In 1997 there were 57 000 notifiable crimes of serious or sexual violence recorded by police in England and Wales (Home Office, 1998) – more than 1000 per week or approximately one every 10 minutes. On 15 February 1999 the Home Secretary, Jack Straw, announced new measures “better to protect the public from dangerous people in our society” (House of Commons, 1999). He said the measures were to target “those who are capable of committing acts of a serious sexual or violent nature”. Of the 57 000 potential targets, Mr Straw believes 1800 men are already detained in prisons and special hospitals; he intends to identify a further 500 or so men currently at liberty and lock them away indefinitely, in advance of their offending. His intention in respect of the other 54 700 violent or sexual offenders, responsible for 99% of serious violence, is not stated. Mr Straw believes that the 500 men in the community (and the 1800 in custody) share a common psychiatric condition and that this is what makes them dangerous. His policy for identifying the men, and what he intends to do with them and similar people, is contained in the recently published consultation paper on dangerous people with severe personality disorder (Home Office & Department of Health, 1999).

The final report of the Scoping Study Committee (Richardson Committee) reviewing the Mental Health Act 1983 is eagerly awaited. All psychiatrists, either individually or through the College, had an opportunity to express their views on what changes in legislation are needed and to comment on the draft proposals (Scoping Study Committee, 1999). Many psychiatrists did neither. Yet to use modem terminology, psychiatrists are one of the major ‘stakeholders' of mental health legislation. A valuable way of ascertaining colleagues' views in a structured way is by surveys of the type conducted by Buchanan & Gunn (1999, this issue). Given that the Richardson Committee has yet to publish proposals for ‘Part III’ the survey is timely. The response rate is, of course, very important and one is left wondering why a third of the general and community psychiatrists did not respond. Work load, burn-out or lack of familiarity with Part III of the Act are possible explanations.

While carrying out research in a special hospital, I encountered a small group of middle-aged patients who spent most of their time engaged in sporting activities. They had considerable freedom within the high security perimeter, and were regarded as presenting no risks, as long as they had no access to children. All were detained under the legal category of psychopathic disorder, and none of them were receiving psychiatric treatment, unless the term milieu therapy were to be stretched to include a patient's mere presence within a hospital. Their past offences were such as to lead to a shared understanding that they were unlikely ever to be released, and a compromise had been reached. The patients were aware that they enjoyed a quality of life that was as good as they could expect in the circumstances. The hospital accepted that it would have the patients for as long as their restriction orders lasted, and saw itself as providing a valuable public service by keeping them locked up.

This is one of three articles describing how one National Health Service (NHS) trust is tackling clinical governance. The first is by the trust chief executive, the ‘accountable officer’ in the White Paper The New NHS (Department of Health, 1997). The second is by the trust's director of research and development whose responsibilities include assisting clinical directorates to carry out an annual programme of improvements in clinical effectiveness. The third paper is by the mental health lead clinician’ for clinical governance.

Clinical audit has had a limited impact in the NHS because clinical outcomes and standards, while important to clinicians, have not received the investment required from NHS management which has been preoccupied with efficiency and customer satisfaction. With the advent of A First Class Service (Department of Health, 1998) the emphasis is changing and clinical audit committees and departments now have a central role.

In this paper, I explain the strategy for achieving clinical governance within the trust's mental health directorate, and describe the role that clinicians and managers would like the chief executive to play in helping us to achieve our targets.

Dear Mr Straw, I awoke on Monday 19 July to the news that you were publishing a Consultation Paper to explore the possibility of introducing preventive detention for people with severe personality disorders. In your interview on radio that morning you seemed very determined to be sure that such legislation was introduced in the expectation that incarceration of the 200 people with severe personality disorders who would be subject to such detention, would somehow enhance public safety.

In June 1997, the Royal College of Psychiatrists published an occasional paper entitled Model Consultant Job Descriptions. The Faculty of Child and Adolescent Psychiatry Regional Representatives considered that further guidance was required to assist those writing job descriptions and for Regional Representatives assessing the job descriptions in consultation with Regional Advisors, on behalf of the Royal College. Hence, this Faculty document which may additionally be helpful for those contemplating applying for consultant posts.

Professor Roland Martin Littlewood was born in 1947. He started his training at St Bartholomew's Hospital Medical School London, where he obtained his BSc and later graduated MB, BS in 1973. Further studying at the Institute of Anthropology, University of Oxford led to a Diploma In Social Anthropology, obtained in 1979, and a DPhil in Social Anthropology, gained in 1987. He was awarded the MRCPsych In 1978. Since then his impressive career has been marked by equally impressive distinctions, such as the presidency of the Royal Anthropological Institute from 1994–1997. Having reviewed over 200 books, Professor Littlewood is himself the author of four: Pathology and Identity: The Work of Mother Earth In Trinidad (1993) won the Wellcome Medal For Anthropology as Applied to Medicine in 1993. He has also written innumerable scientific, theoretical and review papers and edited three books. Professor Littlewood has recently been elected Fellow of the Royal College of Psychiatrists.

