There appears to be a growing public interest in “holistic” and alternative medicine which can be seen as a reaction to the scientific–medical role (Mechanic, 1978) of a conventional medicine which often fails when confronted by emotional or psychosomatic problems, and to fears, by the public, about the side-effects of therapeutic drugs.

The decision concerning who is fit to practise medicine is rightly considered a serious one and universities hand this responsibility to a small number of senior clinicians. However, it is on patients that the doctor will practise and while all patients have a concept of what makes a good doctor, their views are never canvassed in the Final MB.

At the present time, changes in the NHS provision for people with mental handicaps mark the end of one era and the beginning of another. The Yorkshire Region is seeing a far-reaching change from a previously regionally organised hospital system to district-based services. It is a time to take stock of what has existed before it is altered completely.

Good Practices in Mental Health (GPMH) is a national charity set up to disseminate information about local mental health services which are found to work well. Its general aim is to promote and assist the development of good mental health services. By providing an exchange of information about effective services in both hospitals and the community, GPMH encourages others to build on what is already proving successful. GPMH developed from a survey of mental health in big cities carried out by the International Hospital Federation (IHF) and was set up in 1977 with the support of the IHF, MIND and the King's Fund. It has the backing of all the major professional organisations concerned with mental health in the United Kingdom, the World Health Organization and the World Federation for Mental Health internationally. It is now funded mainly by the DHSS; some funding comes from the London Boroughs Grants Committee and charitable sources. There are three units within the organisation: information, development and evaluation.

Little did we know, as fledgling conference attenders, what lay in store for us when we learnt that our papers had been accepted for the VIIIth World Congress of Psychiatry in Athens, October 1989.

Community care around Edinburgh was very poor during the early 1850s. Insane paupers were often detained without warrant in poorhouses and private houses, with no official visits from the sheriff and no records of care kept. Accommodation was often bad, with scant furnishing, such that inmates might have to eat their meals off their knees. Where patients had dirty habits conditions were described as “very close and unpleasant”. Those who received a wash were those who were noisy or violent, using water that was likely to be cold. Only in the summer might a patient be allowed to bathe in the sea. Sexes were often imperfectly separated though restraints might be used, for example, to a bedstead at night. In some establishments, females might fare better in terms of clothing and food (Scottish Lunacy Commission 1857).

Last year I was fortunate enough to visit two GP friends running a district hospital in northern Malawi. As I had just taken Part 1 of the Membership Examination, they were intrigued to know my professional view of a condition called ‘the vimbusa’. In their experience, the vimbusa was a common complaint with a wide variety of presentations, none of which corresponded with disease entities they had learnt during their training. After a fascinating two weeks I was unable to categorise the vimbusa according to ICD-9, but the following essay summarises my attempts to understand this condition.

The emphasis of psychiatric care is being moved from the large mental hospitals towards community-orientated care and there seems also to be a need for a shift in the training of psychiatrists to include greater emphasis on the special issues involved in this approach to service provision.

Mental health services in general are at present receiving a bad press. Recent complaints focus on two main areas: the widespread prescription of tranquillising drugs, and the social consequences of the policy of community care. There is now serious concern, both among the public and in the profession, about the over-prescription of tranquillisers. The legal implications are serious. An article in the Journal of the Medical Defence Union was recently quoted in the Bulletin: “Dr Ashton's article is a timely reminder that the prescription of benzodiazepines is now a high profile activity for the psychiatrist that has been scrutinised much more closely than many of our other functions. It is well to be aware that one of the potential onlookers is a lawyer” (Tyrer, 1988).

There are two episodes which remain in my mind from the first night I was on call at the Clarke Institute of Psychiatry, Toronto in 1980. The first person I assessed in the Emergency Room was a young university student in her early twenties who had been reading “Jung” and urgently needed to discuss “archetypes and the animus”; the second incident some hours later involved a middle aged man who was manic on admission and responded rapidly to the 10 mg of haloperidol I administered intravenously in front of a silent and, as I later discovered, astonished night nurse and junior resident. The patient settled rapidly and my unorthodox treatment was a talking point for several weeks. These two vignettes alerted me to the fact that things were different here. No-one had ever used intravenous neuroleptics in Toronto at that time, and equally no-one in Newcastle on Tyne, which I had left only two weeks earlier, would consider the casualty department of the Royal Victoria Infirmary a necessary stop as they waded through Jung.