slowness of movement, tardive dyskinesia, is a major problem. And the other big problem is that the traditional drugs work quite well with the people with positive symptoms - the hallucinations and aggression - but they didn't work with people who had become mentally retarded, that went inside of themselves and couldn't relate to others."

Perceiving the effectiveness of the newer atypical drugs in a high proportion of these chronic cases, it seemed "sensible" to Dr Pelta and his team to use "the better therapy".

A beneficial effect of this policy of prescribing atypicals was that drug compliance amongst patients improved "enormously" he says. Whilst acknowledging that the treatment does not work for everybody, previously chronic patients have now begun to re-integrate back into the community: "Quite a number of people that were introverted have come back and are now able to lead a more normal life than they could before."

And, he says, it has "revolutionised long term care management" with a significant decline in the "revolving door" pattern of care (where a patient is prescribed drugs with side effects, their psychiatric condition improves but lack of compliance with the medication leads to relapse). "There is a great saving on social support as well," Dr Pelta says. "If you can get someone to lead an independent life and, a number of them back into gainful employment, that is a vast difference."

However, as a result, Dr Pelta says that despite their success with patients "we get stick because we are told that our drug-costs are higher". Hidden costs - such as unemployment and housing benefit and attendance in casualty - are often over-looked by the powers-that-be. "And how do you put a cost on quality of life?" he asks. "People are now able to contribute to society in a positive rather than negative manner."

Despite the success of the arrangement, Dr Pelta does not know how much longer his practice will be able to retain the CPNs once the new Primary Care arrangements are in place. The Primary Health Care teams, he says, are aware that "we have difficulties, yes, people are sympathetic, but they are unable to do anything about it".

"I am just hopeful that the CPNs will stay with us because they are like gold-dust," he says. "It is only the good personal relationship that keeps them here."