From the back of the school hall a boy spoke: ‘If you agree to play cricket you can hardly complain when they put the fast bowlers on against you.’ Eighty of his fellow sixth-formers laughed, but his view differed little from most of theirs. The discussion was about ECT.

“When early summer with its bright clear days has brought the academic year to a close, emptying chalky classrooms and leaving books at rest on library shelves, then academic folk long to go on pilgrimages.”

It is an expectation of the Royal College of Psychiatrists that its members should demonstrate a knowledge of the psychiatry of childhood and adolescence. Prospective members are examined on this and a clinical placement in child and adolescent psychiatry is a recognised specialty component of general training. That this is so reflects the fact that one quarter of the population is composed of individuals under the age of 18. This group has an appreciable psychological morbidity rate with patterns of psychological disability and suffering which differ appreciably from those encountered in general adult practice. A competent general psychiatrist should be familiar with the pattern of psychiatric pathology is childhood and be conversant with the services available for its treatment. For the health of the psychiatric profession as a whole, it is important that trainees have some working experience of child and adolescent psychiatry so that they may find whether this area of practice is attractive to them. Experience at registrar level provides an important recruitment opportunity for future senior registrars and thus consultants in child and adolescent psychiatry. Successful completion of general training in psychiatry with possession of membership of the Royal College of Psychiatrists is effectively a universal prerequisite for entering the senior registrar grade and higher training in child and adolescent psychiatry.

Since its introduction in 1953, the preregistration year has been divided equally between medicine and surgery. The General Medical Council has recently shown renewed interest in possible modifications to this time honoured scheme. One pilot scheme at St Mary's Hospital in London has successfully incorporated a four month period of general practice in the preregistration year, reducing the preregistration medical and surgical jobs to four months each. Another pilot scheme in Sheffield involves four months of psychiatry, four months of general medicine, and four months of general surgery. A psychiatric perspective on possible changes in the preregistration year is included in a report that derives from a conference held by the Royal College of Psychiatrists, the Association of University Teachers of Psychiatry, and the Association of Psychiatrists in Training.

This course was organised so that future general practitioners might learn those aspects of psychiatry which are relevant to their future work. It has been recognised that six months working in a mental hospital is only helpful to the future GP in terms of assessment and treatment of severe psychiatric illness of which the general practitioner sees relatively little. The vast majority of psychiatric illness seen by a general practitioner in his day-to-day work is not represented at all in an in-patient psychiatric unit.

It is 16 years since the Royal College of Psychiatrists published its recommendations for the training of psychiatrists. The guidelines for the training of general psychiatrists in psychotherapy have recently been reviewed and, once again, experience in behavioural psychotherapy was an integral part of such training.

Current government policy and the need for higher standards of training are leading to reductions in registrar posts and more emphasis on ‘consultant based’ services. My first consultant post was in such a service. I hope that a description of some of the difficulties encountered will assist informed debate.

Oxfordshire is a pleasant, prosperous county dominated by the City where about one third of its 480,000 population lives. Oxford itself has nearly 15,000 students attending the University or Polytechnic. The active rehabilitation of long-stay patients was started in Oxford over 25 years ago, with the result that by 1986 there were only 40 non-dementing psychiatric-in-patients with a current admission of five or more years. This successful programme of rehabilitation, now virtually completed, was achieved by creating a wide range of sheltered work and other activities, and by the provision since 1963 of over 40 group homes and hostels by the Oxford Group Homes Organisation. However, many psychiatric illnesses still have a chronic and relapsing course; 65% of all admissions, aged 18 to 65 to the Oxford District mental illness units in 1982 and 1983, were readmissions. For those diagnosed as suffering from schizophrenia the figure rises to 80%. In 1972 and 1973 Mann & Cree surveyed 400 ‘new’ long-stay patients (current admission one to five years, aged 18 to 65) in 15 hospitals in England and Wales. They found a rate of 25 per 100,000 population and concluded that for about one third continuing hospital care was the only realistic option. If the remainder were to leave hospital, hostels providing a high level of support would be needed. The recent 1982 survey of ‘new chronic’ in-patients in 14 Scottish psychiatric hospitals still showed a rate of 17.2 per 100,000 population, of whom only 38% were not thought to be in need of continuing hospital care.

The cities of Bristol and Bath have played an eminent role in the history of mental handicap.

Unfortunately, documentation is rather scanty, particularly on the pre and post Reformation era but much more is known about the Holy Cross Hospital in Bath, perhaps the oldest mental handicap hospital in Great Britain. The Romans contributed to its foundations when they built Fossway Road on the outskirts of Bath which the pilgrims later used to visit Glastonbury.

The recent announcement of a further £5 million which has been distributed to Regional Health Authorities makes a total of over £22 million that has been made available specifically for the development and expansion of services for drug misusers over the past three years. An important element in the development of such services has been the formation of Regional Drug Problem Teams; this seemed a useful time to review the working of one such team over the past year.

Depot Clinics or ‘Moderate Clinics’ tend to be similar. They are usually regarded as ‘low priority’ and often staffed by clinical assistants with only a limited training in psychiatry. Typically a large number of patients turn up each week, and there is little time for a detailed assessment of their needs. The clinic is often seen as ‘a chore’ by medical and nursing staff who may feel that the long-term care and support of patients with chronic disabling illnesses lacks excitement. One gains the impression that the patients with the less attractive personalities or those presenting repetitive management problems are more likely to be referred.

There had been repeated staff dissatisfaction with the community meetings. Particular concerns included staff interrupting each other; frequent changes of theme; insufficient time for adolescents to speak or answer questions before the next staff intervention; some staff, particularly the more experienced, tending to fill the time with their questions or contributions. Repeated discussion of the meetings resulted in transient improvements lasting only until the next period of competition between eager therapists, or the next assertion of ‘need to know’ by the oncoming shift.

Selective abstraction of information and good communication are essential in the practice of psychiatry. A good psychiatric discharge summary performs both these functions and can therefore be a significant aid in patient management. The need for a good psychiatric discharge summary is no less necessary in the psychiatry of mental handicap than in general adult psychiatry. However, the psychiatry of mental handicap does differ in some respects from that of general adult psychiatry. This difference therefore should be reflected in the psychiatric discharge summary in mental handicap settings if the summary is to represent accurately the clinical process. This fact was recognised by the Medical Executive Committee of Leavesden Hospital and it was therefore decided to provide specific guidelines on the writing of discharge summaries in a mental handicap in-patient setting to junior trainees in that hospital. Below is a document which I prepared at the request of the Medical Executive Committee, and which has now been officially accepted by them. It is hoped that its publication will be of interest to readers working in other mental handicap hospitals.

A mixed audience of health professionals at a recent Mental Health Film Council screening welcomed this video which shows a variety of community-based initiatives. Most participants thought it would be useful in several contexts, for fellow professionals and for the general public. Those working with individuals who are ill, have a handicap or are old could be helped by the video, it was believed, to clarify their own attitudes to institutions: local residents might be introduced to the idea of care in their own community.