Future patterns of service

In the past psychiatry was practised in asylums; more recently it has been the responsibility of departments of the general hospital. In the future we must look to a situation in which specialized mental health teams work closely with primary care teams. Psychiatry in general practice is here to stay. Seen from the vantage point of the community mental health team, the primary care team should and could be an extension of their services, and close collaboration between the two is highly desirable. In the United Kingdom, purchasing of health care will be progressively done by primary care groups, which is likely to have major implications for mental health care. GPs are likely to direct more resources towards staff who can help them in primary care settings, so that we can confidently expect an enlarged mental health role for practice nurses, community nurses, and counsellors. The emphasis on evidence-based medicine ought to influence the kinds of psychotherapies made available by counsellors, with a progressive emphasis on structured treatments, such as cognitive-behaviour therapy, interpersonal therapy, and problem solving, and away from non-directive counselling.

At present, there are insufficient trained staff to take on this burden, and there is a major training task which is likely to involve both psychologists and psychiatrists. The work of the community mental health team with more severely ill patients needs to be co-ordinated more closely with primary care, who can and do take some responsibility for monitoring them. The scale of the training task is formidable, but if successful a working partnership between the two teams will be the reward. In this way psychiatry will remain in touch with a wide range of psychological problems, rather than being marginalized and confined to the care of the dangerous and the disruptive, which would represent a return to the alienism with which the twentieth century began.

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