Child and adolescent psychiatry is a growing speciality. Significant increases in workload, the reasons for which have been described elsewhere (Black, 1989), have led to an expansion in consultant posts across the UK. Recently the Joint Planning and Advisory Committee (JPAC) reviewed senior registrar numbers and recommended an increase in the establishment by 38 whole-time equivalents in England and Wales, a rise of 38%, to meet the expected shortfall. How existing senior registrars, as well as this large number of new recruits, are trained is clearly a matter of some importance.

Medical practice can be reframed in terms of research and teaching, possessing and using the relevant knowledge, skills and attitudes. The doctor's curiosity and the diagnostic challenges of medical practice (and in particular of psychiatry) demand a capacity to think systematically, measure comprehensively and accurately and analyse the information obtained within the consultation as a preamble to management and treatment. The word ‘doctor’ means ‘teacher’ and the same communication skills are essential to both professions. Psychiatric practice is especially dependent upon them. They are also often essential for good clinical research.

It is recognised that the consultants of the future will have a greater management role than those of the past. The Griffiths report (1983) regarded doctors as ‘natural managers’, although this has been challenged by some authors. They suggest that medical training, with its emphasis on the individual case and rapid decision-making (Higgins, 1989), leads to a very different perspective from the manager considering the often competing long-term needs of many individuals.

Health and social care in Britain is undergoing the most profound changes in its structure and organisation since its inception (Griffiths, 1988); indeed, some would argue that it is about to change beyond recognition. The purpose of this article is to describe contemporary developments in the delivery of such services in the USA. Given that many of the political changes here have been directly influenced by thinking and practice in that country, it is argued that there are two important lessons to be learnt. The first concerns the coordination of service delivery between different agencies, the second involves an emphasis on the delivery of acute and rehabilitation services in the community. In short the traditional distinctions between the two would be blurred.

Some of the proposals in Achieving a Balance (DHSS, 1987) seem to have developed with little regard for postgraduate training in psychiatry. In psychiatry it has become common practice for SHO posts to be incorporated in training schemes with registrar posts, allowing several years of overall basic specialist training in preparation for obtaining the MRCPsych. This is in accord with the GMC Education Committee's position (GMC, 1987a) that specialist training can, on the ‘fast track’, follow on immediately from satisfactory completion of pre-registration posts (general clinical training) and full registration. Achieving a Balance states clearly that specialist training begins at registrar level and that any doctors in SHO posts should be receiving further general training. There are few guidelines concerning the necessary nature of such general training.

The role of the clinical tutor may differ from that set out in the helpful guidelines given by the Royal College of Psychiatrists. It may differ depending on the setting of the training for instance. I was made clinical tutor some three and a half years ago for a large, mainly rural area – North Wales. The area does not have its own medical school, but is associated with the University of Wales College of Medicine, at Cardiff, some 150 miles away.

If three psychiatrists are needed to change a light bulb — one to change the bulb and two to interpret the experience — how many does it need to operate a computer? Judging by the attendance at the 1989 CIPG meeting, held at Keele University in October, the answer is about 54.

A new centre to study the needs of people with learning difficulties (mental handicap) was opened at the University of Bristol on 1 February 1990.

Child and adolescent psychiatry training has progressed considerably in recent years. Additional training posts have been created, as well as senior academic appointments, and some pre-existing rotations have coalesced, allowing innovative schemes of high quality to evolve. CAPSAC (Child and Adolescent Psychiatry Specialist Advisory Sub-Committee) has continued to oversee established standards and encourage these changes.

The Centre Hospitalier Specialise de Ville-Evrard is situated 17 kms from the centre of Paris and serves an area of approximately a quarter of the north-eastern outskirts of the city. I visited as one of a multi-disciplinary party of 20. The visit took place over five days and returned their visit to Bexley Hospital, Kent in South East England, which took place in November 1989. English lessons take place in the hospital as part of the hospital's responsibility for continued education for its employees and they had initiated the visit to England to improve the standard of their English.