The psychiatric emergency service is a major focal point of entry into the mental health system. Depending on the health care policy and other sociocultural factors, the pattern of attendance in a psychiatric emergency unit tends to differ from one country to another (Bassuk et al, 1983).

Liaison with the various agencies which deal with mentally abnormal offenders is one of the prime roles of the forensic psychiatrist (Royal College of Psychiatrists, 1988). The probation service is a key agency in this regard. The importance of such collaboration has once again been highlighted with the clear message that the care of the mentally abnormal offender is improved as a result (DOH/Home Office, 1991). However, the provision of a satisfactory psychiatric consultation service to probation clients who have been remanded on bail can be problematic. Much of the work of forensic psychiatrists is institutionally based. Non-attendance rates at hospital based out-patient clinics are high (Bowden, 1978). However, general psychiatrists have found that psychiatric clinics based in general practitioners' surgeries are more acceptable to patients than hospital clinics (Tyrer, 1984). The probation office as a community base for forensic psychiatrists is a valid equivalent.

Many mental disorders are associated with an increased risk of fire setting. As a result, its assessment and management is an important part of the management of people with psychiatric disorders. As more patients are managed in the community, away from the protection of high levels of hospital staff and fire regulations, such assessments are vital to ensure appropriate and safe placement. The presence of fire regulations in hostels offers only limited protection. Further, as residences with four people or less are not subject to fire regulations, assessment by psychiatric staff may have to extend to the fabric of the placement. Despite psychiatric hostels tending not to accept patients who are ‘a fire risk’, figures suggest that fires in hostels are common. One health authority reported 26 fires in hostels over 12 months (Moxom, personal communication).

While working as a registrar on a Regional Alcoholism Treatment Unit (ATU), I took part in a weekly support group for women. This afforded a valuable insight into the way in which alcoholism affects women, and showed how a group could be used by its members in a variety of ways. It was an important and valuable learning experience which is not commonly available to trainees in psychiatry.

In 1991 the Royal College of Psychiatrists awarded two overseas teaching fellowships. Tom Harrison and Alexandra Espejo described their visit to Chile in the March 1993 Psychiatric Bulletin. We were asked to visit Bulgaria to teach liaison psychiatry in both child and adolescent and adult psychiatry.

The 1983 Mental Health Act brought several changes aimed at improving the rights of detained patients. Included was a new provision safeguarding the position of nursing staff – Section 5(4); no provision equivalent to the nurses' holding power existed in the 1959 Act. Nurses previously were expected to act in good faith to restrain patients where necessary while the doctor was sought. Such actions under common law were viewed by some to provide nurses with insufficient protection. The 1983 Act made clear the legal position of nurses. A suitably qualified psychiatric nurse can compulsorily detain a hospital patient receiving treatment for a mental disorder for up to six hours. This allows time for the responsible medical officer or nominated deputy to be obtained. The mental disorder must be of a degree where immediate detention is required to protect others from the patient, or to protect the patient's own health or safety.

Old age psychiatry has been steadily developing as a specialty in the United Kingdom. In 1978 the Royal College of Psychiatrists established a specialist section for old age psychiatry, and since October 1989 it has been formally recognised as a sub-specialty of psychiatry. In 1989 the Royal College of Physicians and the Royal College of Psychiatrists published a joint report entitled ‘Care of Elderly People with Mental Illness’ in which recommendations were made about both postgraduate and undergraduate training.

Clinical research attempts to find out the best way to treat patients and audit attempts to make sure that patients are treated in the best possible way. The two are thus inextricably linked and should benefit from each other (Smith, 1992). In running a clinical research unit in which the personnel involved (two psychiatrists and two psychologists) have only honorary contracts, it is sometimes difficult to match the service offered to the clinical population required. A constant flow of patients does not mean a constant flow of those prepared or suitable to participate in research projects. Unlike clinical referrals, which are received passively, referrals of patients for research have to be looked for, even when treatment is on offer.

