The current method of delivery of psychiatric training and education in the UK is still almost solely based on the ‘firm’ or consultant-led system. Traditionally, these units have had fairly wide-ranging loci of clinical responsibility, ensuring a broad exposure to mental health conditions for both undergraduate students and psychiatric trainees. However, changes over the past decade, particularly in terms of functional splits within psychiatric services, have led to some limitation of this exposure. Various strategies have been employed by those responsible for educational provision within services, such as assigning trainees and students to in-patient and community ‘pairs' of teams. Although this has had some success, the introduction of more fundamental restructuring of mental health services and the advent of service lines will have even greater and more wide-ranging implications on education. This editorial examines some of these implications and looks at potential solutions to ensure that training is not forgotten in the wave of far-reaching and strategically driven reorganisations occurring within the National Health Service and more globally.

Substance misuse is widespread among individuals with early-phase psychotic disorders and is associated with a worse illness course. Thorough assessment of patterns of substance misuse at admission for psychiatric care is often lacking and can compromise the accuracy of a diagnostic assessment that distinguishes between a primary psychosis and one that is substance induced. Given the risk to recovery from psychosis posed by substance misuse, close monitoring of the course and treatment of early-phase psychosis that is accompanied by substance misuse is indicated and could inform the development of more effective dual-diagnosis treatments.

Mitchell discusses the moral responsibilities of psychiatrists who, when outside professional settings, suspect that a person might benefit from psychiatric help. Is making an unsolicited psychiatric diagnosis ever the right thing to do? The American Psychiatric Association's guidance is that it is not, unless the psychiatrist has been granted authorisation. Although sensitive to harms from ‘unsolicited diagnoses', Mitchell argues that this guidance is too blunt: the benefits may outweigh the harms. We foresee, however, the possibility that psychiatrists may become pressured to make unsolicited diagnoses to protect or improve society rather than serve the best interests of the individual.

Being happy is associated not only with better health, higher earnings and a longer life, but also with a stable family upbringing, stable financial situation, employment, good health, freedom and personal values. Psychiatrists may increase their patients' happiness by promoting effective, evidence-based mental healthcare. Individuals may enhance their own happiness by optimising physical and mental health; recognising the importance of personal values and happy communities; and optimising their financial situation. Government may boost citizens' happiness by deepening democracy; providing effective healthcare; supporting evidence-based well-being initiatives in communities; and then leaving citizens to seek out personal happiness in their own way.

In this editorial we look at the implications of organisational changes to the National Health Service and financial constraints on addiction psychiatrists, and how creativity and adaptability could be the key to fostering survival and sustainability of subspecialties in danger of extinction.

The Health and Social Care Bill currently going through the UK Parliament seeks to further increase cooperation in the English National Health Service (NHS). The proposals are controversial in significant part because the benefits of competition in healthcare are uncertain. Will patients benefit from innovation and choice brought about by new providers of care or will the vulnerable be faced by geographically variable, fragmented and non-integrated services? Will there be financial savings to reinvest in patient care or will there be increased administration driven by the transaction costs of market driven care? This editorial advocates a cautious targeted approach for the implementation of competition in those areas where current NHS provision is poor rather than whole scale potentially disruptive change.

Blogs have become increasingly popular over the past 15 years, especially with young people. In this editorial we discuss how the blogosphere is reshaping information exchange in healthcare. More specifically, blogs may change the doctor–patient relationship and provide clinically relevant information to mental health practitioners. However, the use of blogs as a source of clinical material raises ethical and legal issues.

In common with all elements of public services, mental healthcare in England faces a troubling and uncertain future. Two things, however, are certain: demographic trends ensure that demand will rise and harsh economic realities dictate that resources will in real terms shrink. In order to cope with these challenges, commissioners and providers will have to review very critically all aspects of the mental health system, including those that are currently fashionable. There is a need to identify and promote activities that are evidence-based and effective and to jettison practices and services that lack an evidence base.

Prisons have high levels of psychiatric morbidity and function as mental illness recognition centres. Their healthcare wings are not hospitals and timely transfers to hospital are often unavailable. The United Nations' right to the highest attainable standard of health is assessed according to whether healthcare services are available, accessible, acceptable and of good quality (AAAQ). It is proposed that the AAAQ framework goes beyond the principle of equivalence of care and provides a more sophisticated measure for exploring prison healthcare.

Thousands of papers have been published on the biological associations with psychosis yet this has had a limited impact on the routine clinical care of people with psychosis. Cognitive dysfunction, genetics and neuroimaging are the research areas likely to integrate into clinical practice in psychosis most rapidly. Clinical and academic collaborations in partnership with patients and carers are necessary to make progress, along with an acceptance that not all new approaches will necessarily prove effective in the longer term. Most discoveries do not just jump from bench to bedside, but require active interactions between scientists and clinicians.

Contingency management is a highly effective treatment for substance use and related disorders. However, few psychiatrists are familiar with this intervention or its application to a range of patient behaviours. This paper describes contingency management and evidence of its efficacy for reducing drug use. It then details areas in which contingency management interventions can be applied in the context of psychiatric treatments more generally, including increasing abstinence in individuals with dual diagnoses, encouraging attendance in mental health treatment settings, enhancing adherence to psychiatric medications, reducing weight, and improving exercise. Greater awareness and use of contingency management in practice may improve outcomes across a range of mental health and related conditions.

The ageing population presents a major challenge to health and social care services now and for decades to come. Age discrimination in mental health services is more pronounced than in other areas of healthcare. Legislation, currently being reviewed, which will make unjustified age discrimination unlawful from 2012, has implications for the organisation and delivery of mental healthcare that need to be understood.

Independent sector psychiatrists believe that they work hard for the benefit of vulnerable people. Differences between them and National Health Service colleagues are not clear cut in terms of motivation or quality of care. However, unfair generalisations are made about the diverse ‘private sector’, with selective comparison such as with the worst of US healthcare. Although there are many examples of excellence in the UK state, commercial and charity sectors, global economic changes are bringing risk of care failures from which no area can be immune. We should all be working together to protect our patients from the mistakes of others.