Dr Middleton suggests that the Mental Health Act Commission's criticism of acute psychiatric in-patient services in its last biennial report is a reflection of rising expectations and increased awareness of human rights, rather than an indication of any recent deterioration in such services (Psychiatric Bulletin, November 2006, 30, 404). As the principal author of the report (Mental Health Act Commission, 2006a ), I am less sanguine.

Although Dr Middleton lists a number of ‘recurrent issues’ in acute care, he does not mention the key issue of bed pressures. This has an impact across many acute services, leading to ‘over-occupancy’ of beds; delayed admissions; and the use of leave for bed-management purposes; as well as disruption and distress for patients and distraction for staff. Concern over these matters has been raised with increasing urgency by many Mental Health Act commissioners over recent years, and now by the psychiatry sub-committee of the British Medical Association Central Consultants and Specialists Committee ( BMA News, 2006). A recent paper on bed occupancy suggests that, over the past 2 years, certain areas in England have experienced unprecedented problems in finding beds for the admission of patients under the Mental Health Act 1983 (Mental Health Act Commission, 2006b ).

Dr Middleton is surely correct to suggest that recognition of acute inpatient care as a psychiatric specialty would be unlikely to address the most pressing difficulties facing the acute inpatient sector, not least because the improvement of patient services is a matter for clinical teams (as well as hospital managers and service commissioners) and not just the nominally responsible clinician. Indeed, in some services it would appear that improvement may be reliant upon a much more fundamental question of resources: beds for the patients.