Teams, multidisciplinary teams and democratic multidisciplinary teams
Planning care should be a team-based activity. Clients referred to mental health and well-being services, whether seeing an individual therapist, attending alternative day services or admitted to residential care, should expect to have their full range of relevant needs assessed and then addressed by an appropriate range of properly qualified specialists. As I mentioned in my introductory chapter, the joint UK Department of Health and Royal College of Psychiatrists' 'New Ways of Working' report argued that proper care for people in deep personal distress was a team effort; a multi-professional effort. As I have made clear throughout this book, the range of needs - social, psychological and medical (in different proportions for different people) - means that the team would require a range of specialists working together. In this model, as I argued in my introduction, the nature of extreme distress means that medical colleagues may well be valuable members of the team but they should be consultants to the team rather than having sapiential authority over it.
The word 'sapiential' was new to me, too. I was involved in the discussions surrounding the New Ways of Working report. One of our tasks was to look at the specific and distinctive contribution that each profession makes to a multidisciplinary team. We received a draft of the working party looking at the distinctive contribution of the consultant psychiatrist. In part, the document acknowledged that; ' ... a well functioning multi-disciplinary team requires leadership from several individuals with different levels of expertise in different areas - leading on what each knows best . .. ' . But it went on, immediately, to suggest; ' . .. such is the clinical primacy of the consultant in dealing with treatment resistant, acute, severe or dangerous clinical situations that require the broadest possible approach covering all physical, legal, psychological, and social aspects, as well as analysing and making explicit the value and ethical aspects of choices or decisions to be made. It is more sapiential than hierarchical leadership. This will become much clearer with the shift from delegated to distributed responsibility for patients in community mental health teams. It will be up to the autonomous professional to decide when to seek advice or case review with a consultant. And every time that happens it will give meaning to the clinical primacy of the consultant with whom the 'buck stops' in given situations'. In other words ... teams need a range of skills, but the consultant psychiatrist should always be in charge. Deconstructing the language used is important. 'Clinical primacy of the consultant' is a phrase that implies a medical professional should be in charge, directly contradicting the immediately preceding statement. This point becomes even clearer when the text suggests that 'the autonomous professional' should seek review from a consultant . .. with whom the 'buck stops'. So much for autonomy! I, of course, had serious objections to this suggestion. But I was also intrigued by the use of the word sapiential. I had to look it up. The dictionary definition is: 'relating to wisdom'. Most dictionaries add that the word is 'from ecclesiastical Latin' and relates particularly to the wisdom of God.
Well ... I disagree. Specifically, I agree that: ' ... a well functioning multidisciplinary team requires leadership from several individuals with different levels of expertise in different areas - leading on what each knows best ... '. I do not agree with the concept of 'clinical primacy' and I do not believe that any one profession has 'sapiential leadership'. This draft does not feature in the final report.
The right place for mental health care is in the community - alongside GPs, public health physicians and social workers. There should be a network of community-based care teams, linked to social services provision and other local authority care and services, as well as to the NHS and third-sector organisations. In the UK, at least, this is consistent with a general intention to integrate mental health care, physical health care and social care. We've seen a major integration of GP services with wider community and social services. Importantly, we've recently seen UK public health services transferred wholesale into local authority management. This offers a precedent and a model for similar transfer of responsibilities for mental health care. This vision would see opportunities for GPs, properly trained in mental health care, to help support people's well-being. It would obviously see many more clinical psychologists ... But, as with our medical colleagues, they would be working in the community, not in hospitals or 'clinics'. As mentioned earlier, medical psychiatrists would be consultants to, not in charge of, those teams. I envisage psychology-led teams (with an appropriate mix of staff), not psychiatrist-led teams with medical and nursing colleagues.
One of my colleagues, a senior and respected psychiatrist (whom I think it would be unwise and unhelpful to name), recently told me: ' ... I think you can make a perfectly coherent argument for the total dissolution of psychiatry. In an ideal world, I don't think it would exist, or if it did, it would simply be medical professionals interested in the care of the mad alongside other professionals, much as it started out being in the asylum days of the 19th century ... '. I tend largely to agree. Since our mental health and well-being is predominantly a social and psychological phenomenon, since diagnosis is unhelpful and the prescription of drugs should be reserved for a minority, we should see a much greater reliance on GPs to provide for the holistic healthcare of their patients. In this vision, medical psychiatrists would still perhaps have roles: as specialists, as consultants to GPs and as consultants to residential units. But we should see a major rebalancing of investment away from what is now traditional psychiatry towards a different system. Perhaps not the 'total dissolution of psychiatry', but a very significant change.