The profession awaits the Government's White Paper on a new Mental Health Act (MHA) with trepidation. At the time of writing, the closing date for consultation on the Green Paper (Department of Health, 1999a) has passed. None the less, discussion and lobbying must continue.

We are on the verge of major advances in understanding the pathophysiology of major mental illnesses – including the likely discovery of several susceptibility genes for these conditions. For many this holds the prospect of a future in which improved prevention and better treatments will end the terror these conditions hold over so many lives (Farmer & Owen, 1996; Jones & Craddock, 1997, 1998). For others the vision is of a ‘brave new world‘, our futures mapped from birth by the genetic hand we have been dealt and in which those with mental illness will suffer increased stigma and discrimination (Rose, 1998). This debate (McGleenan, 1995) occurs in the dark shadow cast by the eugenic movements of the 19th and early 20th century (Galton, 1943) and the horrors to which they led (Hanauske-Abel, 1996; Seidelman, 1996). As we leave the decade of the brain and enter the new millennium it is an appropriate point to ask what advances are likely to occur and to consider the moral and ethical issues that will undoubtedly arise.

Early intervention in psychosis is a strategy for which there is increasing theoretical and pragmatic justification. Many studies have been published describing the benefits of early intervention as carried out by specialised and innovative projects. The present paper describes how a generic community mental health team (CMHT), covering a population of 50 000, introduced strategies for early intervention with no extra funding. The team worked together to change old attitudes and practices. A style of intervention was developed to engage with and keep in contact with people with recent onset psychosis. This appears to be achievable – and this model may be an alternative to the setting up of specialised teams.

I can vividly remember my first exposure to psychiatry as a medical student in the USA. By drawing the short straw, I won the privilege of night call on my first day on the service. It was February and by early evening it was black and cold outside. To avoid the night, I took a seldom travelled tunnel between the hospital and the state mental facility. Alone, and frequently passing broken-down equipment from a bygone era, I felt as if I were entering another world. I took an elevator to the sixth floor. The elevator was operated by a middle-aged pale woman who wore a calf length skirt that blew around in the wind generated by the elevator's ascent. She said nothing. To this day I remain unconvinced that she was not an apparition. My patient was a severely cognitively impaired woman who was said to have neurosyphilis. My task was to replace her nasogastric feeding tube, which she had pulled out despite wrist restraints. Her nose was bleeding and she was spitting blood between attempts to bite anyone who came near her. It was a sad and dehumanising interaction for both of us. When the psychiatry resident came to help, at my request, she displayed only callousness and incompetence. The night nurse was certain to tell me this after the house officer had left. This event, among others during my training more than a decade ago, froze the worst stereotypes of psychiatry into my mind. Subsequent positive experiences in out-patient psychiatry were too weak to thaw the negative perceptions.

There is a recognition that doctors require management skills and many are now studying for formal qualifications in management. This article describes a Masters degree in Business Administration (MBA) with the Open University.