There are a number of key issues which those who have criticised the ‘Wake-up call for British psychiatry’ ^{Reference Craddock, Antebi, Attenburrow, Bailey, Carson, Cowen, Craddock, Eagles, Ebmeier, Farmer, Fazel, Ferrier, Geddes, Goodwin, Harrison, Hawton, Hunter, Jacoby, Jones, Keedwell, Kerr, Mackin, McGuffin, MacIntyre, McConville, Mountain, O'Donovan, Owen, Oyebode, Phillips, Price, Shah, Smith, Walters, Woodruff, Young and Zammit1} have failed to address.

1. (a) In order that any illness be treated, proper assessment and diagnosis is necessary. Is there definitive evidence that complex problems such as very early psychotic illness (atrisk mental states) or type II bipolar disorder can be properly identified by non-medical staff without specific training? Is there a possibility that cases may be missed – and how big is this risk?

2. (b) How certain can any doctor – or indeed any person – be that they can assess ‘service users’ appropriately based only on the reported assessment of others? This is different from asking other respected professionals for their considered opinion in a multidisciplinary meeting.

3. (c) Why is psychiatry the only medical specialty where many seem to feel that we can accept ‘patient choice’ to take or not take medication with entire equanimity, even though we know that antipsychotic medication and antidepressants do actually help treat symptoms… and then why do we suddenly become concerned when tragedy happens because of non-concordance with medication?

4. (d) Why do we in the UK expect other professions to deliver all psychological interventions, while we simply seem to provide biological treatment? Why do we not provide psychotherapy as well as medication as many of our colleagues in Europe do? Should there not be one standard for how psychiatric help is delivered across the continent of Europe… and should this not obviously be holistic?

5. (e) Having been a GP for many years before going into psychiatry, I would ask, why are psychiatrists and their teams happy to dispense with the common courtesy of expecting the person addressed to answer a GP referral; in what other profession is ‘sending the referral back because it is inappropriate’ after a brief discussion in a multidisciplinary meeting considered an appropriate response? When this happens, is it not the service user who suffers because their problem is not dealt with?

6. (f) On the other hand, as a GP, I would certainly consider carefully who to refer to secondary care and would use all my skills, as acquired in my GP training, before referral. I would also consult my liaison community psychiatric nurse or other attached mental health professional if I had one, and if necessary consult the consultant psychiatrist over the phone. However, a good GP will expect to be able to refer problems which they cannot solve to secondary care, and then expect the referral to be treated with respect by the consultant psychiatrist colleague with an adequate response, for GPs are specialists in their own right.

7. (g) Finally, in all of this debate, we have entirely forgotten that the reason service users consult doctors is the doctor–patient relationship, which is a relationship based on trust in another person, who may or may not have a greater or lesser knowledge of psychology and neuroscience, but who most of all is a person to be confided in during difficult times. This is what we must be as doctors, and all our discussions about ‘the role of the consultant’ pales into insignificance before this.

We must remember how Sir James Spence defined the consultation: ‘The occasion when, in the intimacy of the consulting room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation’. ^{Reference Spence2} If we forget this, then what indeed is the point of our being doctors?