Dementia is a clinical syndrome that is estimated to affect 46 million people worldwide. This number is estimated to increase to 131.5 million by 2050 (Prince et al., 2015). Dementia has a huge impact on people with the condition, their families and on health and social services. In the UK alone, it affects some 850 000 people with an estimated annual cost of £26 billion. It is a progressive neuropsychiatric condition leading to a significant strain on individuals, their families and the wider society. The risk increases with age and the burden of disease is set to rise in the coming years (Prince et al., 2015). While symptomatic treatments for the commonest cause of dementia, Alzheimer’s disease, are available, no disease-modifying therapy has emerged and the majority of trials in this space have been negative although there is room for optimism (Aisen, 2017).

A 64-year-old, obese patient is admitted to the critical care unit. He presents with hypotension and evidence of shock. He has pneumonia and acute-on-chronic renal disease. He has a history of ischaemic heart disease and had a pacemaker inserted following coronary angioplasty 2 years ago. He is also diabetic with known autonomic neuropathy.

It is perhaps important for everyone working in the National Health Service (NHS) to have some idea of the origins, development and current structure of what is one of the biggest and most complicated organisations in the world. A detailed analysis of the NHS and its history is outside the scope of this chapter; suggestions for further reading are given at the end. Its purpose is instead to outline briefly how the NHS has evolved and to put into perspective the current changes.

Healthcare before the NHS

Until the middle of the 19th century, the state had virtually no control over the medical profession. Doctors had developed their own organisational structure which satisfied the need for self-protection. Members of the Royal College of Physicians mainly worked in the London teaching hospitals and treated those who could afford their fees. Members of the Royal College of Surgeons (which was the Company of Barbers a century before) were more experienced in the practice of medicine and treated patients both in London (in competition with the physicians) and outside. The vast majority of people were treated at the hands of members of the Society of Apothecaries, who basically prescribed medication. For a considerable time churches provided forms of treatment to people with mental illnesses.

The state became more involved in the health of the population and regulation of the medical profession throughout the 19th century and in the early 20th century. The 1834 Poor Law was the first acknowledgement that government had some responsibility for the care of the population. Among its effects was the statutory provision of a parish medical officer to care for the poor. These established that the parish workhouses should have sick wards where the able-bodied inmates could be treated when they became ill (Levitt, 1976). Free services were offered by boards of guardians to those who could pass a means test.

The Public Health Act 1848 established statutory powers that enabled a local medical officer of health (an official of the local authority) to cater for the health of the local population. Following the Poor Law reforms, the medical officers’ responsibilities were extended to some Poor Law hospitals which were considered to be providing healthcare rather than welfare.

It is indeed a great pleasure to bring out the fourth edition of this book. When the first edition appeared, in 1992, management in general and medical management in particular were seen as dirty words, and clinicians who became medical managers were seen as having gone over to the dark side. Over the past quarter of a century, management by doctors has become respectable, and leadership and management skills have taken on a certain degree of prominence. There is no doubt that management and leadership skills have a degree of overlap, but by and large they are separate activities, as detailed in this book.

The entire volume has been completely revised, with many new chapters reflecting the current medical management and leadership skills. The changes in the National Health Service and resulting changes in working conditions have also meant that clinicians must be aware of competing interests and demands and yet forge a way forward in their professional lives. We very much hope that readers of all seniorities will continue to find this book useful. For early-career psychiatrists and trainees, the book will provide an introduction to the skills they need; and for more senior clinicians, it will provide an opportunity to keep up to date and continue professional development. We persist in believing that the relationship between personal skills and clinical management needs to become mainstream.

We are most grateful to our authors, who, in spite of (or perhaps because of) their busy schedules, have led from the front and delivered material which is not only a pleasure to read but also helpful and provocative in equal measure.

We thank Andrea Livingstone for her sterling support and project management of the book; her gentle and persistent style in communicating with the authors has proved to be extremely successful.

Thanks are also due to Dave Jago, Andrew Morris and the staff in the publications department of the Royal College of Psychiatrists for their help.