The 1990s witnessed a strikingly accelerated rate of change in the structure and delivery of mental health care in the UK. The preceding 15 years had been marked, in my practice, by two inexorable processes which transformed the face of clinical psychiatry, but without the convulsive upheavals and discontinuities that we have come to live with since. The first was the running down and eventual closure of the large mental hospitals – a change so fundamental that it may be difficult for those trained recently to grasp just how different mental health care was then. The second was the internationalisation of research, and the growing influence of evidence and formal instruction as a determinant of practice, rather than simply relying on the consultants to whom one was apprenticed. For all the occasional criticisms of it, evidence-based medicine dominates modern psychiatry, and this is evident in the much greater consistency of practice than 30 years ago. The changes in the 1970s and early 1980s were essentially egosyntonic within the profession; the past 15 years have been more dramatic and less comfortable.
