This paper describes the development of a community orientated mental health service including the introduction of a community-based admission unit. The catchment area is a compact conurbation with a population of 56,000 in a deprived part of North Tyneside. Most people come from social classes IV and V and less than 1 % are from ethnic minorities. The male unemployment rate varies from 16–24% and the area is ranked 58th (out of 192) on the Jarman deprivation indices. The primary health care services suffer from many of the problems of inner-city general practices, with the Family Practitioners Committee being the highest prescriber in the country.

This study compared the mean change in the total Health of the Nation Outcome Scales (HoNOS) with the general practitioners' (GPs) assessment of clinical improvement and satisfaction, in a shifted psychiatric out-patient clinic. The total HoNOS fell significantly between the first and last appointment, suggesting that it was sensitive to change even in patients with a lower level of morbidity. There was a weak association between change in the total HoNOS and the GPs' assessment of clinical improvement (r=0.4; P=0.06), and a trend towards a greater HoNOS fall in patients that the GPs assessed as having improved clinically (5.3) compared with those the GP thought had not changed (2.5), but this difference was not significant (95% Cl, 6.6 to −1.1). There was no evidence of a relationship between change in HoNOS and GP satisfaction, and no trend towards a greater fall in the HoNOS in cases where the GP was satisfied, despite a lack of improvement being the commonest reason given by GPs for dissatisfaction. The results suggest that the fall in total HoNOS relates to some degree with GPs' own assessment of clinical improvement in their patients, and that the HoNOS may be regarded as useful by GP fundholders.

Elderly patients constitute nearly two thirds of resident hospital patients (DHSS, 1988): 60,280 people were resident in mental illness beds at the end of 1986, and 34,340 were aged over 65 years; 21,500 had been resident for more than a year and 11,300 for more than five years. This represents a 15.7% fall in numbers of resident elderly patients over a decade, while numbers of younger resident patients fell by 40%. Mental hospitals are increasingly dominated by their population of elderly patients. Some patients have grown old in the hospitals, but more are admitted in late life and remain in care, usually because they are suffering from severe dementia.

Safety planning is recommended as a part of the response to everybody who presents after self-harm, although there is surprisingly little evidence for its effectiveness. There is potential for such plans to be experienced as unhelpful if patients are not genuinely involved in their production and if the plan does not include information about meaningful sources of support. Staff training is needed to ensure that plans are delivered in a collaborative way and self-harm services need to be improved nationally if such plans are to be effective.

Clozapine is an effective antipsychotic medication but is associated with agranulocytosis, neutropenia and leucopenia. The reintroduction of clozapine improved management of treatment-resistant schizophrenia, yet resulted in a paradoxical situation whereby the risk of blood dyscrasias is rigorously managed but other adverse effects (e.g. seizures, cardiovascular complications) are less well monitored. Monitoring of weight, lipids, plasma glucose and other metabolic parameters is recommended. There is also a need to reconsider routine haematological monitoring with other medications associated with blood dyscrasia (e.g. phenothiazines, carbamazepine). In particular, individuals who develop clozapine-induced blood dyscrasia may require haematological monitoring during treatment with other antipsychotics.

The online environment brings both challenges and opportunities. The skills learned in journal clubs remain highly relevant where the ability to critique rapidly generated information and apply evidence to patient care is vital. Creativity and flexibility are needed to ensure that learners’ needs are met and efforts are made to involve those who may not be naturally drawn to online environments. This article explores how journal clubs have been approached in the past, both in person and more recently online, considers techniques for maintaining engagement in online teaching and proposes new approaches for future journal clubs.

In common with all elements of public services, mental healthcare in England faces a troubling and uncertain future. Two things, however, are certain: demographic trends ensure that demand will rise and harsh economic realities dictate that resources will in real terms shrink. In order to cope with these challenges, commissioners and providers will have to review very critically all aspects of the mental health system, including those that are currently fashionable. There is a need to identify and promote activities that are evidence-based and effective and to jettison practices and services that lack an evidence base.

Medical audit has been defined as the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patients (Department of Health, 1989). The medical profession has been under pressure to extend and improve audit procedures in recent years (McKee et al, 1989), but there have been doubts about the most satisfactory methods, particularly in psychiatry (Garden & Oyebode, 1989). There are numerous methodological problems in measuring the outcome of psychosocial care (Shaw, 1989; Royal College of Psychiatrists, 1989). Indicators of outcome which have been used in medicine include incidence of adverse events. Reintervention rates do offer some measure of outcome, and have been used widely in other medical specialities.

Many typical antipsychotic drugs may be manufactured as alcohols, which react with carboxylic acids to form esters (organic salts). These compounds are highly oil-soluble, but are only sparingly soluble in aqueous fluids such as blood. Thus, an oily solution of an antipsychotic can be injected into a muscle, where it forms a reservoir or ‘depot’ of drug that is slowly dissolved in the surrounding blood. Once released into the blood, drug esters are rapidly hydrolysed by endogenous esterase enzymes to produce the parent antipsychotic. Stable serum concentrations of antipsychotics are usually engendered (although this is not always observed in practice (Tuninger & Levander, 1996)), and administration need only take place every few weeks or so. Adherence can be assured and relapse rates are reduced (Groves & Mandel, 1975: Davis et al, 1994).

Dean (2001) found conflicting views among consultant psychiatrists about ‘what is actually meant by having responsible medical officer (RMO) status'. Many clearly feel that they are responsible for virtually all patients referred to secondary care: Tyrer et al (2001) found in a large audit many consultants with big personal case-loads of 200–300 patients. They concluded that the statutory duties of a RMO needed to be revised to avoid consultants merely becoming bureaucratic administrators of their case-load’.

A multinational pharmaceutical company recently launched a drug for dementia in Pakistan and flew about 70 Pakistani doctors to Bangkok, Thailand for a 3-night all-expenses-paid trip (Khan, 2004). Pakistani doctors were part of a larger group that also included doctors from other countries. A conservative estimate of costs for the Pakistani doctors alone is about 7 million Pakistani rupees (Rs) (£70 000, US$120 000).