It cannot be ignored that community care is now a fact, and not merely an issue. Some mental hospitals have closed and the number of mental illness beds have been reduced overall by about 40% over the last decade and a range of hostels, multidisciplinary rehabilitation teams and community mental health centres have been launched. The move towards well integrated and well coordinated community care has been urged by a large number of reports, white papers and policies including the second Griffiths report, Working for Patients, Caring for People, The Health of the Nation, the Care Programme Approach and care management, with social services becoming the lead agency in community care.

The new system of funding introduced by the National Health Service reforms has led to an increased awareness of financial concerns within the NHS. This was indeed one of the main aims of the reforms, with the expectation that a more efficient and better quality service would result. This may be a realistic aim, as long as clinicians' freedom to make appropriate secondary and tertiary referrals do not become totally dependent upon financial considerations. Yet it has become clear from findings within our own unit, Henderson Hospital, that, in at least 42% of cases, requests for ECR funding for treatment were refused on a purely financial basis (Dolan & Norton, 1992).

This study was undertaken to analyse training needs and to formulate a training plan to meet the needs of psychiatrists in non-training posts.

This brief article reports the results of a questionnaire survey of Academic Departments of Psychiatry in the UK in August 1992 initiated by the Association of University Teachers of Psychiatry (AUTP). The survey was undertaken in an effort to gauge more objectively a growing sense of anxiety within academic psychiatry, whose key functions – education, training, clinical research – seemed to many to be threatened by changes in the logistics of funding within universities and the NHS. These changes include the introduction of the internal market in the NHS, changes in the funding from the Universities Funding Council (UFC) and the service increment for teaching and research (SIFTR), ever stiffer competition for research grants, changing funding patterns for clinical research with the Peckham initiative, and, for the ten London departments, the Tomlinson report.

The asylum movement was developed in the 19th century to provide care and cure for people with mental disorders. In the 20th century the old vision of asylum was abandoned, but no new alternative vision of community mental health care has taken its place. A divide between acute psychiatric services and provision for the social aspects of care has been described by Murphy (1991).

In a rapidly changing NHS, there is a great awareness of the need to consult with general practitioners about their expectations of a service. A number of studies have looked at GPs' perceptions of psychological and psychiatric services (e.g. Eastman & McPherson, 1982; Whitfield & Winter, 1980) but to date little is known about how GPs view psychotherapy services. About 40% of the referrals to the Leicestershire psychotherapy department come directly from GPs and the present study aimed to ascertain local GPs' perceptions of the service. This was timely for the purpose of planning local development but clearly has important implications for psychotherapy services in general.

Electro-convulsive therapy (ECT) is a safe and effective treatment for some psychiatric disorders, but its mechanisms of action remain unclear. In the last decade ECT seems to have enjoyed a resurgence of research interest and some recent findings have raised exciting possibilities of making it a more rational and targeted treatment.

Electroconvulsive therapy is widely seen by the public as a barbaric and outmoded form of treatment. Even within groups of health care professionals, ECT does not have a ‘good press’. Most research into the area of patient attitudes to ECT has been retrospective and often considerably so, and is therefore unlikely to illustrate patients' feelings about a course of treatment at the time it took place (Freeman & Kendell, 1980; Kerr et al, 1982). The only prospective study is that by Malcolm (1989). This showed a low level of understanding of treatment and a high level of anxiety both before treatment and afterwards, but, despite this, a high level of compliance with ECT therapy.

Our aim was to re-examine these findings in order to find a way of improving the experience of ECT.

Audit is certainly the topic of the moment. It is much talked about and a lot of money is being made available for it, yet it seems that there are few real guidelines about how to do it. Many junior doctors who would like to do audit may be put off by the computers and other paraphernalia which are deemed necessary for this purpose. While technology can help, it is by no means necessary and some of the best audit follows the same principles as research: keep it simple.

