As a general adult consultant psychiatrist who has worked full-time in the National Health Service (NHS) for 15 years, I have seen that things do change, but rarely in the ways expected or planned for. Having done the same job for six different reconfigurations of local services, I can confirm that reorganisation is largely irrelevant. However, new treatments (such as selective serotonin reuptake inhibitors and atypical antipsychotics) and new buildings, along with enthusiastic staff, can be seen as genuine advances. Changing social attitudes, in particular the rise of morbid individualism and an increasingly virulent, reactionary anti-science lobby, alongside sheer social overcrowding and pollution, do bring fears for the future. Community care has become a joke term rather than a watchword for acceptance of the stigmatised among ‘normal’ society. Three visions are possible: the dystopian, the normotopian and the utopian, looked at along the biopsychosocial spectrum.