I read with great interest the interpretations offered in the study by Macdonald et al.^{Reference Macdonald, Adamis, Craig and Murray1} In trying to understand links between lack of continuity of care in the community and poor outcomes for patients with schizophrenia, the authors wonder whether a ‘disrespect of continuity’ manifest in repeated organisational change somehow translates into everyday clinical situations. For me, it is not a reassuring discovery that here is hard evidence for what we as clinicians have always suspected: that repeated organisational change seems driven neither by the best interests of the patient nor an economic imperative. The study beautifully highlights the important idea that what is really being attacked here is continuity.

But why attack continuity? Because of the obvious reason, of course – it is easier to attack it than to offer it. It is easier to create newer, smaller teams and splice the patient temporally into acute versus chronic/early versus long term/compliant versus non-compliant/risky versus not risky, rather than to bear that these are all aspects of the same patient and may need to stay in the same place as opposed to being scattered to the four winds!

The great British psychoanalyst Wilfrid Bion^{Reference Bion2} writes about his struggles in trying to treat a patient who is psychotic who experiences him as obstructive and unhelpful. Bion is troubled; and takes this up seriously. He then explains that he discovered he had been trying to impose his own language on the patient, rather than trying to bear the patient's language of projective identification. Bion's realisation led to a breakthrough. Thus, for coining one of the most popular terms in psychiatric services today- ‘containment’, we owe a debt to him.^{Reference Bion3} It goes without saying that the need for their anxieties and fears to be contained is something all patients bring to us, and as an example of a serious mental illness, psychosis requires skilful intervention on the part of services.

Schizophrenia is an illness rubric that brings together people with many vulnerabilities, but all with a common theme:^{Reference Postmes, Sno, Goedhart, van der Stel, Heering and de Haan4} patients whose minds struggle to integrate conflicting feelings and thoughts safely, leaving themselves and others connected to them at an ever-present risk of alienation. The harmful effects of failings in continuity are well documented.^{Reference Sanatinia, Cowan, Barnicot, Zalewska, Shiers and Cooper5} The chilling conclusions of this study also highlights declining outcomes linked to poor continuity, independent of service reorganisation. It raises the obvious question: does ‘poor continuity’ also mean that staff become cut-off from the patient in a cut-off state of mind?

Returning to Bion, what changes his practice is his interest in and concern for his patient. If an organisation, claiming to care, conveys ‘disrespect’ as the authors astutely point out, what state of mind does the clinician find themselves in? It is difficult to manage and treat seriously ill patients, and it cannot be done safely by staff who feel alienated all the time, from their own team and from the organisation.^{Reference Menon, Flannigan, Tacchi and Johnston6} The authors suggest a more sober approach in the future towards casual change; I think there needs to also be a closer look at the nature and function of organisational attacks on good clinical care in the name of change.