The Special Committee on Electroconvulsive Therapy (ECT) has received numerous requests for advice in the last few weeks about suitable replacement agents for methohexitone in ECT anaesthesia.

Sir: We read with interest Paul & Oyebode's paper regarding the competence of voluntary psychiatric patients (Psychiatric Bulletin, August 1999, 463–466). We too have data on a related, but distinct, area of research. One hundred consecutive informal patients were interviewed on the third day of admission and one week later. At the first assessment, 78% thought they needed to be in hospital and 74% thought they needed treatment. Only 43% recalled receiving an explanation of their admission and treatment plan. We assessed their knowledge of their rights to refuse admission and treatment. At the first assessment, 67% were aware of their right to refuse treatment with 52% anticipating coercion if they exercised this right. Seventy-three per cent were aware of their right to leave hospital an 42% anticipated coercion if they exercised this right.

Sir: I have had the opportunity, as the specialist registrar representative on a Child and Adolescent Psychiatric Special Advisory Sub-Committee team, to visit a different child and adolescent training scheme than my own. This was a very interesting experience both with regard to the process of the visit and seeing how another scheme functions. It also exposed me to new ideas about training. I strongly support the view expressed by Laurence Sheldon (1994) that approval visits should be open for any interested specialist registrar and recommend other trainees to consider offering themselves for approval visits.

Sir: Bristow (Psychiatric Bulletin, August 1999, 23, 478–480) found 9.5% of psychiatrists said their trust restricted clozapine funding. By contrast, the Maudsley National Schizophrenia Fellowship (1998) survey of health authority pharmaceutical advisors reported in the Pharmaceutical Journal found clozapine funding restricted by 45% of health authorities. We have recently carried out a postal questionnaire of members of the UK Psychiatric Pharmacists Group on the use and evaluation of atypical antipsychotics. We received 82 replies giving a response rate of 45%. Eleven per cent of pharmacists reported their trust capped the number of patients prescribed clozapine. However, there was widespread use of measures by trusts to try and limit expenditure on atypicals, restricting the prescribing of atypicals to consultants only and the use of guidelines in which atypicals are not first line treatment for schizophrenia. Only 12% of trusts, our hospital among them, used no cost-containment measures.

Sir: Thompson (Psychiatric Bulletin, August 1999, 23, 449–451), states ‘the Suicide Act of 1961 prohibits others from encouraging suicide’, and concludes that there may, therefore, exist ‘legal grounds' sanctioning suicide Websites. These suggested measures include possibly tracing Vulnerable individuals' who have disclosed suicidal thoughts, or who have communicated, for example, by way of the site bulletin board, that they have just acted on their suicidal ideation. Yet, it is difficult to see how there could be legal grounds propelling health care professionals (presumably), or any other individual, into such interventions. The Suicide Act 1961, prohibits the ‘aiding and abetting’ of suicide, but this is not necessarily synonymous with merely ‘encouraging’ suicide per se. Criminal liability arises in circumstances where a person takes active steps in assisting the suicide of another, such as by telling someone the amount of a drug required to secure death and leaving this within their reach. The Suicide Act 1961 does not extend to Scotland, although any individual taking similarly unambiguous steps to assist another in suicide might face ‘art and part’ liability in the aiding and abetting of a suicide, possibly resulting in a charge of culpable homicide. Neither does it apply to other countries, and it must be borne in mind that assistance in suicide is not a crime everywhere. Therefore, there can exist no competent application of the English law or governmental quantitative targets over the conduct of others in a wholly different jurisdiction.

Sir: Chaloner (Psychiatric Bulletin, September 1999, 23, 589–66), suggests that being moved by the death of a cultural icon that you have never met, rather than by one's own suffering, may be thought of as a ‘Active personality disturbance’; a pathological process which may be a result of ‘ego impoverishment’ or a failure of development.

Sir: Szasz's views (Psychiatric Bulletin, September 1999, 23, 517–519) are both illogical and barbaric.

Sir: On the last evening of the Annual General Meeting in Birmingham a small group of intrepid golfers made their way beyond the M40 to the Forest of Arden Golf Course for the inaugural meeting of the Royal College Golf Society. With the addition of a very small number of interloping general practitioners we made up a multi-disciplinary band of 24 golfers all intent on a brief period of relaxation after the academic rigours of the meeting. Unfortunately we could not persuade the Continuing Professional Development office to offer us credits for sports psychology, so the altruism of all those who took part is to be applauded.