Bouras & Holt (Reference Bouras and Holt2004) propose a bold solution to a frustrating problem: in a socially inclusive post-institutional society, how should the mental health needs of people with learning disabilities be met? Valuing People (Department of Health, 2001) encourages learning disability services to support access to mainstream services, and only provide specialist services to a minority with particularly complex needs. Their idea of a tertiary level service within adult mental health is, therefore, attractive, although probably more so for people with mild learning disability. Individuals could initially use the same service as everyone else and only be ‘referred on’ if clinically necessary.

But what would this service look like? What, in fact, are the specialist mental health needs of adults with learning disabilities? When do these needs require a specialist learning disability mental health service? If you have a mild learning disability and a new psychotic illness should you go to the ‘first-episode psychosis’ team, the ‘home treatment’ team, the ‘assertive outreach’ team, the ‘long-term intervention’ team or the ‘specialist learning disability’ team? What would be ‘special’ about the specialist learning disability service? It is not only about being ‘secondary’ or ‘tertiary’ but finding a way to participate in a new mixed economy of ‘mainstream’ services, where the number of potential interfaces has grown considerably in recent years.

General psychiatrists often look after mental illnesses in people with mild learning disability and do so extremely well. However, if learning disability psychiatry aspires to tertiary status it will be important to respond to those who will rely on it. This is not just the potential patients, but also staff of the mainstream services who will refer them. In my local service, colleagues want recognition that although some of their patients fall outside traditional eligibility criteria for learning disability services, they would none the less benefit from such services and should have equity of access the other way.

Bouras & Holt propose a new, probably rebranded, subspecialty within adult mental health. This has significant implications not just for the National Health Service, but also for the local authorities and other agencies with which it will work. I hope their views will stimulate wider debate.