The dog didn't bark because it was usefully occupied

An instinctive medical conservatism compromising the ability of psychiatry to adapt for the future has perhaps been inadvertently exposed by Professor Burns. ¹ Very little of his article really stands up. The focus is on the in-patient/community ‘split’. He assumes that the split has or is likely to remain at the ward door. Dysfunctional relations between egocentric psychiatrists reminiscent of the most troubled splitting and projection associated with ‘psychopathology’ sound like a ‘mess’, and would be, if they were to become established or even desired practice. No doubt there are some examples of fractured systems like this. Burns may know of hard-bitten consultant psychiatrists favouring community treatment orders (CTOs) without proper clinical consensus between colleagues; but it is not logical to condemn a movement, a ‘silent revolution’ or otherwise, by reference to its worst exemplars. His reasoning is reminiscent of the Dangerous Dogs Act.

Why is the role of the in-patient consultant ‘obvious nonsense’? It is no such thing. The task of the in-patient consultant is to think clearly about the best interests of the patient in context: doctors should not be in-patient consultant psychiatrists unless they possess the skills to communicate with their community colleagues and hold their confidence. Burns is pessimistic about human nature and consultants in particular. He fears that they will not work well together, and culturally never have. Consider surgeons and anaesthetists. I can recall some examples of pretty odd behaviour; but out of necessity, either would accept or cope with the consequences of decisions taken by the other. Burns' attachment to sustaining individual medical autonomy across the whole process of patient care is just not helpful or necessary. He refers to the Oxford Community Treatment Order Evaluation Trial (OCTET) study highlighting the need for psychiatrists to demonstrate tolerance and collaboration as if this were an unreasonable suggestion. These are characteristics that should be developed in all doctors, but especially psychiatrists. Is that a problem?

A further misunderstanding concerns bed numbers and pressure. I would contend that acute bed numbers have reduced for a variety of reasons in recent years, one being that the introduction of crisis teams has reduced the admission rate by managing the route into acute beds and offering a preferred alternative to admission for many, thereby of necessity setting a different threshold. The in-patient mix has consequently changed. Is this an argument for re-expanding in-patient care? Surely not, the idea that we take people into hospital to dilute the experience of others is absurd. There has been pressure on beds for as long as I can recall it first hand, since 1986, long before the changes Burns contests. He rightly dislikes confusing multiple ward rounds. It is hard to fathom why this is his experience in contemporary systems, other than through eccentric implementation of change. Is something strange happening in Oxford? If there is one in-patient consultant, there will be one ward meeting, or at least if there are more, they will feature the same consultant. This contrasts with old-style sector ward rounds, several per week, each to do with a small number of patients managed in contrasting ways quite arbitrarily by disconnected consultants interacting at times only to argue about what sector someone lives in. I recollect strong views being expressed about a patient moving over the road. That particular problem should be consigned to history.

Burns alludes to a continental professional and service model. The reason for the arguable historical success of the British approach, in so far as it has been a success, is not in the location or otherwise of splits in the system. It is in the existence of a social healthcare system in the NHS and a now strained sense of collectivism. It is in Anglo-Saxon empiricism, sceptical of medical obscurantist elitism feared by Burns, and an excellent and ever-necessary defence against pomposity and hierarchy building.

Finally, it is invidious to infer increased suicide rates from studies of discharge from examples of private sector units with no interest in supported discharge, or indeed follow-up. Considering NHS in-patient services, what is the evidence that suicides have become more prevalent, let alone that there is a causal link?

Burns may overestimate the importance that individual psychiatrists should attach to their role. The flipside of ‘continuity’ is the patient who is shackled to a disliked consultant for years without fresh thinking and no automatic second opinion. Burns concedes potential advantages rather gamely. He acknowledges that we may all need a rest from each other, doctors and patients included. In past years this happened unofficially - let us recall without nostalgia the patients who revolved from one trainee to another for years on end without a shred of consultant continuity. They taught me a lot, but such practice is now hopefully extinct. The care programme approach (CPA) involving continuity with nurses or social workers as an alternative strand to the discussion bears mentioning. Indeed, CPA is probably the key to consultants having a consultant role rather than acting as a kind of parallel, ghettoised general practitioner for people with enduring psychosis.

People do, of course, need stability in their key relationships. I am not at all sure that psychiatrists should appropriate a role, which properly lies ‘out there’; our difficult job is to try to help make that a reality and then quietly withdraw. Good psychiatrists are quite capable of sharing thoughts and plans, do not unilaterally and thoughtlessly impose directives on their colleagues, are considerate of their own limitations and ultimately the very conditional nature of the impact that we personally should aim to have on peoples' lives. When the water closes over us as if we were never there, we succeed. We have to see ourselves as less linear and more systemic, less unique and more integrated, and act humanely mindful of all, which may involve a healthy modesty and ability to share and even to let go.