Is the United Kingdom’s National Health Service Encouraging Stigmatized, Discriminatory, Fragmented, and Expensive Specialist Psychiatric Care?

Dear Editor, The author is an Indian psychiatrist who has worked/working at both mental health institutes (MHIs) and general hospital psychiatry (GHP) settings continuously in India for more than two decades. The author observed the significant differences in working patterns and patient profiles among these psychiatric settings in India. A quest to answer why these differences were in mind for quite a long time. The author learnt from multiple discussions with many of the author’s friends and students who migrated to developed countries, especially the UK, about what/why the differences are. The author recently attended a Joint World Congress of the World Association of Social Psychiatry, and RCPsych Faculty of Rehabilitation and Social Psychiatry held on January 16–18, 2023, in London. I met a couple of psychiatrists working in the United Kingdom (UK), including my ex-colleagues who migrated to the UK. With this background, the author visited London this year and got a few answers to some of the questions that led to this viewpoint article. It was surprising to consolidate my understanding of the nature of specialist psychiatric care provided in the UK, which I feel is highly stigmatized, fragmented, and very expensive to the public exchequer, especially psychiatric inpatient care (though I am open to newer understanding if I am wrong). Undoubtedly, the UK’s National Health Service (NHS) revolutionized health care after World War II using the socialistic model and providing free health care to their citizens. Since the inception of NHS in 1948, mental health services remained separated from physical health services1,2 could have some valid reasons at the beginning. King’s Fund Report-2016 states that despite 23% of the mental health burden, 11% of the total NHS budget are spent on mental health.3 However, there are calls to reform the NHS now.4 There are criticisms about the mental health services of NHS.5 I understand that general practitioners (GPs) are the backbone of the NHS and provide primary care to all psychiatric patients in their general outpatient consultations. GPs refer psychiatric patients for specialist care to psychiatrists working in MHIs, which provide outpatient and inpatient psychiatric care when needed. This write-up focused on a critical analysis of the delivery of specialist psychiatric care in the UK. The specialist psychiatric care in the UK for GP’s referred patients occurs in isolated MHIs in outpatient or inpatient settings managed by exclusive mental health trusts of NHS. But in general hospitals (which are managed by NHS general/non-mental health trust), whenevere need arises, other medical specialtsts are referring their admitted patients for their inhouse psychiatrists who have been referred as consultation-liaison psychiatrists (CLPs) within these general hospitals provide complete consultation-oriented psychiatric care for co-occurring psychiatric conditions if present. Please note that these CLPs do not provide out- or inpatient exclusive psychiatric care for psychiatric patients within general hospital settings. This separation of psychiatric care in this developed country between general hospitals and MHIs is glaringly discriminatory and encourages stigma for psychiatric patients and their care. From a public health perspective, the author broadly categorizes psychiatric disorders into three groups: Severe mental disorders (SMDs), common mental disorders (CMDs), and alcohol and other substance use disorders. In the UK, inpatient psychiatric care for exclusive psychiatric patients is provided only in isolated MHIs, which is more stigmatizing. By continuing this discriminatory and exclusive care, NHS is encouraging more stigma for mental health issues. I understand that this exclusive inpatient care predominantly covers patients with SMDs. By nature, these patients have no insights into their socially deviant behaviors and illness. Concerning CMDs, by nature, the patients of CMDs have complete insight into their illness. They are reluctant to reach out to these exclusive and isolated MHIs (meant to be for SMDs, at least from public perception) because of the stigma related to SMDs and MHIs. NHS encourages these CMD’s patients to reach out to their GP network, which is very good. Further, the NHS also needs to understand that more than 50% of CMDs treated by GPs need specialist psychiatric care for various reasons. With this kind of exclusive MHIs, these nonremitted CMD patients may not reach out to these NHS-empanelled MHIs because of stigma and discriminatory practices toward psychiatric care. Another glaring example of fragmented psychiatric care in the UK is confusion about treatment settings for alcohol and other addictions kept out of MHI’s purview. Patients with alcohol and other addictions are often treated in general hospitals by other specialties with/without consulting their in-house CLPs. I came to understand that addiction treatment is out of the purview of mental health trusts of the NHS but cared for in general hospitals managed by the general health trusts of the NHS. Overall, I feel psychiatric care in the UK is fragmented, stigmatized, and discriminatory, leading to the cost escalation of the prevailing specialist-based psychiatric care of MHIs. Having worked at multiple MHIs and GHP settings in India, I feel that the cost of psychiatric care in general hospitals is much cheaper than in MHIs. However, the author acknowledges that direct comparison of cost is challenging. The author understands that exclusive MHIs are escalating the cost of psychiatric care in the UK, where the majority of the expenses of MHIs can be clubbed under existing general hospital expenditures, which could save significant amounts of money to public exchequers. Apart from these, I am more concerned that the UK’s NHS discriminatory policy toward mental health could be misguiding many countries worldwide. For example, India’s Mental Healthcare Act (MHCA) 2017 is borrowed and adapted from the UK. Following the UK model of stigmatized and fragmented mental health care, the authors feel India could face difficulties implementing MHCA 2017 because of the cost escalation of MHIs and the higher numbers of GHPs than MHIs in India.6,7 Author feel it is time for the UK to relook at the functioning of its NHS and promote integrated psychiatric care within its general hospitals (by integrating mental health within the general health-care trust of the NHS). This could be a progressive step toward reducing stigma and the cost of psychiatric care. In addition, this sets an example for many LAMIC countries to follow their progressive, advanced, cheaper, less stigmatized integrated psychiatric care within their general health care. The authors suggest systematic research on in-depth analysis of issues raised in this article, especially the cost comparison, and benefits versus challenges of integration of mental health in general health. The author also states that by understanding the complexities of health-care systems and the diversity of patient needs of both counties, future collaboration and sharing of the best practices could improve integrated, accessible, and person-centered psychiatric care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.