Social agents in a social model

In my vision of mental health care, we should act primarily as social agents in a social model of care. The best system for organising and delivering this care would therefore be through the social services of the local authorities. In the UK this would see what is now considered part of the NHS, the health care system, becoming part of the local authority Social Services provision. In other countries, the systems for provision are slightly different, but the basic separation of social and medical care is commonplace. The transfer of responsibilities that I am suggesting may, in fact, be somewhat easier in other countries than in the UK, because city and regional authorities often have responsibilities for healthcare, which in the UK is organised on a quasi-national basis.

Let's take a concrete example: the city in which I work, Liverpool in North West England. I would like to see Liverpool City Council take over responsibility for the strategic direction, management and delivery of mental health care for the city. In this vision, all the mental health care - the services that are now delivered through health services structures such as NHS trusts - would be managed and delivered by local authorities. This would see psychiatry and associated professions organised and managed alongside existing social services and the public health colleagues who have already been brought under local authority management. Of course, at present, much of our mental health care is already delivered in community settings. But it remains part of, and organised by, the National Health Service. And residential care in particular remains dominated by hospital-based in-patient psychiatric wards. A more appropriate model would be for mental health to be based entirely within local social services. That would mean seeing local authorities assuming management of the whole system, including residential or 'in-patient' units. And those in-patient wards would be re-configured as residential units along social, not medical, lines. This would be a fundamental change.

Psychiatry as a profession is a branch of medicine - psychiatrists are medical practitioners, members of the British Medical Association, regulated by the General Medical Council and organised into a Royal College. As psychiatry is de facto the dominant profession in mental healthcare, much of its ethos, structural organisation and operational practices follow from the premise that it is essentially a medical service. Care for people with all kinds of social and emotional problems is offered in what is unambiguously part of the medical system - in the UK, the National Health Service. Psychiatry and therefore the bulk of mental health services fall into the generic, medical basis on which physical health services are planned and delivered. This has the unfortunate consequence of meaning that social and psychological problems tend to be regarded as illnesses, even diseases. This means that a wide range of planning and commissioning decisions are made on this basis and, for the individual, medicalised solutions are the default response. So, people's problems tend to be classified into 'diagnoses' - despite the invalidity of that approach. Even psychologists' formulations tend to focus on what goes on inside rather than outside people's heads, concentrating on what individuals themselves are doing or not doing, and pathologising their responses rather than seeing their problems in a wider social context. In the current system, even when psychosocial interventions are offered, people are still given diagnoses such as 'conduct disorder' or 'post traumatic stress disorder'. Medication is offered routinely: as we've seen, the vast majority of people are offered medication and only medication.

From the top down, and from the bottom up, mental health care is currently predicated on a medical model. In the UK, the most influential single individual is the Medical Director of the National Commissioning Board. Mental healthcare is currently part of the medical infrastructure, which in the UK is the NHS. The Government's Department of Health provides funding and significant strategic direction, but more detailed decision-making is deferred to the 'arms-length' National Commissioning Board, the Medical Director of the Board, and the 25 National Clinical Directors. These expert clinical leaders provide expert advice and research on conditions and services, ranging from obesity and diabetes to emergency preparedness and critical care. This is all positive and necessary. But it does mean that mental healthcare falls under the directorship of a clinical director within this very medicalised structure and system. This 'clinical primacy' is also seen further down the system. NHS Trusts - the UK's core delivery units - have 'medical directors' to lead and guide services. While as individuals and as a group, medical directors - and the national clinical directors - perform a valuable service, any service run in and by a healthcare system will reflect the ethos and dominant methodologies of that system. This profoundly affects every aspect of our mental healthcare system. Indeed, even the term 'mental health care' conveys this medical dominance; psychological well-being may be a more appropriate phrase.

