A significant proportion of patients referred to psychiatric out-patient clinics fail to attend the first appointment. Previous work suggested that typically 30% do not attend (Burgess & Harrington, 1964; Skuse, 1975) and this results in an inefficient utilisation of psychiatrists' time. One solution would be to overbook new patients by 30%. Unfortunately the proportion of non-attendance at each clinic is variable and difficult to estimate in advance. Psychiatrists have been shown to be poor predictors of non-attendance from examining referral letters (Woods, 1992). Overbooking might result in a long waiting time and short time for assessment. Previous research has suggested patients are more likely to attend if they received a personal letter rather than a standard card, had a previous psychiatric history, and if they were seen in a health centre rather than a hospital (Hillis, 1990). Allaying the patient's fears and misconceptions about psychiatry also improved attendance (Skuse, 1975). Work in a child and family setting suggested that sending a family questionnaire prior to the appointment reduced the non-attendance rate (Mathai & Markantonakis, 1990).

Policy for mental health services in England is based on two straightforward principles. These are, first that care should be provided as locally to where a person lives as is reasonably possible, and secondly that treatment should be available in the least restrictive conditions that are compatible with the safety of the patient, of those looking after him and of the public at large. I make no apology for reviewing the history of policy and practice; it is not possible to understand the mental health services that we are trying to achieve for the future without understanding how the service has developed over the years. I shall use the mental illness service as an example – similar considerations apply to the mental handicap services.

A questionnaire was completed by 135 of the 161 (83.9%) National Health Service (NHS) trusts who provide specialist health services for people with learning disabilities in England and Wales. From these, cumulative frequencies were calculated to describe the current level of provision of NHS beds. Results vary in different parts of the country, but the majority of NHS trusts provide assessment and treatment admission beds, long-stay beds (including those NHS trusts who have completed their resettlement process) and respite care beds. A half of NHS trusts directly manage NHS day places. The high response to questionnaires indicates the current high level of interest in this issue.

A group of interested people met for two days last year in order to attempt to reach a consensus on good practice in the management of patients with generalised anxiety. The result of their efforts is published below.

Most patients presenting with anxiety, whether acute or chronic, mild or severe, were until recently treated with tranquillisers. Recognition that these drugs can cause dependence in some patients has prompted a re-evaluation of the pharmacological management of anxiety and the value of non-pharmacological treatments is now recognised. Uncertainty remains among many doctors about the efficacy of the whole range of current therapies and the place of the new classes of drugs for anxiety. However, research findings are now accruing which indicate the relative merits of these various therapies, and clarify the principles on which they are based.

Quality improvement (QI) projects have been shown to positively influence patient care. They provide opportunities for trainees to present and publish their work locally and nationally, and to gain valuable leadership and management experience. We describe a pilot project to engage in QI trainees across a National Health Service trust and a school of psychiatry. After the first year of this programme over half of psychiatry trainees in the school (58% of core trainees and 47% of advanced trainees) are participating in 28 individual QI projects and QI project methodology is to become embedded in the core psychiatry training course. Specialty doctors, consultants, foundation doctors, general practitioner trainees, medical students and the wider multidisciplinary team have all become engaged alongside trainees, working with patients and their families to identify problems to tackle and ideas to test.

With the increasing importance of evidence-based medicine in psychiatry, the recent inclusion of a critical analysis paper in the MRCPsych Part II Examination and the current emphasis on clinical governance, it is now necessary for all psychiatrists to have some degree of training in evidence-based practices.

Quality improvement (QI) approaches are becoming increasingly important in the delivery of mental healthcare internationally. They were originally developed in the manufacturing industry, but the principle of having a systematic approach to improvement has spread to many other industries, not least to healthcare. Quality improvement approaches in healthcare were pioneered in the USA at organisations such as Virginia Mason and the Institute for Healthcare Improvement. In recent years, they have become firmly established in mental health services in the UK's National Health Service (NHS). There are a number of different approaches to quality improvement, but two leading models have taken root: ‘lean thinking’ (also known as ‘lean methodology’ or simply ‘lean’), which arose out of Virginia Mason, and the ‘Model for Improvement’, which came out of the Institute of Healthcare Improvement. This article describes these two quality improvement approaches, critiques their philosophy and explores how they can apply in the provision of mental healthcare, particularly with reference to the use of data, evidence and metrics.

The psychiatric treatment decisions made by two multidisciplinary psychogeriatric teams in 100 new referrals were compared with those made by a group of psychiatrists following independent formal research assessments. There was satisfactory agreement between the team and research decisions with regard to psychiatric hospital admission, antidepressant treatment and neuroleptic treatment. Agreement was less good for psychological treatments.

The British benefit system provides for disabled people. However, disincentives within the existing system reduce uptake of benefit entitlements. The link between mental illness and poverty is now well known. If welfare benefits are essential for mentally ill people to function effectively in the community, then changes may be necessary to the current system. These changes include increasing the availability of accessible literature and information from both health and social services sources, further training for mental health staff, and the automatic evaluation of benefit entitlement by the Department of Social Security.

Psychiatric services for the elderly are evolving rapidly. The Government has recently reiterated that this area needs special attention. The reasons for upheaval are well-known: the changing age structure of the population, the historical neglect of the elderly mentally ill and a growing emphasis on community-based approaches in place of traditional institutional solutions. In the London area and elsewhere, adjustment has been complicated by geographical transplantation from old suburban mental hospitals to locally situated units, often within district general hospitals. New specialist services also suffer from the effects of financial stringency and inadequate recruitment. These and other changes have ensured that the process of restructuring services has been difficult. Planners have had few precedents to fall back on, and have been heavily dependent on available guidelines. There has been comparatively little information available about how effectively services work in practice.

This short review outlines the clinical profile of the selective serotonin re-uptake inhibitors (SSRIs). There has been much recent publicity and promotion of this group of drugs and this review attempts to give a balanced account of their current place in the treatment of depression. Although a large number of preclinical and clinical trials have been carried out many questions and problems remain – it is important to proceed carefully and carry out (and replicate) controlled independent clinical trials. The views of general psychiatrists and GPs about these drugs in normal clinical practice will be the acid test – this will be particularly important in view of their cost.

The Royal College of Psychiatrists has established a Working Group on Choice in Mental Health and held a conference to include service users in formulating a challenging view of the choice agenda for mental health. This is set out here to stimulate wider interest. Choice-based practice develops in a climate of trust and information, and goes beyond simple variety or individual consumerism. For some service users, limited initial areas of choice can be of great importance, but a true culture of choice requires the widespread participation of service users and carers in service improvement. It is important that psychiatrists champion the empowerment of their patients through choice, in policy and training, and in clinical practice.