Dr Ros Ramsay interviews Lord Victor Lord Adobewale, CBE, Chief Executive, Turning Point

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 things:

1. 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 half-way.
2. I think we have to look at, in the new landscape of health and social care, at integration together.
3. 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.

4. 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:

1. Money: £20 billion is a lot to save.
2. Commissioning and what it means – because in times of short supply of cash. Commissioning becomes purchasing and it’s not the same thing.
3. 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 problems.

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 good idea.

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 you?

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 point.

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 recover.

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 abuse.

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 consistent treatment.

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 psychiatry.

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 doing.