In his introductory article, Jeremy usefully identifies three key processes that are reshaping practice in the mental health field: managerialism, marketisation and medicalisation. My response will seek to expand on their nature, dynamics and interaction within community mental health services in England. The discussion will begin with an overview of the form taken by managerialism and marketisation in mental health services. This is followed by an outline of the mechanisms through which front-line practice is medicalised and its impact on social workers, other mental health practitioners and service users. I will then go on to briefly examine risk, and conclude with consideration of the prospects for resistance to the neoliberal restructuring of the mental health field. Where practitioner quotes are used, these are drawn from a research study I conducted recently within two community mental health teams.

Front-line practice in the health and social care professions has undergone significant restructuring in the neoliberal period since the early 1980s. A managerialist regime of targets and performance indicators has been introduced to impose a quasi-market discipline on the public sector (Harris, 2003). This has led to the intensification of work, with the loss of the breathing space that enabled reflection on practice and an overwhelming increase in administrative burdens (Law and Mooney, 2007).

Statutory mental health work has been subject to these broader pressures, but with certain additional and more specific features. Perhaps the most notable of these is that neoliberal reforms have reinforced biomedical approaches. This is in spite of policy rhetoric promoting a more holistic orientation and widespread support for social approaches to understanding and responding to mental distress, particularly among service users (Beresford, 2002; Tew, 2005). In order to explain this contradiction, I will now examine some of the mechanisms through which managerialism and marketisation have been imposed upon community services.

The first significant factor emerges from the broader socioeconomic context of mental health service provision. The shared economic and financial interests of both the major pharmaceutical corporations seeking to maximise profit1 and neoliberal governments aiming to reduce levels of welfare spending represents a mutually reinforcing dynamic that tends to increase the emphasis on biomedical interventions.