Social and Community Services in Local Authority Management
Mental health services should be based in local authorities, alongside other social, community-based, services. The psychological, emotional and behavioural problems that are commonly referred to as mental health problems are fundamentally social and psychological issues rather than medical illnesses. It follows that the correct place for services to support mental health and well-being is within the social care system. We should, to be clear, go further than design what are essentially medical teams for psychiatry, managed as out-patient hospital-based teams. Instead, mental health and well-being teams should be part of community social services, and therefore under local authority control. The recent transfer of UK public health services to local authority control is a positive example of this approach in practice.
The thrust of the arguments in this book culminates in a simple message. The psychological, emotional and behavioural problems that are commonly referred to as mental health problems are fundamentally social and psychological issues. Psychologists, therapists and social workers must work closely alongside GPs, public health physicians and nurses. But mental health and well-being is fundamentally a psychological and social phenomenon, with medical aspects. It is not, fundamentally, a medical phenomenon with additional psychological and social elements. It follows that the correct place for mental health care is within the social care system. That doesn't mean that we should design medical teams for psychiatry, and manage them out of hospital-based, NHS-based trusts but housed in a building away from the hospital site as a gesture towards being 'community-based'. Instead, it means that we should locate the whole service in the community - put it entirely under local authority control. In the UK, we have the model of public health, recently transferred to local authority control, to build upon. Such services should be - and could then be - under democratic local governance.
Change is needed, because the present system places care for people with psychological problems - so-called 'mental health' care - in a medical context. In many ways, this is an unhappy relationship. As with public health (an example to which I shall return), complicated and unusual arrangements need to be put in place in order to ensure that we can meet people's very real social and psychological needs, which do not always fit well within a medical model. The fundamental 'mission statement' of a medical healthcare system is very different to that of a system for social care and support. In the first, leadership, even dominance, by medical practitioners is natural, and medical assumptions pervade the system. The 'disease-model' and 'diagnosis-treat' approach, the assumption that we are dealing with 'syndromes', 'illnesses' and 'pathology' are all taken for granted. In many ways, the structures within which mental health care is currently located are part of the problem. We can imagine a service in which problems are identified and solutions developed without any need for assumptions of 'illness' and 'pathology'. But it is difficult to imagine that service operating easily within a wider, overarching system that remains reliant on precisely those inappropriate assumptions.
I once attended a rather odd meeting of a range of senior 'mental health' professionals. It was odd because it was arranged over dinner . .. which led to people being quite informal in their conversation. Towards the end of the meeting, one of the participants, a very senior psychiatrist, tried to sum up the emerging friendly consensus by saying: 'ultimately we all have the same aim - we're all in the business of treating illnesses . .. ' . I disagree . .. and said so. That simply does not sum up my role as a clinical psychologist. I do not think that I am 'in the business of treating illnesses'. My business is using my knowledge of psychology to help people improve their psychological and emotional well-being and to solve difficult problems in their lives. That is not the same as 'treating illnesses'. I recognise that psychiatry and nursing, because they are professions related to medicine, are happier within that role. But the concept of 'treating illness' is a wholly inappropriate basis for a consensus - because it simply fails to reflect non-medical perspectives. It is also an inappropriate model for our service more generally. In my view it is inappropriate to regard people as 'ill'. But this kind of casual language use reflects a mistaken assumption about the ethos and character of a nationwide service employing many thousands of dedicated professionals. Many of these professionals understand their clients' - and indeed their own - emotional lives very differently. This kind of language also reflects the dominant mode of operation in our current structures for delivering care. A fundamental shift is needed.