We report on the first two years of a novel, controversial approach in East Dorset where consultants in old age psychiatry have taken on the consultant responsibility for patients who have mental handicap. We discuss our experience as it may be of interest to others where there are problems recruiting consultants in the psychiatry of mental handicap.

The aim of audit is to monitor and evaluate clinical practice with the intention of refining and improving practice. Once implemented the changes can in turn be monitored, creating the audit cycle. This paper illustrates one way to capitalise on the changes generated by an auditing process in an in-patient adolescent unit.

Since its inception (Hounsfield, 1973), computerised tomography (CT) has become an invaluable diagnostic and research tool, particularly in clinical neurology and neurosurgery. Clinically, CT has proved useful in differentiating between ‘functional’ and ‘organic’ psychiatric disorders where it is particularly helpful in the diagnosis of potentially treatable organic disorders. For example, Owens et al (1980) found clinically unsuspected intracranial pathology in 12 of 136 chronic schizophrenic patients examined by CT and Roberts & Lishman (1984) found diagnosis, management, and/or prognosis were influenced in approximately 12% of cases referred by psychiatrists for CT imagining.

The aim of this paper is to continue a dialogue regarding the possible future use of log-books during training. The Royal College of Psychiatrists has been considering their use at various stages of training in psychiatry. Cole & Scott (1991) rejected log-books as a tool for self-audit during registrar training because they were often not kept up to date. The situation in higher professional training is more complex; there is not the clear focus of studying for the Membership examination and there are many more training components to cover during a four year period. Thus, we feel that a system for self-audit and monitoring could well prove valuable at the senior registrar level. There is a tension for senior registrars with whom we discussed this issue at the last Annual Meeting of the Section and among colleagues on our rotation.

Informal discussions between psychiatric trainees reveal frequent difficulties and frustrations in providing adequate medical care to psychiatric patients. Our writing this article was prompted by the death of a patient who had been referred to casualty with behavioural and physical problems, and who, once labelled as a ‘psychiatric patient, did not receive the medical attention he required. Other trainees will have their own similar examples, at best resulting in only inconvenience to the junior doctor. This may seem surprising given the knowledge that people with psychiatric problems suffer increased physical morbidity. We were all taught as medical students that a physical presentation may mask a psychological problem and vice versa, and that both problems may co-exist. However, this knowledge does not always impinge on hospital clinical practice. From the viewpoint of junior psychiatrists, cross-specialty referral and consultation, and the provision of adequate medical care to our patients can be difficult. In this discussion, we will deal briefly with the contribution of ‘physical’ medicine to this state of affairs and then turn in more detail to the influence of psychiatry. Recommendations for improvement are made.

At a meeting of the United Kingdom Standing Conference for Psychotherapy on 7 March 1992, a series of working papers describing the organisation of a register of psychotherapists was discussed, amended and accepted.

At the Department of Psychiatry, Royal South Hants Hospital, an Audit Committee of two consultant psychiatrists and the three senior registrars working in the department meet every two to three weeks to plan and execute audit projects.

In 1987 and 1989 surveys of junior doctors' experience of behavioural and cognitive psychotherapy in the South West Thames Region were published (Drummond & Bhat, 1987; Drummond & Bhat, 1989). These surveys demonstrated that a marked increase in the numbers of trainees gaining cognitive and behavioural experience was shown following monthly visits by the peripatetic Senior Lecturer in Behavioural Psychotherapy. The number of trainees gaining experience of treating at least one case under supervision increased from 17% to42% over this period. However, this still fell short of the College recommendations that every trainee should receive this experience and treat at least two cases under supervision.

For more than a decade there has been no opportunity for formal post-graduate training in psychiatry in Romania. In February 1992, as part of a World Health Organization (Regional Office for Europe) initiative, we travelled to Romania as WHO temporary advisers to give seminars on: (i) the role of primary health care services in providing mental health care; and (ii) the development of community-based services for the mentally ill and disabled. Our seminars were designed to complement the biological and clinical elements of a developing psychiatric training programme.

Recent guidelines recommend that where appropriate, procedures for the development of audit in medicine and professions allied to medicine can be replaced by comprehensive multidisciplinary audit of services. The Royal College of Psychiatrists (1990) suggests that clinical audit, involving the work of other staff in the multidisciplinary team, is preferable to purely medical audit. Given the importance of team work in child psychiatry, it seems appropriate to establish a system of audit which enables all disciplines to be involved.

