The NHS

In the UK, just after the Second World War, there was a profound revolution in the provision of a wide range of social services. The National Health Service was founded in 1948 (established by an Act of Parliament passed in 1946, to explain a few anomalies with dates). The idea was controversial - many people (including doctors) were concerned about the idea of a nationalised, socialised system. Indeed, the British Medical Association formally opposed the idea of a national health service. But the general idea of a National Health Service had broad support - that, through a system of what is effectively general taxation, every citizen has immediate access to a comprehensive system of gold-standard healthcare free at the point of need. The details, however, were also a matter of debate. In particular, there were differences of opinion in respect to whether the network of healthcare providers should be organised through existing local authorities - that local authorities should manage their local hospitals and doctors under the auspices of the new proposed scheme - or through a new, national, structural organisation. For various reasons, it was eventually decided that the local authority solution was less attractive than the idea of a new, bespoke structure, and the NHS as we know it was born.

These complex discussions were largely (and understandably) driven by the needs of physical health services. But, of course, the management of mental health services followed. In a remarkably short period of time, the National Health Service (a structure independent of local authorities, city mayors and town Councils) was established. Even then, there was considerable discussion over whether mental health services should be part of this system. Some commentators took the view (a view I would now share) that mental health care and the physical health services brought under the new NHS were essentially different. They argued that mental health care should be separately organised and should fall under local authority control. There were three powerful arguments for inclusion of mental health care within the NHS. In conventional medical science and practice, psychiatry was (and it was argued had been for a long time) part of the profession of medicine. It was also argued - and this is an argument we've seen rehearsed many times - that conventional medical research was on the brink of revealing causal mechanisms and effective interventions that would enable much more effective, medical, treatment. And, more negatively, it was argued that local authorities were not sufficiently well-organised or well-resourced to meet the needs of people with mental health problems. So, mental health services in the UK were, and as we can see today still are, squarely located within the National Health Service.

That may well have been a necessary decision back in 1946 - when local authority administration was considerably different - but seems much less appropriate today. Since 1948, the network of community- based mental health services has experienced massive development. There is, now, a growing and positive relationship between on the one hand largely community-based NHS mental health trusts offering both traditional 'out-patient' services and residential 'in-patient' units and, on the other, the various social services provided by local authorities. The pattern of provision is highly complex. Healthcare is, rightly, an important part of our economy and an important element of our social provision, and there are many different specialist teams and services. So, for example - and this is definitely not an exhaustive list - the NHS offers specialist mental health care for new mothers (often delivered by community mental health trusts, but based in general hospitals or maternity hospitals) and child and adolescent mental health services (CAMHS), sometimes delivered by community mental health trusts, but occasionally by specialist children's hospitals. It offers a very wide range of services for people of working age - specialist learning difficulties services, services for people with physical disabilities, services for people with substance misuse problems, support for people returning to work, help for offenders who have mental health problems, and services for older people. There are even very specialist services for, for example, commercial sex workers, asylum seekers, war veterans and young people leaving local authority care. All these services interface with family doctors - GPs - and with similar, synergistic services offered by local authorities and third-sector organisations.

The close liaison between NHS and local authority services can be seen in what are called 'Section 75 arrangements'. For obvious and understandable reasons, local authorities and health services have developed (relatively) effective and efficient ways of working together. These are lubricated by Section 75 of the National Health Service Act (2006) - hence the name - which encourages health trusts and local authority social services departments to pool money, delegate functions to each other and to integrate their resources and management structures. This effectively means that a nurse, a psychologist or a psychiatrist could find themselves employed by an NHS Trust, but under day-to-day management by a local authority manager ... or vice- versa. This is seen as hugely advantageous to planning services across a wide range of areas of mental health care, but has so far been particularly used in learning disability services and in services for children and for older people.

This collaborative approach between health and local authority agencies is further strengthened by the development of local Health and Wellbeing Boards in the UK. In 2012 the UK Government introduced a highly controversial piece of legislation - the Health and Social Care Act 20122 - which was seen by many as a horrifying step towards privatisation of the NHS. But it also did something rather wonderful. It established, under statute law, Health and Wellbeing Boards in each major local authority. These Boards act as opportunities for NHS and local authority managers, as well as leaders and opinion-formers from the wider community to work together to improve the health and well-being of their local population and reduce health inequalities. These Health and Wellbeing Boards bring together clinical commissioning groups and local councils to develop a shared understanding of the health and well-being needs of the community - a Joint Strategic Needs Assessment (JSNA) - and a joint strategy for action. These Boards are designed to enable joint commissioning and integrated services across health and social care, joined-up services between the NHS and local councils, and stronger democratic legitimacy and engagement. Because local authorities are responsible for services such as housing and education, there is huge potential for fully-integrated services.

In my view, these initiatives are very positive and hopeful. Even as things stand, they offer great potential for improving mental health care. But things need to progress further down this route. Indeed, it offers what is effectively an escape route for psychiatry - a pathway away from crisis and contention towards a positive future. Mental health care should be a matter for local authorities. Psychiatry should be a proud and strong, valued and effective profession, offered as part of the services provided by local authorities for the benefit of their citizens.

 
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