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Dear Editor, The author recently went through the article by Manjunatha1"Is the United Kingdom's National Health Service Encouraging Stigmatized, Discriminatory, Fragmented, and Expensive Specialist Psychiatric Care?"1 and begs to differ from his approach to the related topic. Manjunatha1 states that he observed significant differences in working patterns and patient profiles in the psychiatric settings in India and tries to at look at its causes. Moreover, through research and understanding from his colleagues concludes that "the specialist psychiatric care provided in the UK is highly stigmatized, fragmented, and very expensive to the public exchequer, especially psychiatric inpatient care."1 I am curious to know if the author did find answers to the observations he made in Indian settings, as the structure and functioning of health care in both countries are varied and the same rationale will not hold good. Moreover, there are also genetic, political, cultural, social, economic, legislative, and population-size variations to consider. It is important to note that National Health Service (NHS) is free at the point of delivery providing the major percentage of mental and social care. With time, the UK has come far from the Victorian legacy of austere asylums to community-based care.2 The National Institute for Health and Care Excellence guidelines stress a multi-agency approach involving mental health care, social care, education, housing, and employment so that individuals lead normal lives.2 Currently, both physical and mental health are on equal footing.2 General practitioners are the backbone and first point of contact for any physical or mental ailments, unless emergency, and guide patients to appropriate care pathways; or a patient can self-refer to NHS talk therapy and addiction services.3 Patients can seek help through their workplace and children through schools.3 Although mental health is classified as primary, secondary, and tertiary, care has been integrated by community mental health through long-term NHS plans,4 addressing fragmentation through new partnerships and "integrated care system." The community mental health teams, crisis teams, early intervention, and assertive outreach teams are doing phenomenal work. Care can come from the general practitioner services, a large local health center, a specialist mental health clinic, or a hospital4 not necessarily only the mental health institutions (MHIs). A number of times care happens by the community health services that includes for the ones with severe mental disorders (SMDs). The liaison psychiatry services in general hospitals comprise multidisciplinary teams that include liaison psychiatrists, psychologists, nursing staff, occupational therapists, support workers, pharmacists, and social workers.5 Although most services by liaison psychiatrists are at general hospitals, steadily they are working in the community and primary care. The liaison psychiatrists handle integrated care.5 The cause for this fragmentation of general hospitals and MHIs that the author notices is simply because of the course of "history of mental health," as it evolved from the Victorian asylums stage to the present stage where it is on par with physical health. With time, as community-based care evolved, the existing infrastructure and resources have been integrated into seamless network avoiding unnecessary expenditure. Moreover, the requirements for the psychiatry unit are different. The drug and alcohol team/addiction services deal with addictions. Those that have comorbid mental health issues are dealt with, by psychiatrists that look into dual diagnosis. As far as addictions go, it is a great strategy to segregate because it is a huge problem and the community outreach and support system are quite good and well in place even during an emergency. On comparison, the mental health establishments in India comprises deemed institutions, the general government, and private hospitals/colleges that have psychiatry departments similar to liaison psychiatrists and stand-alone psychiatry hospitals. When a visit or a consultation with a psychiatrist in itself is a cause for stigma to the service users be it in general hospitals or MHIs, there is no point in arguing about separation of care being a cause of stigma as Dr. Manjunatha1 suggests. UK does face stigma associated with mental health like many in other parts of the world, it is stigma per say with regard to mental health. Various steps have been taken to tackle the same. The Equality Act and the support system for those facing stigma are well in place.6 It is true that in the past, persons with SMDs would have be admitted in a large "mental hospital" or "institution" which has evolved in the last two decades to a new national clinical model, community-based care.7 Although patients may need admission when acutely ill, the stay is as short as possible until the patient can safely go home, to receive community-based support.7 Patients with CMDs are encouraged to see the GPs first, to be guided to appropriate care pathways. It makes the same difference as it does in India if a physician referred the patient to a deemed institution or a private psychiatry hospital for common mental disorders. The system is flawed in terms of providing care at appropriate timelines. About 1.2 million people are on the waiting list for community-based care.8 The system is also quite rigid because they are not flexible to slightly depart from procedures and protocols for patient well-being. The care is also fragmented because of staff shortages and funding issues.8 In 2023, government called for joined strategy that ensures mental health conditions are considered alongside physical health.4 As far as The Mental Health Act goes, the white paper was published in 2021, to reform the act that will be less restrictive with better scope and patient autonomy.9 When it comes to the Mental Healthcare Act 2017 of India, that appears to have basis from the UK, is a wake-up call to have it revisited and make appropriate amendments that are appropriate for India rather than find the shortcomings of England's Mental Health Act. As suggested by Math et al., the law requires to be amended according to the available local requirements and resources.10 Stigma with mental health has been ever constant in most parts of the world and more work needs to be done through community and patient education; community and patient engagement; and normalizing and promoting mental health on equal ground as with physical health. Integrating psychiatric care has been addressed by liaison psychiatry in general hospitals. To treat secondary and tertiary care in general hospitals is hugely challenging and an unlikely possibility with the given infrastructure and resources and will cost exorbitant expenditure and not a practical solution. The NHS has instead taken a great step in integrating psychiatric care through complex networks involving various authorities and providing commendable community care. Every country has its own unique challenges and strengths. The UK worked with their resources and infrastructure to suit the requirements of their population and continues to improvise to their needs and challenges. The author suggests that it is high time we look into our strengths, pitfalls, challenges, resources, social, technological, and financial provisions to plan the future of mental health care in our country rather than go by a template that may not suit us. Financial support and sponsorship Nil. Conflicts of interest The author is a doctor, mental health professional, healthcare leadership coach, and strategy and marketing consultant, currently working in India. The author holds an MBA in healthcare management from one of the top business schools in the UK, and is aware as to how both health-care systems function.
Hoskote Pallavi (Thu,) studied this question.