It was a great relief to read Professor Burns' editorial Reference Burns1 concerning the loud silence around the separation of in-patient and out-patient consultant care. The dogs have certainly not barked, not even growled.
This is the largest single change in clinical practice in my working life and appears to go against the grain of other developments. There is no evidence base for it, nor could it be described as patient-centred. The past two decades of enquiries have often pointed to discontinuity of care and communication problems as potential risks, and both are likely consequences of ‘functionalisation’. There may well be positive outcomes with regard to in-patient care, but I believe these could have been achieved without reducing the quality of community care.
Consultants are an expensive resource and I wonder whether the future will see reduced numbers of senior medical professionals working mainly as psychopharmacologists with in-patients, whereas the community service is provided by other disciplines alongside primary care. Is this the way psychiatry ends, not with a bark but a whimper?
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