We strongly support the views expressed by Craddock et al. ^{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} In our opinion, their perspective is shared by many NHS consultant colleagues and is not limited to academic psychiatry.

At the heart of the debate is the progressive downgrading of the role of the consultant psychiatrist in diagnosing and managing severe mental illness as opposed to ‘mental health problems’. The latter may not require specialist psychiatric input as medicalising problems of living is clearly undesirable.

The centrally driven ‘one size fits all’ approach to ‘modern’ service delivery has left many patients with serious psychiatric illness bereft of the clinical expertise and leadership to effectively manage their condition. Notions of complexity (undefined) and risk have superseded diagnostic context. The ‘diffusion of responsibility’ as conceptualised in New Ways of Working often leads to unfocused care plans and risk management assessments without the one element essential to modifying any risks – that is, effective psychiatric treatment based on a comprehensive diagnostic formulation and understanding of the nature of the illness. Accurate diagnosis not only allows appropriate treatments for individual patients but also prioritisation of resources in service delivery. Furthermore, a diagnostic threshold is an essential requirement of the Mental Capacity Act in the assessment of capacity of our most vulnerable patients.

Major changes in psychiatric management and service structure have been introduced that are mostly not evidence based and certainly not consequent upon real advances in treatment. The political dimension to this process makes constructive criticism difficult. The letter to The Times from Kinderman and members of the New Ways of Working Care Services Improvement Partnership and National Institute of Mental Health exemplifies this. ^{Reference Kinderman, Vize, Humphries and Hope2} In response to the article by Craddock et al they refer disparagingly to the ‘traditional medical model’ in contrast to ‘modern mental healthcare’ which is a ‘collaborative team effort’ as if the medical model concerns itself only with medical matters in the most narrow sense. They also suggest that some psychiatrists are unable to ‘cope with the loss of hegemony’ and refer by implication to Craddock et al as demonstrating ‘intellectual arrogance… and assumptions of superiority’. Their response to put it mildly offers little basis for constructive debate and has previously been described as ‘messianic’ in tone. ^{Reference Lelliott3}

Like many psychiatrists engaged in the treatment of serious mental illness and organic brain disease we look to our professional body the Royal College of Psychiatrists for a lead but find our views are not adequately represented.