I could not have been alone among the readers of APT to have returned home after a hard day's toil in my out-patient clinic to be irritated to read that my patients and I had been wasting our time. Reference KillaspyKillaspy (2007) makes some bold statements about out-patient psychiatric care, casting doubt on the relevance of out-patient clinics to contemporary psychiatric practice. This theme is taken on and broadened by Reference HarrisonHarrison (2007) in a somewhat uncritical review of changes to the role of the consultant (adult) psychiatrist over the past decade, particularly in the light of New Ways of Working and the functionalised model of adult mental health services.

The argument goes something like this: contemporary services are comprised of multidisciplinary teams whose members have an increasing range of generic competencies that are together providing secondary mental healthcare to people with severe mental illness under the auspices of the care programme approach. Generic competencies include skills in the assessment and ‘signposting’ of people referred to services who do not have a severe mental illness, and risk assessment and care coordination of those taken onto the case-load who do. Non-medical practitioners are increasingly developing traditional medical competencies, including independent prescribing. The Mental Health Act 2007 introduces the ‘responsible clinician’, thus breaking the monopoly of the doctor in having charge of the care of the involuntary psychiatric patient that has been effectively in place for 200 years. Within this brave new world the out-patient clinic becomes an irrelevance as, perhaps, soon will the adult psychiatrist. This scenario has already been played out in slightly different ways within learning (intellectual) dis ability and child and adolescent psychiatry, disciplines that remain in mysteriously good health.

There are a few unfortunate facts that get in the way of this, for adult psychiatrists at least, somewhat depressing vision. First, as Reference KillaspyKillaspy (2007) notes, although the majority of people who are on the current case-load of community mental health services have demonstrable severe mental illnesses (a code word for psychotic disorders), the majority of referrals for assessment and treatment to secondary services present with other problems that are often conceptually more complex than the psychoses. (The same is true for the in-patient population: there are more admissions of people with non-psychotic disorder, although psychosis accounts for more bed-days overall.)

Second, for many services in inner-city areas the available care coordination capacity cannot manage everyone with a diagnosis of psychosis, let alone those cycling through the system with non-psychotic disorders, many of whom are in fact both disturbed and ‘risky’.

Third, current training reliably provides psychiatrists with set of skills that is unique in the mental health workforce, particularly in terms of assessment, formulation, diagnosis and psychopharmacology. (It is surely unlikely that a brief protocol-driven course on prescribing, as described by Reference Baldwin and KoskyBaldwin & Kosky (2007), will allow a nurse-prescriber to dabble in the muddy waters of off-label prescribing.)

Fourth, there is continuing demand from referrers, patients and carers for out-patient services. In my own service I could comfortably run additional clinics, to which patients and carers would turn up (helped by our local practice of telephone reminders, which are effective, greatly appreciated by the patients and leave me with distressingly little unstructured time, pace Killaspy) and my work quite appropriately forms part of our trust's activity-based contract. Office-based psychiatric practice flourishes throughout the advanced world and (I understand) private practice is alive and well in the UK.

This is not to argue against the importance of multidisciplinary team-working, of which I am a strong advocate (Reference Holloway, Chorlton, Bhugra, Bell and BurnsHolloway & Chorlton, 2007), nor to suggest that the traditional roles that psychiatrists hold are theirs of right. However, we need a much more nuanced discussion about the future role of psychiatrists within adult mental health services than offered by Reference KillaspyKillaspy (2007) and Reference HarrisonHarrison (2007). This requires both firmer conceptual analysis, particularly in relation to the appropriate care pathways that should be provided for people with suspected mental illness, and a lot more empirical work on a neglected aspect of care. It's surely premature to throw out the out-patient baby as we modernise the mental health bath water.