How can the on-call child and adolescent psychiatrist operate most effectively within an often rigid system to enable the most appropriate outcomes for young people presenting to emergency hospital services?

Every year the Royal College of Psychiatrists awards a number of memberships to psychiatrists without examination. This is done under Bye-Law III 2 (ii). The sub-category Bye-Law III 2 (ii) (a) states that the ‘Membership of the College may be extended to senior psychiatrists who have practised with distinction over many years and are of international repute’. Candidates should be nominated, proposed and seconded by two members or fellows of the College. If the candidate is from outside the UK, one of the sponsors must be from the applicant's home country. Nominations are accepted from all over the world (Royal College of Psychiatrists, 2001).

Traditionally doctors have been excused from jury service, as I was on a couple of previous occasions when I received a jury summons. However, changes to the Criminal Justice Act 2003 came into force in April 2004, with the effect that doctors would normally not be excused from jury service.

A multinational pharmaceutical company recently launched a drug for dementia in Pakistan and flew about 70 Pakistani doctors to Bangkok, Thailand for a 3-night all-expenses-paid trip (Khan, 2004). Pakistani doctors were part of a larger group that also included doctors from other countries. A conservative estimate of costs for the Pakistani doctors alone is about 7 million Pakistani rupees (Rs) (£70 000, US$120 000).

Over the past 2 years the Global Initiative on Psychiatry has developed a wide range of initiatives in the fields of prison mental health and forensic psychiatry in Eastern Europe and the former Soviet Union. Both areas, until recently, were either ignored or deliberately avoided. This is not coincidental. The prison systems in the former Eastern bloc are in essence military organisations with a strict hierarchy and a rather tarnished past. Although some reform programmes in this field were implemented or started during the past decade (e.g. by Prison Reform International and the London Institute for Prison Studies), none of these projects has involved mental health services within the penitentiary system. A society that often limits itself to locking away those who have committed crimes or are suspected of having committed them, and pays only little attention to the physical and emotional well-being of those imprisoned, does not see the mental health of these persons as a priority. Equally unimportant seems to be the mental health of those who guard the prisoners and who are under constant stress.

A new approach to research and development (R&D) for mental health services is developing in the North-East, Yorkshire and Humber. It derives from experience with service redesign using the ‘collaborative’ approach developed by the US Institute for Health Improvement. Kennedy & Griffiths (2003) described such an approach involving 37 mental health trusts, each with a multidisciplinary team, with the aim of improving acute in-patient wards. After studying the patient's journey through care they agreed a set of improvement targets that all teams would work to achieve. Progress towards targets was measured and reported by all teams, who met periodically to compare performance and learn from each other. Remarkable energy to achieve objectives was released among front-line staff involved. Focus was sustained on what most concerned and benefited patients. Good ideas and results quickly spread to all these services affecting thousands of patients.