Three years is a long time in the life of a President, rather longer than the gestation of an elephant, and about the time that my vines took to start bearing fruit! As I write this in February we are in the middle of the rugby season; Union in the four nations served by the College, and League, also here in Yorkshire. I see the role of the President rather like a good fly-half – a strategic and accurate pass will enable somebody else to score; when in trouble, kick for touch and gain as much territory as possible: A fly-half rarely scores tries himself! The College and its Officers try to improve the ground for the practice of psychiatry, but it is Members and Fellows locally who can capitalise on this and improve the quality of care for their patients.

Effective participation in the work of Mental Health Review Tribunals (hereafter the “Tribunal(s)”) held under the Mental Health Act 1983 (MHA) requires a knowledge and understanding of detailed points of law, and practice. This summary and commentary may be of assistance to new or infrequent participants.

Under the Mental Health Act (1983) Mental Hospital Review Tribunals act as a safeguard against unwarranted detention of patients in psychiatric hospitals. Detention, other than in special hospitals, is most commonly under section 2 (assessment order) or section 3 (treatment order) of the 1983 Act. Patients thus detained have the right to appeal to a Review Tribunal, which has the power to order their discharge.

It is well established that there is a strong relationship between psychiatric admission rates and socioeconomic deprivation; the more deprived the area, the more admissions may be expected (Hirsch, 1988). In the development of community resources for the mentally ill, therefore, an aim might be to site the majority of facilities in areas of greatest social deprivation, as that is where the majority of patients will live. It might also be expected that areas of greater deprivation would have more professional NHS staff. The present survey examines the siting of rehabilitation and support services in the catchment areas of Scottish psychiatric hospitals in relation to measures to socioeconomic deprivation. It also examines the relationship between deprivation and numbers of professional NHS staff in the different catchment areas.

A survey of Scottish psychiatric rehabilitation and support services, carried out in 1983 (McCreadie et al, 1985), found that although there were wide between-hospital differences, the National Health Service in Scotland was making considerable efforts to provide services for the long-term mentally ill. However, services provided by local authorities were seriously deficient.

In spite of the moves over the last 20 years towards community care, there remain substantial numbers of elderly people with both physical and mental illness who require residential, nursing home and hospital care. There is evidence to suggest that health service provision of long term care for the mentally ill has been, and continues to be, reduced. In addition there has been reduction in beds for long term care by geriatric physicians and while the nursing home and residential care sectors have expanded, this expansion has been entirely within the ‘independent’ private and voluntary sector, with considerable contraction of local authority provision. Representations have been made about this to the Old Age Section of the Royal College of Psychiatrists and they have reported on this (Benbow & Jolley, 1992). Concern has not been confined to the profession. Over the last year, there has been considerable media publicity about the long term care of elderly people in institutions. Some of this has been very critical [Panorama, 20.1.92] and has provoked debate on the pages of the national papers.

A significant proportion of patients referred to psychiatric out-patient clinics fail to attend the first appointment. Previous work suggested that typically 30% do not attend (Burgess & Harrington, 1964; Skuse, 1975) and this results in an inefficient utilisation of psychiatrists' time. One solution would be to overbook new patients by 30%. Unfortunately the proportion of non-attendance at each clinic is variable and difficult to estimate in advance. Psychiatrists have been shown to be poor predictors of non-attendance from examining referral letters (Woods, 1992). Overbooking might result in a long waiting time and short time for assessment. Previous research has suggested patients are more likely to attend if they received a personal letter rather than a standard card, had a previous psychiatric history, and if they were seen in a health centre rather than a hospital (Hillis, 1990). Allaying the patient's fears and misconceptions about psychiatry also improved attendance (Skuse, 1975). Work in a child and family setting suggested that sending a family questionnaire prior to the appointment reduced the non-attendance rate (Mathai & Markantonakis, 1990).

In 1991, Derek Humphry published Final Exit – The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. The book was written for mature adults who were suffering from terminal illnesses and required guidance in committing suicide, but it has encouraged suggestive and susceptible people to attempt suicide (Lavin et al, 1992). There appears to be a thin line between assisted suicide and culpable suicide. ‘Culpable suicide’ is used here to describe contributory negligence attributed to persons who unknowingly assist another person's suicide.

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 referral rate to the Psychotherapy Department at the Warneford Hospital, Oxford, has increased by 84% in the last three years, creating a bottleneck at the assessment stage. As part of the response to this we carried out the audit reported here. Assessment for psychotherapy is costly in professional time. If any group of referrers is significantly better at referring patients who need, and make use of psychotherapy, we would have to consider selectively accepting referrals from these sources. We thus asked whether different referrer groups, and different “levels” of referral (secondary or tertiary), were more or less likely to provide patients who ultimately entered treatment.

Over recent years there have been a number of articles in the Psychiatric Bulletin considering the vexed question of research and trainees in psychiatry, most recently the suggestion of ‘research troikas’ by Sims (1992). Although this might work well in teaching hospitals with a reasonable number of academic staff, we see problems for the more peripheral areas. This article addresses these problems particularly as they affect people working outside the main centres. We are not concerned here with what trainees need to know about research, but rather how conducting research fits into their clinical job. We will do this by posing a number of basic questions.

As a consultant in the psychiatry of learning disability for the past 18 years, I had assumed that the Mental Health Acts referred to those patients who have some understanding of the concept of treatment and who are able to clearly express an objection to any proposed management. Those who could not express an objection because of severe handicap (“non-volitional patients”), I treated as informal patients. This view was supported by a representative of the Medical Protection Society, with whom I had discussions soon after I became a consultant. It agrees with the assumption that is widely held that for informal admission to occur, a person need not express positive willingness to be admitted to hospital, that it is sufficient that he is not unwilling to be treated in hospital (Gostin, 1983).

Over the last 20 to 30 years, the team, multidisciplinary, approach to psychiatry has become firmly established. Proponents would argue that it is essential that a patient has the benefit of the different knowledge bases, skills and approaches, which come from the various professionals forming the clinical team. Using the common Gestalt concept, one might hope that a well-functioning team would exceed in its therapeutic effectiveness the sum total of the skills of its individual members. Such a team should be able to communicate well, draw freely from particular skills of members and be able to adopt a consistent approach in its relationships and interventions with patients. This, however, is not always the case. In my experience, it is not uncommon for clinical teams to suffer from unresolved conflicts between their members. Such conflicts can diminish the team's overall potential and make difficulties in adopting a consistent approach with patients. When conflicts are severe, the clinical team can sometimes exacerbate, through its own chaotic element, the disturbances in the minds of its patients. In this extreme, patients may be pulled into staff conflicts and used to augment one side or another of a particular staff difference. This paper argues that for the clinical team to endeavour to reach its maximum potential, there has to be a reasonable degree of resolution and agreement around three ‘constructs’ of potential conflict: ideology, power and boundaries.

The Court of Appeal in its judgement of this case ruled that special care needs to be taken in cases where the defendant suffers from “a significant degree of mental handicap” (This term is used with a specific legal meaning – see below) if the only evidence against him is his confession.

We were interested to read J. J. Hutchinson and A. Puranik (1992) on journal clubs at St Edward's Hospital, and would like to share our experience of running journal clubs in Sheffield. As stated, the College does not provide guidelines on the format of journal clubs, but they do provide a suggested reading list. While this contains interesting and relevant papers, it does not provide a good basis for a journal club programme.

The widespread move to community care for people with a learning disability has caused a change in roles for both the psychiatrist and the general practitioner. The general practitioner is now widely recognised as the primary medical carer for people with a learning disability (Howells, 1991), with the psychiatrist providing specialist support.