It is over a year since the Government introduced its reforms of the NHS and, despite surveys of consultant attitudes to these changes (Whitfield et al, 1989; Delamothe, 1990) and numerous letters to journals from those working in Trusts, there has been no attempt to systematically investigate the experiences of consultant psychiatrists working in NHS trusts. This information would be of use to those contemplating whether to countenance trust status for their own hospitals and those yet to make up their mind about their attitudes to the reforms.

In 1984, the Department of Health and Social Security issued guidelines, based upon the recommendations of a working party of the Royal College of Psychiatrists, on the management of patients admitted to hospital following acts of deliberate self-harm (DSH). Unlike the 1968 Hill report (which recommended that all such patients should be assessed by a psychiatrist before discharge) the new guidelines placed the responsibility for psychosocial assessments on the admitting medical team.

Threats made by patients to harm, or even kill, their psychiatrists, may cause great stress to both the doctor and his or her family. This potential source of anxiety is seldom discussed by the profession and is a neglected area in the literature, perhaps indicating that denial is a common mechanism used to cope with any fear engendered by such threats.

Case registers can provide useful data for research and service planning, but the older manually maintained registers were expensive and required special accommodation, staffing and support. Turning raw data into useful information was a laborious process and most systems could not accommodate ad hoc reports. Partly as a result of these shortcomings, and partly because of spending cuts, a number of case registers were closed in the 1980s (for example, see Hassall, 1991).

The number and diversity of rating scales and tests of psychiatric status has increased dramatically in the last 20 to 30 years. Tests are in screening, e.g. for dementia the Mini Mental State Examination and the Abbreviated Mental Test; to aid clarification of the diagnosis in difficult cases, e.g. Walton-Black New Word Learning Test, to differentiate between depression and dementia; and in assessing severity of symptoms, e.g. Hamilton Depression Rating Scale.

The District Services Centre of the Maudsley Hospital deals with the care and rehabilitation of people with chronic mental illnesses. Three independent teams of mental health professionals comprise nurses, occupational therapists, psychiatrists, psychologists, and social workers. A multidisciplinary team approach is used in the assessment and management of patients. Most of the patients are either day-patients or ‘supportive’ patients who attend less frequently. The service is thus very much community based and orientated, and the support and involvement of close relatives in the care of the patients is seen as both necessary and desirable.

In 1991 we predicted the new contracting system introduced by the NHS Bill would reduce referrals to specialist units, particularly supra-regional units (Dolan & Norton, 1991), and that any resulting decline in patient numbers might lead to the suggestion that these resources were surplus to requirement and hence not viable in a market economy (Dolan & Norton, 1990).

There is widespread recognition that many who seek or are referred for help to psychiatric and social services are acutely disturbed and require only short-term help if they are to come through a period of transient disruption in their lives. The frequency with which people in crisis consult their GP or visit a local Social Service Department is uncertain but suggests that the primary carers are the first port of call for most of them. Services developed to meet the needs of these people include traditional GPs and psychiatric services directed primarily at ‘patients’ (people who meet criteria for illness), but which often offer additional help to their families; traditional social services which place no such limitation on the individuals who seek their help but are directed mainly at people with problems in living, particularly with housing, employment and money; and counselling and advisory services (such as Relate – formerly Marriage Guidance) which focus on particular problems or client groups. A few special crisis services, most of which provide a multidisciplinary team, visit clients in crisis in their homes. These are usually psychiatric services for patients with acute mental illness (Cooper, 1979).

People with a mental handicap may have a variety of behavioural symptoms, and according to DSM-III-R those commonly seen include passivity, low self-esteem, low frustration tolerance, aggressiveness, poor impulse control, and stereotyped self-stimulating and self-injurious behaviour. There is, however, no diagnostic subclassification of these in DSM-III-R.

The increasing awareness that serious mental disorder is common among men residing in homeless hostels has acted as a fillip towards providing new services for this disadvantaged group. Conventional psychiatry frequently fails to meet their needs, not least because of the formality and inaccessibility of the contact. Detailed psychiatric history taking, for example, is often perceived as a barrier to communication with no intrinsic benefit for the homeless. Indeed psychiatrists often appear distant to hostel staff. The Salvation Army have gone so far as to suggest to the House of Commons Social Services Committee that community psychiatric nurses are effective because of their ability to mediate with consultant psychiatrists.

Aggression directed towards health care workers has been widely discussed (Health Services Advisory Committee, 1987), but information relating to British psychiatry has been anecdotal. The Collegiate Trainees' Committee (CTC) has recently expressed concern about the apparent dearth of training opportunities in the recognition and management of aggression, and the difficulty in obtaining post-incident counselling (1991).

Over the past three decades there has been a shift in emphasis from hospital based to community care of psychiatric patients. Central to this change has been the development of the community psychiatric nursing services and an increase in its numbers. Until recently community psychiatric nurses (CPNs) were almost entirely hospital based, working as members of a multidisciplinary team and providing follow-up for psychiatric patients.

Testing the ability to write a simple sentence has long formed part of the clinical assessment of the cognitive state in the elderly, and has even been incorporated into standard brief cognitive tests (Folstein et al, 1975). Writing a sentence tests a number of faculties including language skills and praxis. As part of a comparative study of four tests of cognitive function—the Felix Post Unit (Institute of Psychiatry, 1987), Mini Mental State Examination (Folstein et al, 1975), Abbreviated Mental Test (Qureshi & Hodkinson, 1974) and Medical Research Council (MRC, 1987) – sentences written by 158 elderly newly admitted psychiatric patients, as requested in the Mini Mental State, were collected. Our aims were to assess the value of sentence-writing in discriminating between dementia and depression, and to compare the style and content of what was written. Would the material chosen by the patients for their sentences be associated with their diagnoses? In particular, would depressives write miserable sentences and the demented be more likely to write nonsense?

Occupational stress is frequent among individuals whose work brings them into close contact with other people. One putative means of preventing or alleviating such stress is meditation (West, 1987). A six week course in meditation was recently held for staff in the Drug Dependence Service based at University College Hospital, London. The idea for the course came from the head of the unit who had personal experience of meditation. The course and its acceptability to staff are described below.

A 44-year-old man was treated with amitriptyline by his general practitioner for ‘mild depression’. Shortly after starting treatment he was said to have become ‘beserk’; he hit his wife and a family friend with an iron bar and attempted to sever their heads with a kitchen knife. He was found guilty of manslaughter on the grounds of substantially diminished responsibility and sentenced to life imprisonment.

As more people with mental handicaps∗ (MH) live in the community, in line with government community care policies (Department of Health, 1989), referrals to CMHTs∗ and other community based services will increase. Such referrals may be routine, urgent or emergency, come from various sources, and concern health and social care needs.

Stones of mishap and disaster have a grisly if reluctantly acknowledged appeal. Who can resist flicking through the annual reports of the medical defence organisations or reading the epitomes of the Health Ombudsman? What newspaper editor with an eye for the circulation figures omits tales of human misfortune?

It is not uncommon to hear a psychiatrist claim to be able to judge from general practitioners' letters which new referrals will attend and which will fail to turn up. However operational research has failed to define clear characteristics of patients who do not keep first appointments (Hillis and Alexander, 1990; Skuse, 1975; Zegleman, 1988). Also the standard of referral letters has been criticised in the past and shown more recently to omit key items of information (Pullen & Yellowlees, 1985). The aim of this study is to test the ability of psychiatrists of varying experience to predict non-attenders.