The idea that a psychiatrist should attend the police operation at a protracted or terrorist siege has gained ground. London has had more than its share of sieges, Balcombe Street, Spaghetti House, Iranian Embassy, and the Libyan Embassy to name four of the most notable. Dr Peter Scott took on the role of adviser to the Metropolitan Police in such incidents single handed until his death in 1978. He gave his own account of his work (Scott, 1978). This current account carries the topic forward a little in the light of experience gained since his death and is in response to repeated requests, by other psychiatrists, for information.

In setting out a health strategy for England the White Paper, The Health of the Nation includes mental illness as one of its five key areas for action. Within mental health three targets are set out.

The populations in the large mental handicap hospitals are known to be diverse, ranging from elderly non-psychiatric residential groups to acutely psychotic and behaviourally disturbed patients. At present demographic variables, medical and psychiatric characteristics of populations in these hospitals are changing in parallel with implementation of community care and resettlement programmes. In resettlement programmes, discharge priorities have been given to the easy to manage and less dependent residents while new challenging behavioural units and admission assessment wards are being opened to care for the multi-handicapped population.

It has been claimed (Abbati et al, 1987) that patients benefit from continuity of professional involvement sustained over a long period. Schizophrenia sufferers in particular find it harder than non-sufferers to articulate their difficulties and concerns, and may adjust poorly to change, only building up trust in professionals over an extended period. In their turn, professionals need time to get to know such individuals and to recognise ‘early signs’ (Birchwood et al, 1989) of possible relapse. Management of potential decompensation involves a knowledge of how the individual has responded to changes in medication in the past and what psychosocial factors may be relevant. Working with such patients refines the clinician's skills in interacting with them, obtaining their compliance with a particular regime, and pre-empting potential problems. Without this background of knowledge and experience, the management of sufferers may be crude with adverse results for the patient.

In view of concern regarding rising youth suicide rates, suicide being a critical event in increasing emphasis on clinical accountability, I conducted a quality assurance exercise in relation to casualty department assessments of parasuicides. While much has been written in the area of suicide assessment and rating scales, I found nothing adequate for my purpose. Accordingly, I present a format for conducting such an exercise with the aim of providing suggestions as to which clinical assessment items might usefully be emphasised in future clinical assessments. It has been designed solely to guide this process with no attempts to estimate reliability or validity.

Liaison with the various agencies which deal with mentally abnormal offenders is one of the prime roles of the forensic psychiatrist (Royal College of Psychiatrists, 1988). The probation service is a key agency in this regard. The importance of such collaboration has once again been highlighted with the clear message that the care of the mentally abnormal offender is improved as a result (DOH/Home Office, 1991). However, the provision of a satisfactory psychiatric consultation service to probation clients who have been remanded on bail can be problematic. Much of the work of forensic psychiatrists is institutionally based. Non-attendance rates at hospital based out-patient clinics are high (Bowden, 1978). However, general psychiatrists have found that psychiatric clinics based in general practitioners' surgeries are more acceptable to patients than hospital clinics (Tyrer, 1984). The probation office as a community base for forensic psychiatrists is a valid equivalent.

The 1983 Mental Health Act brought several changes aimed at improving the rights of detained patients. Included was a new provision safeguarding the position of nursing staff – Section 5(4); no provision equivalent to the nurses' holding power existed in the 1959 Act. Nurses previously were expected to act in good faith to restrain patients where necessary while the doctor was sought. Such actions under common law were viewed by some to provide nurses with insufficient protection. The 1983 Act made clear the legal position of nurses. A suitably qualified psychiatric nurse can compulsorily detain a hospital patient receiving treatment for a mental disorder for up to six hours. This allows time for the responsible medical officer or nominated deputy to be obtained. The mental disorder must be of a degree where immediate detention is required to protect others from the patient, or to protect the patient's own health or safety.

Up to one third of patients referred for psychotherapy fail to attend for their first appointment (O'Loughlin, 1990). Psychotherapy assessments are usually allocated a considerable portion of uninterrupted time, and an unexpected non-attendance wastes significant clinical resources. A variety of strategies have been used to ensure that assessors are not left waiting for a patient who never comes. One method is to send out forms which must be completed and returned before a first appointment date is given. In O'Loughlin's study, in which a similar questionnaire to that detailed in this paper was used, it was suggested that sending a pre-appointment questionnaire reduced the default rate.

Over recent years there has been an increase in the number of training schemes in general psychiatry which offer posts in the psychiatry of mental handicap. I will describe my experience as a registrar during a nine month full-time placement in psychiatry of mental handicap as part of the Charing Cross Rotational Training Scheme in Psychiatry.

Electroconvulsive therapy (ECT) is an effective treatment in severe depressive illness (Kendell, 1981). It is unusual in being administered predominantly by junior doctors, although prescribed by consultants. Pippard (1988) has drawn attention to a tendency for practice to depend on established custom rather than research evidence, and to a lack of consultant involvement in ECT teaching.

The concept of personal time management does not, perhaps, generate immediate enthusiasm among junior doctors: the terminology seems somewhat alien and the idea more relevant to the world of business than that of clinical practice. There is a lack of coverage of this issue in the citations concerning the applications of time management to the medical profession. Although allied professions have made an attempt to address the matter (Shubin, 1988), they have tended to concentrate more on personality types (McAlvanah, 1989) and obstacles to effectiveness (Sheridan, 1988), rather than providing practical guidelines.

Rotational training schemes are now well established as appropriate means of organising psychiatric training in the UK. There are already a number of good descriptions of how schemes are organised and managed (Soni et al, 1987; Davies, 1990) and one report of the experiences of trainees in a particular scheme (Fahy & Beats, 1990).

In 1991 the Royal College of Psychiatrists organised two overseas teaching fellowships. In this paper we describe our visit to El Peral Hospital in Chile and discuss the value of our going there.

We are now well into the second year of the separation of purchaser and provider functions in the National Health Service. District health authorities as purchasers of services are required to assess the health care needs of their population (NHS Management Executive, 1991a) and seek professional advice regarding both the need for, and the provision of, services. The NHS Management Executive acknowledges that local clinicians in provider units will continue to make a major contribution to this advice (NHS Management Executive, 1991b).

A Confidential Enquiry has been set up to review cases of homicides and suicides by mentally ill people. It is appreciated that those looking after people with psychiatric illnesses have always been alert to the need to protect those in their care. However, the objective of the enquiry is to discover whether some of these distressing deaths might have been prevented by different approaches to clinical management or by different provision of care.