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.

Universal suffrage has been a cornerstone of democracy in Britain since 1948. However, by application of the common law, the vote is denied to people deemed “insane” or “idiots”. In practice mentally disordered people have been, until recently, disenfranchised by section 4(3) of the Representation of the People Act 1949 which prevented recognition of a mental hospital as a place of residence for the purpose of electoral registration. Significant change was introduced by section 7 of the Representation of the People Act 1983 which applies to both England and Wales, and Scotland. This enables informal patients in mental hospitals to register for the vote provided they can complete a patient's declaration. We examined the implementation of these provisions in the 1992 general election at two hospitals in Edinburgh for people with mental illness and learning disabilities respectively.

The main principle of the Children Act 1989 is that the welfare of a child at risk of abuse or neglect takes precedence over all other considerations. In complying with the Act, these considerations may include the principle of medical confidentiality and the health and safety of some adult patients. Nowhere is this more poignantly illustrated than in the case of childhood sexual abuse disclosure by a distressed psychiatric patient who may be unprepared or unwilling to cooperate with the immediate reporting and ensuing investigation of their abuse as required by the Act.

The rise in the proportion of female medical graduates has led to an examination of the alternatives to full-time continuous postgraduate training. Part-time training has become more common, particularly in psychiatry and non-acute specialties. The means of establishing this type of training have been described in detail (Royal College of Psychiatrists, 1987) and the training requirements are discussed in the JCHPT Handbook. However, when part-time training is written about it is presented as a daunting process, fraught with concerns about a less than optimum training and practical difficulties. The survey by Ann Gath (1988) of supernumerary senior registrars in child and adolescent psychiatry detailed problems such as prejudice, a sense of exploitation, and lack of support and advice. These issues are clearly of great importance to those considering this option but there is also a more positive and optimistic view of part-time training which seems of particular relevance to child psychiatry. At the time of writing I am nearing the end of my higher training on the PM 79(3) scheme and am in a position to describe some of these more positive aspects.

The development of hospital hostels was advocated by the DHSS in 1975. These combined the clinical expertise and back-up of hospital resources with a domestic environment. The suggested level of provision was eight to ten places per 200,000 population in areas of average need and ten to 12 places in high need areas.

Observation levels are widely used in the management of acutely disturbed psychiatric patients (Shugar & Rehaluk, 1990). Although clinicians are involved in decisions about observation levels, there is rarely any specific training and very little formal structure to the decision making process. We report a survey of the views and knowledge of clinical staff regarding observation levels. Questionnaires were sent to all the nurses of the six acute psychiatric wards in the Nottingham Mental Health Unit, and all the doctors involved in the care of patients on these wards.

Up to one third of patients referred for psychotherapy fail to attend for their first appointment (O'Loughlin, 1990). Psychotherapy assessments are usually allocated a considerable portion of uninterrupted time, and an unexpected non-attendance wastes significant clinical resources. A variety of strategies have been used to ensure that assessors are not left waiting for a patient who never comes. One method is to send out forms which must be completed and returned before a first appointment date is given. In O'Loughlin's study, in which a similar questionnaire to that detailed in this paper was used, it was suggested that sending a pre-appointment questionnaire reduced the default rate.

Audit is certainly the topic of the moment. It is much talked about and a lot of money is being made available for it, yet it seems that there are few real guidelines about how to do it. Many junior doctors who would like to do audit may be put off by the computers and other paraphernalia which are deemed necessary for this purpose. While technology can help, it is by no means necessary and some of the best audit follows the same principles as research: keep it simple.

The aim of medical audit is to improve the quality of medical care (Department of Health, 1989). There was concern that patients referred to a psychogeriatric service (Service X) did not have adequate access to computerised tomography. The nearest computerised tomography scanner was located in a neighbouring district and direct referrals were not accepted. Computerised tomography scans could be obtained indirectly by referral to neurosurgeons. Because of these difficulties “potentially treatable structural lesions” (such as cerebral tumours and subdural haematomas) may have been missed. We decided to compare the use of computerised tomography scans with a nearby service (Service Y) which had a computerised tomography scanner on site. Service X had a catchment population of 33,000 aged over 65 and Service Y a catchment population of 23,420 aged over 65.

