My paper deals with the provision of psychotherapy services for forensic patients and the training available to the would-be forensic psychotherapist. Psychotherapy in the context of this paper refers to psycho-analytically based psychotherapy, either individual or group, and not to behavioural or cognitive models. In addition, two aspects of psychotherapy should be borne in mind: supportive psychotherapy in the context of ongoing therapeutic relationships (e.g. patients suffering from chronic mental illness) and mutative psychotherapy, which aims to change some aspect of the person. Both aspects are important in the practice of forensic psychiatry, perhaps especially the latter.

Roundway Hospital provides all rehabilitation and continuing care (rehab) beds for the Swindon Health District (Swindon), population 245,000; the Wiltshire sector of the Bath Health District (Wilts) population 200,000; and the Bath City sector of the Bath Health District (Bath), population 85,000.

Little is known about those patients who bypass their GP and self-refer directly to hospital. There have been studies of referrals to emergency clinics (Lim, 1983; Haw et al, 1987; Kehoe & Newton, 1990) and to community centres (Hutton, 1983; Boardman & Bouras, 1989). All these studies found that more men self-referred than women. Hutton (1985), Boardman & Bouras (1989) and Kehoe & Newton (1990) found that self-referrals often had a non-psychiatric precipitant and rarely required acute psychiatric intervention.

Broadmoor Hospital is one of the three special hospitals covering England and Wales. It provides approximately 500 beds for mentally disordered patients who on account of their dangerous, violent or criminal propensities constitute a grave and immediate danger to the public, requiring treatment in conditions of special security (Section 4, National Health Service Act, 1977). It is generally recognised, however, that there are patients in special hospitals no longer requiring treatment in conditions of maximum security. These patients could probably be more appropriately cared for elsewhere if the facilities existed in general psychiatric hospitals or the community. However, special hospital consultants frequently encounter significant obstacles when attempting to transfer patients to local hospitals. Dell (1980) highlighted this problem, suggesting that 16% of special hospital patients were waiting to leave, following the agreement of the DHSS and the Home Office to their transfer. This delay appeared to be due to hospitals not wanting to accept patients who might prove to be difficult or dangerous. At the time of this current study (March 1990) these difficulties in transferring patients were particularly relevant as two of the special hospitals, Broadmoor and Ashworth (Park Lane and Moss Side) were full for male patients and therefore closed to male admissions, despite a continuing demand for beds.

In view of the increasing emphasis on community psychiatry (Groves, 1990), there is much interest both locally and nationally as to what training experience is available or should be provided. So far, trainees have been bombarded by suggestions as to the essential content of training (e.g. Connolly & Marks, 1989), and enthusiastic accounts of experience gained have been published (e.g. Malcolm, 1989). Not surprisingly, anxiety has also been expressed (Haigh & Wear, 1989).

Medical audit has been defined “as the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient” (Department of Health, 1989).

A pilot study in Bloomsbury established that the majority of patients were dissatisfied with the information given about medication. Consequently a medication group was set up to which all patients were invited to discuss issues about medication. It emerged that many patients believed they had not been adequately informed about the medication they were receiving, or possible side effects, and would have liked to receive written information. It was therefore decided to review professionals' and patients' satisfaction with the information provided and to test whether leaflets improved patients' satisfaction.

The volume of literature on medical audit and the broader field of quality assurance is expanding rapidly. Medical audit is now a requirement for all medical practitioners; therefore, to perform it, they need to know something about it. There is a multitude of articles written in the journals, especially the British Medical Journal and the Journal of the Royal Society of Medicine. However, in this paper I intend concentrating on some of the many books pertaining to this field which have been published recently.

The psychiatry of old age has come to occupy an increasingly prominent role in psychiatry, because of demographic trends, and also because of service developments. About a third of referrals to most psychiatric services are for the over-65s and a high proportion of beds are occupied by this age group. Recently the training recommendations for senior registrars in the psychiatry of old age have been revised and clarified (Royal College of Psychiatrists, 1989) and old age psychiatry is now recognised as a specialty within psychiatry. Nevertheless there is continued concern about the training opportunities available in this field (Wattis, 1988), reports of difficulties in filling consultant posts, and evidence that the present guidelines for consultant staffing levels are inadequate (Ballinger et al, 1989). It has recently been recommended that one-third of senior registrar posts in general and old age psychiatry should be assigned to the psychiatry of old age (Sims, 1990).

