Day care has been called one of psychiatry's gifts to medicine. The British psychiatric day hospital movement began in the post war years and its philosophy continues to flourish with the decline of institutional care.

There is growing interest in this country in developing training programmes suitable for overseas psychiatrists. The motive is partly one of self-interest. The implementation of current Government policy means that many departments will look to overseas visitors to fill their registrar positions in excess of their career registrar allocation.

Edinburgh. She had recently taken up a locum tenens at the Royal Free Hospital in Gray's Inn Road in place of one of the resident staff who was away on holiday. The Lancet records that she was “seen in the hospital and about the wards up to noon on Saturday 15th (August), but since then nothing has been seen of her nor had anything been heard of her up to Thursday morning. We trust that before the paper is in our readers' hands Miss Hickman's whereabouts and safety will be made known to her father, with whose anxiety in the situation we sympathise deeply”. By 29 August nothing had been heard, though Miss Hickman's sudden and apparently motiveless disappearance had by then attracted a great deal of public interest. She had been a brilliant student, attending the London School of Medicine for Women, where she had consistently gained Honours and Prizes. Her first job was as Junior House Surgeon at Clapham Maternity Hospital. Her independent life-style (there was still controversy surrounding the practice of medicine by women) and the lack of motive for her disappearance led to a range of theories and explanations being brought to bear upon the mystery. The Lancet (29 August) suggested that Miss Hickman's disappearance “may be due to that curious condition of mentality which leads to ‘automatic wandering’ – a condition that is perfectly familiar to psychologists” and recommended to the reader a paper by Dr W. S. Colman, lecturer in forensic medicine. Entitled ‘A Case of Automatic Wandering lasting Five Days’, it described in detail two episodes of prolonged automatism. On each occasion, the patient had ‘woken up’ after a period of days, many miles from home.

Within psychiatry there are two distinct tendencies. On the one hand there is the tendency for the subject to expand beyond its concern with psychological medicine and encroach upon diverse aspects of society. “The psychiatrist who believes that the phenomena of mental illness can be explained on the basis of a universal theory … finds little difficulty in inflating his theory to explain not only mental disease but also normal human behaviour, interpersonal relations, and ultimately human affairs” (Miller, 1970)

Psychiatric clinics see 4% of all hospital referrals by general practitioners (GPs), but the literature contains surprisingly little about the referral behaviour of, and the patients referred by, GPs to psychiatrists (Wilkinson, 1989). We describe an analysis of the Royal Liverpool Hospital psychiatric out-patient clinic which serves a deprived inner city population of 125,000 people and its GPs.

The Mental Health Commissioners recommend that whenever possible two doctors should be involved in the decision to admit a patient to hospital under the Mental Health Act (1983). That is, Sections 2 and 3 of the Act should always be used in preference to Section 4, where only one doctor is required. It further recommends that the use of Section 4 should be confined to emergencies when it is only possible to secure the attendance of one doctor.

This article argues for a new initiative in the training and appointment of consultants in behavioural psychotherapy or with a special interest in behavioural psychotherapy.

It is unarguable that R. D. Laing was the best-known and, certainly outside mainstream psychiatry, the most influential psychiatrist of his time. His ideas have continued to exercise an astonishing appeal to writers, film directors, sociologists and philosophers. He epitomised for many the so-called anti-psychiatry movement and its portrayal of psychiatrists as agents of social control, psychiatric institutions as centres of degradation and psychiatric treatment as a process of invalidation. His rolling Glaswegian rhetoric summoned forth once again the compelling romantic concept of the psychotically ill as bearers of a potent insight into the fallibility, the malevolence and the violence at the heart of the human condition. He was, as his old teacher, and fellow-psychiatrist and Scot, Morris Carstairs, observed in a review in the Times Literary Supplement in 1976, “a guru of our time”. Now that he is no longer with us, how will time remember him?

Recent papers regarding failure to keep appointments at child psychiatry clinics (Plunkett, 1984; Gould et al, 1985; Cottrell et al, 1988) suggest from 15% to 50% failing to keep their first appointments. Benson, Novick & Rembar (1981) calculated an attrition rate of 85.4%, obtained by considering cases of non-agreed termination of treatment at any stage of the referral/treatment-uptake process.

In efforts to improve the acceptability of psychiatric services and their ease of access, the issue of how people get psychiatric help when they need it is one of growing concern. There is now increasing evidence that psychiatric services operate differently for black and white people in Britain, and much concern that services may differentially disadvantage blacks (Francis et al, 1989).

