As students at the Durham medical school in Newcastle during the early thirties, we were taught that illness could be due to certain factors and these were listed. The malady could be caused by infection, acute or chronic, trauma, neoplasia. … there were many possibilities but at the very end was a sort of garbage bin for all the diseases which did not fit neatly into the organic syndromes; these were called hysteria or psychoneurosis. These functional cases were diagnosed in a purely negative way, by a process of exclusion. No attempt was made to explain possible reasons for these troubles and there were no suggestions as to how to treat them. We were led to believe that such people were no more than time-wasters, suffering from unworthy maladies. If neurosis in all its forms gave rise to disdain, psychosis produced overt panic, as exemplified in the following case history. A young woman of 20 was admitted to a medical ward in the late stages of pregnancy because she was suffering from severe Sydenham's chorea. She was so bad, she was constantly in danger of falling out of bed and she was quite unable to speak coherently. It must have been because of this she was deemed mad, and a respectable medical ward was certainly no place for a lunatic. Fear in both the medical and nursing staff had completely obliterated all feelings of compassion. She was certified and transferred to the asylum where she died the next day. It was well known that chorea gravis carried with it a bad prognosis and, after all, there were side wards. The poor lass should have been allowed to die in dignity in one of them.

In 1981, the Labour Minister for Health in a coalition government, Mrs Eileen Desmond, set up a study group ‘to examine the main components, both institutional and community, of the psychiatric services; to assess the existing services, to clarify their objectives and to draw up planning guidelines for future development of the service with due regard to cost implications; to carry out such studies and to take part in such consultations as are necessary to assist this examination’. The result appeared in December 1984 in the form of a report The Psychiatric Services: Planning for the Future. The text of the response of the Irish Division of the College, reproduced in full here, was sent to the current Minister for Health, Mr Barry Desmond, (also a Labour Minister in a coalition government) in October 1985. Meanwhile, in February 1986, Mr Desmond caused widespread alarm in political circles by the sudden announcement of the closure of two of the 22 psychiatric hospitals in the Republic without prior provision of alternative community services. British readers will detect a close parallel between this Irish report and the series of DHSS reports exemplified by Better Services for the Mentally Ill (HMSO, 1975). Perhaps the only significant difference between these two reports is that sectorisation (a mental health team headed by a psychiatrist and assigned to a ‘sector’ of 25,000 to 30,000 persons) is advocated rather more firmly in Planning for the Future. It is also worth remembering that the Republic of Ireland, in its population size and urban-rural distribution is comparable to the whole of Yorkshire. Half the population lives in Dublin. Elsewhere, psychiatric services must cope with widely scattered rural populations, with a minority only of working adults. There is a large private sector in Irish medicine and 20% of psychiatric admissions are to one or other of five private psychiatric hospitals. Despite these social differences from the UK, several comparative studies have shown a remarkable similarity in declared attitudes and practice amongst Irish compared with British psychiatrists. Finally, the method of remuneration of Irish family doctors differs from the UK: Irish GP's are paid, not on a capitation basis, but on a ‘fee-per-item-of-service’ basis with a majority of the population availing of this service free: patients tend to move from doctor to doctor and many use private health insurance to opt for private care. Psychiatric referral rates from general practice are low as in Britain.

We are mad, not only individuals but nations also. We restrain manslaughter and isolated murders; but what of war and the so-called glory of killing whole peoples?

The community mental health movement remains an important force in American psychiatry and a shift towards community orientated mental health care is now being actively promoted in Britain. Nevertheless, concepts of community mental health care are not clearly defined, and the term has been variously misused, as a label applied to existing facilities without real change in philosophy, as a political justification for closing large mental hospitals, and as a platform for the propagation of anti-medical ideology. The development of community orientated services involves a change in role for the psychiatrist, which many find difficult to accept. Psychiatrists have been warned that they are at risk of being left behind in the current moves towards community mental health care in Britain.