The patient absconding without leave (AWOL) produces considerable anxiety to staff, relatives and the public, and involves a great deal of staff time in notification, search and enquiry to the detriment of the care of other patients. Incidents of AWOL are potentially dangerous and all efforts to predict these incidents and to deal with them appropriately should be made.

The dangers of cigarette smoking are well recognised, and a number of public health measures designed to reduce the level of smoking have been introduced over the past 20 years. These measures have been fairly successful, and there has been a steady decline in the prevalence of cigarette smoking in the UK over the period 1972–1988 (Office of Population Censuses and Surveys, 1990). A number of studies have shown a higher prevalence of cigarette smoking among psychiatric patients (Hughes et al, 1986); however, the majority of these have been of highly selected populations, or have failed to control for factors such as age, sex, socioeconomic status and alcohol abuse, all of which are known to affect the prevalence of smoking. This study compared the prevalence of cigarette smoking among a heterogeneous group of psychiatric out-patients with that of the general population with control for these confounding variables.

An instrument for a systematic assessment of mental handicaps and associated disabilities has been needed for a long time. Recent legislation, for example the Education Act 1981 and the Disabled Person's Act 1986, introduced new statutory responsibilities for education and local authorities to assess an individual's needs. There is no standard assessment or screening tool currently available which covers all aspects of the lives of people with mental handicaps and their interaction with the environment. Ideally a data-base providing such knowledge will also be required by all professions concerned with mental handicap, particularly during the transition to community care.

As more health authorities close large psychiatric hospitals the provision of small local facilities in which former residents of such hospitals are housed is increasing. Such houses tend to share many common characteristics dictated both by practical necessity and by deliberate policy – they tend to be large Victorian houses chosen because they have a larger number of bedrooms and they tend to be run in a much less formal manner than hospital wards (Goldberg, 1985).

The 17th century saw the transfer of Bethlem from its original monastic site to more spacious accommodation at Moorfields in 1676, the development of an organised admissions system, and the establishment of an admissions register in 1683. The register contains often no more than the patients' names and the dates of their admission and discharge. Examinations of the admission register for the period 1684–1700 however, reveals 20 cases in which the entry is a copy of a warrant for admission in the form of a letter from the referring authority.

Working for Patients (1989) demonstrates the Government's intention to “encourage all Royal Colleges to make participation in medical audit a condition of a hospital unit being allowed to train doctors”, suggesting this may also become a requirement for psychiatric trainees. The Psychiatry Department at Fazakerley Hospital moved into the rather uncharted territory of clinical audit with monthly unit audit meetings in 1989. At each meeting randomly selected cases are reviewed and data presented which are relevant to clinical practice on the unit. The majority of topic audits have been presented by trainees with support from consultants. Most Colleges agree that casenotes should be available for scrutiny (Warden, 1988). Consequently I undertook a casenote audit.

The Mental Health Act Code of Practice has recently been published. Its introduction has been discreet, low-key and virtually unnoticed. Yet in a quiet and determined way it points out the direction that all professionals involved in the case of mentally disordered people must now anticipate. It has a smart, blue cover and is eminently ‘user-friendly’. Its contents will make it essential reading. Indeed it would not be an exaggeration to suggest that it might soon be any ambitious lawyer's pocket vade mecum as he prepares his case. Its arrival has been anticipated since 1983. There have been a few miscarriages on the way which probably explains why its mother finally consented to artificial insemination techniques and conceived of her Code without formal consultation with its potential fathers.

The proportion of female medical graduates has steadily risen in the past decade. Although it may be argued that men should take on an equal share of the child-rearing and housekeeping roles of the housewife, there is evidence that women doctors are falling behind in their careers because of domestic pressures (Rhodes, 1990). Part-time work is perceived in theory as being a suitable option for women doctors with domestic commitments, but the number who choose this option in practice is surprisingly small. The following study sought to establish what demand there is for part-time training in psychiatry among junior doctors and whether what is on offer meets that demand.

Communities and psychiatrists differ with regard to how they have been ‘conditioned’ to accept responsibility for caring for the mentally ill. Some are reluctant to change the style of care they have become accustomed to (Lancet, 1985). The White Paper (Community Care in the Next Decade and Beyond) has emphasised the added ‘where/how/who’ meaning of psychiatric care: from treatment to prevention, clinical to management skill, and from a position of superiority to one of equality. Some psychiatrists feel threatened by the possibility of a ‘non-medical takeover’. Mental health care is not a social service priority and future consultants should equip themselves to take an effective lead in ensuring that adequate resources are made available (Freeman, 1985). Appropriate training opportunities are scarce (Scott, 1988) and we have only two years grace.