The design of community-based mental health services to replace institutional patterns of service has proved a weighty responsibility for districts engaged in the task. A major challenge has confronted clinicians, planners and managers of change: to seize the not-to-be-repeated opportunity of redeeming the investment in outdated buildings; to revitalise forms of practice that have become increasingly divorced from the needs of those who use these services; and to set up valid systems of care which can stand the test of time.

A postal questionnaire survey of nearly a thousand doctors investigated their awareness of the Defeat Depression campaign. Nearly all the consultant psychiatrists had heard of the campaign compared to less than half of the geriatricians and the general practitioners (GPs). Just over half of the psychiatry trainees had heard of the campaign. GPs who had not heard of the campaign were also less likely to continue antidepressant treatment beyond three months after recovery, less familiar with the psychological therapies, and less confident about treating depression in the elderly. The campaign may benefit from an increased emphasis on doctors other than psychiatrists.

“You try to be kind, but you know you feel it when a patient despises you because of your colour. They give you a cold look and you cannot reach them”.

The major problem of manpower planning in psychiatry has until fairly recently been one of securing enough posts in the training grades to place doctors wishing to train in psychiatry and to ensure an adequate supply of applicants for consultant posts. Numerous consultant vacancies and a ‘bottleneck’ between registrar and senior registrar grades was the frustrating combination largely consequent upon the failure of some regional health authorities to fund the posts which Joint Planning Advisory Committee (JPAC) had approved.

In February 1994 the Royal College of Psychiatrists contacted the Benefits Agency Medical Services (BAMS) to take part in their consultation exercise before bringing in the new Incapacity Benefit (IB) in April 1995. This new benefit was to replace the then existing Invalidity Benefit which was being paid to over 250 000 people with a primary diagnosis of mental illness. The main changes were that a patient's own general practitioner (GP) would certify incapacity for work for the first 29 weeks of sickness and after this the continuation of benefit (IB) would require assessment by a BAMS doctor, with some illness categories being exempt from medical examination. The aim was to create standardised criteria across the UK and to do so in an objective fashion, based on function rather than diagnosis. The test is designed to look at ability to work in any capacity rather than the claimant's own work which is the criterion for the first 29 weeks.

The mayor of Sao Paulo, Paulo Maluf, has a bullish approach to arguing and is not renowned for his subtlety. Despite this he has been a key campaigner and instigator of various public health policies that form part of an international “healthy city” initiative. The most successful of these has been the introduction of a law making the use of car seat belts compulsory, which has led to a massive reduction in the number of fatal road traffic accidents. An attempt to prohibit cigarette smoking in restaurants has been less successful owing to a number of legal challenges that have left the legislation in a consitutional and legal limbo – but the fight goes on.