This is a personal view on the implications for mental health services of the Executive Letter of the National Health Service Management Executive (NHSME), published in July 1992 (EL (92) 48): ‘Guidance on the extension of the Hospital and Community Health Services elements of the GP Fundholding Scheme from 1st April, 1993’.

“The therapist can cite Bertrand Russell's observation that the degree of certainty with which one holds a belief is inversely related to the truth of that belief. Fanatics are true believers, scientists are sceptics”. (Beck et al, 1979)

I propose to describe the evolution of behavioural treatments, and the more recent leap forward made by cognitive therapy. Exciting new treatments are now available that did not exist when I was a trainee. The accepted term for these treatments is “behavioural-cognitive psychotherapy’ (BCPT). They are behavioural in the sense that emphasis is on observable behaviour, e.g. avoidance of supermarkets in agoraphobia. They are cognitive because many approaches involve working with patients' thoughts, e.g. the negative thinking of depressed patients. The treatment is psychotherapy as it is therapy that works at the mind level, rather than at say the synaptic level as pharmacotherapy does. BCPT combines well with pharmacotherapy, and other therapeutic methods such as social therapy, and so is suitable for a multidisciplinary approach to a psychiatric problem, as well as offering specific techniques for identified disorders.

I have had a very busy professional career and have not been much concerned with its formative influences. I was born in Edinburgh on 2 October 1915 into an orthodox Jewish family which migrated to Scotland from Lithuania at the turn of the century. As my father was serving in the army during World War One I did not see him till he was ‘demobbed’ and as my mother had the responsibility of bringing up a family and running a small business on her own I did not see very much of her either. Yet, I consider that I was brought up in a very caring home. I attended Boroughmuir Secondary School where the standard was first-class and I concentrated on modern languages (French, German and English) and mathematics and was offered a place at Edinburgh University when I was 16 years old. I had also acquired a better than average knowledge of Hebrew as well as of Holy Writ and a smattering of Talmud. I then decided to study medicine so I spent an extra year at school to get the necessary grades in physics and chemistry and enrolled in the Faculty of Medicine at 17 years and qualified in July 1938 at 22 years.

Three years is a long time in the life of a President, rather longer than the gestation of an elephant, and about the time that my vines took to start bearing fruit! As I write this in February we are in the middle of the rugby season; Union in the four nations served by the College, and League, also here in Yorkshire. I see the role of the President rather like a good fly-half – a strategic and accurate pass will enable somebody else to score; when in trouble, kick for touch and gain as much territory as possible: A fly-half rarely scores tries himself! The College and its Officers try to improve the ground for the practice of psychiatry, but it is Members and Fellows locally who can capitalise on this and improve the quality of care for their patients.

It cannot be ignored that community care is now a fact, and not merely an issue. Some mental hospitals have closed and the number of mental illness beds have been reduced overall by about 40% over the last decade and a range of hostels, multidisciplinary rehabilitation teams and community mental health centres have been launched. The move towards well integrated and well coordinated community care has been urged by a large number of reports, white papers and policies including the second Griffiths report, Working for Patients, Caring for People, The Health of the Nation, the Care Programme Approach and care management, with social services becoming the lead agency in community care.

In November 1992, Lord Clyde's Report of the Inquiry into the Removal of Children from Orkney in February 1991 was published. This showed that there were similarities with what had happened in Cleveland.

The idea that a psychiatrist should attend the police operation at a protracted or terrorist siege has gained ground. London has had more than its share of sieges, Balcombe Street, Spaghetti House, Iranian Embassy, and the Libyan Embassy to name four of the most notable. Dr Peter Scott took on the role of adviser to the Metropolitan Police in such incidents single handed until his death in 1978. He gave his own account of his work (Scott, 1978). This current account carries the topic forward a little in the light of experience gained since his death and is in response to repeated requests, by other psychiatrists, for information.

Inner London, together with many other inner city areas, faces a crisis of funding in health services. Budgets are now allocated to commissioning authorities primarily on the basis of the sizes of resident populations. Although it is recognised that different communities have different needs and that some adjustment to this simple approach (capitation weighting) is required, there is no clarity about the best mechanism to achieve a fair resolution (Stern, 1992). Those inner city areas with high levels of social deprivation, high indices of health service need and especially those with high numbers of homeless people require additional resources to provide acceptable levels of overall care. Failure to take adequate account of these pressures may result in further gradual reductions in funding and consequently in service provision.

In mid-1991, the Conference of Medical Royal Colleges and their Faculties initiated an Advisory Group on Information Services with broad representation from the profession, the NHS Management Executive, and the Department of Health. The aim of the group is to facilitate and co-ordinate input from the profession to the NHS Information and Technology Strategy. It is chaired by Sir Duncan Nichol, NHS Chief Executive.

As psychiatry broadens its perspective beyond a predominantly hospital focus, the tools of its trade need some reshaping to serve the needs of an altered working environment. The instrument indispensable to every psychiatrist is the scheme for assessment, comprising history-taking and examination of the mental (and physical) state. Honed by long familiarity and usage, its employment is the fundamental skill demanded of aspirants to medical practice and to psychiatry.

Antidepressants are increasingly being used for the treatment of anxiety disorders, although they are not specifically licensed for this indication. This has come about partly because of concern over the problem of benzodiazepine dependence and the search for alternative, and preferably better, treatments. Antidepressants and other treatments have proved to be an effective alternative to benzodiazepines despite having more unwanted effects and a delayed onset of action. They may even be more effective than benzodiazepines and their benefits are alleged to be independent of concurrent depressive symptomatology. What is the evidence in favour of these claims?

Although several studies have found the frequency of postnatal depression to range from 9 to 13%, optimal services for the recognition and management of this disorder are not fully established. There is a lacuna in the provision and costing of comprehensive services for women with postnatal mental illness, although it is recommended that each large district requires a consultant led team (three to five sessions per week) and a district or supra-district mother and baby unit (Oates 1988; Royal College of Psychiatrists 1992).

In setting out a health strategy for England the White Paper, The Health of the Nation includes mental illness as one of its five key areas for action. Within mental health three targets are set out.

The new system of funding introduced by the National Health Service reforms has led to an increased awareness of financial concerns within the NHS. This was indeed one of the main aims of the reforms, with the expectation that a more efficient and better quality service would result. This may be a realistic aim, as long as clinicians' freedom to make appropriate secondary and tertiary referrals do not become totally dependent upon financial considerations. Yet it has become clear from findings within our own unit, Henderson Hospital, that, in at least 42% of cases, requests for ECR funding for treatment were refused on a purely financial basis (Dolan & Norton, 1992).