We describe the development of a pilot personality disorder outreach service. A case series of 13 patients was studied. Data were collected using pro forma, semi-structured interviews and a structured assessment of personality disorder.

All personality disorder clusters were represented among the 13 patients. Treatment recommendations usually supported the existing approach – the ‘added value’ of the outreach service was that difficult interpersonal dynamics could be considered and thought through with an objective observer. Opinions differed on whether the service was more useful for the assessment and brief treatment or continuing care teams.

Personality disorder services need to develop expertise in all clusters. There is a need to moderate the harsh self-critical attitudes of the care coordinators. The national framework for personality disorder is useful for service development, but the services need to be tailored to the individual needs of specific teams.

To identify problems with the management of perinatal mental health disorders and areas where improvements are thought-required. The study used qualitative methods comprising focus groups with recovered patients and interviews with health professionals.

Issues we identified included a lack of knowledge, skills, integrated working, poor access to resources and ill-defined professional roles and responsibilities. Improving care and service provision requires the development of training and education programmes, care pathways and protocols, and referral guidelines and liaison services.

Difficulties over managing perinatal mental illnesses occur at all levels of healthcare provision. Our findings confirm best practice recommendations which emphasise improved joint working and the provision of specialist services in all localities.

To determine the nature of current liaison psychiatry services in Wales, a structured telephone interview was conducted with representatives of all 11 National Health Service trusts.

Three trusts (27%) had no dedicated liaison psychiatry service and only one of the eight (13%) with a service had a full-time consultant liaison psychiatrist. Only two services (25%) had a full-time junior doctor and three (37%) were not multidisciplinary, comprising nursing staff alone. No team had a clinical psychologist and only two (25%) provided a psychological treatment service.

Liaison psychiatry services across Wales are fragmented, under-resourced and unlikely to meet patients' needs. They fall well short of the recommendations of the Royal Colleges of Physicians and Psychiatrists.

To describe the implementation of supplementary prescribing and nurse-led care in an acute in-patient unit. The issues of delegation and distribution of responsibility were explicitly addressed. Structures were developed for training and supervision, to ensure improved medicines management in the acute setting.

We present our five-step model of nurse-led in-patient care and our experience of using a clinical management plan for 33 patients.

Implementation of supplementary prescribing provides a model for new ways of working, requiring engagement of both doctors and nurses, clear delegation and distribution of responsibilities, and well-developed governance structures.

We established two ‘dual diagnosis’ community psychiatric nurse posts within community mental health teams in Lanarkshire to improve the service care for individuals with comorbidity. A questionnaire-based evaluation of the service over a 2-year period was conducted.

Comorbidity was under-reported by community mental health teams and under-referred to specialist addiction services. The presence of new specialist nurses enhanced the detection of comorbidity, improved staff perceptions of working with patients that misuse substances, and was associated with a clinical and functional improvement in patients over 2 years.

Our findings support the recent trend to provide integrated care for comorbid service users within mainstream mental health services, and suggest a model of service delivery that might be more widely developed to address the concern that such users ‘fall through the gaps’ between services.

Confusion in an older patient on a general hospital ward requires prompt and appropriate management. To this end, evidence-based guidelines have been produced and disseminated by Gwent Healthcare NHS Trust. An audit was carried out when it became apparent that junior doctors might not be aware of the guidelines and that their availability on the wards was limited. An action plan was generated and a second audit carried out. Our aim was to establish whether the doctors' knowledge of the guidelines and their availability on wards changed as a result of our action plan and audit.

The audit consisted of a survey of general wards at the Royal Gwent Hospital and at St Woolos Hospital to assess availability of the guidelines and a questionnaire administered to a sample of junior doctors. The guidelines were available on 17% of wards; 11% of junior doctors were aware of them. Results of the audit informed implementation of an action plan. The second audit showed a limited improvement in availability (increased to 34%) and awareness (increased to 15%) of the guidelines, with no statistically significant difference.

Apparently well-thought-out action plans may produce minimal change, but unless the audit cycle is completed this fact cannot be corroborated. In generating action plans, more consideration may need to be given to the factors that influence the spread of change in healthcare systems.