The mental health revolution that is happening in England, but not here in Scotland

A revolution in mental health services is unfolding across parts of the UK. Sadly, this revolution has not extended to Scotland.

NHS England last year took two radical steps. Firstly, it recognised that its existing system of mental health care was broken.

Mental health hubs are being strengthened in NHS England. | Adobe

Secondly, it allocated £30 million for six pilot projects based on the Trieste model, the globally renowned system of community mental health care.

This seismic shift cannot be overstated and the question posed here is simple - why has Scotland not done the same?

The mental health crisis we face is every bit as severe as it is in England. We live with unacceptably high rates of suicide, drug and alcohol abuse, crime, violence, incarceration and homelessness – all of which, to varying degrees, trace their roots to inadequate mental health care.

Meanwhile, prescriptions in Scotland for antidepressants and anti-anxiety drugs have skyrocketed over the past decade. The latest figures from Public Health Scotland reveal around 8.3 million antidepressants alone were prescribed to more than a million Scots. That means more than 20 per cent of the population take these drugs.

Even the typically cautious Royal College of Psychiatrists (Scotland), in its manifesto for the 2026 Scottish Parliament Elections, described the current situation as a "mental health emergency”.

Psychiatrists around the world have long regarded community-based approaches, which respects the rights of individuals and use networks of social support as treatment options. as the answer to the failings of traditional psychiatric systems.

What is the Trieste model?

The Trieste model is named after the Italian city, where it began in the 1970s. It is a system of 24/7 holistic, open-access mental health hubs, based on community psychiatry, human rights, hospitality and the continuity of trusted support relationships. The World Health Organisation has called it the world’s most successful model for recovery from mental illness.

In the spirit of transparency, I need to declare my own stake in the Trieste model.

As the co-founder of The Joshi Project, a Scottish mental health charity that my wife and I established the year after our daughter’s death in 2020, we have been pushing the NHS to set up Trieste-style mental health hubs in Scotland for the past four years – so far, without success.

In that time, I have spoken to hundreds of Scots touched by our mental health crisis. Anyone who thinks that services are functioning adequately isn’t paying attention.

Ask any parent who has lost a child to mental illness, or a sibling, friend or loved one who has tried to navigate the ineffectiveness and the awful outcomes of mental health care in Scotland.

Or ask the doctors, psychiatric nurses and support workers, who tell me how stymied they are within the fragmented and ineffective care system in which they work.

Families also tell me of their desperate efforts to find a place to go during a mental health emergency - I was one of those with my daughter - or the frustrating search for effective care for a loved one suffering from a complex condition that an antidepressant or a few CBT sessions won’t fix.

The resistance against change

The Scottish NHS boards I have met have persistently resisted change. We are now in the process of raising enough funds to set up a Trieste-style hub ourselves. It is our hope that the NHS will join us, but we’re not holding our breath.

Yet, the Trieste model has already been adopted successfully at city, regional and national health levels in more than 30 countries – Brazil, Poland, India and the Czech Republic among them.

In Trieste, the model has dramatically reduced rates of homelessness, alcohol and drug addiction, enforced hospitalisations and, over a period of 15 years, cut suicide rates by a jaw-dropping 50 per cent. In Scotland, suicide rates have barely budged over 15 years.

I have no doubt that my daughter’s life – and by extension, the lives of thousands of Scots – could have been saved if access to Trieste-style care and treatment had been available.

Based on recovery rates alone, the most extraordinary fact about the Trieste model is that it works.

Traditional models for psychiatric care, like the one practiced in Scotland, generally assumes that all mental health problems are the result of brain defects and are best treated by hospitalisation and medications.

The Trieste model instead focuses not on our brains, but on our lives, our relationships and our interaction with the world around us.

I believe we must learn from the failures of our existing system – just as NHS England has done.

Scotland needs to build an open process of recovery like the Trieste model – one that’s awake to a wider picture of mental illness and all its interactions and social determinants. We need a system that points us toward our universal human struggles with self-control and psychic pain – thus making mental illness profoundly ordinary and contiguous with all human suffering.

The Trieste model also understands that mental illness, addiction and often homelessness, incarceration and other social scourges have the same roots.

Shouldn’t this grab the attention – and the small amount of funding it would take – of the Scottish Government and every NHS board?

Mark S Smith

I’m still at a loss to understand why it hasn’t done so – even as the Scottish Mental Health Law Review and Audit Scotland’s report on mental health have recommended the Trieste model’s implementation.

The pilots south of the Border

South of the Border, all six Trieste-model pilots – Sheffield, Birmingham, York, Cumbria and two in London – are expected to be up and running within the next three months. Two are already operating. More are likely to follow.

It’s also worth noting that if the pilots are successful, the model is intended to become the standard of mental health care.

The problem in Scotland cannot be cost – the most common objection I’ve heard from NHS management – because Trieste models are significantly cheaper to operate. The real problem is complacency and lack of vision.

Dr SP Sashidharan, a Glasgow-based psychiatrist consulting with the Birmingham project, told me that a recent internal study concluded that if the Trieste project were rolled out across Birmingham, it would save the NHS £50 million a year.

When asked about Scotland’s resistance to change, he said: “The Scottish Government and NHS Scotland appear to be oblivious to the urgent need for a fundamental reform of our mental health services, as demanded by service users, their families and carers, as well as voluntary groups. But based on my involvement in the Birmingham pilot, similar initiatives would certainly work in Scotland.”

It’s worth remembering that poor mental health isn’t just deadly, as it was for my daughter. It’s also disabling.

It robs people of quality of life, which may be more important than mortality. Too many people are warehoused in psychiatric hospitals or in prisons, or even in their own homes, where they spend their days medicated and incapacitated as prisoners of their own reduced lives.

At the political, economic and social level, it robs our communities and our country of the precious contributions of thousands of people who have so much more to give. Our communities deserve better, as does our nation.

Now that England has joined the mental health enlightenment, it’s time Scotland did the same.

- Mark Smith is the co-founder and co-chair of The Joshi Project, a Scottish mental health charity.