A postal questionnaire assessing key professionals' and managers' views about local services achieved an overall 72% response rate. The results demonstrated concerns about the range, quantity and quality of mental health and social care provision for adults with learning disabilities and mental health needs in all 15 districts. Only eight (14%) respondents provided specific local service utilisation data, and confusions about care co-ordination responsibilities were evident. Improving future service provision should involve utilising needs assessments and quality assurance data to better inform multi-agency commissioning and purchasing strategies.

Therapists differ in their effectiveness in the delivery of psychological therapy. Can trainees who are exposed to similar training in psychological therapy achieve the same standard of competence regardless of professional background? This is a timely question given the planned expansion of psychological therapists to treat common mental disorders in England and Wales and the Scottish initiative to increase access to psychological therapies.

The practice of medicine does not occur in a vacuum. We work within a culture and a society, and we owe it to the society that our services are of a standard that will ensure their use by patients and one in which carers will have confidence in our abilities to look after their loved ones. Society expects certain standards of care and skills from its clinicians and as in any contract we, in turn, expect things from society. However, as such a contract is not specifically written down but is instead a virtual and an implicit one, some factors become crucial in understanding the relationship between society and the psychiatrist. Here, I propose to highlight some of the components of such a contract and how we renew this in the 21st century.

It cannot be ignored that community care is now a fact, and not merely an issue. Some mental hospitals have closed and the number of mental illness beds have been reduced overall by about 40% over the last decade and a range of hostels, multidisciplinary rehabilitation teams and community mental health centres have been launched. The move towards well integrated and well coordinated community care has been urged by a large number of reports, white papers and policies including the second Griffiths report, Working for Patients, Caring for People, The Health of the Nation, the Care Programme Approach and care management, with social services becoming the lead agency in community care.

Consensus is growing, in many areas of the humanities and social sciences, that aspects of the material world we live in have causal efficacy on our minds – the major dynamic being the plasticity of the brain linked to the affordances of our bodily engagements with things. The implications of that on how we approach and understand important mental health issues have not been adequately addressed. This paper proposes a material engagement approach to the study of the processes by which different forms of materiality achieve their effects. Focusing on the example of dementia, I propose that a collaboration between archaeology, anthropology, philosophy and psychiatry could help us to fill this gap in our knowledge, allowing us to understand the exact effects of everyday objects, personal possessions and forms of material engagement on people with dementia.

There has been a substantial increase in the number of Mental Health Review Tribunals (MHRTs) and hence the cost of administering the tribunal system. We report an estimate of the cost of MHRTs taking account, for the first time, of both direct and indirect costs to the various government departments. We estimate that the total cost is currently £12,274,380 per annum.

In this article we suggest that controversy over interventions such as prayer in psychiatric practice distracts attention from a serious consideration of the role of spirituality in our society. There is abundant evidence that spiritual belief, experience and practice gives meaning to many people and thus whatever they think of its truth value, psychiatrists cannot ignore it.

New Ways of Working is about developing new, enhanced and changed roles for mental health staff, and redesigning systems and processes to support staff to deliver effective, person-centred care in a way that is personally, financially and organisationally sustainable. It is about developing capable teams attuned to the needs of their users, supported by good systems (particularly information systems) and adequate resources, embedded within a values-driven organisational culture with leadership and effective team working modelled at all levels. New Ways of Working is what it says – new ways of working – rather than a single service model or structure that has to be adopted. It recognises that services catering for the different types of needs of service users across their lifespan and differing demographics and geography will need different configurations to manage their task most effectively. However, the underlying principles relating to using the skills of the workforce in the most productive way are common. It is about achieving cultural change; a shift in the way teams think about themselves, the skills of the individuals within them, and the reasons they are there. However, cultural change is difficult to achieve and it is difficult to measure the extent to which it has been achieved.

An audit of antipsychotic prescribing was carried out on community and in-patient samples. A novel method of expressing total daily antipsychotic dose as a percentage of the British National Formulary maximum recommended dose was used. Of 226 patients who had been prescribed antipsychotics, 16 (7%) were found to be on high closes. Their medical notes were examined to ascertain whether the Royal College of Psychiatrists guidelines were being followed. Recommendations on ways in which practice could be improved were made and a re-audit was carried out. The number of patients receiving high doses fell to 6 (3%) out of 206.

Child and adolescent psychiatry is a growing speciality. Significant increases in workload, the reasons for which have been described elsewhere (Black, 1989), have led to an expansion in consultant posts across the UK. Recently the Joint Planning and Advisory Committee (JPAC) reviewed senior registrar numbers and recommended an increase in the establishment by 38 whole-time equivalents in England and Wales, a rise of 38%, to meet the expected shortfall. How existing senior registrars, as well as this large number of new recruits, are trained is clearly a matter of some importance.

Adolescent in-patient units within the NHS generally provide a broad range of services to large catchment areas and populations. ‘Pine Lodge’ Young People's Centre in Chester has piloted a new emergency admission service which it has run in conjunction with its existing treatment service. This paper sets out to discuss the potential difficulties in providing such a service in the setting of a general purpose adolescent unit; describe the specification of the piloted emergency service; and present the results of monitoring its use and efficacy during the first six months.

Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and ‘ordinary’ experience to escape the fear-related prejudices associated with the imagined ‘otherness’ of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a ‘likeness-based’ and ‘unlikeness-based’ conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.

Shame is a highly prevalent, though rarely discussed, emotion experienced by trainee doctors. Seeking to avoid the pain of shame can cause significant distress and maladaptive behaviours. However, it plays a key role in helping doctors identify their moral values which, in turn, form the basis of their medical professional identity. This article uses personal doctors’ narratives together with sources from sociology, psychology and medical education to address shame as experienced by medical trainees – its causes, effects and remedies that doctors and medical educators can use to neutralise its malign effects.

The Royal College of Psychiatrists has stressed that psychotherapy skills are seen as a core element of psychiatric practice. To formalise this a new set of guidelines for psychotherapy training as part of general professional psychiatric training was published in November 1993. Concerns have been expressed over the implementation of previous guidelines from 1986. We have surveyed the psychotherapy training experience in our area and have worked with the psychotherapy department to address the findings. The future of training in the psychotherapies and implementation of the most recent guidelines are considered.