National policies promoting a shift from institutional to more community based patterns of care for people with mental health problems, have not evolved in a single, coherent way, nor have they been implemented uniformly. In devising strategies appropriate to developing psychiatric services in the next decade, lessons should be learned from previous experience. This paper focusses particularly on the pattern of mental health services required to support people with severe psychiatric disabilities, and examines the practical strategies required to make good use of opportunities for progress.