The interpretation in The Times Reference Hawkes1 of Craddock et al Reference Craddock, Antebi, Attenburrow, Bailey, Carson, Cowen, Craddock, Eagles, Ebmeier, Farmer, Fazel, Ferrier, Geddes, Goodwin, Harrison, Hawton, Hunter, Jacoby, Jones, Keedwell, Kerr, Mackin, McGuffin, MacIntyre, McConville, Mountain, O'Donovan, Owen, Oyebode, Phillips, Price, Shah, Smith, Walters, Woodruff, Young and Zammit2 risks alienating multidisciplinary colleagues and patients alike, turning a call for quality services into an appeal for primacy for the psychiatric profession.
New Ways of Working is similarly open to misinterpretation, including by Craddock et al. A fundamental principle of New Ways of Working is freeing up the appropriate staff to work with the patient. That means consultant practitioners working with those with the most complex needs – exactly what these doctors ordered.
Yet Craddock et al appear defensive, undermining their own call for self-confident progress. Why get exercised about use of the term ‘mental health’ rather than ‘mental illness’? The government has stressed repeatedly in the National Health Service Next Stage Review that maintenance of health and well-being is its job just as much as treatment of illness. Performance management, outcome measures and payment by results drive vague ‘support’ out of the system, promoting more structured, evidence-based care delivery.
The Future Vision Coalition, comprising leading mental health charities, directors of social services, the Mental Health Foundation and, crucially, the network of our employer trusts, has just published A New Vision for Mental Health, 3 bringing health and social models together, focusing more on health promotion and on quality of life rather than illness, and redefining relationships between services and users. If the psychiatric profession endorses Craddock et al's vision instead, who is likely to end up out of step and disregarded?
The current investment in improving access to psychological therapies demonstrates how those evidence-based services have not been over-provided or over-used to date, whereas 93% of patients have been prescribed medication. The National Institute for Health and Clinical Excellence 4 stresses the efficacy of both psychological and psychosocial interventions. The relevant expert should lead discussions where biomedical approaches are key, but where that is not the case or the whole story, which is often, the other experts are similarly important. ‘Jollying along’ was seen when other professions were the handmaidens of psychiatrists, only trusted to give ‘support’; now they may be prescribing as well as delivering other therapeutic interventions.
Politically correct terms like ‘service user’ have arisen because of stigma, which psychiatrists have played their part in perpetuating, being accused of low expectations, making assumptions about behaviour based on diagnostic labels, patronising or unhelpful letters, using patients as ‘cases’ for training, and promoting the ‘medical’ model while dismissing side-effects as ‘psychological’.
Our answer to their ‘thought experiment’ question – would you opt for a distributed responsibility model if a member of your family was the patient – is a resounding ‘yes please’. Going back to a psychiatrist with a case-load of hundreds, or awaiting the arrival of yet another locum for a decision, is neither safe nor satisfactory. Lord Darzi 5 heralds a ‘new professionalism’ based on teamwork; teams can only be efficient and effective if members are appropriately skilled, competent and take responsibility for what they do.
We agree with Craddock et al that psychiatry can have a great future, but only by embracing teamwork, abandoning hegemony and accepting the importance of social and psychological as well as biological determinants of mental ill health, rather than harking back to a past which was actually far from ideal.