The National Director for Mental Health, Louis Appleby, is optimistic about the improvement in mental health services (Psychiatric Bulletin, December 2003, 27, 441-442). However, he acknowledges that we are some way off providing care that our patients deserve and we would like to deliver. In the same issue of the Psychiatric Bulletin, Ruddy and House (Psychiatric Bulletin, December 2003, 27, 457-460) show that this is particularly true for liaison psychiatry. In addition to their survey of the Northeast of England, they cite work that indicates that liaison psychiatry services are inadequate or nonexistent in many areas. This is despite the joint recommendations of the Royal Colleges of Physicians and Psychiatrists (2003).

Appleby (2003) asserts that in England and Wales the Department of Health has no certain way of dictating where resources go, and that such decisions have been devolved to local commissioning systems. This runs counter to the recent experiences of myself and colleagues when bidding for resources to provide effective liaison psychiatry services. Although there are well rehearsed clinical and financial arguments for specialist psychological care in general hospitals, a common response from the commissioners of local health services is that liaison psychiatry is not something they ‘must do’. The allocation of resources is heavily influenced by government strategies and targets, which become the ‘must dos’ for the commissioners.

Liaison psychiatry has a particular difficulty in attracting new resources, because it implicitly contributes to other services meeting their targets, but is not itself an explicit target for funding. For example, general hospitals are currently trying to achieve attendance times of less than 4 hours for all patients attending an accident and emergency (A&E) department in the UK (Department of Health, 1999). A liaison psychiatry service can assist in ensuring patients with mental health problems do not have a prolonged stay in A&E, but it is usually not seen as a priority for new funding. Similar issues apply to targets set by the Department of Health in the various National Service Frameworks.

Professor Appleby underestimates the importance of national priorities in the local commissioning of health services. In a target-driven National Health Service (NHS), liaison psychiatry cannot expect to develop robust psychological services for medical and surgical patients unless it becomes an explicit government priority, and something that the NHS ‘must do’.