We conducted a questionnaire survey of all 120 health authorities and boards responsible for the commissioning of services for the assessment and treatment of transsexual people in England, Scotland and Wales, in order to identify the nature of the input offered and assess conformity to current international standards of care.

Eighty-two per cent of the commissioning authorities responded and confirmed that most health authorities/boards provide a full service for the treatment of transsexuals, although this would be delivered at a local level in only 20% of cases. However, 11 commissioning authorities gave confused and inaccurate responses and three other health authorities appear to hold views on the commissioning of these specialist services that are not in keeping with the current legal situation and a recent High Court ruling, which establishes the right of transsexual people to NHS assessment and treatment.

There are discrepancies in prioritisation and provision of clinical services for this group that are not standard across Great Britain.

The aim of the audit was to ensure that the case-load and case mix for trainees in child and adolescent psychiatry met Child and Adolescent Psychiatry Specialist Advisory Committee guidelines and that trainees were seeing cases with an appropriate mix of age, gender and diagnoses. Data on case-load and case mix were analysed annually and problem areas were identified and reviewed when the audit cycle was repeated. The audit cycle has been repeated three times.

Specific findings from the audit included: female trainees were seeing a high percentage of girls; male trainees were seeing a high percentage of boys; some trainees were seeing a high proportion of cases of deliberate self-harm; and there was a recent increase in the number of cases of attention-deficit hyperactivity disorder. The first two issues were rectified as a result of the audit process; the last is being monitored.

Training needs should come before service needs. Auditing trainees' case-loads and case mixes helped best to utilise the time available for clinical work during training.

We aimed to determine, using clinical audit, the effect of implementing national guidelines on the quality of responsible medical officers' (RMOs’) reports to the mental health review tribunal (MHRT). We blindly assessed the quality of 50 consecutive reports concerning patients detained under Sections 3 and 37. Twenty-five reports were written before guidelines were circulated; a further 25 were written following the distribution of guidelines and a checklist with every request for a report.

The quality of reports, as measured by our checklist, significantly improved following the circulation of guidelines.

Increasing the awareness of guidelines by widespread circulation and the audit process is an effective way of improving the quality of RMOs' reports to the MHRT.

To introduce a monthly screening clinic for new patients referred to the community mental health team with less severe mental health problems.

Sixty patients were selected for screening in the first year. Their non-attendance rate of 48% was more than double the rate for all new patients. We did not diagnose severe mental illness in any patients on first assessment or during the 6 months of follow-up.

Patients referred from general practice with minor psychiatric morbidity may have particularly high rates of non-attendance. The brief screening clinic model offered us considerable savings in consulting time. The outcome for our service is shorter waiting times for patients with more severe mental health problems.

There is increasing evidence-based knowledge in the drug treatment of psychotic and behavioural symptoms in dementia, but drugs do not possess a formal licence for these indications. Drug companies, health authorities, NHS trusts and medical defence unions were asked for their advice on the medico-legal implications for the prescribing clinician.

Drug companies, health authorities, medical defence unions and NHS trusts are aware of out-of-licence prescribing and leave ultimate accountability with the clinician. A suggested best practice is that of obtaining the patient's consent.

Out-of-licence prescribing for psychotic and behavioural symptoms in dementia is widespread. This patient group may be unable to grant consent. The accountability of individual clinicians should be supported by more adequate medico-legal frameworks.