Ensuring clinically effective practice and service models is now a major challenge for the National Health Service. It requires a clear focus on the purpose of healthcare provision – care which is most likely to result in the best possible individual or population outcomes within existing resources.

Most clinicians understand the advantages of basing their practice on the best available evidence, but sometimes doubts are voiced about the feasibility of applying the strategies of evidence-based medicine (EBM) in everyday clinical practice. This article describes one strategy for beginning to use EBM in ‘real-time’ which could already be used by the majority of clinicians. The rapid developments in clinical informatics are likely to enhance the feasibility and value of this strategy.

Controlled trials show that about 80% of schizophrenic patients remain relapse free when given adequate neuroleptic maintenance therapy but this level of efficacy is not achieved in clinical practice. Guidelines for proper use of neuroleptics in relapse prevention were developed by a group of experienced psychiatrists – the ‘Consensus Group’ – in 1989. In this survey, the views of UK psychiatrists, GPs, CPNs and pharmacists involved in community care of schizophrenia were compared with the Guidelines.

The strong recent public interest in attention deficit disorder and its drug treatment has led to the need for, and development of, guidelines for clinical practice. As a first step in this process our aim was to ascertain the current level of professional consensus on certain points regarding the use of medication in attention deficit disorder. Although a high level of consensus was found in relation to indications and prescribing issues, opinion was divided on details of how the treatment should be delivered – including the role of paediatricians, and the use of psychological treatments.

A volunteer project for elderly people with severe mental health problems and social isolation was developed with close links with a community mental health team. The functioning of this service is described from 1988–1995. The volunteers benefited from training and supervision from the professional community team, while the volunteers took over the role of monitoring, allowing the earlier discharge of these patients by the community team.

For many years, doctors in the staff grades, clinical assistants and associate specialists have made a substantial contribution to the care of psychiatric patients in the NHS but their position within the NHS and the College has been largely unrecognised. This article will describe recent attempts to remedy this situation. Numerically they comprise an important group of doctors (Table 1) and have always been more important in psychiatry than in other specialities, particularly in non-teaching districts where there are fewer consultants and junior doctors.

A retrospective survey was undertaken to evaluate the prescribing practices of medical staff in a District General Hospital in light of the Consensus Statement by the Royal College of Psychiatrists on the use of high dose antipsychotics (1993). Two per cent of 247 patients were prescribed a higher than recommended dose of antipsychotic. None of these cases had been prescribed ‘supra-BNF doses of antipsychotic on a regular basis, but with the addition of ‘as required’ (PRN) medication the recommended dose was exceeded. In only one patient was the high dosage administered. A further analysis of these patients is made.

Trainees in psychiatry frequently employ rapid tranquillisation (RT) measures. In this study we surveyed trainees as to RT regimes used. We found that a variety of drugs were chosen. On 45 (46%) occasions one drug was used, on 53 (54%) a combination. Drugs were administered in intramuscular form in 88 (90%) incidents. Zuclopenthixol acetate was prescribed on a total of 45 (46%) occasions. In 38 (39%) incidents the trainee used a high-dose regime. The literature regarding RT indicates inconsistency in practice. We address the reasons for this and make suggestions as to possible improvement in practice.

Recent studies in child mental health show that fundholding general practitioners regard sexual abuse work as a priority service, and also that sexually abused clients take up more out-patient time than others in the same diagnostic group. This paper provides supporting data on the issue of workload and argues that specific purchasing arrangements should be made to cover this area of well recognised need.

This paper offers a descriptive survey of RAF community psychiatry. It shows that most of the morbidity encountered in the community now served by RAF psychiatrists is at the ‘minor’ end of the psychiatric spectrum. It mostly requires supportive psychotherapy and the key worker is often the community psychiatric nurse. The study allows discussion of four related issues: the essential nature of military psychiatry; the future provision of community psychiatry to the RAF; psychiatric training and continuing professional development in the RAF; and the possibility of research.

