Over the past few years, numerous articles have highlighted the strain on (and drain of staff from) our specialty. Many general adult psychiatrists are developing bleak views of themselves, the world and the future. Encouragingly, consultants such as Hampson (2003) are structuring their roles with some success. However, we are going through a major overhaul of the model of delivery of care and need to adapt our roles accordingly. Although tuning a Triumph Spitfire might make it run more smoothly for a while, it is still an inferior beast compared with a modern car and might be better on the scrap heap. A more radical approach is needed, which we outline in this article. One of the authors (G.I.) has experience of working as a consultant psychiatrist in Australia, where the state of Victoria changed the model of delivery of general adult psychiatric services to adopt a superior American model, leading to improved patient and carer satisfaction (Joy et al, 2001). The same model has been adopted by the UK government (Department of Health, 2001) through the creation of crisis assessment and treatment services (CATS), assertive outreach teams, and specialist community and in-patient services. Consultant psychiatrists are challenged to adapt their practice accordingly. The Royal College of Psychiatrists has recently set up a Working Group to address this issue (Royal College of Psychiatrists, 2004).

The NHS International Fellowship Scheme was launched in 2003 to recruit doctors from outside the UK to fill the shortage of doctors in the NHS. While the intended and stated primary purpose was to fill the service needs of the NHS, a secondary purpose appeared to be the opportunity the scheme would offer to overseas doctors to work in a ‘unique health care system’ (Goldberg, 2003). Doctors would be appointed at consultant level in the NHS for a maximum period of 2 years.

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.

As a general adult consultant psychiatrist who has worked full-time in the National Health Service (NHS) for 15 years, I have seen that things do change, but rarely in the ways expected or planned for. Having done the same job for six different reconfigurations of local services, I can confirm that reorganisation is largely irrelevant. However, new treatments (such as selective serotonin reuptake inhibitors and atypical antipsychotics) and new buildings, along with enthusiastic staff, can be seen as genuine advances. Changing social attitudes, in particular the rise of morbid individualism and an increasingly virulent, reactionary anti-science lobby, alongside sheer social overcrowding and pollution, do bring fears for the future. Community care has become a joke term rather than a watchword for acceptance of the stigmatised among ‘normal’ society. Three visions are possible: the dystopian, the normotopian and the utopian, looked at along the biopsychosocial spectrum.

When the National Health Service (NHS) was born in 1948, there was no specific agenda for clinical quality, which was assumed to be inherent in the system. The received wisdom was that good professional training with self-regulation and appropriate opportunities for ongoing professional development all inevitably added up to high-quality health care. Unfortunately, as we now know, this was not and is not true. What quality initiatives there were tended to be disconnected, with duplication, inefficiency and complicated processes all too often the result. Understanding of the relationships between structures, processes and outcomes improved in the 1970s, but in the 1980s, effort was arguably constrained by a prominent emphasis on organisational performance and cost containment.

European nations – including Britain – have a common pattern in their history of mental health care. Most western and central European countries established large asylums in the 19th century and engaged in some form of de-institutionalisation during the second half of the 20th century. Since the 1950s, major mental health reforms have significantly improved the quality of care. Although time of onset, pace, fashion and outcomes of reforms varied greatly between countries, throughout western Europe community-based services have been established and become part of routine service provision (Becker & Vázquez-Barquero, 2001). Compared with the heyday of the reform spirit in the 1970s, we now appear to be experiencing a relatively calm period. Developments currently seem to be dominated by fragmented pragmatism rather than by dreamy visions. This may reflect a wider trend in politics: throughout Europe, ambitious long-term visions appear less relevant as drivers for political change than was the case a few decades ago.

Advance directives in mental health care are currently attracting interest, although there is some anxiety that they can restrict clinical freedom. The so-called ‘Ulysses contract’ is a form of opt-in to services that has been suggested in the USA. Psychiatrists might thus consider themselves to be the equivalent of Ulysses' crew in being bound by the contract. This paper suggests, in some cases, that they might function more as Circe, who suggested the directions to Ulysses, and considers this in the light of contemporary relationships between psychiatrists and patients.

The human rights group Amnesty International has recently expanded the range of rights it promotes to include the right of persons with mental illness to enjoy the best available mental health care. The Irish section of Amnesty has launched a report and promotional campaign on the rights of persons with mental illness, using internationally recognised norms of best practice reflected in international conventions that generate binding legal obligations of the Irish state. The report is critical of piecemeal reforms and inadequate resourcing of mental health services, and calls for a more comprehensive implementation of the recommendations of domestic and international reports.