Current operation of Mental Health Review Tribunals

DEARSIRS We have been commissioned by the Department of Health to carry out a one year study of current practices regarding the operation of Mental Health Review Tribunals, with a particular emphasis on patterns of delay. Over the next few months we will be contacting a random sample of general and foren sic psychiatrists to ask for their views. However, we would be most grateful to hear from any member of the College who has views on this subject, and in particular for decreasing the length of time it takes to obtain a tribunal hearing. These views will influence both the nature of our study, and its conclusions. All views will, however, be received in strict confidence. Finally, the study is only concerning the current situation in England. STEPHENBLUMENTHAL SIMONWESSELY Academic Department oj Psychological Medicine King 's Healthcare King 's College Hospital


DEARSIRS
There has been much correspondence recently con cerning the interpretation of the Mental Health Act. It seems that even with guidelines there are still situations where interpretation of the Act is difficult.
A number of scenarios appear to cause particular problems, some involving differences of opinion between psychiatrists and social workers; for in stance, a conflict between psychiatrists wishing to recommend a Section 3 Treatment Order for a patients whom they know well while the social worker may wish to use a Section 2 Assessment Order as being 'the least restrictive alternative'.

Correspondence
I would suggest that detailed case vignettes are devised and that the Mental Health Act Commission produce recommended guidelines as to how the Act should be interpreted in these cases. This should help the situation that can occur when there is an honest disagreement between disciplines as to correct management.

TREVOR FRIEDMAN
Leicester General Hospital Leicester LE5 4P W Prospective refusals of health authorities tofund psychiatric admissions DEARSIRS Many colleagues may have received a clinical de scription of a patient of a health authority in south eastern England accompanied by a letter from that health authority refusing to fund any admission to a psychiatric bed without prior consultation with the patient's consultant. This is being circulated as a strictly confidential document. There are two aspects of this exercise that have caused me concern.
The first concern I have is entirely selfish but it should not be expected of me as a duty psychiatrist to bear in mind a list of the names of patients of other health authorities who should not be admitted to hospital on the basis of my judgement alone.
The second concern is an inevitable consequence of this exercise. For it to be effective it has been necessary to circulate the name and clinical descrip tion of the patient to every district health authority with a request that the information be circulated to all appropriate psychiatric units. In order for this to be then implementable the information must go either to the treasurer of all units or to every doctor who may be on-call to grant or refuse admission to a unit. I think such an exercise can hardly be described as strictly confidential.
I can well appreciate that health authorities need to try and keep some control over their liabilities but I really do think that this requires a rather wider debate before further exercises of this kind take place.

Campbell Centre
The Hospital Campus Eaglestone Milton Keynes MK6 5NG Self-audit: benefits in training and clinical practice DEARSIRS The monitoring and evaluation processes of audit were applied to the activities of a registrar during a six month attachment to a learning disabilities unit. Monitoring was by means of written records of all clinical contracts. Specially designed forms were used which encouraged a problem-orientated approach, recording interventions made and outcome. Evalu ation occurred during consultant and pharmacist supervision, allowing changes in clinical approach to be introduced. The limitation of too close an adherence to a medical model were highlighted and the benefits felt of an outsider commenting on pre scribing habits. Inter-disciplinary discussions were facilitated by the audit forms (in the community setting case notes are often absent) and the desire to measure outcome of medical interventions led to requests for information about client behaviour from nursing staff in an objective form, such as the charting of events or the use of rating scales. The audit high lighted differences in multidisciplinary involvement between long-stay in-patient and hostel patients. A medication review confirmed a large reduction in the use of neuroleptics for behaviour control had been achieved without deterioration in behaviour. Appraisal of the range of experience gained by the trainee was facilitated, so that deficiencies in training could be rectified. The benefits of a self-audit exercise merits advertisement to colleagues. J.L. GILLOW R.BANKS P. PRATT Brunswick House 299 Glossop Road Sheffield S10 2HL Environmental change and violent incidents DEARSIRS I read with great interest the paper on environmental change and violent incidents (Psychiatric Bulletin, 1992, 16, 489^90). The conclusion that "the reduc tion in violent incidents ... was primarily due to change of environment" needs to be challenged. The definition of violent incidents was not specified. Data on the validity and reporting reliability of violent incidents were not provided. For example, it may be that fewer staff in hostels or only 14 hour staffing in homes may result in a poor reporting reliability for violent incidents. A number of other factors need to be considered and have been summarised elsewhere (Shah et al, 1991). These include demographic characteristics of nonviolent patients, activity patterns (admission rates, length of stay and bed occupancy) and staff attitude, training and nature (temporary or permanent) in all three settings. Unless consideration is given to the above array of factors the conclusion becomes weak. Having said this, the study in question has attempted to address 49 the important issue of changing environment for our patients, which is occurring at increasing frequency in the modern era of community care.

AJITSHAH St Vincent's Hospital Clinical School
University of Melbourne Melbourne, Australia