The different cultures of doctors and managers and the impact of these on their working relationships are described. A historical resumé tracks organisational change, the evolving nature of the relationship and the stresses it engenders. The phenomenon of scapegoating and an approach to managing risk is explored. Vignettes describing familiar problems, with suggested strategies for analysing them and resolving difficulties, are presented.

The NHS is an organisation populated by groups who often compete with each other over sparse resources and avenues of influence. Professional rivalry is endemic in this situation as groups position themselves to acquire, consolidate and protect professional territory.

Use of both licit and illicit drugs can lead to a range of medical, psychiatric and social problems, and the situation becomes further complicated if the user is pregnant. Prescribed and non-prescribed substances can affect a pregnancy, and substances are seldom used in isolation. In this review we focus on users of illicit drugs (including prescribed drugs used illicitly) during pregnancy and describe some of the issues in managing such cases. We consider the impact of subtance use on the foetus, the mother and the newborn child, and highlight the importance of multidisciplinary working in this area. Space precludes a detailed account of the issues surrounding the use of legal substances such as alcohol and tobacco during pregnancy, but we note their significant impact in this group.

Amphetamines, cocaine and methylenedioxymethamphetamine (MDMA, ‘ecstasy’) have been prominent on the UK drugs scene over the past decade. Much cocaine is now in the form of ‘crack’, which produces particularly acute versions of well-known complications including paranoid psychosis, mood disorders and cardiovascular problems. Ecstasy has additional hallucinogenic properties, and the slightly different range of psychiatric effects can be long-lasting. Assessment for stimulant misuse should include drug screening more than is currently common in general settings. Management comprises psychosocial (particularly behavioural counselling) and pharmacological approaches. A wide range of dopaminergic and other medications have been studied in cocaine misuse, and specialised substitute prescribing may be appropriate for heavy amphetamine injecting. There has been recent focus on problems of dual diagnosis, with particular strategies required to address stimulant misuse by people with severe mental illnesses.

The 2001 foot and mouth disease outbreak in the UK was widespread and devastating. Some areas (e.g. Cumbria) were very badly hit, but all farmers were affected to some degree. Huge numbers of animals, infected and healthy, were slaughtered. Tourism was badly affected. Data from three systematic studies found elevated levels of psychological morbidity among farmers and other rural workers, especially those directly affected. Most farmers turned to family and friends (and veterinary surgeons) for support; relatively few approached health or social services, mainly because they did not see their reactions as illness. Many farmers and other rural workers prefer to use supports within their own community, or anonymous supports such as self-help materials or computer-based treatments. Mental health services should take account of these preferences by adopting an educational and consultative role in any similar outbreak.

Schizophrenia continues to challenge services: recent advances in antipsychotic drug treatment and psychosocial interventions are hindered by non-adherence, disengagement and substance misuse. Furthermore, new side-effect concerns attach to atypical drugs, and psychosocial interventions may be underresourced or of unproven benefit. It is important to address all issues with which patients, families and carers need assistance, and to take a well-informed, creative approach to pharmacological treatment, using medication according to individual patient need rather than mechanistic adherence to guidelines. Psychiatrists should be realistic in their expectations of patient outcome, accepting outcomes that fall short of recovery and imply long-term supportive care, and insisting that this care be available to their patients. Psychiatrists should support early diagnosis and intervention as being possibly the only means to alleviate the burden of long-term schizophrenia for patients, families and services.

Psychotic symptoms in elderly people can be seen in a variety of conditions. This article reviews treatment strategies (both pharmacological and non-pharmacological) for such symptoms in schizophrenia and neurodegenerative disorders in this population. Traditionally, antipsychotics have been the most commonly used treatment for psychotic symptoms. Their usefulness in treating schizophrenia, both chronic and late onset, is well established and the atypical antipsychotics, which have a better side-effect profile, are more suitable for elderly people. More recently, there have been increasing concerns about their safety in psychoses due to dementia. The debate about whether an absolute ban on their use is required is still ongoing, but it has highlighted the need for adopting and developing non-pharmacological interventions.

The role that carers play in supporting older people with mental health needs in the community is well recognised by professionals and in current government policy. This article promotes the view that a systematic planned approach that engages the carer as an integral part of the system of care has potential benefits for patients, carers and services. Ways of working in partnership are outlined and evidence that psychosocial interventions with carers are effective is briefly reviewed. Examples of individual and group interventions for dementia carers are given, drawing on clinical experience and research literature. Areas for further development are highlighted, including greater partnerships with carers in primary and continuing care, as well as at the level of planning and service development.

Benchmarking has been advocated by the Department of Health as a tool of clinical governance. The essence of benchmarking is learning from the best practice of others. Its ability to compare services and outcomes of care can facilitate change, ensuring quality control and continuous service improvement. The concept is in its infancy in the National Health Service despite its exceptionally rapid growth in business organisations over the past 25 years. Many of the characteristics that make the process so valuable in business are equally relevant in healthcare. This article reviews the history of benchmarking and describes its application in mental health services for improving patient care. It includes an analysis of the centrality of the benchmarking doctrine to the core principles of clinical governance and reflects on the assets health services possess to facilitate benchmarking. It concentrates on the principles of setting up a team and uses a case example to highlight the organisational and clinical effect that a benchmarking project could have.