I was delighted to see that Dr De Silva has further developed his interest in working with Primary Care colleagues (Psychiatric Bulletin, 2003, 27, 326-327) having previously worked in our service in Grampian many years ago, which is fully committed to working with Primary Care, mainly in a liaison consultation model, but also with a clear attachment of specialist services such as outreach and assertive outreach and core primary care aligned mental health teams.

I and many colleagues from all disciplines have worked in this way for over 10 years, holding regular clinics within general practice and regular liaison meetings with primary care colleagues, including joint assessment where necessary. In my opinion, the outcome of this approach has been to dramatically reduce our need for in-patient provision to well below the recommendations of the College (e.g. we will shortly have 23 acute beds per 100 000 population in general adult psychiatry), and I have no doubt that this model has allowed early detection and intervention for patients with significant mental illness, both through the education of general practitioners and through their ability to rapidly access services.

From a personal viewpoint, therefore, I cannot support Dr De Silva's suggestion of a ‘sub-specialty model’ where different psychiatrists are responsible for community services as opposed to hospital services. I fear this does nothing but reinforce the ‘community is good, hospital is bad’ divide, which often continues to pervade the thinking of politicians, users and professionals. Furthermore, I believe that one of the greatest strengths of our current system in Grampian is that consultants are made responsible and accountable for their bed usage and thus are also seen as responsible for ensuring adequate community provision wherever possible.

However, for a variety of reasons, the continuum model, which I believe we have successfully offered in Grampian, unlike other parts of Scotland, over many years is now under threat from a number of different sources. These include local management changes, a continued belief from the Scottish Executive that community mental health services are in some way completely separate from hospital mental health services, and thus can be aligned with social care and other services, and from the new Mental Health Act in Scotland, which from 1 April 2005 will undoubtedly push consultant psychiatrists into much more of a pure secondary care situation. It has the potential to completely exclude the general practitioner from the detention process and emphasises repeated appeal against detention in the form of Tribunals.

This may lead to the situation that Dr De Silva describes under his joint working model, in which the consultant psychiatrist has a caseload of a low number of complex, often dual diagnosis patients. Yet I fear for many psychiatrists such as myself that this will be a retrograde step, which will be at the detriment of the very close links that we have achieved with primary care through our aligned services. It will make it much harder for us to work with general practitioners in an educational way, to offer early intervention and adequate management to patients with a variety of psychiatric conditions, and thus to continue to limit our usage of acute psychiatric beds to which admission should be seen as part of an ongoing continuum of care, led by the responsible consultant psychiatrist rather than being seen as a separate process that continues to reinforce the unhelpful hospital v. community divide.