Following the publication of correspondence between the then Minister for Health, Mr Kenneth Clarke, and the National Schizophrenia Fellowship (Bulletin, March 1985, 9, 49–55), we are now publishing the concluding letters in this exchange of correspondence. (Mrs Joyce Major has been succeeded by Mr R. N. Lines as Chairman of the NSF.)

We use the expression ‘long-term patient’ to describe one who, whether in hospital or elsewhere, needs a great deal of supervision and/or nursing care. We use ‘long-stay patient’ for the smaller category in hospital or equivalent health service institution. The great majority of long-term who are not long-stay are at present cared for by relatives, if at all; a small fraction are in staffed homes provided by the voluntary sector, or are in local authority hostels.

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.

Estimating demand for psychotherapy is like trying to evaluate the size of a mountain range from the foothills—the higher one climbs, the more potential needs become apparent. The unspoken dream that at some point all these needs will be met by trained psychotherapists seems firmly destined to stay in the realms of fantasy. In reality, specialist psychotherapists will always be thin on the ground. In Surrey, where my own practice is based, I am, and am likely to remain, the only medically trained psychotherapist with four sessions allocated to a population of 200,000. The psychotherapy department at St. George's Hospital, Tooting, to which I am also attached, has a catchment which extends to the whole South-West Thames Region, encompassing places as far afield as Chichester and Haywards Heath.

Although the Academic Department of Child and Adolescent Psychiatry of the University of Glasgow came into being with the establishment of a Chair only in 1977, the subject had been taught to medical undergraduates since the early 60s. This was possible, even without a formal academic base, because of the long-established Scottish tradition that NHS consultants and their junior medical staff accept as a matter of course, and usually as something of a privilege, to participate in the teaching of medical students. As the Department of Child and Family Psychiatry was based in the main paediatric teaching hospital at the Royal Hospital for Sick Children, Glasgow, it was a natural development that this should also be the location for the teaching of the specialty, and throughout its development in Glasgow this course has been a part of the final year block placement of undergraduates for instruction in child health and paediatrics. Over the years there has also been some participation in the lecture course in general psychiatry which takes place in the fourth year of undergraduate study.

In 1968 the Royal Commission on Medical Education recommended that ‘every psychiatrist should be familiar with the conduct of community psychiatry’. This seems an uncontroversial piece of advice, but what is ‘the conduct of community psychiatry’? At the time of the Royal Commission, there was certainly no special training at all in anything that could reasonably have been regarded as such.

The dramatic changes in Italian psychiatry since 1978 when the practice of Democratic Psychiatry was officially started has had a controversial response from both inside and outside Italy. In an attempt to know more about the system that made sweeping changes in Italian psychiatry, five Italian psychiatrists and psychologists were invited to Sheffield for a two-week exposition of films, paintings, photographs, lectures and meetings on the art of Democratic Psychiatry from Italy. This was the final leg of the visit to England, after London and Manchester. The events were organized in a truly varied and democratic manner by the University Department of Psychiatry, the Division of Continuing Education at Sheffield University, and the Graves Art Gallery, in co-operation with MIND, the District Health Authority, the Family and Community Services Department, and staff from hospitals in Chesterfield, Doncaster and Sheffield. The aim of the exposition was to provide an opportunity to discuss the prospects for changes in the mental health and mental handicap services in the light of the Italian experience.

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.

I am just back from taking part in a fortnight's refresher course in Chengdu, Sichuan, People's Republic of China, attended by about 35 psychiatrists from other provinces and about 35 more from mental hospitals locally or from the host department of psychiatry of Sichuan Medical College. My part was to give six lectures and eight question-and-answer sessions on general adult psychiatry, and to hold four case conferences. With the help of good interpreters I learned that Chengdu patients are much like those in London, and are given the same psychotropic drugs in the same doses with similar effects. Although oral language is a barrier, facial expression, body posture and gesture appear to be international and one can learn a good deal from them.

Once it was generally supposed that people were afraid of psychiatrists. The fear of insanity, that ultimate loss of control, made people joke about psychiatrists as they joked about other fearsome things such as death and sex. Now it seems there are fewer jokes but much more open suspicion and hostility and there is much to suggest that over the years psychiatrists have become afraid of people. We have been so preoccupied with the clinical and heuristic aspects of our profession that we have not recognized the emergence of damaging paranoid forces, let alone made any adequate or appropriate response to them. This failure has created formidable problems for the mentally ill and their families and has been a significant factor in promoting one of the vicious backward swings in the pendular history of psychiatry.

In this article, ‘mind science’ refers to any knowledge derived from the study of behaviour, in which I include self-reports of mental states. ‘Brain science’ refers to anatomy, physiology, and biochemistry. Psychiatrists have contact with both types of science, especially in helping to construct therapies. Some choose help more from the one or the other, but even those who make use of both rarely see any connection between the two sciences. There are also difficulties over what is truly scientific in the ‘mind science’ sector. This article looks at these two problems.

Education for consultants may appear to some to be a paradox. Consultants are often expected to be providers of an endless fund of knowledge, expertise and skill. Their own needs have perhaps been subordinated as a consequence. Traditionally education for consultants has been provided by postgraduate conferences where the participants are invariably passive recipients of a series of lectures. For the participant, weighted down by the excellence of the gastronomic hospitality, these occasions may become a personal battle against creeping postprandial somnolence, and are only enlivened by the conviviality of social encounters and renewed aquaintances. Their educational value may be less profound.

Stimulated by the First International Conference on Organization and Management of Psychiatric Services in Montreal in Spring 1983, an idea arose which was translated into the first UK Workshop on Psychiatric Service Management held from 17 to 20 July 1984 in York. The theme was economics, addressed by a talented group of British health economists. The meeting was structured into a series of presentations followed by group discussion, culminating in group exercises involving informed criticism of selected research papers on economic appraisals of psychiatric services. Seminar topics included: What do we mean by efficiency in the delivery of psychiatric care? (Professor Alan Williams); What are the costs of delivering psychiatric care? (Ron Akehurst); Switching resources (Professor Alan Maynard); Measuring outcomes of health (Professor Alan Williams); Choosing options with a limited budget (Mike Drummond and Ron Akehurst). A special evening discussion was led by Tim Nodder (Deputy Secretary at the Department of Health and Social Security) who gave an eloquent account of Health Service Strategy vis-à-vis mental health over a thirty-year historical perspective.

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.