The move towards community care essentially aims at the provision of a comprehensive psychiatric service in each District with facilities for the chronically disabled based outside the hospital for the greater part. Parallel with this move runs the aim to close all large mental hospitals. The present debate centres around the extent to which we can move towards a system of comprehensive District psychiatric services alone at this stage in time and the question of whether it is desirable to abandon totally the large psychiatric hospital style of care. The brief of this paper is to summarize the reasons for concern about a wholesale move towards District-based services from the large mental hospital from the psychiatrists' view-point. Unfortunately, much of the debate is based on speculation because of the experimental nature of this move and the fact that objective research is lacking on any changes already made in this country.

In Britain there are almost 200 pain clinics concerned with the diagnosis and treatment of patients with chronic intractable pain. These patients have frequently run the gamut of medical and surgical services and they are referred to a pain clinic for further assessment and treatment, especially those cases where no organic basis can be found to account for the complaint of pain. Other reasons for referral include specialist treatment only available in a pain clinic, where conventional therapy has failed or where further surgical or medical treatment is not considered justifiable.

Albert Kushlick first showed me this technique. He used it for setting up hostels for the mentally handicapped and I then used it when setting up a Medium Secure Unit. It could be applied to any Unit and I am writing it up because I found that staff members in new units had run into problems where they had not adopted this or a similar approach. The idea is to show how one can translate ‘aims' or ‘principles' into ‘brass tack’ practices by design and with consultation in a multidisciplinary setting.

A timely conference on Mental Health Services Planning, organized jointly by the Royal College of Psychiatrists and the Department of Health and Social Security, took place in London in March 1985. The conference concentrated on difficulties associated with the implementation of government policies for mental health service planning in England and Wales. Particular emphasis was given to the problems of transition from hospital-based services to community-based services.

Suggestions have been made that the Preliminary Test for the Membership of the College should be modified in the direction of a reduced theoretical and enhanced clinical content. I would applaud such a move. Behind it is the idea of testing, early in a junior's career, his or her talents for the processes central to the practice of their chosen specialty. This sort of test has for too long been lacking throughout the profession of medicine. There is no reason why psychiatry should not now, with the advantage of modern technology, set the pace by combining an element of aptitude testing in the earlist hurdle on the road to specialist status.