Psychiatry is a complex enterprise, requiring the longest training period required of any mental health profession. Yet doctors are playing a declining role in deciding health care policy. It is almost as if while acknowledging they would rather see a doctor than anyone else when seriously ill, lay public and politicians also prefer practically any alternative, other than a physician, when determining who should decide how health care is delivered.

The exclusion of services for older people from the Mental Health National Service Framework and the delays in publication of the National Service Framework for the elderly have caused many old age psychiatrists to be concerned that, as in many other areas of health service planning and provision, the needs of older people are not being adequately addressed by Government and health service planners. The recent Audit Commission Report, entitled Forget Me Not: Mental Health Services for Older People†, gives us much encouragement that the needs of older adults have not been forgotten. Its recent publication should provide an authoritative focus, which will help old age psychiatrists, their multi-disciplinary and management colleagues and commissioners of services to push forward improvements in services for older people with mental illnesses.

The articles by Geddes & Wessely (2000, this issue) and Lelliott (2000, this issue) describe the current evidence base and guidelines from which clinical standards can be developed in mental health. They highlight some of the issues and complexity surrounding the development of standards. It could be argued, however, that an even greater challenge lies in getting clinical standards used in routine practice.

Launched with little more than a whimper during the Labour Party Conference the much vaunted National Service Framework for Mental Health (NSF–MH) outlines the Government's ‘ambitious agenda’ for mental health services (Department of Health, 1999a). The official driving force has been the desire to deliver a quality service throughout the whole NHS via clinical governance and underpinned by professional self-regulation. Developed following widespread consultation and with the advice of the External Reference Group (although some of this advice was clearly disregarded), the NSF–MH provides a series of seven core standards with examples of good practice. Although developed with general psychiatry and severe mental illness in mind, the NSF is not quite the ‘National Schizophrenia Framework’ that some envisaged, since it also acknowledges the needs of young people and the influence of developmental factors on adult mental health. The NSF–MH sets standards in five areas: mental health promotion, primary care and access to services, services for the severely mentally ill, caring about carers and preventing suicide. It is only the second to be published (the other being for coronary care) which is hopefully a reflection of the ‘priority’ once more being given to mental health. However, the near-simultaneous appointment of a cancer ‘tsar’ suggests that ‘priority’ is a readily used and easily diluted term.

Towards the end of 1998 we decided to introduce a facility to lock the doors of the acute psychiatric wards at Bootham Park Hospital, York. At first sight this would appear to be a retrograde step for modern psychiatric care in the UK. But this was a reasoned and planned move which has resulted in improved care for patients overall.

We recently had a homicide inquiry in our trust. The events around the release of the report made for a demoralising experience. The visible pain in the families of the victim and the perpetrator caused by the tragedy was heart-rending. As Medical Director, I also saw at first hand the powerful impact on the members of the team involved, my colleagues in general, the trust management and the health authority, all of whom strive to provide effective mental health services in one of the most deprived areas in the country. There were also political influences, especially the need to be seen not to tolerate poor performance. Allusions to disciplinary issues were not infrequent. We all found it very disturbing. I was forced to think a lot about homicide inquiries and became increasingly struck by a growing number of internal contradictions. I started making notes to help order my thoughts. I offer for discussion some conclusions using this inquiry (Scotland et al, 1998) as an example.

There has been much debate about effective treatments, service configurations and costs within Britain's mental health care system, but it has largely taken place in academic and management circles. We were interested in the views of those providing care. We organised a meeting of community psychiatric nurses, general practitioners and consultant psychiatrists (funded with an educational grant from Zeneca Pharmaceuticals). Participants worked in various parts of Great Britain, including rural and inner city areas. The authors facilitated the discussion, the emphasis of which was on participants' clinical experience.

The Team for the Assessment of Psychiatric Services (TAPS) was established in May 1985 with the explicit purpose of evaluating the national policy of replacing psychiatric hospitals with district based services. TAPS' remit was to mount the evaluation with respect to the closure of Friern and Claybury Hospitals in north London. Funding was provided by the Department of Health and North-East Thames Regional Health Authority (latterly North Thames Regional Health Authority) with supplements from the King's Fund and the Sainsbury Family Trusts. During 13 years of research TAPS has employed more than 50 members of staff and associated researchers. A full listing is given in Leff (1997). This summary of the research is organised by topics. However, there was very close integration of the various projects.

Distinctions between mental illness and learning disability have existed since the last century (Pinel, 1801; Ireland, 1877). The conditions have been accepted as coexisting in the same individual since the beginning of this century (Kraepelin, 1902). More recent papers have investigated the frequency of their coexistence and concluded that most psychiatric disorders are more common in those with learning disability than the general population (Turner, 1989).

We were encouraged by the many, varied, responses to our paper on the roast breadfruit psychosis (Hickling & Hutchinson, 1999). We have no intention of defining or creating a new nosological entity. We are proposing the centrality of identity negotiation as a psychological process occurring when one is faced with the concrete reality of racism and social exclusion. This process of negotiation, if unsuccessful, is a mechanism through which psychopathology can result as defined within the rubric of psychiatry. Identity negotiation as a trigger for psychosis must not be confused with nosological definition. One of the by-products of empires has been the European propensity to believe that their nosological constructs are universal and can therefore be applied to the cultural behaviour of their former subjects. This becomes dangerous when nosological characterisation is synonymous with pathology and the need for treatment, again in ways that are determined and deemed appropriate by the colonial hegemony. The construction of semiotic equivalence of knowledge and cultural systems that are widely diverse is another demonstration of the moulding of otherness into terms and perceptions understandable to the European mind and is as such the sine qua non of the European colonial experience. The post-colonial challenge is to seek liberation from these mechanisms and so foster insight into the behaviour and thought processes of both the former colonisers and those people they colonised.