Between 1983 and 1991 mental health services in Buckinghamshire, as in many other parts of the country, underwent a radical restructuring. Facilities previously dominated by the mental hospital (St John's, near Aylesbury in the centre of the county), were devolved to the three health districts, Milton Keynes, Aylesbury Vale and Wycombe. These changes culminated in the closure of the hospital in September 1991.

We followed up 33 cases over three months where psychiatrists recommended the compulsory detention in hospital of mentally ill men and women but social workers disagreed. Seventeen of the cases were detained a mean of 25 days after the index date of assessment by social workers, but the group as a whole spent fewer days in hospital than a “control” set of patients whose detention had been agreed (P = 0.02). The terms of reference of the Mental Health Act Commission should be extended to cover such cases.

Since 1959, the responsibility to detain a patient in hospital compulsorily has been given to doctors, social workers and hospital managers. The 1983 Mental Health Act stipulates that medical recommendations are made by two medical practitioners (one an “approved” doctor) for compulsory admission for assessment (Section 2) and compulsory admission for treatment (Section 3). When this was debated in Parliament, the importance of the independence of the two doctors making medical recommendations was stressed. This was to avoid collusion, influence or interference with clinical judgement (Bluglass, 1983).

Personal experience shows that discrepancies are common when out-patient psychiatric medication records are checked with the information held by a patient's GP. This could lead to duplicated or conflicting treatment regimes, dangerous drug interactions, abuse of prescribed drugs, and failure to monitor therapeutic drug levels.

The role of the accident and emergency department in the care of psychiatric patients has been long recognised. Mindham et al (1973) reported that many psychiatric patients, at their first or subsequent contact, present themselves as emergencies, and therefore a suitable service must be provided for them. It is interesting that a large number of reports describe various aspects of one particular service in London, namely the Maudsley Emergency Clinic. Several recent reports describe emergency psychiatric services in different district general hospitals in the United Kingdom.

The Psychiatric Bulletin was launched in October 1971 as a separate news and notes supplement to the British Journal of Psychiatry. At first, the Bulletin confined itself to publishing College statements, the details of divisional meetings, lists of fellows, and forthcoming events. Over the years, the Bulletin has undergone an ambitious expansion in the range of subjects covered. A special emphasis has been placed on publication of studies of practical clinical management, including the Mental Health Act, audit and training matters. There has also been an increase in papers on cultural, historical and media topics related to psychiatry. Other regular sections include interviews, usually with the elder statesmen of psychiatry, obituaries, conference reports and correspondence. The Bulletin also publishes educational articles, such as those on computing or good practice guidelines.

Thyroid treatment was used at the beginning of the 20th century for people with Down's syndrome, and an improvement in the physical and mental response was noted (Smith & Berg, 1976). Later studies reported conflicting findings about the prevalence and type of thyroid dysfunction (Sare et al, 1978; Lobo et al, 1980) but there now seems little doubt about the existence of a high prevalence of hypothyroidism (Mani, 1988; Dinani & Carpenter, 1990).

Observation levels are widely used in the management of acutely disturbed psychiatric patients (Shugar & Rehaluk, 1990). Although clinicians are involved in decisions about observation levels, there is rarely any specific training and very little formal structure to the decision making process. We report a survey of the views and knowledge of clinical staff regarding observation levels. Questionnaires were sent to all the nurses of the six acute psychiatric wards in the Nottingham Mental Health Unit, and all the doctors involved in the care of patients on these wards.

Earlier this year a senior Department of Health official asked me if I had seen an article in the Health Services Journal about child psychiatry (Light & Bailey, 1993). Shortly afterwards a consultant colleague asked me about the same article, having been told about it by her manager, and one of my own managers mentioned it to me and asked for my thoughts. Now the Psychiatric Bulletin wants 500 words on this same article. If nothing else, Professor Light and Dr Bailey have stimulated debate.

Section 58 is in the part (Part IV) of the Act which is largely concerned with consent to treatment by patients detained on Sections 2, 3, or 37 of the Mental Health Act (1983). It applies to drug treatment if three months or more have elapsed since drugs were first given during the period of detention. It also applies to ECT at any time during the period of detention. Where a patient consents to treatment which comes under Section 58, and which the responsible medical officer (RMO) has proposed and explained to the patient, the RMO is required to certify in writing, on Form 38, that the patient is capable of understanding the nature, purpose and likely effect of the treatment and that the patient has consented (DOH, 1987). The Code of Practice (DOH, 1990) advises that the RMO should indicate on the certificate the drugs proposed, by the classes described in the British National Formulary (BNF), indicating the dosages if they are above BNF advisory maximum limits. The method of administration should also be indicated. This paper will argue that Section 58 in its present form does not strengthen the patient's right to consent to treatment and that the form of words advised in the Code of Practice with respect to Form 38 is faulty in conception.

The Commission welcomes the opportunity to comment on Dr Oyebode's paper. As a former medical member of the Commission, Dr Oyebode can write with authority on the frustrations felt by many Commissioners when carrying out their statutory obligations to ensure that the requirements of Section 58 of the Act are being met. His paper is particularly opportune considering the recent publication by the Law Commission of its consultation paper No. 129 (Law Commission, 1993).

The following recent murder trial at a Scottish High Court raises some points of interest to all UK psychiatrists in relation to the use of brain imaging test results as psychiatric evidence and their relevance to the question of diminished responsibility. It should be noted that in Scotland diminished responsibility has a much narrower scope than that encountered in the England and Wales (Chiswick, 1991) and is dependent upon the presence of a “mental disorder or a mental illness or disease” (Connelly v HMA 1990).

It is 25 years since the Royal Commission on Medical Education recommended that “every psychiatrist should be familiar with the conduct of community psychiatry”. This is now more important than ever. As the National Health Service and Community Care Act (1990) comes into force and community care initiatives are developed throughout the country, psychiatrists are at risk of being left behind. To be effective players in these developments, psychiatrists need to be armed with a thorough knowledge and understanding of the workings of community care. Training future consultants in all aspects of community care must be a continual priority.

One of the most unpleasant things that can happen to the senior house officer or registrar on call alone in a psychiatric hospital is a “crash” call. He or she has to get to the patient, institute appropriate immediate management, arrange for disposal to a more suitable facility, and hand over to the responsible team. The problems facing the psychiatrist in this situation may be complicated by several factors, and these come under the following headings.

Give or take a few months, it must be 20 years since I led a College Study Tour Group on a tour of Italy, or, to be more exact, of the area north of Rome, economically privileged and steeped in the academic tradition from the Renaissance onwards.