We report two cases from a study of Oxford hostels for the homeless of patients who were suffering from schizophrenia and are not receiving medication. After compulsory admission to hospital and treatment both showed a dramatic improvement in behaviour which was confirmed by a standardised rating scale. We discuss how hostels for the homeless have become both asylums and traps for those who suffer from schizophrenia and conclude that doctors should not under-estimate the potential benefit of anti-psychotic drug therapy even in homeless people with chronic psychosis.

Thyroid treatment was used at the beginning of the 20th century for people with Down's syndrome, and an improvement in the physical and mental response was noted (Smith & Berg, 1976). Later studies reported conflicting findings about the prevalence and type of thyroid dysfunction (Sare et al, 1978; Lobo et al, 1980) but there now seems little doubt about the existence of a high prevalence of hypothyroidism (Mani, 1988; Dinani & Carpenter, 1990).

A significant proportion of patients referred to psychiatric out-patient clinics fail to attend the first appointment. Previous work suggested that typically 30% do not attend (Burgess & Harrington, 1964; Skuse, 1975) and this results in an inefficient utilisation of psychiatrists' time. One solution would be to overbook new patients by 30%. Unfortunately the proportion of non-attendance at each clinic is variable and difficult to estimate in advance. Psychiatrists have been shown to be poor predictors of non-attendance from examining referral letters (Woods, 1992). Overbooking might result in a long waiting time and short time for assessment. Previous research has suggested patients are more likely to attend if they received a personal letter rather than a standard card, had a previous psychiatric history, and if they were seen in a health centre rather than a hospital (Hillis, 1990). Allaying the patient's fears and misconceptions about psychiatry also improved attendance (Skuse, 1975). Work in a child and family setting suggested that sending a family questionnaire prior to the appointment reduced the non-attendance rate (Mathai & Markantonakis, 1990).

The responsibility for patient treatment is shifting from physician to non-physician professionals throughout medicine. Multidisciplinary teams are replacing hierarchical structures in which the consultant is dominant, particularly in disciplines which care for patients suffering from multiple or chronic disabilities.

Electroconvulsive therapy is widely seen by the public as a barbaric and outmoded form of treatment. Even within groups of health care professionals, ECT does not have a ‘good press’. Most research into the area of patient attitudes to ECT has been retrospective and often considerably so, and is therefore unlikely to illustrate patients' feelings about a course of treatment at the time it took place (Freeman & Kendell, 1980; Kerr et al, 1982). The only prospective study is that by Malcolm (1989). This showed a low level of understanding of treatment and a high level of anxiety both before treatment and afterwards, but, despite this, a high level of compliance with ECT therapy.

Our aim was to re-examine these findings in order to find a way of improving the experience of ECT.

Recent changes in the provision of health and social care in the UK such as the institution of a purchaser/provider system and regular screening of the elderly by GPs are of importance to the relationship between primary health care teams (PHCT) and psychogeriatricians. These changes have clarified the necessity for sensitivity by psychogeriatric services to the needs of GPs and commissioning authorities.

The Newcastle Mental Health NHS Trust Medical Audit Committee has become increasingly concerned with the problem of doctors within the Trust being unable to find sufficient time to devote to medical audit.

The last ten years have seen the development of sectorised psychiatric services across many areas of the country. The characteristic feature of such a service is that a given team is responsible for serving a population base defined either on geographical grounds or by general practice (Tyrer, 1985). However there has been little research on the impact of sectorisation (Tyrer et al, 1989).

Medical audit has become an overt part of our work over the last few years, hastened by the 1989 White Paper. At a meeting on 1 November 1989, the mental handicap psychiatrists of Bristol and Weston, Cheltenham, Frenchay, Gloucester, and Southmead Health Authorities agreed to meet monthly to audit agreed topics in mental handicap across district boundaries. These meetings were to be in addition to any local district audit that may already have been occurring, and were to provide a peer group for audit and a means of cross-fertilisation of ideas for projects. The group has now operated for over two years, and would like to present some examples of the topics covered and some comments on its experiences to help stimulate correspondence in the Psychiatric Bulletin on medical audit in learning disabilities.