UK devolution and the international perspective of the College

Abstract

Some principles of psychiatric practice are applicable across all healthcare settings and epochs, whereas other issues are more specific to one healthcare model and/or time. The increasing divergence of service models and underlying policies in the four UK devolved jurisdictions (England, Northern Ireland, Scotland and Wales) means that this distinction between general and specific issues has increasing relevance to the College. There are many benefits in identifying, and being strong advocates for, the generic principles of excellent psychiatric care, which are transferable across settings and relatively stable over time. These are also, of course, the principles that will have the most relevance in a broad international perspective that goes far beyond the UK.

The role of the psychiatrist in healthcare inevitably varies over time and place, according to the specific service model, statutory legal framework, needs of the population served and the number and skill mix of other professionals. It is unrealistic (and probably undesirable) to think there should or could ever be a ‘one size fits all’ service model for how psychiatrists use their skills optimally to benefit patients. This applies at all levels of service variation. Perhaps most obviously, major differences occur between different areas of the world, as geographical and cultural context (e.g. Sorketti et al, 2010) as well as economic constraints (e.g. Muijen, 2010) exert profound influences. However, although the variations may be within a much more moderated range, there are increasingly important differences within the UK. The four political jurisdictions have increasingly divergent approaches to service model, budget and strategic priorities. Further, even within a particular jurisdiction (in the UK or elsewhere) there are often substantial regional or local variations in funding, clinical priorities and context, which may mean that psychiatrists work in very different ways in different locations.

Recent major changes in organisation and strategic vision of mental health services in the UK (Craddock et al, 2008), as in other high-income countries (e.g. Madianos & Christodoulou, 2007; Muijen, 2010), have meant the traditional role of the psychiatrist has been changing, even to the extent that the very future of psychiatry as a specialty has been questioned (Katschnig, 2010). Whatever the developments, it is essential that role changes are not purely driven by legislation, politics or ideology (Craddock et al, 2008). Rather, changes should make use of psychiatrists’ core expertise, and the special expertise of other professionals, in a way that enhances patient care and ensures the quality and safety of services (Craddock & Craddock, 2010).

The readership of International Psychiatry will be fully aware that there are many parts of the world in which psychiatrists and mental health services are non-existent, sparse or rudimentary. Where and when it is available, psychiatric expertise is a very valuable resource for a healthcare service and it is important that this resource is used as effectively as possible. The core skills of the psychiatrist should be matched to the professional role in a way that maximises benefits to both individual patients and to the service as a whole (Craddock et al, 2010). Such matching and clarity may also enhance psychiatric professional identity, encourage recruitment and increase morale and job satisfaction.

Implications for the Royal College of Psychiatrists

The Royal College of Psychiatrists is a major international professional organisation with a membership from a wide range of geographical and cultural backgrounds and active international structures, including the International Divisions and, of course, this journal. Many members have experience of working in widely differing service settings (Ghodse, 2003), for example moving between one or more UK jurisdictions and even between services on different continents. The College is, therefore, ideally placed (perhaps uniquely among organisations that provide training and accreditation) to be able to take a ‘big picture’ perspective that has relevance and influence beyond any local political, ideological, economic or cultural imperatives (Kulhara & Avasthi, 2007; Mullick, 2007) and is capable of offering some degree of temporal and situational stability. The richness and breadth of experience of the College’s members can usefully inform the principles used in all service developments: in other words, the general features of psychiatric excellence (perhaps they might be called the ‘psychiatric basics’?).

This will help to ensure that, two centuries after J. C. Reil, the eminent German physician, first described the specialty of psychiatry (Reil & Hoffbauer, 1808; Marneros, 2008), patients can continue to benefit from the particular expertise and training of medical practitioners who specialise in psychiatric illness and who use their broad medical and biological expertise and diagnostic skills effectively within the context of an appreciation of psychosocial factors and the full range of available treatment modalities (Craddock, 2010).