Data were collected on a six month sample of patients attending a psychiatric emergency walk-in clinic (n=378), based on the clinical impressions of the interviewing doctor. This information was then compared with a hypothetical model emergency service on the following five items: nature of patient problem, severity of problem, diagnosis, referring agent and current contact with psychiatric services. The severity of the perceived threat to the interviewer was recorded. Only 4.7% of referrals conformed to the hypothetical model on all five criteria. The majority of patients referred themselves, and the problems of self-referrals were significantly less severe than those of general practitioner referrals; 17.2% of consultations were perceived by the interviewing doctor as presenting a moderate or severe threat to his or her safety. The findings suggest that such an emergency facility operates as a form of primary care and is therefore inappropriately used. The level of perceived threat to interviewing doctors is unacceptably high.

European Integration confronts both Individual psychiatrists and psychiatric service planners with ethical dilemmas that should best be dealt with proactively by medical and psychiatric organisations. Selected examples are presented of ethical Issues arising out of differences In psychiatric practice across Europe. Some of the ethical implications may seem relatively minor, but still require a major adjustment effort on the part of psychiatrists who are exposed to transcultural practice In the European Union. Other examples have been selected, not because they are common, but because of their massive ethical ramifications.

A retrospective comparative study of violent incident forms covering the acute general adult wards at a London teaching hospital and a district general hospital was performed. Although no significant difference was observed between the overall rates of reported violent incidents, there was a significant increase in the proportion of violent incidents directed at persons in the inner city hospital. Grade 3 incidents were rare. Caribbean patients were over-represented among the perpetrators.

Consultants psychiatrists have a limited time to offer their services. Current contracts, based on population norms, do not establish limits to consultants' workload. Reorganisation of service provision, rising demands and marked social differences in different localities have brought these population norms into question. What is the desirable workload for a consultant to ensure a decent level of care to patients? A model is proposed that specifically applies to whole-time consultants within a catchment area, and those working in adult general psychiatry. It will need to be adapted for other specialities. The figures given are estimates, which will need to be audited appropriately for refinement. It is hoped that such an analysis will facilitate the process of purchasing care for specific patient groups, and be a clearer way of identifying gaps in clinical service.

Although the principles behind the care programme approach have generally been welcomed, its implementation has at best been patchy and at worst a complete failure. The principles behind supervision registers have not been welcomed by most psychiatrists. This paper presents a practical solution to the major problems associated with the implementation of the care programme approach and supervision registers by defining pragmatic criteria for inclusion on these registers and the services which should be provided to registered patients. This solution was agreed between purchasers and providers following a series of consultative meetings and this is a process which must be recommended.

The challenge facing services for people with learning disabilities is to create the environment in which clients have the best quality of life without preconception. The heterogenous nature of people with learning disabilities requires diversity of care provisions sensitive to their individual needs. The different demonstration and presentation of their mental health needs has influenced the development of services and different models of specialist services have emerged with local variations. There is still, however, a great deal of confusion on both ideological and service delivery level. Although services for people with learning disabilities have succeeded in resettling people in the community and supporting them in developing adaptive skills, unfortunately these successes are not matched by equally effective and efficient services to those with mental health needs.

The rehabilitation service for West Gloucestershire utilises a range of facilities to accommodate the long-term severely mentally ill. Group homes, supported lodgings, long-stay rehabilitation hostels and an inpatient slow stream rehabilitation ward provide increasing degrees of support according to levels of dependency. The findings of this study support the use of the Clifton Assessment Procedures for the Elderly Behaviour Rating Scale (CAPE BRS) as an aid to assessment of appropriate placement for the long-term severely mentally ill of all age groups in the community, both at the time of placement and to monitor ongoing need.

Our objective was to establish a mechanism for monitoring indicators of the state of health of inner London's mental illness services. Data were collected for a census week around 15 June 1994. Local data collection was coordinated by consultant pyschiatrists working in inner London services. Twelve services participated with a combined catchment population of 2.6 m. They included ten London services which were among the 17 most socially deprived areas of England. Main indicators were admission bed occupancy levels (including an estimate of the total requirement), proportion of patients detained under the Mental Health Act, number of assaults committed by inpatients, number of emergency assessments and CPN caseloads. The mean true bed occupancy (which reflects the number of patients who were receiving, or required, in-patient care on census day) was 130%. To meet all need for acute psychiatric care, including for patients who should have been admitted and those discharged prematurely because beds were full, a further 426 beds would have been required. Fifty per cent of patients were legally detained. Physical assaults were virtually a daily occurrence on the admission units. Average community pyschiatric nurse caseloads were 37, suggesting that the majority were not working intensively with limited caseloads of patients with severe mental illness. These indicators, although imperfect, will allow for some measurement of the impact of local and central initiatives on the poor state of London's mental illness services.