Priorities

Question: What should our priority be as psychiatrists?

Answer: The mental health of our patients!

Unfortunately, it is not as simple as that! Questions such as ‘where does the responsibility for our patient’s mental health begin and end?’ and ‘what measures do we use to define mental health?’ begin to surface, alongside many more questions… 

Does our responsibility start when patients walk in the clinic room and end when they leave it? Does it begin when they join our caseload and end when they leave it? Or does it begin when patients are born and end when they die? Surely this is the realm of public health physicians? Should our priority be focused on treating or maintaining health or both?

Should we as psychiatrists see the mental health of everyone living in the communities we work as our priority? One interesting model is that of the barefoot doctors in China who were only paid by the healthy people in the community that they worked in. In other words they were motivated to maintain the health of the whole community. This is far from our focus or priority. What would happen if our priority changed?

Some important developments in this area are being made. Mental health charities Mind and the Mental Health Foundation published the report ‘Building Resilient Communities’ that called on every local council to prioritise mental health within their public health strategy. As public health teams are now located within local authorities, it is a key moment to be making the case for public mental health. One example of this is Tyneside Mind that offer wellbeing, preventative and resilience services and are currently supporting more than 1,500 people. This service has unsurprisingly seen an increase in demand due to the recession.  Alternatively, should our priority be social networking sites? Some might argue that monitoring people’s wellbeing online is rather ‘big brother’. I wrote an article published online this week in the Journal of Medical Ethics questioning the possibility of setting up a system on social networking sites like Facebook, where mental health services could ‘listen in’ and respond to certain words or phrases that are associated with either risk or relapse. This could act as an early warning system and lead to rapid, responsive management by informing mental health workers of risk related messages. This is a divisive subject and one where I have many more questions than answers, but as communities begin to develop and exist in different forms with the advent of the electronic age, we as health care professionals need to respond to ensure we remain a part of these communities.

Another question that arises out of thinking about our priorities as psychiatrists is that of whether we are able to define mental health. Are we as psychiatrists as good at defining mental health as we are at defining mental illness? Is this potentially the reason for our individualistic-illness focus? How much do we allow our patients to define what mental health means to them? Are there structures or ways of living that can ensure mental health? Should we be defining the parameters of mental health as keenly as we have set about defining mental disorder? If we had the same verve for defining a mentally healthy life as the authors of DSM V had for defining mental illness then would we see the mental health of the population improve?!

Thinking sustainably in mental health involves asking these big questions as demands on mental health services and rates of activity continue to increase while our budgets do not.  Are there new ways of providing mental health care that reduce demand on services but keep psychiatrists at the centre? Could a change of focus be a solution? Malcolm Grant, Chairman of NHS England, thinks it could be. He stated at the Healthcare efficiency Expo last month that a patient who receives long-term medical support receives on average 4 hours of medical attention for every 4800 hours of self-care. He stated that a shift of focus from the 4 hours to the 4800 hours is part of the solution.

If you would like to engage with these questions please do join the mental health network or contact me.