The aim of medical audit is to improve the quality of medical care (Department of Health, 1989). There was concern that patients referred to a psychogeriatric service (Service X) did not have adequate access to computerised tomography. The nearest computerised tomography scanner was located in a neighbouring district and direct referrals were not accepted. Computerised tomography scans could be obtained indirectly by referral to neurosurgeons. Because of these difficulties “potentially treatable structural lesions” (such as cerebral tumours and subdural haematomas) may have been missed. We decided to compare the use of computerised tomography scans with a nearby service (Service Y) which had a computerised tomography scanner on site. Service X had a catchment population of 33,000 aged over 65 and Service Y a catchment population of 23,420 aged over 65.

The frequency with which a given drug is prescribed (the number of doses per day) should be influenced by several factors. First, frequent prescribing is likely to be more expensive and to consume more resources. About a third of the time spent by psychiatric nurses in interaction with patients is devoted to technical activities such as drug administration (Altschul, 1972). Second, it is especially difficult to persuade psychiatric patients to take medication as prescribed whether as in-patients or as out-patients so treatment regimens should be kept as simple as possible. There is evidence that compliance is better with once or twice daily regimens than with a four times daily regimen.

A leading article in the British Medical Journal (Miller, 1992) comprehensively criticised the Joint Planning Advisory Committee (JPAC) for failing to implement the changes in manning levels needed for Achieving a Balance. This leader came as no surprise to psychiatric trainees, and nor did it offer much comfort. The ‘bottleneck’ between registrar and senior registrar has become a ‘log-jam’ and although prospects for trainee psychiatrists are not as bleak as for the unfortunate would-be thoracic physicians cited in the leader, they are bad enough. For example, when a single SR post in adult psychiatry was recently advertised for the NW Thames region, there were over 60 enquiries, 45 of which transformed into definite applications, even though the post offered was in a less than popular sub-speciality. Local selection committee members for NW Thames in other psychiatric specialities have also been surprised by the number of applicants. JPAC may not be entirely to blame: the economic recession may be a disincentive for consultants wishing to retire early, thus slowing-up career progression throughout the profession.

With the current balance of manpower, being appointed to a senior registrar post is seen as more of a hurdle in the NHS career path of junior psychiatrists than the MCRPsych examination. Numerically, it is the most significant bottleneck in the system, with substantially more suitable applicants than available posts. One effect that this has had is to encourage a climate where rumours and myths circulate about what is necessary to become an SR. As well as being stressful and demoralising, this can give candidates the wrong ideas of what is realistically required.

A question asked by most children but avoided by adults is “Why am I me?”. It seems obvious and important when one is young but, to a grown-up, is too difficult and perhaps meaningless. Questions of this sort often have culturally sanctioned answers. For instance, “How did the world begin?” could have been answered (somehow) by any educated adult in any period of which we have records, and now the cosmologists are adding their own gloss to the replies.

British Medical Association members are now able to use a new service to doctors which, until recently, has been largely exlusive to libraries in big hospitals and other institutions. At the time of writing, the BMA Library Dial-Up Medline Project has just completed its pilot stage and is due to be launched formally at the beginning of June. Trials started in November 1992 and the system is now up and running.

In the imposing surroundings of the Moses Room in the House of Lords, the United Kingdom Council for Psychotherapy (UKCP) launched its first National Register of Psychotherapists on 20 May 1993. Or rather, celebrated the launch of the Register, as one of the arcane rules of the “other place” is that official launches of such documents cannot take place in the building. These regulations were brushed aside in a successful and upbeat meeting attended by representatives of the Council, politicians and members of the press.

The Substance Misuse Committee of the Mental Health Foundation has produced a booklet called Guidelines for the Prevention and Treatment of Benzodiazepine Dependence. The problem addressed is twofold: encouraging and managing withdrawal, and preventing new cases of dependence. There is no room for complacency because although prescriptions for anxiolytics have halved over the past ten years, prescriptions for hypnotics are unchanged – now twice the number for anxiolytics. The average GP can expect to have about 50 long-term benzodiazepine users on his or her list. The long-term safety of these drugs is uncertain and there are side effects, e.g. memory impairment, ataxia and falls in the elderly, and road traffic accidents.

Ann Barker

In the preface to the BNF you state that “comments and constructive criticism will be welcome”. I should like to ask a question. I should like to know how members of the Committee reach a decision on what dose should be considered the upper limit of medication, and in particular psychotropic medication, commonly known as “the BNF maximum”.