My jokey title, like most jokes, incorporates a serious truth. The truth is that, despite the apparent clinical expansion and academic wellbeing of our subject, the experience of being in a senior position within it is that it is under threat as a medical enterprise. The sense of threat is felt mostly from the stagnation of the retrenchment in the physical and human resources needed to mount a real service, although I grant that consultant numbers have increased. Management will opt for the least costly alternative when they are presented with a broad range of advice of apparently equivalent worth which is available from various professionals within the subject. Indeed, given the degrees of diversity of views that exist, managers might at times wonder what it is that purports to be the subject. It is not difficult for child psychiatry to achieve a negative image within health management since a number of negative stereotypes naturally accrete around people with serious problems of living and coping, or developmental failure, mental impairment, or chronic sickness. Combined with small size, often a single representative in a District, and dealing with small people who suffer lack of political clout, the management case for neglect of child psychiatry when faced by harsh choices may be overwhelming. Further, child psychiatry arose from a triune of social work, psychology and psychiatry and their quite proper individual professionalisation has afforded the possibility of splitting, not only as among psychiatrists but between psychiatrists and other professionals. In the current political climate and faced with resource shortages those splits are likely to accentuate in ways which leave managers rather than practitioners in control.

I qualified in Belfast (Queen's University) in 1942. I did not have any interest in psychiatry, having the ambition to become a clinical physiologist. I had worked with Henry Barcroft, who was professor of physiology. I joined the Army and later the Airborne Forces. Fortunately, the casualties expected amongst the medical personnel of the 6th Airborne Division during the Normandy incursion did not occur, leaving myself and other medical colleagues, who had just completed our parachute training, redundant. I was posted to France and in the late summer of 1944 found myself regimental medical officer to the 1st Battalion The Herefordshire Regiment. I must confess that it never occurred to me during the winter and spring of 1944–1945 that the emotional reactions and the physical expressions of anxiety encountered, particularly amongst the young conscripts, had anything to do with the subject of psychiatry.

The Families Unit at the Cassel Hospital is the only medical establishment with in-patient beds for whole families, and it can provide the opportunity for detailed and relatively safe observation and treatment of severely disordered families. A number of different kinds of family are treated, including those in which a mother has suffered a severe post puerperal breakdown, those in which one or more members of the family have a severe psychiatric condition such as chronic depression, as well as families whose whole functioning in many aspects of life has broken down.

The 1983 Mental Health Act introduced new powers for courts to remand mentally disordered defendants to hospital. The provisions came into operation in October 1984, and were preceded by a Ministerial statement that the new arrangements were becoming available because the Government believed.

The slow progress in providing community-based care for mentally ill people and thus closing large psychiatric institutions has been well researched and documented. The enquiries have typically sought to demonstrate the gap between national policy intent and reality and have highlighted the structural, financial and organisational barriers to achieving new forms of service provision. Equally, an important recent study has shown that there are marked intra-Britain differences in how the assumed unitary national policy is interpreted and implemented. There is general agreement that the present ‘statutory framework’ inhibits radical service change and, furthermore, that centralised planning, joint-working, joint-planning mechanisms are flawed and underpinned by a poorly formulated financial and manpower strategy. Some management ‘process’ factors have also been isolated such as the presence/absence of clear leadership and ‘committed local champions of change’. The issue of ‘interprofessional tensions’ has been only briefly alluded to, with even less recognition of how the other powerful organisational groups interrelate. Certainly, there has been little ethnographic detail of how these tensions between dominant groups are played out at a local level or indeed impinge on local decision-making and progress. More typically, existing accounts of the closure of the large institutions have had a structuralist bias, with more emphasis upon the impact of regional and national policy and on the machinery of collaboration than on internal politics or the effects of local power relations.

This paper has been prompted by the decision to close a large psychiatric hospital in its entirety and reprovide its services within the community. This was announced in 1983 with the aim that it would be effected within a ten year period. The hospital at that time had approximately 1,000 patients and the decision, which came as a shock to the staff, was taken not by the local management or clinicians but by the more distant administrative structure.

Over recent years attention has been directed towards providing appropriate facilities for the mentally abnormal offender. In the past such individuals were probably absorbed into the hospital system. However, the open door policy of the 1960s and 1970s, together with hospital closures and reduced bed numbers, has meant that this invisible absorption has been unable to continue. It has been suggested that many of these mentally abnormal offenders are inappropriately placed within the penal system, thus contributing to prison overcrowding. The Butler and Glancy Reports recommended Regional Secure Units as a possible solution. At the beginning of 1987, 14 of these had opened. The tendency has been for Regional Secure Units to deal mainly with the mentally ill offenders and the needs of the mentally impaired have been largely overlooked. The literature on the subject of this latter group has been sparse. Craft described an isolated unit in Wales, which dealt with mentally abnormal offenders, and there are hospitals which provide secure facilities for the mentally handicapped. The purpose of this study is to describe the characteristics of the patients admitted to an open forensic unit in order to assess the suitability of the facilities and the outcome of the treatment provided.

Families who have a child with a life-threatening disease need support during the illness and in the bereavement phase. Although few would disagree, the means to provide such a network is not easy. During 10 years working in an oncology clinic, I have become aware of the importance of close liaison links within the clinic itself and in the community. By the nature of life-threatening and terminal illness, staff members need opportunities to discuss their feelings towards their patients if such extremes as patient avoidance or identification are to be prevented. Once a close team spirit exists, the likelihood of an individual becoming over-stressed diminishes. Although all team personnel are potentially at risk, I would suggest that those at greatest risk are at opposite ends of the hierarchy, i.e. the consultant constantly faced with challenging medical decisions and involvement with emotionally drained parents and the junior nurses, seen as ‘safe’ people on whom to unburden. The latter spend more time with the families and have no legitimate mode of escape!

The 100th Annual Dinner of the Gaskell Club for Winners of the Gold Medal was held at the Royal College of Psychiatrists on 30 October 1987.

Looking round the tables I was struck by the number of people who had worked at the Maudsley, a tangible reminder of the contribution of that centre of excellence to psychiatry.

I do not doubt that the standard of psychiatry at the Maudsley remains as high as it ever has been, but inevitably my thoughts ran to the post-war period when, as a 21 year old, it seemed one was surrounded by giants.

The Darwinian model is employed to study the phylogeny and taxonomy of psychiatrists in the UK. External hazards which could threaten psychiatric practice are examined and the part that psychiatrists themselves play in bringing about-their difficulties are emphasised. Ways of ensuring a more satisfactory and secure future for psychiatrists are explored.

Hospital visiting teams, review bodies, and inquiries have become a fact of life in psychiatric settings in the Health Service. In the last 20 years or so there has been an intensification of efforts aimed at examining and evaluating psychiatric services. There can be no doubt that the purpose of the visits—to monitor and improve standards of care and to facilitate changes in service delivery—is a worthy and important one. Clearly, too, a great deal of expertise and energy goes into the visits. Descriptions of the range of visits and the arrangements involved, as reflected in the HAS Annual Report (1985–1986), are impressive.