Tardive dyskinesia (TD), literally meaning a late occurring, abnormal movement disorder, was first described by Schonecker in 1957, about five years after the discovery of chlorpromazine (cited in Kane, 1992). TD generally occurs after long-term antipsychotic therapy: Kane et al (1984) reported that the incidence was increased with each subsequent year of exposure to antipsychotics, starting with an incidence of 5% after one year of exposure and increasing by 5% each subsequent year. Certainly, the prevalence of TD has increased over the last 20 years, probably as the result of more patients being exposed to antipsychotics for longer periods.

The Care Programme Approach (CPA) was introduced as a cornerstone of the Government's mental health policy in 1992 (Kingdon, 1994). It was meant to clarify the complex issues surrounding the coordination of care for the severely mentally ill and to promote interprofessional communication and effective targeting of resources by community mental health teams (CMHTs). The Ritchie report into the care of Christopher Clunis (Ritchie, 1994) underlined the need for clarity about who has overall responsibility for coordination and review of the progress of care – the key worker. The report makes a compelling case for a clearly documented care plan with identified problems, therapeutic goals and an unambiguous statement of who is responsible for what and when. How, then, could this virtuous proposal generate conflict and bad feeling? And why is there relatively little debate about it in the professional press?

After seven years of circulars, monitoring, conferences and discussion, frank talking about the CPA may still be welcome, but proposals to CPA coordinators and members of community mental health teams (CMHTs) to revise the procedures implemented by trusts are less likely to be. The previous paper (Burns & Leibowitz) identified a number of difficulties that have accompanied the implementation of the Care Programme Approach, particularly confusion related to care and case management. The CPA was introduced in response to the Spokes Inquiry (Spokes, 1988) as a therapeutic strategy to ensure that a coordinated safety-net of care for people with severe mental illness (SMI) was put in place in every district. Identification of those with SMI means that the approach includes all those accepted by mental health services; those with SMI need a coordinated multidisciplinary response. The CPA Audit Tool developed by the College Research Unit for the National Health Service Executive (NHSE) and disseminated to all districts in 1995/96 may be valuable in reassessing CPA implementation.

In common with other psychiatric units throughout the land, we have been struggling to come to terms with the Government directives regarding the Care Programme Approach. A great deal of time has been spent attempting to devise a system which is workable and useful but which might leave some time for face-to-face contact with patients; implementing it forces the psychiatrist into a catch–22 situation. If things are seriously wrong for a patient, the psychiatrist could be criticised for not putting somebody on CPA, or criticised for putting them on it but not carrying the process through thoroughly enough. In spite of this, I have participated in the scheme, if only because the consensus would seem to be that it is necessary to have the system in place, mainly as a defensive measure or in the hope of ensuring adequate resources. My overwhelming feeling, however, has been that it has been a time-consuming way of formalising good practice, and that the time spent filling in the forms would be better spent talking to the patients. I have always felt uncomfortable listing needs and solutions with the patient and ‘the team’, because it seemed reductionist, but I thought that this was my idiosyncratic response, and that I should get on with it. Recently, however, there was a near disaster with a patient which served to strengthen my reservations.

The speciality tutor is recognised but not appointed by the College. He or she may be appointed by the University, the Regional Post graduate Education Committee, or by a local committee, for example, the local Division of Psychiatry. The appointment, however, must have the agreement of colleagues (Royal College of Psychiatrists, 1996).

The management of acute behavioural disturbance in psychiatric patients is an area that continues to require investigation, as it is potentially dangerous for both patients and staff. We conducted an audit of the management of these episodes, looking particularly at the drugs given, the doses and any polypharmacy. We also examined whether the issue of guidelines led to any changes in prescribing patterns. We found that we were prescribing appropriately and that the guidelines did lead to some shift toward safer prescribing.

Standards developed from the Royal College of Psychiatrists' consensus statement on the use of high-dose antipsychotics were audited. The baseline survey and two completed audit cycles are described showing improvement in the monitoring and management of out-patients on higher dose depot antipsychotics. Initially the main problem was poor attendance at hospital appointments. Practice was changed by (a) medical staff becoming more assertive and visiting non-attenders at home; (b) a phlebotomist visiting patients at home. Deinstitutionalisation has relocated many patients with chronic psychoses into the community, but services, including the ancillary services, have sometimes been slow to follow. This audit found that the most effective change was the provision of services to patients in their own home.