From their beginnings, county or municipal psychiatric services have reflected the political and social attitudes of the times. Traditionally they were public facilities that delivered acute inpatient care and a variable range of outpatient services, and, within their mandate, they functioned well. During the past two decades institutional psychiatty has evolved in such a way that there is little difference in the range of services delivered by county, state, and voluntaty facilities. The logical role of the county hospital continues to be the provision of acute care for the poor. But for county systems to survive and flourish, they must be prepared to regionalize some services, and to differentiate their role in relation to voluntary and state facilities, yet integrate services with them where needed. They must strengthen ties with academic institutions and effectively address problems of third-party payment and other financial issues.