At most conferences on medical audit we are reminded that medical audit is centuries old. What is new is the push for medical audit as a formal activity in which each clinician must take part. This push came from Mrs Thatcher's NHS review in 1989, invoking the spirit of market forces in the NHS. Whether this spirit is that of a goddess or demon, it is perhaps too early to know. As many of the Royal Colleges (Hoffenberg, 1989; Royal College of Psychiatrists, 1989; Royal College of Surgeons of England, 1989) and the Standing Committee on Postgraduate Medical Education (1989) produced their guidelines, the push to make medical audit a formal activity in which each doctor should take part became reality in 1989.

This paper discusses the concept of Psychiatric Register Integrated Support Modules (PRISM). It addresses issues around the linkage of longitudinal data held on individual patients in case register systems to expert and other decision support systems. The paper describes two developed systems which link to the SafetyNet case register system, an inexpensive and comprehensive Mental Health Information System which runs on single or networked computers and which was previously described in detail (Taylor & Bhumgara, 1989). The merits of the two approaches in aiding clinical decision making on anti-psychotic medication are discussed as are the medico-legal implications of using expert systems.

In an era where computerised information is dominant, it may seem an eccentric enterprise to assess the quality of case-notes and to propose changes in the notekeeping process. There are no institutional incentives for clinicians to provide organised and standardised clinical notes (Casper, 1987) and there is no clear evidence that poor notekeeping means that satisfactory care has not been provided.

Trainees are often called upon to organise educational events. We hope that our experience will be helpful and that some of the lessons we have learnt will be of use to others.

Medical students at University College Hospital are attached to medical firms during their first clinical year, where they receive one hour of liaison psychiatric teaching every week. The teaching usually takes the form of a presentation to the group of a patient seen by one of the medical students on the medical ward, followed by a discussion with particular emphasis on the doctor-patient relationship.

Academic medicine in South Africa was created largely by talented graduates who, having travelled overseas (especially to Britain) for postgraduate training, returned to teach in the newly established medical schools and teaching hospitals. However, over the past three decades fewer have decided to return. Consequently academic medicine generally is in decline. Hospital specialists are demoralised, and about 80% of those recently surveyed indicated that they intended leaving the public health service if the present imbalance between service commitments, research opportunities, and poor pay persists (Curtin, 1991). About 40% of graduating medical students emigrate, usually to avoid conscription. The continuing violence and political uncertainty within the country probably ensure that few will ever return.

“to neglect the study of history is not prudent”. Samuel Johnson. (Quoted by Hunter and Macalpine in the preface to their Three Hundred Years of Psychiatry)

Many admissions to general adult psychiatric beds occur as emergencies, either due to social crisis or relapse of psychiatric illness. Other admissions are planned to arrest or reverse deterioration in mental state. Length of stay varies from days to months depending on reason for admission and adequacy of support in the community. Rapid readmission or failed discharge, defined as readmission within three months, has been linked with multiple previous admissions and personality factors (Jones, 1991).

The Senior Registrars (SRs) in the Psychiatry of Old Age (POA) group was formed in June 1990. This is an account of our creation, structure, and development and is followed by our ‘policy statement’.

It is considered valuable for senior registrars to have experience of liaison with other agencies and of setting up and evaluating projects as part of higher training in community psychiatry (Guthrie, Black & Osborn, 1991; Royal College Of Psychiatrists Working Group, 1990). However, this may not be easy to arrange due to, for example, lack of suitable opportunities and insufficient time for initiating a project and carrying it through. Such projects are often difficult to establish and the trainee may find that a good idea founders on a variety of unexpected problems.

From time to time I am asked to help colleagues from other disciplines with interprofessional issues. Here is an example. To avoid identifying the workers concerned, names have been changed and some details omitted.

As part of an ongoing educational audit of the process, content, and outcome of higher training in the Mersey Region, the Senior Registrar Tutor (MA-S) and the Psychotherapy Speciality Tutor (MG) organised a whole-day workshop for the senior registrars, involving them in internal audit as well as providing an experience of strategic thinking on the impact of NHS changes on higher training. We modified a package used in industry for strategic planning called the Quick Environmental Scanning Technique (QUEST) (Nanus, 1984). The QUEST process involves two whole-day meetings usually separated by a month which we condensed and adapted to one day, alternating large group discussion with small group work.

An understanding of research methodology and design including the appropriate use of statistics is considered by the Royal College of Psychiatrists to be an essential part of the education of psychiatrists. The report of the working party for the review of the MRCPsych examination emphasises this by mentioning statistics and research methods as one of the major areas that will be examined as part of the sciences basic to psychiatry (Royal College of Psychiatrists, 1985). They point out that over recent years there has been an increase in the number of questions devoted to this subject, and state that this trend should continue. Pre-membership psychiatric trainees are often encouraged to undertake or participate in research (Sims, 1988), but many commence projects which never come to fruition (Hollyman & Abou-Saleh, 1985); lack of adequate supervision seems to be the cause (Royal College of Psychiatrists, 1991). The Royal College of Psychiatrists is unique among the Royal Colleges in that it enables candidates for the membership examination to be exempted from the essay paper by submitting a dissertation in advance based on a piece of original research. This is known as the research option.

The College library is continuing with its project to photograph some of the large old psychiatric hospitals. With the planned closure and possible demolition of many of these institutions it seems worthwhile to record the architecture of the buildings, although inevitably most have been extended, renovated or dissected over the years. Initially hospitals in the vicinity of London are being photographed but we hope to include establishments throughout the country and would be pleased to receive photographs of any architecturally interesting psychiatric hospitals to add to our collection. (Photographs on this spread by Mr C. Priest/MAGPIE Reprographics.)

Recent changes in psychiatric services have produced a movement away from large hospitals to management within the community. A successful home treatment service with 24-hour cover has been described for severe acute psychiatric illness, though hospital admission was not entirely avoided (Dean et al, 1990). It is difficult to manage violent patients or those who will not comply with medication at home. If relatives are not supportive hospital admission will be required. Although living alone is not a contraindication to treatment at home, those who require constant supervision because they are, for example, suicidal need to be admitted. Concurrent physical problems may also necessitate hospital admission. Any future services must therefore include some in-patient care.

During 1991–2, the Department of Health is spending £3 million on an experiment. Consultants with an interest in management are being sent to Business School to rub shoulders with middle managers from outside the NHS. Without setting any specific individual objectives, the Department hopes that the acquired learning will be beneficial in the new market-orientated NHS. Together with a community paediatrician, an anaesthetist and a microbiologist, I was selected for a place on the G-course at Ashridge Management College, an intense, four week residential immersion in the theory and practice of profit-driven business.