2. BACKGROUND

For nearly twenty years now the process of audit has been applied to the use of ECT as a form of treatment for mental illness. In 1977 the Royal College of Psychiatrists produced a statement on the administration of ECT. This was followed up in 1980-81 by a major survey of practice (Pippard & Ellam 1981) based on a postal questionnaire to all consultants and members of the College, visits to 180 ECT suites in England and Wales and the responses of 614 GPs regarding effectiveness. Results showed a 17 fold variation in usage of ECT for various reasons but concluded that ECT was a safe procedure. Several recommendations aimed at improving practice at ECT were made and included: the appointment of one senior psychiatrist to take responsibility for the organisation of the service, the implementation of procedures for treatment and the training and supervision of junior staff. A special committee on ECT was set up and in 1989 published the first set of guidelines for good clinical practice (Freeman 1989).

In 1992 a repeat audit (Pippard 1992), restricted by financial constraint to two regions of England, was carried out to assess the effect of these recommendations. Forty ECT suites were visited and these showed an improvement in the premises, the quality of nursing and the anaesthetic equipment. Of disappointment was the standard of ECT machines still in use and the mediocre psychiatric practice still being employed in many units. Subsequent initiatives by the College have included: the production of educational material, the running of training courses for consultants and the publication of a new comprehensive handbook on ECT practice (CR 39. Ed Freeman 1995).

Recently the College Research Unit have completed their third cycle of audit (Duffet & Lelliot 1998). This involved a postal survey of all clinics in England and Wales in 1996 and visits to at least the same clinics as the 1992 audit. Although many of the most obsolete machines had now been phased out still only 30% of clinics visited met the current standards.

Meanwhile psychiatrists in Scotland were planning a comprehensive audit of ECT which would follow on from a postal survey carried out in 1994 during the production of the CRAG Good Practice Statement on Electroconvulsive Therapy (Freeman 1997). This was the first survey to collect national data on ECT services in Scotland, the results and recommendations providing a framework for change. [Since completion of the audit the Department of Health have commissioned a demographic survey of the use of ECT in England between January and March 1999 (Statistical Bulletin 1999).]

At the end of 1995, under the auspices of CRAG, the directors of this project (CF and JH) invited all 35 psychiatrists responsible for ECT in Scotland to attend a meeting to explore interest in an audit which would look both at current practice and also more ambitiously at clinical outcome. All centres agreed to take part and a steering group was set up (Annex A). A project co-ordinator was appointed (GF) and a project worker was employed on a full time basis for the duration of the audit. Funding was obtained from the CRAG National Projects Committee firstly, for a pilot study and subsequently for three phases of audit as described below. Details of the funding are provided at Annex B.