The Italian Reform Act (Law 180) has been considered one of the most revolutionary Mental Health Acts in Western countries and has been the subject of considerable attention since its promulgation in May 1978. Interest in the Italian model of community psychiatry has been reflected in the number of articles, special supplements and letters, published in noteworthy European and American journals. However, for a better understanding of the meaning of Law 180 (now part of Law 833 concerning general health measures) the political and sociocultural climate surrounding the enactment of the Italian Mental Health Act should be considered.

As a senior registrar training in child and adolescent psychiatry I am preparing for an uncertain future. In addition to essential clinical and management skills, the ability to withstand stress and burnout seems crucial. I should like to write about my experience of working as a senior registrar at the Young People's Unit (YPU) Macclesfield which is a specialist adolescent unit under chronic threat of closure.

Working for Patients (DOH, 1989) has provided considerable impetus to the development of medical audit. The Royal College of Psychiatrists (1989) Preliminary Report on Medical Audit defined and distinguished between clinical audit, peer review and performance indicators, and referred to some of the particular problems affecting the development of audit in psychiatric practice. There are special concerns for child and adolescent psychiatrists developing medical audit programmes because of the wide diversity of child and adolescent practice and the considerable variability of resources in the subspecialty. Nicol (1989) has described the initial concern of the National Child Psychiatry Section's Working Group on audit with the Korner Report (HMSO, 1982) and the proposals on performance indicators outlined by the DHSS in 1987.

Section 5(2) of the Mental Health Act, 1983 allows for the detention of an informal in-patient, should he/she wish to leave hospital but be considered a danger to him/herself or others if allowed to do so. The 72 hour period of detention allows time for a completed assessment for application for admission under Section 2 or 3 of the Act; it is not intended to replace this fuller assessment. The 1983 Mental Health Act introduced new provisions with regard to Section 5(2). The equivalent Section 30 of the Mental Health Act 1959 did not provide for a nominated deputy to act on behalf of the registered medical practitioner in charge of the patient's treatment (RMP). The nominee must exercise his/her own clinical judgement but, as indicated in the Code of Practice (1990), must contact the nominating doctor or another consultant to discuss the need for Section 5(2), before implementing it. The nurses' holding power, Section 5(4), was also a new provision in the 1983 Act.

UKSCP was inaugurated in January 1989 as a sequel to the “Rugby” Psychotherapy Conference, itself a sequel to the Sieghart Committee. In 1990 UKSCP resolved to establish psychotherapy as a separate profession and to seek to establish itself as the competent authority in relation to EC regulations, present and impending, which regulate the freedom of movement of professional people in the EC. The key to being a competent authority lies mainly in holding a register for the profession.

It is increasingly recognised that all consultants have to undertake management responsibilities at several levels. Consultants are an expensive resource and it is therefore fundamental that they manage themselves and their time effectively. Secondly, consultants need to manage their resources, both the clinical team and the facilities available to it. Thirdly, the consultant has a strategic role in developing the service to meet the changing needs of the population served. Finally, some consultants may choose to undertake executive management roles such as clinical director or unit general manager. In these roles a broader view of overall service provision is necessary.

During their period of training, trainee psychiatrists are usually involved in multiple educational activities. Clinical activities include case demonstrations at the bedside, ward rounds, and other multidisciplinary team meetings. Another group of activities, not directly clinical, include didactic teaching in the form of lectures, case presentations at conferences, seminars, audit and journal clubs.

Much of a typical general practitioner's time is spent dealing with people who present with “psychological” problems. Of those people who are detected as suffering from a mental health problem, most are then dealt with by the GP without recourse to specialist services. There is a wide variation in referral rate, and a recent review (Wilkinson, 1989) suggests that GPs are most likely to refer a patient to a psychiatrist when he/she has failed to respond to previous GP treatment, an opinion about diagnosis is sought, or there is some specific request either by the patient or another person involved. One of the reasons why GPs are disinclined to refer is their perception of stigma associated with attending a psychiatric clinic, although they do not appear to be unduly perturbed by aspects of the referral process itself, such as a waiting list. Overall, it appears that around 95% of patients in general practice presenting with mental distress are not referred to a psychiatrist. As well as being concerned about the stigma associated with traditional psychiatric services, we hypothesise that another concern of GPs may be a lack of liaison and consultation between primary and secondary care services.

This study is an evaluation of the use of two health status measures for monitoring the outcome of acute psychiatric treatment. The measures are the Sickness Impact Profile (SIP) and the Classification of Illness States (CIS). The SIP is a measure of the impact of sickness on patients' daily activities and behaviour. The CIS was initially developed to measure ‘morbidity states’ after hospital treatment and can be used to generate the ‘Rosser Index’, both of which have been shown to be valid and reliable measures (Rosser, 1988).