These postings are the opinions of the authors and do not represent the official policies or positions of WHO or GCP.Network.

ICD-11 Implementation in Scotland: Interview with Dr. John Mitchell

This article is part of a series that aims to highlight the ways in which countries around the world are preparing to implement the ICD-11 Diagnostic Guidelines on Mental, Behavioural, or Neurodevelopmental Disorders. In this interview, Dr. John Mitchell, who is currently a Scottish Government Advisor and Chair of the ICD-11 Implementation Group in Scotland, shares how Scotland is moving forward with the implementation process at the national level.

How is your team – and country as a whole –  preparing for official implementation of the ICD-11?

I first met the World Health Organization’s ICD-11 Advisory Group in 2017 while I was in my previous role as the Principal Medical Officer in the Mental Health Directorate in Scotland, and I subsequently joined the Advisory Group on Training and Implementation for ICD-11 Mental, Behavioural, or Neurodevelopmental Disorders. These initial meetings inspired increased interest among Scottish government officials to actively engage with WHO and the ICD-11 implementation process. Then, with the COVID-19 pandemic in 2020 and related research indicating an increase in mental health challenges, there was an urgent need to prioritize mental health services. In the autumn of 2020, the Scottish government was in the process of formulating its strategic policy – The Mental Health Transition and Recovery Plan – so it was the perfect opportunity to advocate for and obtain a written commitment that Scotland would promote the use the ICD-11 in mental health service systems beginning in the spring of 2021. By weaving ICD-11 implementation into formal government policy, the foundation was set to garner support, obtain financial investment, and to assure its delivery.

Could you tell us more about the ICD-11 Implementation Group that you lead?

Consistent with WHO’s advice for countries establishing a national implementation group, I think successful and effective implementation can only happen by pulling together people who are directly impacted by these changes. To lay the groundwork for a Scottish ICD-11 Implementation Group, we have invested considerable time in sharing the importance of this initiative and have learned a great deal about why using the new ICD-11 guidelines matters to various stakeholders. We’ve frequently heard from individuals with lived experiences and their caregivers that the quality of the therapeutic experience is what matters most to them, and we’ve found it is constructive to clarify how the ICD-11 may impact diagnoses and care. Talking with people has shown us how the adoption of the ICD-11 offers us an opportunity to point the spotlight back on the quality of services and amplify the voices of people with lived experiences.

Additionally, almost all professionals within the healthcare sector will be impacted by the changes in the ICD-11. Psychiatrists, psychologists, nurses, social workers, and healthcare administrators will actively use the ICD-11 diagnostic guidelines in their work; allied health professionals (such as occupational therapists, speech and language therapists, and dieticians) work closely with individuals with mental health conditions and need to have an general understanding of mental health diagnoses to serve their patients. So it has been paramount to hear directly from these professionals what is significant to them and how they anticipate the ICD-11 will impact their work. We will then consider variety of trainings that is needed for these groups to learn about the changes in ICD-11, which will range from expert training to general awareness, and the spectrum in between.

Lastly, it is imperative to work with organizational and legislative systems, such as Public Health Scotland, to advance the changes in coding of mental health and behavioural disorders; with NHS Education Scotland, to create training and professional development materials; and with legislative professionals, to update and revise existing laws that will be affected by changes implemented in ICD-11 diagnostic guidelines. 

This rich and purposeful process has enabled us to devise a list of groups and individuals who are part of the Scottish ICD-11 Implementation Group. It’s also shown us that there is a broad appetite for participating in the implementation group and thus, our group continues to expand, as it should, because there is a need to bring communities together to agree on what we need to do and the steps we need to take.

What recommendations or advice would you share with other countries that are preparing to implement the ICD-11?

My advice is two-pronged. First, you’ve got to enact it as official policy, which can take the form of legislation, policy, ministries, or high level organizations in your national context. Second, you have to think about the two sides to implementation: the people affected by this change, and the systems that are involved. You must not neglect either of them, because they are synergistic. For example, if I only engage the caregivers of people with schizophrenia in viewing the ICD-11 as really important, but I don’t get buy-in from the people coding and collecting data, it’s not going to be effective or make a difference. Likewise, if only the coding is changed, how am I going to meaningfully improve the therapeutic experience for a person receiving care? So, you’ve got to work concurrently on both the systems involved and the people impacted. The power to effect real change lies in bringing the two components together so that they can influence one another.

What inspired you to pursue a profession in the field of mental health?

At 11 years old, I read the book, Manwatching, about nonverbal communication. I was absolutely fascinated by this idea and read the book cover to cover. I went on to think about the mind and the body, and what makes us who we are. Given that my mother was a biology teacher and my father a doctor, medicine seemed inviting as a career. Early on in my medical training, I learned that medicine is less about a “cure” and more about chronic disease management. I also found that psychiatry offered me a chance to truly sit down to talk with people and understand them. So, for many years, I worked as a general psychiatrist in Glasgow as part of a multidisciplinary team, primarily supporting individuals with severe mental illnesses, such as schizophrenia and bipolar disorders. Later, I took on leadership roles within the medical management team and worked my way up to become an Associate Medical Director. It was this shift in my career trajectory that ultimately led me to my role as the Principal Medical Officer in Scotland’s Mental Health Directorate. In this role serving as the primary mental health adviser to ministers, I found that I absolutely loved working in policy at the national level. At the same time, though, I continued to spend one day per week working at the clinic in Glasgow to really stayed connected to the clinical side of the mental health.  

The GCPN is comprised of 16,000 clinicians from over 160 countries. If a GCPN member were to visit Scotland, what would you recommend that they make sure not to miss?

We’re a small country, so you can travel around easily. In general, the scenery in the northwest of Scotland is utterly breathtaking. If you go to Glencoe, or Torridon, these are beautiful places. If you are seeking history, culture, and a world-class city, then Edinburgh is the place to go. It has so many treasures, it has the feeling of a big town, and it’s wonderful. But really, if someone were to visit, I would first ask what their interests are, so then I can tailor my answer to tell them specifically which mountain, restaurant, island, or castle to visit! 

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Acknowledgments: This article was prepared by Rayna Wang and Asha Retnasami-Kennedy, with editing support from Patricia Dunne.