How can RCPsych best work with voluntary sector organisations
to support the needs of people with mental illness?
The following things are true. We actually employ
psychiatrists in Turning Point. You can do the following
- Meet us half-way which means
not expecting us to come to you because my experiences of medically
qualified people is that they can assume, not always, that all
roads lead to them. That isn’t true so they have to meet us
- I think we have to look at,
in the new landscape of health and social care, at integration
- I think we have to do early
intervention together. I don’t think you guys can do it. (a)
there’s not enough of you and (b) you needs us to create the right
pathways and the right access of entry points into the system.
We have a common story – I am not sure
that we have done very well explaining to the public, or trying to
engage the public enough in the debate about mental health and
prejudice. There is a lot we would agree on together about mental
health. My personal view is that mental health is so ubiquitous.
The term has become denigrated and this is almost an argument for
it to become a strand in everything in our society.
What do you think are the real challenges for us all now,
thinking in particular about the Health and Social legislation and
what that is going to mean?
I think the following challenges:
- Money: £20 billion is a lot
- Commissioning and what it
means – because in times of short supply of cash. Commissioning
becomes purchasing and it’s not the same thing.
- Service design and redesign –
I believe that most interventions in health and social care do not
require interventions from people, with due respect, who are as
qualified as you. They require people with the equivalent of a NVQ
level 3 max so there is a question about how we engage people in
the communities and the delivery of low-level support mechanisms
that mean they don’t need to go to the more expensive services. I
think again to repeat it but without apology, the challenge of
integration of health and social care.
And how do you think psychiatrists can move out of
their own silo and see the bigger picture?
Some time ago I gave a talk at a conference
with a group of psychiatrists. I pointed out that, at the time,
psychiatry was being challenged by a drop in the number of
undergraduates interested in becoming psychiatrists – I don’t know
what the current position is – and I pointed out that I think there
are two kinds of psychiatrists. There are the philosophers, those
who have understood the need to earn a living so they go into
psychiatry, and then there are the clinicians, those that are
interested in brain structure or pharmacological interventions.
But I am a firm believer that the original
meaning of psychiatry which is the healer of souls still is
relevant. It’s not ‘either’ ‘or’, it’s ‘and and’. Psychiatrists
need to see themselves as the real champions for excellent service
design, delivery and outcome, but should be less precious about
their control of patients. I am amazed how very senior
psychiatrists still feel the need to keep their hand in. It’s the
equivalent of me, as Chief Executive of Turning Point and a member
of the Chartered Institute of Housing, still collecting the rent on
estates in Camden Town just to keep my hand in. It's
an expensive use of my time which would be better spent
designing some of the community-based, community-led health and
social care integrated services. You should be using your precious
time and expertise in accessing a wider group of people.
And can you say a bit more about tackling these issues
around stigma and marginalisation and people with mental health
Well there are two things that really strike
me. The middle classes have quite an American attitude towards
mental health and it’s quite fashionable to be in therapy. There is
nothing wrong in people seeing a psychotherapist – I myself have
enjoyed the indulgence and delight. I mean the support of
psychotherapy; it’s a great thing. What did Freud say? The life
left unexamined is a life not worth living. But somehow, the lower
down the social strata you get, the more the stigma becomes
apparent. If you are black basically, and by black I mean African
or Caribbean actually, the stigma is double and it’s not just me
saying that. Every statistic I have ever seen says it and I think
having been involved in delivering race equality programmes, there
is a resistance in the professions, not just psychiatry, to accept
that as a reality, both perceived and real.
I think that the stigma is less an issue in
the middle classes. However, when it comes to emotions, the more
you talk about direct interventions into diagnosable illnesses, say
psychosis, the more it becomes a challenge, and then if you
are working class it’s a real problem, more so if you are black and
working class. I think psychiatrists haven’t done enough to address
that perception and that is reality. It’s interesting that the IAPT
programme comes from an economist and not a psychiatrist.
Thinking about your background in housing, psychiatrists talk a
lot about how housing issues they have to deal with for their
patients, how do you think housing and psychiatrists, mental health
services can work together?
Unless you are an extraordinarily resilient
human being, the environment plays a massive part in our emotional
and mental well-being. I think that psychiatrists have a powerful
position in society because they are doctors. My mum still thinks I
am unemployed because I am not a doctor or a priest.
So now GPs and also consultants have even more
influence because of the Health and Social Care Act. You can use
that influence to dictate or indeed to engage with health and
well-being boards and public health, to get them to see that things
like housing are a key component of public health. If you look at
the history of public health, sanitation and housing were very much
at the fundamental to its development. I think it’s a
challenge but you’ve got to try.
I think coming together with some of the lobby
groups in housing, like the Chartered Institute of Housing or the
National Housing Federation, to create a joint lobby platform for
housing both in terms of its quality and its quantity, would be a
And you particular vision, thinking about your work
with Turning Point and people who are homeless, can you tell me a
bit about that?
Turning Point is a social enterprise. We work
with people with mental health problems, learning disabilities,
substance misuse. We also provide community commissioning services
and employment services. We employ about 3000 people and we operate
in 250 locations. We work with a significant number of homeless
people but that’s not the core body.
