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 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.

Psychiatry might be seen as a three dimensional space, with two of its dimensions caricatured in the title. Of the first, ‘phenomenology’ stands for scientific rigour, the medical view favouring diagnosis based on analytical activity, followed by construction of syndromes from individual symptoms/measures. The ‘price of beans’ stands for materials; the economics of care in the post Griffiths era, value for money, hospital closures, massive reorganisation and the negative implications for service users.

Last summer I spent two weeks as visiting psychiatrist at Chestnut Lodge Hospital, one of the pioneering institutions in the psychoanalytically oriented treatment of psychotic disorders. This approach has been modified over the years until the present time having been complemented by new developments in the social, psychological and biological fields of psychiatry.

The electroencephalogram (EEG) is widely reported to be of limited value in psychiatry. This is particularly so with regard to the neuroses and functional psychoses. The value of the EEG in organic states is not much better, especially since the advent of computerised tomography (CT). However, it should be noted that the former gives a functional and the latter a structural assessment of cerebral disturbance.

We spent part of this morning's ward round making a priority list; which of the five patients in need of admission was most acute, which could wait. There are two elderly ladies, both living alone, both very depressed. Edith is no longer taking care of herself, picking at her skin to the point where nasty sores have formed, and pulling her eyebrows out in her distress. Jonathan should have been admitted last week, we delayed and he took an overdose of Ativan. Alan is an elderly man who gets recurrent depressions. They seem to resolve of their own accord without medication if only he can be admitted for two or three days. Eleanor is a young mother of 28 who has been depressed for three months. Now she is completely preoccupied with ideas of killing both herself and her children.

Clinical experience suggests that accident and emergency departments are increasingly adopting the role of primary health care providers, particularly those departments situated within the inner cities. Previous studies have shown that there is a high rate of psychiatric morbidity contained within the group of patients attending accident and emergency departments. The question arises as to how adequate provision for serving such patients can be made. Traditionally these patients have been referred to a duty psychiatrist for assessment or have been discharged from the department without a specialist psychiatric opinion having been sought. This approach has its drawbacks as an inappropriate emergency referral creates unnecessary work for an already busy duty psychiatrist. On the other hand no referral at all may result in serious psychiatric disorder remaining undetected and untreated with possible tragic consequences.