Rampton Hospital is one of four Special Hospitals in England and Wales. Along with the other Special Hospitals, it usually has a small number of deaf patients. I had developed a special interest in the particular problems of psychiatrically ill deaf patients and it seemed fortuitous that I should spend a year of my senior registrar training at Rampton Hospital.

The career paths of many trainees in psychiatry are influenced by their experience of a six month SHO/registrar training post in a particular speciality. Not all trainees, however, may be aware of the training requirements for a specialist consultant post, career prospects and most importantly of the practicalities of working on a day to day basis as a specialist consultant or a consultant with special interest or responsibility. Furthermore, some SR trainees may have a limited choice of placement in a SR training scheme and with the diminishing availability of pure general psychiatry consultant posts, a year's training at senior registrar level may determine a trainee's whole career.

The objects and purposes of the constitution of the Royal College of Psychiatrists in 1971 included to “advance the science and practice of psychiatry” and “to promote study and research” (Supplemental Charter and Bye-Laws, 1989).

The East-Anglian CTC Trainees' Day was held at Friern Hospital, London, on 14 December 1989. The programme comprised a morning session with two speakers and lunch sponsored by Duphar, followed by an open forum on CTC training issues and an address by the final speaker. Approximately 30 trainees attended, mostly SHOs and registrars. Professor A. Wakeling, chairman of the East-Anglian Division of the Royal College, was present and took the opportunity to meet trainees from the region.

For the past three years I have been involved in a study of the effects of depot neuroleptic therapy on the social functioning of chronic schizophrenics with Dr D. A. W. Johnson. Having had to screen the bulk of the depot patients of two Area Health Authorities (South and Central Manchester) in the search for possible study entrants, and then monitor a large group of patients for two years who were under the clinical control of a range of Consultant Units, I have been in a good position to make observations about depot management. These are generalisations and may not apply equally to other psychiatric services, but I suspect they will have some relevance.

Cognitive behaviour therapy is now widely accepted clinically as a treatment for depression and anxiety, and there is increasing research evidence to confirm its efficacy (Rush et al, 1977; Blackburn et al, 1981; Murphy et al, 1984; Butler et al, 1987; Beck, 1988). Of the various short term psychotherapies currently available, it is probably the most widely known and best researched. Despite this, and the recommendation of the Royal College of Psychiatrists (1986) that trainees receive training in cognitive therapy, there is little opportunity to gain a formal training in this psychotherapy. Short workshops are often available through the British Association for Behavioural Psychotherapy and from other sources, and ad hoc supervision from interested psychologists and psychiatrists may be available in some centres. Scott et al (1985) described a workshop and peer supervision training scheme in Newcastle. Macaskill (1986) reported a course for psychiatrists in training in Sheffield which extended over 20 weeks and combined Beck's cognitive therapy and Ellis' Rational Emotive Therapy.

The Government's proposals in the White Paper have given rise to exceptional controversy and concern not only among professional groups working in the NHS but also among the general public. It is therefore not surprising that the medical profession has somewhat lost sight of the significance of the radical proposals in the report issued in October 1987. The report Hospital Medical Staff: Achieving a Balance ‘Plan for Action’ (1988) was issued on behalf of the UK Health Departments, the Joint Consultants Committee and the Chairmen of the Regional Health Authorities. The report, after a careful review of the alternatives, formulated proposals for an integrated package of measures to achieve gradual reform of hospital staffing structures in the interests of patients and doctors alike. The results of deliberations identified three principal areas:

1. (1) an increase in the number of consultants to provide leadership and career opportunities

2. (2) sensible planning of the number of doctors in career training grades, taking account of career prospects

3. (3) maintenance of necessary levels of support for consultants particularly in the acute specialities.

Until the mid 1950s, the management of persons suffering from chronic mental illness in Australia was the responsibility of the large mental hospital. With the advent of psychotropic drugs and concern about the ‘negative’ influence of the institutional environment on patients there was a shift to shorter but more frequent periods of hospital admission. As the pattern of shorter admissions increased, community services for the mentally ill were expanded in the early 1970s. Between 1950 and 1985 in the state of New South Wales, the numbers of patients in large mental hospitals decreased from 256 to 55 per 100 000 population. However, no special arrangements for accommodation, as distinct from treatment, were made for these ex-mental hospital patients. The decline in hospital numbers can be attributed to a general reduction in the length of hospital stays. Initially, there seemed to be no pressing need for extra accommodation in the community as the provision of social security benefits was adequate to allow patients without homes to afford basic accommodation, a situation different to that in the United States (Lamb, 1984).