My vision has always been to work for a
developing organisation which systematically reverses the inverse
care law which states that those people in need of health and
social care the most, tend to get it the least. It’s remained my
vision since I started in public policy and service provision, and
it will always be my vision which is shared by everyone I work for
and work with at Turning Point.
And a topical matter for psychiatrists and also I
saw from your information from Turning Point is to
take the recovery approach. What does that mean for
The term recovery is an interesting one in
that it means different things for different people. Certainly in
substance misuse, recovery has tended to focus on attacking things
like the use of methadone or actually more so, a support for
abstinence. So you haven’t recovered until you are abstinent.
In psychiatry, however, recovery can mean coming to terms with and
managing your mental illness. I am not so sure how many
actual cures there are for psychosis, you know better than I, but
there are several schools of thought about how people manage that
illness and how people come to terms with it, and in other areas,
such as personality disorder, for which recovery is a moot
So I guess recovery for me is a journey of
discovery. In some ways the term recovery ought to be replaced with
the term ‘discovery’ because it starts with the discovery that you
are human and you have frailties as a human. Some of those
frailties are significant challenges, like psychosis, and the
journey to recovery starts with early intervention. In my view,
early intervention and support starts the journey, and the start of
the journey in the sense that you are always in recovery
as opposed to the idea that ‘1 in 4 of us will suffer mental
illness at some time, at some point’, which assumes that we will
If you look at the DSM classification, there
are hundreds of diagnosable psychiatric illnesses and I reckon I
have got a good few of them frankly and I don’t know a human being
that hasn’t. So in that sense we are all in recovery, and the human
being who considers themselves not to be in recovery is probably
the most poorly.
I am thinking about your work with people with
substance misuse problems and alcohol and dependencies, how do you
think we can work to change our attitudes to drinking and how we
use alcohol in this country?
I always say we work with alcohol and drugs
rather than just drugs because alcohol is not perceived as a drug.
There is a conspiracy of silence around alcohol because it’s such a
lucrative business, and the alcohol manufacturing industries are
very much wedded to the politics of that. I have nothing against
alcohol, I like a drink, but I think the mechanisms, the kinds of
interventions that work are not applied widely enough.
For instance, Turning Point has an A&E
intervention service. Research shows that one of the key
intervention you can make and which is very powerful with a person
who has arrived at A&E drunk and incapacitated, is to ask that
person the next morning or even at the time – ‘How many times have
you done this?’ ‘Can you remember what you did tonight?’ and then
to get the person the help they need. There is a lot of evidence to
show that this can work, but it’s not available everywhere. For
most towns and cities now, on a Thursday/Friday/Saturday A&E –
alcohol. Indeed recent research has shown that billions of pounds
of NHS spend goes on Thursdays/Fridays/Saturdays. And then there is
the medium- and long-term effects of this kind of alcohol
So what I am concerned about is the lack of
treatment, the lack of early intervention and the lack of on-going
support including detox – we need detox. We talk about alcohol, we
know it’s available virtually everywhere but we don’t provide any
We did some research about five years ago that
showed that one in 11 of children go home to alcohol misusing
parents, even though we know there is a direct line between alcohol
misuse and parents in childhood and criminal activity, poor
education and attainment, unemployment and mental illness. So it’s
a no brainer that we need to be doing something about intervention.
My view is that it’s highly unlikely that we will do anything about
supply. I think we can raise the price, I’m all for that, but the
problem with addictions is that they are irrational so if you raise
the price, people do irrational things to get the alcohol –
heroin’s expensive but it still doesn’t stop people taking it.
So I think the question is about education.
Although it’s difficult to measure the impact of education, I do
think it has an impact. And treatment has to be widespread and
integrated. It’s possible to have an alcohol service for acute
cases for people who have got alcohol problems, with interventions
from A&E, but I don’t think the mental health service can be
called a mental health service in my view, unless staff are trained
in addictions because dual diagnosis is the biggest challenge. I’ve
always thought it was pretty hard to kill yourself with alcohol, I
think you have to be mentally ill to want to do it. So it just
strikes me as odd that the two things are so separate. It’s less so
than it was, but it’s still common to find silo services that
behave as though the two things cannot be put together which
doesn’t make sense to me at all.
Working here in Standon House with the RCPsych CCQI and
NCCMH, what’s that like and does it lead to anything?
We certainly do work together. I’ve had very
many useful and powerful discussions with the current President of
the Royal College of Psychiatrists.
The Mental Health Team here are working on
joint programmes and joint work with the College and we see them as
a powerful ally in the work we are doing in terms of developing
care and influencing policy. We don’t have a large policy team
here; I think the College is better resourced actually than we are,
but we are very much wedded to working together. The fact that we
are working in the same building just makes it easier to be able to
do so. I think we are involved in joint training programmes and
certainly my people are telling me that we are in discussions about
influencing dual diagnosis and work on substance misuse and
What keeps you motivated to keep going?
I am very lucky; I get paid to work with
people who I really admire and like. What could be more rewarding
than actually providing industrial skilled help to other human
beings? What we do is provide the framework within which we can
define ourselves as human. I might decide to do something else, who
knows? For the last 30 years I have been happy doing what I am