Polypharmacy is usually employed where single drugs are considered insufficiently effective. Some polypharmacy is rational and evidence based, some neither. Antipsychotic polypharmacy remains stubbornly widespread despite condemnation of the practice by numerous bodies. The practice could not be said to be evidence based. Its persistence probably stems from a well-meaning desire to improve response and from confusion about the mechanism of action of antipsychotics. In particular, the concept that more antipsychotic(s) must always be, or might be, ‘better’ is virtually groundless. Nonetheless, some specific antipsychotic polypharmacy regimens have shown particular benefits on adverse effect profiles. Targeted, evidence-based polypharmacy may be the way forward.

Bohmer's concepts of custom and standard care are briefly discussed with specific reference to their implications for the role of doctors in mental health services. It is argued that these concepts help to clarify the unique contribution of doctors within multidisciplinary teams and help define the limits of standardisation in mental health services.

Lack of policy for mental health rehabilitation services has led to disinvestment and expansion of out-of-area placements in in-patient, nursing and residential care settings in the independent sector. Although a minority provide very specialist services that cannot be provided locally, and many provide good-quality care, there are significant concerns about the lack of rehabilitation focus in some of those services, poor links with local care managers and the social dislocation caused by being placed many miles from home. Additionally, out-of-area placements cost more than local rehabilitation services. There is, therefore, a compelling case for all individuals with complex mental health problems to have access to local rehabilitation services in order to expedite their recovery and social inclusion. The Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists has recently published a service template to guide commissioners and service providers in the UK in the kinds of rehabilitation services they need to provide locally.

A prominent radio news programme reported on escapes from secure psychiatric units in the UK and linked that with subsequent offending by psychiatric patients. The report cited did not distinguish between escapes and absconding but, it is argued here, these are very different activities. The acceptable rate both for escapes and absconding from secure psychiatric units is not defined. A certain level of absconding is a consequence of the therapeutic use of leave, which, as part of rehabilitation, is likely to be linked with a reduced reoffending rate post-discharge.

Coercion is a subjective response to a particular intervention and has been considered an unfortunate but necessary part of the care of people with psychiatric illness. Its ethical underpinnings, evidence base and clinical implications are not commonly considered in day-to-day care; however, this requires reconsideration as the potential for an increase in coercion stretches beyond the boundaries of the hospital into the community. Much of the research that has been undertaken highlights the prevalence of coercion, the ‘grey zone’ between compulsory interventions and the experience of patients and patient outcomes in the light of coercion. Policy makers need to consider the evidence for interventions that increase the experience of coercion in order to reduce its impact. Clinicians need to understand the principles of procedural justice, minimise the use of legal detention and be mindful that implied consent for one intervention may lead to experiences of coercion involving linked management strategies.

Across academic medicine, including psychiatry, women are underrepresented in senior positions. Various reasons have been put forward, for example the lack of high-ranking female role models or mentors and a reduced rate of career progression for women compared with men. Mentoring has been shown to be a popular and feasible intervention which can improve the success of those perceived as disadvantaged groups (in this case women) by having an important impact on personal development, career guidance and research productivity.

Offender health is an important part of general mental healthcare. To improve the health of offenders, we need reforms similar to the reforms in community care of the last decade – early intervention, alternatives to the institution and multi-agency community services. Front-line clinicians are in a key position to bring about such reforms. It will be crucial to argue that improvements in offender health will help bring about broader government aims such as reduced reoffending.

Treatment of mental illness in Black and minority ethnic groups differs from that in the White majority. Large differences in admission, detention and seclusion rates have been recorded. These disparities extend into the physical healthcare setting, particularly in the USA but also within the UK National Health Service. There are many influences on prescribing of psychotropic medication, not least the metabolising capacity of the individual. Ethnic differences do occur, particularly for East Asian peoples. However, these differences are broadly similar across ethnic groups, particularly for the cytochrome P450 enzymes responsible for metabolising psychotropic medicines. Psychotropic medication prescribing also differs by ethnicity. Specifically, antipsychotic dose, type and route of administration may differ. However, most data originate in the USA and UK studies have not replicated these findings, even after controlling for multiple confounding factors. Similarly, antidepressant prescribing and access to treatment may differ by ethnicity. These differences may have complex causes that are not well understood. Overall, prescribing of antipsychotics appears to be broadly equitable in Black and minority ethnic groups.

UK mental healh services have been distinguished by their continuity of care but recently there has been a move to separating consultant responsibility for in-patient and out-patient care. Local examples of the success of this approach have been published but there has been remarkably little careful thought about its longer-term impacts. International comparisons would suggest that there are significant potential disadvantages, including increased bed pressures. Some disadvantages, such as the poor fit with the Mental Health Act and patient dissatisfaction with structural discontinuity are already obvious. A more considered debate is called for.

The Royal College of Psychiatrists has established a Working Group on Choice in Mental Health and held a conference to include service users in formulating a challenging view of the choice agenda for mental health. This is set out here to stimulate wider interest. Choice-based practice develops in a climate of trust and information, and goes beyond simple variety or individual consumerism. For some service users, limited initial areas of choice can be of great importance, but a true culture of choice requires the widespread participation of service users and carers in service improvement. It is important that psychiatrists champion the empowerment of their patients through choice, in policy and training, and in clinical practice.

Mystery shopping is being increasingly used in psychiatric service evaluation but because it involves an element of deception, akin to research involving pseudo-patients, questions have been raised about its ethical acceptability. Here we discuss these ethical issues and argue that mystery shopping should only take place subject to certain conditions. First, it ought to be clear that the evaluation cannot be done by using non-deceptive methods. Second, independent scrutiny should conclude that the importance of the aims of the evaluation is sufficient to justify the deception used.

Psychiatrists make important and specific contributions to the care of those with mental health problems and high-quality services should enable patients to benefit optimally from a psychiatrist's distinctive skills. In this article we seek to identify and consider the core expertise of the psychiatrist.

In answer to Louis Appleby's editorial, I am proposing that the role of mental health services in offender healthcare is to improve people's mental health and it is the role of the courts and the government to reduce the prison population. I also argue that with a reinvestment of existing resources into prison mental health we can reduce admission to expensive medium secure and low secure placements, save money and further reinvest in better care.