Medical audit has been defined as the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient (DOH, 1989). The White Paper Working for Patients states that the Government proposes that every consultant should participate in a form of medical audit agreed between management and the profession locally. It also states that management should be able to initiate an independent professional audit.

The Government White Paper, Working for Patients (1989), although presented as a discussion document, should be seen as a position paper. It is clear that the government intends to implement the major proposals, and will be able through its control of general management, enhanced by a stream-lined management structure (Working for Patients para 2.3–2.11), to put pressure on health authorities to take action accordingly.

What follows is concerned with the role of the consultant. To avoid stereotyping of gender or race, this consultant will henceforward be referred to as she and should be considered as of minority ethnic origin.

A cynic might regard the plethora of reports on community care as a study in how to create the impression of activity while doing nothing. Demands or suggestions for action are easily deflected by holding up the spectre of a forthcoming inquiry – for example the Griffiths' report on community care. Only six months after its launch, one could be excused for thinking that Sir Roy's report never happened. But it would be short-sighted to view Griffiths as a non-event. It embodies a workable framework for implementing community care, emphasises the importance of individual choice and demonstrates the foolishness of relying on those above to wave magic wands and produce instant national solutions. Community care is about localising services and must evolve locally.

The Community Psychiatry Research Unit at Hackney Hospital have established a support team for the care of people disabled by long-term mental illness living in the community. The work of the support team in coordinating and managing the care of their clients in supportive accommodation using a review system and an information package is described.

It was decided to plan the introduction of a benzodiazepine policy in North East Essex when the result of a health authority survey of all local general practitioners in 1986 revealed a substantial dependence problem among patients in the area.

On 4 June 1839 the first patient walked with friends the mile uphill to the new Crichton Institution from the lunatic wing of Dumfries and Galloway Royal Infirmary. Detailed clinical records support a diagnosis of melancholia; the patient was discharged well in 1844 and follow-up confirmed her recovery.

In April 1987 the Bulletin of the Royal College of Psychiatrists published the results of a survey of the training of junior psychiatrists in behavioural psychotherapy in the South West Thames Region (Drummond & Bhat, 1987). This survey reported the experience of trainees based at 10 postgraduate teaching rotations in the Region. The survey was conducted shortly after the appointment of a new peripatetic senior lecturer. Prior to this appointment there had been no regular senior lecturer teaching in behavioural psychotherapy in the Region for at least one year. The paper demonstrated that the majority of trainees had received little or no previous teaching or supervision in behavioural psychotherapy. It also demonstrated that trainees welcomed the introduction of such teaching and that their knowledge of the subject improved significantly after three teaching sessions held at monthly intervals. However, after this short time only 17.1% of the trainees reported that they had started to use any of the techniques they had learned in clinical practice.

Mental Health Review Tribunals were introduced in the Mental Health Act (1959) to safeguard psychiatric patients against unjustified detention in hospital. The powers of tribunals form “an important part of the fabric of civil liberties” (Wood, 1974). However, in exercising their prime function of preventing unjust detention, tribunals in practice also have to take into account patients' clinical needs and the protection of the public. Further weight was added to this complex burden of decision making following a judgement by the European Court of Human Rights in 1981 which upheld the right of all detained patients to a periodic judicial review of their detention. As a result of this judgement the Mental Health Act (1983) extended tribunal powers to include the release of offender patients sentenced by Crown courts and given hospital orders with restrictions on discharge. Such individuals may have been convicted of grave criminal offences, and their discharge or transfer from hospital would otherwise require the consent of the Home Office.

Shiwach & Murray (1986) have outlined why research experience is desirable for trainee psychiatrists. The majority will use their experience to gain a better understanding of publications in professional journals; however, only a minority will become full-time researchers. Although most trainees have a positive attitude to research (Davidson & Abou-Saleh, 1987; Burford, 1987) only a few manage to complete a project before the second part of the Membership examination (Kendell, 1984; Davidson & Abou-Saleh, 1987; Burford, 1987). Kendell has highlighted some of the difficulties encountered on the Edinburgh MPhil degree course. He fears that “rising standards of the College's Membership examination” might deter even some of the more determined registrars to take on an extra commitment while preparing for the MRCPsych examination.

Community care around Edinburgh was very poor during the early 1850s. Insane paupers were often detained without warrant in poorhouses and private houses, with no official visits from the sheriff and no records of care kept. Accommodation was often bad, with scant furnishing, such that inmates might have to eat their meals off their knees. Where patients had dirty habits conditions were described as “very close and unpleasant”. Those who received a wash were those who were noisy or violent, using water that was likely to be cold. Only in the summer might a patient be allowed to bathe in the sea. Sexes were often imperfectly separated though restraints might be used, for example, to a bedstead at night. In some establishments, females might fare better in terms of clothing and food (Scottish Lunacy Commission 1857).

A review of the role and function of the Mental Health Act Commission is a natural outcome of the first five years experience of its workings. By the Autumn, when the third Biennial Report will be published, the new direction and operation of the Commission will be determined by the Secretary of State for Health on the basis of the recommendations of the review. It is too early to indicate the changes that are likely to be wrought by this development. It is possible, however, to reflect on the activities to date.