The trouble with …

In two related articles – ‘The trouble with NHS psychiatry in England’ ¹ and ‘New Ways not Working? Psychiatrists’ attitudes’ ² – misgivings about the role of the psychiatrist and service delivery in England are described. As psychiatrists working in Scotland, we have witnessed a divergence between the two National Health Services since devolution. The National Service Framework for mental health, ³ for example, was not implemented in Scotland. Further, bed closures have happened more slowly and the rushed ‘top-down’ functionalisation of mental healthcare enacted in England has been generally more measured north of the border. Indeed, it appears that only crisis resolution and home treatment teams have been widely adopted (reflecting in part the supporting evidence, for example Joy et al ⁴ ), there being a more conservative adaptation of New Ways of Working.

Partially, this reflects a different politico-cultural backdrop in Scotland. There is, for example, a substantially smaller private and independent sector in mental healthcare here compared with England; funding, therefore, is not (usually) diverted in that direction. Furthermore, there is less preoccupation with risk to others, again limiting private secure facility expansion.

Additionally, New Ways of Working was in part a pragmatic solution to endemic problems with recruitment and retention into psychiatry. In Scotland, this has been less of an issue overall, with notable exceptions. Scottish workforce planning indicates that only child and adolescent mental health consultants are difficult to recruit in Scotland, and there has been a genuine uplift in consultant numbers in the past 5 years. Although there are important imminent universal challenges which could change the landscape (such as the diminishing number of junior doctors, and the evolving role of the psychiatrist as a medical doctor providing leadership within the multidisciplinary team), we contend that there is probably less dissatisfaction with current service configurations, less urgency to overhaul systems, and more opportunity to plan service change meaningfully on the basis of evidence and others’ experience.

Thus, we have naturalistic experiment with separate and diverging systems of government-based healthcare in adjoining countries with similar underlying populations. This could be an ideal opportunity to examine optimal service configuration, as long as consensus on the best outcomes for patients could be achieved.