At present about 4% of doctors opt for a career in psychiatry. Between 1974 and 1977 almost a quarter of the consultant posts in general psychiatry remained unfilled; in 1981 there were no less than 220 unfilled consultant vacancies. This shortage is regarded by many as representing a deficiency in quality as much as quantity of applicants. If the consultant grades are expanded in the future to the levels suggested by the Short Report these problems are likely to increase rather than decrease, unless recruitment into the speciality is enhanced.

In times of pessimism when psychiatry is described as in decline, subject to public scepticism with the psychiatrist's role threatened by social workers, psychologists and community nurses, one's immediate reaction is to adopt a historical perspective. The advances achieved during the last 50 years which I recall are so impressive that it seems reasonable to see current legal and bureaucratic problems as resembling a ditch rather than a precipice! These advances have occurred in spite of adverse administrative situations. It is important to remember that in spite of its merits the National Health Service was not conceived with Mental Health Services in mind—nor were Social Work Services.

The possibility that estimates of psychiatric manpower needs could be informed by knowledge of what doctors do and should do with their time was discussed in a previous paper. In this paper, we outline a procedure for calculating the psychiatric manpower needs of a Health District. The basic assumption is that the numbers of psychiatrists in a District ought to be sufficient to do the work that needs to be done. We suggest that this work should be assessed in terms of the amounts of doctor time required for specified activities.

Book reviews published in professional journals provide an interesting glimpse of contemporary interests, ideas and attitudes. The third number of the Journal of Mental Science (formerly Asylum Journal) included book reviews and, after appearing intermittently for a while, they became a regular feature throughout the remainder of the nineteenth century. These reviews were probably the principal source of information for asylum doctors about current books in their field, although there were a small number of alternatives for the more specialist readers.

In 1793 Pinel started the move towards modern psychiatry by removing the chains from patients at the Bicetre Psychiatric Asylum. In 1986 the Mental Health Commission through their draft Code of Practice (COP) are metaphorically attempting to place those chains upon the professionals whose job it is to treat psychiatric disorder. Psychiatry will not benefit by having either the patients or the carers chained. I feel that if the COP in its current form is accepted, then it is likely in the long-term to lead to a deterioration of services for the mentally ill and we should ensure through the Royal College that we are not forced into accepting proposals from people who are in a worse position than ourselves to determine what is best for our patients.

The Report of the Social Services Committee of the House of Commons in 1981 (the ‘Short Report’) recommended the establishment of consultant posts without the support of trainee medical staff as part of a strategy to correct the situation where too many doctors occupied training posts for the number of consultant posts available.1 The Royal College of Psychiatrists has endorsed this policy,2 and the withdrawal of approval for training from an increasing number of hospitals around the country is leading rapidly to a situation where a large number of them need to look at alternative arrangements for providing medical cover. We would like to report the establishment and early development of such an arrangement based in a district general hospital.

The Education Act (1981) was brought into effect on 1 September 1983. Explanatory and guidance documents were published in 1983. The Education Act has effects on the work of child and adolescent psychiatrists in two ways. Firstly it affects those in-patient and day units that have education on the premises. Secondly it affects the placement of children who have special educational needs because of emotional or behavioural problems, the children who in the past would have been deemed maladjusted. While child psychiatrists should be involved in all cases where emotional and behavioural problems are the main issue, they will also be involved with some of the children who have special educational needs because of intellectual and learning difficulties, children who in the past were deemed educationally subnormal. These children between them constitute a high proportion of those who will, under the new Act, be subjects of statements of need.

608 is a Community Mental Health Centre (CMHC) in Waltham Forest Health District which came into service in February 1983. It serves a catchment area in North East London of approximately 95,000, and caters primarily for the 16 to 65 age group. It is linked with the services provided by a large psychiatric hospital—Claybury—which has been scheduled for closure by 1993. Planning is now under way to provide alternative services in each of the five districts covered by the hospital.

Like it or not, we all live on a planet teeming with variety. East and West for example have developed very differently, even though many of the problems faced by these divergent cultures are similar. True, Europe's colonising yoke in the past four hundred years introduced western infrastructure to many eastern countries, particularly in the fields of administration, communication, health, and education. However, traditional habits run deep, particularly in countries with large rural populations, and the apparent degree of westernisation can be deceptive.