I suspect I have a certain modest reputation in psychiatric circles as a “cautious researcher”. What follows is neither cautious nor research; it is an intensely personal account. I have no doubt that many of my colleagues, medical and non-medical, saw things in a very different way.

Consultation-liaison psychiatry had its inception in North America, the term making its first appearance in the 1930s to describe the department at Colorado General Hospital in Denver. As Mayou (1987) points out, when comparing British and American liaison services, the role, boundaries, and organisation of this subspecialty are very different in the two countries. Money and resources do not exist in Britain within the National Health Service to provide the extent of involvement liaison psychiatry now enjoys with the general wards of many American hospitals. Thomas (1985) refers to basic differences between the countries. He points out that few British district general hospitals have consultation psychiatric units now in place and that the theoretical background of psychiatrists in the two countries are different. In addition, he suggests that there may well be differences in the referral patterns and expectations with regard to psychiatric consultation requirements of general hospital doctors in the two health care systems.

I had acquainted myself with the psychiatric services in New Zealand some years ago during my student elective. I wanted to return to experience further a system which was both similar and different to the NHS. The New Zealand hospital system was funded in a similar way to the NHS. One organisational difference was the managerial layer, which was still filled by medical superintendents. Another difference was the extensive no-fault accident compensation scheme through which settlements were made without resort to lawsuits. Thus doctors paid low medical defence fees and were rarely sued, but the Government had regularly to meet a large bill. The psychiatric services were in the process of moving from hospital-based to community-based, in line with prevailing clinical and public attitudes. This was fuelled by some headline-making scandals over patient care in the asylums. One cause for general alarm was the poor health of ethnic minorities, especially the indigenous Maori. This issue resonated with racial and political overtones.

The structure of mental illness services is changing rapidly. Large hospitals are closing or preparing to close and the service will be provided in other ways, partly by smaller units, partly by increased care in the community outside hospital and partly by amalgamations of two or more large hospitals. Smaller units allow closer working relationships with GPs, social workers and other professionals.

Traditionally, general practitioners and psychiatrists relate to one another through a system of cross referrals, from primary care to secondary care and back again, the referral being initiated by the GP through a request for a domiciliary visit or more usually for an out-patient assessment of the clinical problem. However, in the mid-1960s, individual psychiatrists began to report a new way of working, which consisted of the psychiatrist going by invitation into GPs' surgeries or health centres to work directly with the general practitioners and with other members of the primary health care team. A survey undertaken by Strathdee & Williams of the General Practice Research Unit of the Institute of Psychiatry, showed that by 1984 in England and Wales, one psychiatric consultant in five, sometimes with, sometimes without, junior staff, spent some time in a general practice setting. At the College meeting in Cambridge (April 1988), Pullen reported that in Scotland a similar survey showed that as many as 40 to 50% of psychiatric consultants spent some time in primary care settings.

The Yorkshire Regional Psychiatric Association is a group of psychiatrists, general practitioners, psychologists, nurses, social workers, occupational therapists, chaplains, health managers and others working in the field of mental health. Its main functions are to promote vocational, academic and social discourse between members of the professions with an interest in mental health and handicap. It has about 300 members. The Association was founded in January 1949 as the Leeds Regional Psychiatric Association. This became the Yorkshire Regional Psychiatric Association in 1982. In 1989 the Association reaches its 40th anniversary. The Association can claim the distinction of being the first multi-professional society of workers in mental health to be established in the United Kingdom.

Up to 37,000 chronic mentally ill and mentally handicapped patients have been discharged from long-stay hospitals over the past ten years and nobody knows for certain where most of them are. This is one of the findings of the 1986 Audit Commission into community care which prompted Sir Roy Griffiths (1988) to state in his report on community care that.