Immediately after I qualified as a clinical psychologist, I was asked by my boss to offer a psychological perspective to the construction of a new in-patient mental health unit. The hospital in which we worked was expanding and modernising, and a new in-patient unit was included in the plan. So I visited the manager responsible for commissioning the development and liaising with the architects. I hope that my perspective was useful (to be honest, the main thing that I suggested was to try to make sure that the unit was as dissimilar to a prison as possible). However, I was intrigued by the fact that the hospital manager was briefing the architects using an NHS document entitled something like 'guidance on the design of hospital wards'. It was, actually, quite helpful, but it also assumed that beds on hospital psychiatric wards naturally required all the paraphernalia of general hospital wards caring for people with serious physical health conditions. To the authors of this slim pamphlet, and therefore to my colleague, a ward was a ward was a ward, and a bed was a bed was a bed. In his carefully written brief for the architects, therefore, each bed was carefully supplied with an alarm button for the nurses, a vacuum (a nozzle allowing easy attachment of medical devices that require a vacuum), oxygen and other pipes and devices. I thought then, and I think now, that this is not the basis on which to plan psychological well-being services.

People with psychological problems of various kinds are not offered residential care lightly. People are likely to be acutely distressed, sometimes confused and often in despair. So we absolutely need to pay very careful attention to the design of their surroundings. It may be reasonable to have access to an emergency call button. It is obviously wise - as in any good hotel - to have plenty of power sockets. As I said earlier, we need to be careful about ligature points (places where someone who is contemplating suicide might be able to attach a means of ending their life). We would almost certainly want to ensure privacy but also that staff could achieve access to private places in an emergency. Planning for a residential unit for people in acute emotional distress will not be identical to planning a good hotel. But it clearly isn't the same as planning a conventional hospital ward. Things have improved over the 20 years that I have been qualified as a clinical psychologist, and more enlightened planning is now apparent. But it remains true that most in-patient psychiatric wards are planned, designed and operated as exactly that - as hospital wards for people who are ill. In a different system, predicated on different assumptions, residential units should be just as carefully planned, but planned on different assumptions, and the result would be very different.

In my experience, working as a clinical psychologist, this medical dominance has important consequences. Decision-making within organisations often reflects not only the external context, but also the specific and dominant role occupied by psychiatrists (individually often excellent, but nevertheless reflecting one particular perspective) in the hierarchy of the organisations. On a clinical level, key decisions are often made by consultant psychiatrists. Multi-disciplinary team meetings are often essentially only convened to discuss how those decisions should be implemented. In practice, those multi-disciplinary meetings are often strongly influenced by a biomedical perspective; it's instructive to observe what happens if the consultant psychiatrist is absent - frequently the meetings are postponed, or automatically led by a more junior psychiatrist.

But the care and support for people struggling with emotionally and psychologically challenging circumstances needs to be organised very differently. In place of this inappropriate medical service, we need a new, psychosocial one. There should be a network of community-based care teams, linked to social services provision and other local authority services, as well as to the NHS and third-sector organisations. Fortunately, that's the direction of travel nationally. There is 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, and - importantly - we've seen UK public health services transferred wholesale into local authority management. What I'm proposing takes those ideas and drives them forwards. Mental health and well-being should be a local authority-managed, social and community resource, not a medical and hospital-based service. So, psychiatry - the profession of psychiatry, psychiatrists and indeed all mental health services - needs to stop trying to 'diagnose' illnesses, and focussing on the social determinants of mental health. A social service with medical input, not a medical service with a bit of social work added on.

This does not mean dispensing with psychiatric colleagues nor denying their importance. In this model, psychiatrists' contribution would remain significant and important. But they would be consultants to, not in charge of those local teams. This echoes the principles of the 'New Ways of Working' project - itself initiated by psychiatry to address the needs of psychiatry. It also reflects the principles of Pat Bracken and colleagues' model of best practice for mental health care.1 A good analogy here is the medical advisor to Manchester United Football Club. Proper medical care and advice is undoubtedly vital to such a physical, high- value organisation. It would be bizarrely risky for a multi-million pound, international business, based on the physical prowess of a small number of athletes, to ignore their physical health. Medical care is an essential element of any world-leading sporting body. But Sir Alex Ferguson (or his replacement, David Moyes, following Ferguson's retirement) would never have suggested that his medical consultant has authority over him in terms of management; she'll be a consultant to the team, not the manager of the team.

 
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