Many trainees contemplating becoming a consultant admit that their greatest concern is how they will find their way through the NHS bureaucracy and politics and relate to managers and colleagues who them selves are embroiled in these webs. We have therefore made management a high profile component of senior registrars' training during their 16-months placement in the Centre. As well as attending formal courses run by the King's Fund or the Region, trainees are exposed to diverse management issues and we ensure that the weekly hour of consultant supervision includes discussion of managerial and clinical matters.

Over recent years there has been an increase in the number of training schemes in general psychiatry which offer posts in the psychiatry of mental handicap. I will describe my experience as a registrar during a nine month full-time placement in psychiatry of mental handicap as part of the Charing Cross Rotational Training Scheme in Psychiatry.

Non-attendance at new patient clinics is a well-known problem in psychiatry and particularly common in alcohol treatment units. Reported non-attendance rates in this field range from 12.3% (Addenbrooke & Rathod, 1990) to 52% (Wanberg & Jones, 1973). A number of factors may contribute to this failure to attend including a long waiting time, lack of consent to the referral (e.g. by the GP), postal and administrative problems and the nature of the disorder itself. Hyslop & Kershaw (1981) contacted patients who failed to attend an alcoholism referral clinic in an attempt to establish their reasons for non-attendance. Out of the 39 patients contacted 23 appeared to have good reasons for not attending while 16 gave poor reasons and refused the offer of a second appointment. Ways of increasing attendance at new patient clinics have included reduction of waiting time (Hyslop & Kershaw, 1981) and telephone and written prompts prior to the appointment (Bourgoyne et al, 1983; Grover et al, 1983).

In 1986 the report Bridges over Troubled Waters (NHS Health Advisory Service, 1986) stated quite categorically that patients under the age of 16 should not be treated in adult psychiatric wards. The National Association for Children in Hospital has also worked tirelessly against children and adolescents being treated in adult hospital wards, although this has mainly concerned the paediatric, medical and surgical fields. However few guidelines were laid down about the function of psychiatric units for children and adolescents when the majority of such units were first being established in the late 1960s and early 1970s. Indeed in the circular from the Ministry of Health (1964) about the need for such units it was stated that some adolescent patients could suitably be treated in adult wards. However no age limits were specified in the circular. There have been no specific guidelines issued subsequently by the Department of Health about the use of adult psychiatric beds for adolescents.

The UK has recently held a general election in which the future of the National Health Service has been a major issue. The elderly constitute a growing proportion of the electorate and are frequent users of the Health Service, yet some may have been unable to vote because they are in-patients. Elderly in-patients can vote by post or proxy or by being taken to their polling station by relatives or party representatives, but for many these arrangements may be inadequate.

It is only in the very recent past that health care professionals have accepted the reality of child sexual abuse (CSA), and it has only been classified as a separate category in Index Medicus since 1987. Since then, the literature has expanded enormously and various treatment strategies have developed.

Postgraduate psychiatric training is usually assessed by regular College visits. A number of training schemes, including the Liverpool training scheme, also scrutinise their training independently of the College. As far as we know, trainees as the ‘consumers’ of training have never assessed its quality themselves. The following account deals with two such audits in the Mersey region organised under the mantle of the Association of Liverpool Psychiatrists in Training (ALPIT).

Earlier this year a senior Department of Health official asked me if I had seen an article in the Health Services Journal about child psychiatry (Light & Bailey, 1993). Shortly afterwards a consultant colleague asked me about the same article, having been told about it by her manager, and one of my own managers mentioned it to me and asked for my thoughts. Now the Psychiatric Bulletin wants 500 words on this same article. If nothing else, Professor Light and Dr Bailey have stimulated debate.