The NHS and Community Care Act 1990 has been described as the biggest shake-up to the NHS since its inception. Most psychiatrists will by now be familiar with the new arrangements for community care, but what are the implications of the structural changes in the NHS for psychiatry?

Access to a senior registrar post is growing more difficult because of increasing competition. The College Court of Electors and Joint Committee for High Psychiatric Training have agreed only two criteria for appointment as SR in Psychiatry (possession of MRCPsych and at least three years of general professional training), but, despite heavy workloads, busy timetables, and the need to prepare for the membership examination, clinical skills and dedication to patients will not ensure career progress if they are not accompanied by other aspects of training, sometimes with insufficient facilities and supervision. Indeed, Lewis (1991), after reviewing a group of applications for SR posts, found that the only variable which predicted likelihood of being shortlisted was having published: “Trainers generally believe that evidence of completed research and publications say more about a trainee than a good reference ever can”.

This Organisation (APP) has been set up to provide a forum for the exchange of information and ideas and to bring together the views and experiences of colleagues working in psychiatry in the UK.

We are now well into the second year of the separation of purchaser and provider functions in the National Health Service. District health authorities as purchasers of services are required to assess the health care needs of their population (NHS Management Executive, 1991a) and seek professional advice regarding both the need for, and the provision of, services. The NHS Management Executive acknowledges that local clinicians in provider units will continue to make a major contribution to this advice (NHS Management Executive, 1991b).

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.

When I began my six month placement at The Lodge, an in-patient therapeutic community for those with emotional and personality disorders, there were 13 residents. Three left and two more joined us over the following month. Our consultant was on annual leave when the community was devastated by the unexpected death of a long-standing resident, who I will refer to as B. At the time of his death he was a well integrated member of the community.

Over recent years the National Health Service has undergone many changes, one of the most important being the development of purchaser/provider roles. From April 1993 district health authorities (DHAs) and general practitioner fund holders (GPFHs) have been able to choose from which provider to purchase their adult psychiatric out-patient services. While discussions on how to attract and keep the contracts from DHAs and GPFHs have been underway at a managerial and consultant level, we believe that the potential role of a key player for hospitals, the psychiatric medical secretary, has been overlooked. This paper examines the secretarial role in the context of the ‘new’ health service.