Psychiatrists, politicians and the public continue to be concerned about the care of mentally ill people who are potentially dangerous or vulnerable. In this context the College convened a conference on ‘Managing the high risk patient’1, which addressed issues of risk assessment, resources and legislation. The issues debated were of relevance beyond ‘high risk’ patients and underscored the difficulties the College and the Department of Health face in trying to achieve a satisfactory level of psychiatric service and practice across the country.

It is in the nature of Health Services that there should exist a balance between the general and the specialised; between the treatment of common conditions with generally applicable techniques and the handling of more unusual diseases. Services which require scarce skills and treat less patients who need more time are expensive. In a cost-driven situation, these skills are likely to be constrained in favour of more generally applicable, lesser standards which are cheaper.

We have evaluated the effects of providing a ‘roving’ psychiatric clinic to local authority residential homes for the elderly. The clinic was well received by the staff in the homes, reduced the need for urgent domiciliary consultations and hospital admission and appeared to be highly cost-effective.

This paper describes the results of a survey of adolescent offenders referred to a tertiary National Health Service forensic psychiatric service based in South Wales over a three year period. Seventy-seven adolescents aged between 13 to 18 years were seen (5.1% of all referrals to the Service during this time). The majority of the adolescents had committed major offences including serious sexual crime, wounding and murder. A high rate of mental disorder was observed in this survey as well as high levels of substance misuse. Eighteen per cent were admitted to a hospital for further assessment and treatment.

Driving during and after a psychiatric illness is an important area about which relatively little has been written. This paper reports on a questionnaire study aimed at seeking psychiatrists' knowledge and views on this issue. Of 187 questionnaires distributed 101 were returned, and replies indicated that psychiatrists are generally unaware of regulations currently in force. Suggestions on how to improve matters are mode.

We have subjected the current structure of the psychiatric consultation to critical examination, and We propose that the concepts of ‘history’, ‘mental state’ and formulation’ should be abandoned. In their place we propose the more carefully defined concepts of ‘narrative’, ‘interaction’, ‘examination’ and ‘inferences'. The clinician should make a dear distinction between information that is reported, observed or inferred, as these sources of knowledge are qualitatively different, and subject to psychodynamic, systemic and cultural influences. We propose that this approach would facilitate a clearer and more comprehensive understanding of the patient, and lead to a more creative therapeutic relationship.

A case note study of antipsychotic prescribing in an inner London hospital showed that although doses of individual drugs were below the British National Formulary limits, polypharmacy occurred in a third of cases. Multiple regression analysis showed high doses were associated with a current risk to the self or others and increasing number of previous admissions in patients with mania and treatment non-responsiveness in schizophrenia.

Most long-stay patients discharged from psychiatric hospitals under community care policy are being accommodated in suburban communities. The communities' attitudes have a major bearing on the success of this policy. A census of perceptions of psychiatric services was conducted in two areas prior to the opening of long-stay supported houses for the mentally ill. Many respondents (37%) had a negative perception of psychiatric treatment in hospital. Most (82%) had heard of community care policy but few (29%) knew about the imminent opening of supported houses for the long-term mentally HI in their own street. Most respondents (66%) were against the closure of psychiatric hospitals and many saw It as a cost cutting exorcise. The majority agreed with the idea of long-stay patients being discharged into smaller units in the community although a substantial minority (20%) thought it would have a bad effect on the local community. An overwhelming majority of respondents (91%) thought it was important for local residents to be given information about new mental health facilities in their neighbourhood. Respondents were worried that patients would not get adequate support and that they might be dangerous. If community care policy is to succeed, attention needs to be paid to the community's opinions and desire for information about local services.

In recent years, the care of people with long-term and persistent mental illness has been shifting from institutional to community care with a consequent increase in the use of informal carers. Given that both professionals and carers are human resources contributing to the health and well-being of patients, it is surprising that so little research on the needs of carers or means to improve their effectiveness has been undertaken.