We can either see mental health problems as essentially medical conditions with social elements, or as essentially social problems with medical aspects. Of course medical, biological factors play a role. But I believe it is right to see mental health difficulties as essentially social problems.
Care for people with emotional and psychological problems should therefore be part of the social service offered by local authorities. The present multi-disciplinary teams managed by healthcare trusts (and similar hospital-based services in countries other than the UK) should be transferred to local authority control. This transfer could happen in a dramatic fashion - with central government legislation mandating a wholesale transfer of assets and responsibilities. Alternatively, it could happen more gradually - with local authorities tendering, and being awarded contracts, for the delivery of mental health care. In the UK, with increased commercialisation of our National Health Service, this could be a very real possibility. This would retain the services of medical, psychiatric colleagues, but world employ them differently. We would expect an over-arching ethos based on promoting well-being rather than treating illness, and a greater focus on the social determinants of mental health. There would be a greater focus on psychosocial interventions, although, of course, these teams would need to have plentiful, varied, high-quality treatment options. It is clear, however, that this would profoundly change our relationship with traditional psychiatry.
This proposal is radical, and will be opposed by many psychiatrists. It is relatively well known that at the point when the NHS was founded, there was considerable debate over whether mental health services should be included. Most psychiatrists passionately believe that it would have been a disaster if mental health had not been included with the bulk of mainstream, physical health - medicine. This is a genuine and honourable belief. And it is possible that, back in 1948, local authority structures would not have been robust enough to provide the services that vulnerable people need. But what might have been right in 1948 is not necessarily right now. And it is possible that some of the passion with which psychiatrists argue that mental health must remain wedded to physical health may have more to do with their profession than their patients. Nick Craddock and colleagues, in their manifesto for old-fashioned, biomedical, psychiatry, demonstrated this point clearly. For at least some psychiatrists, remaining part of a very medical community appears central to their professional identity and to their confidence that their role will remain protected. So I imagine that very many psychiatrists will be highly alarmed at the suggestion that they, their profession, and the services in which they work should be transferred out of the 'medical' community and into the 'social care' community.
I suspect that many people in the pharmaceutical and insurance industries (at least outside of the EU, in nations where insurance- based rather than state-provided healthcare is more common) would be equally concerned. The global pharmaceutical industry makes enormous profit from the sale of drugs to healthcare organisations - and to patients themselves - and healthcare insurers similarly profit from the commercial aspects of a system that treats emotional problems as if they were 'illnesses like any other'. It is obvious that ideas such as those I am suggesting here would threaten that approach. I am directly challenging the notion that mental health problems can be treated as if they were similar physical illnesses; I am suggesting that a medical approach to care is inappropriate; I am arguing for a significantly reduced reliance on medication; and I am suggesting that the healthcare industry is not the right location for services. If implemented, this would be a major impact on the profit-base of important and influential commercial companies. Nevertheless, that is what I believe is right.
Unfortunately, all that means there may be trouble. The medical and psychiatric communities are powerful - with well-established and effective professional bodies, and statutory mechanisms for catching and holding the ears of policymakers. But, despite the likely opposition, this aspect of my prescription will remain - to move mental health care from medical to social management, from the health service to local authority control.