National director for mental health Appointed: April 2000

My achievements

As they say in the Oscar thank you speeches, you don’t achieve much on your own, and as a national director you need all the help you can get. In fact, one of the things you must learn is how to play the system—how to press the points of influence in the government machine and in an increasingly devolved health service. President de Gaulle once asked how anyone could govern a nation that had 246 cheeses, and the modern NHS is a bit like that.

My first day in post saw the start of the process that led to the NHS Plan, and the crucial task was to make sure that mental health—one of the government’s clinical priorities for the next decade—was in it. The NHS Plan launched a set of new services intended to plug the most conspicuous gaps in the mental health system. It brought in community teams for vulnerable patients who might otherwise drift out of care, early intervention for young people with psychosis, and home treatment. It created new kinds of staff, offering psychological therapies in primary care and better support for carers.

We followed it with a set of strategies in areas of neglect—such as services for ethnic minorities and for patients with both mental illness and drug misuse. We set up the National Institute for Mental Health in England to make sure that policy turned into action at local level. We found money to refurbish inpatient wards; most units have now met standards on safety and on privacy for women. We made changes to performance indicators to boost their clinical relevance. We have a national research network and a national research plan.

The past few years have seen substantial increases in funding, workforce, and the use of modern treatments. Suicide rates have fallen. Yet problems remain over resources, recruitment, and poor buildings, and in some areas we are a long way from the services that patients and staff deserve. But at last we are heading in the right direction.

What others say

Dr Trevor Turner, consultant psychiatrist, Homerton University Hospital, London:

The national service framework and the reviews of mental health by the National Institute for Clinical Excellence are nice, but nothing much else has happened. The real problem is that there are so many agencies in mental health that Professor Appleby has got completely cut off from services. He now uses the language of government and managerialism, rather than the language of clinicians. And he has been taken on board, "gone native," so to speak. If there’s going to be a "tsar," that tsar should be independently elected by the relevant part of the profession. So far, I’m rather negative about the usefulness of tsardom.

We should have as few people as possible between the frontline and the centre—from down here it’s muddling. Between the National Institute of Mental Health, the National Patient Safety Agency and the Modernisation Agency, you don’t know who you need to talk to to get things done.

Although Professor Appleby’s a perfectly nice guy and a highly intelligent man, his post has had no impact whatsoever on my day to day life. He’s a very good epidemiologist and clinical psychiatrist. Instead of seeing patients, he’s now doing a government job. This represents how clinical people are being taken up in running a government agenda. The government is so hungry for people to cover its backs it forgets that the more it demands information and sets up agencies, the less time we have to see patients. If in the past 40 years the government hasn’t worked out how to bring in good quality opinions from the professions then it’s not got a very good set up.

Professor Simon Wessely, department of psychological medicine at Guy’s, King’s, and St Thomas’s School of Medicine, London, and the Institute of Psychiatry, London: As a university academic psychiatrist who does not work with severely mentally ill people, it is hard for me to assess the performance of our national director as most of what he has accomplished has been in the field of service development for those with severe mental illness, reflecting the general direction of policy on mental illness. Indeed, if one wanted to assess whether a national director has actually improved the public mental health, such a question might be more appropriately directed to the director for primary care, as that is where most of those with mental health problems are seen, managed, and sometimes treated. However, I can draw attention to one tangible benefit that has affected my world.

The Medical Research Council is currently considering over 400 new applications for research into either the biology of mental disorders or new clinical trials to improve the treatment of mental disorders. In a lean funding cycle this would not have happened without the strong championing of mental health issues—and even the occasional arm twisting—by Professor Appleby, and this has to be warmly welcomed. But there has been one serious adverse effect of his period as national director. Before his rise to eminence, Louis was a gifted and often painfully funny journalist, writer, and gossip columnist. Being a tsar has denied us his skills as a satirist. But let’s hope he has kept a diary. It will make entertaining reading one day.

Richard Brook, chief executive of MIND: Over three years ago, it was brilliant that mental health was one of the top three priorities in the NHS, and Louis was appointed to champion the huge improvements promised. Louis is responsive and genuinely committed to ensuring quality mental health services. He has always been interested in understanding service users’ concerns.

Under his tenure we have developed better strategic thinking towards mental health than we have ever had. Some of the work has taken forward enormously the concepts—and more importantly, specific services—in areas such as acute services. It is disappointing that despite these improvements other key areas of mental health services, such as primary care, have made such limited progress.

Much remains to be implemented. Investment and performance do not match the promises of those early, exciting days. Those ambitious targets are beginning to look further away than originally planned. There have also been some major mistakes, such as the fiasco over the proposed new mental health legislation and the confused plans that led to the creation of the National Institute of Mental Health England. That institute had real potential but quickly became a quango that has led to confusion and lack of direction regarding this new agenda.

The political drive for change seems to be ebbing, and it is here that service users—MIND’s key constituents—especially feel more could and should have been done by the tsar. Publicly, Louis has never been the visible, ardent, and forceful commentator and champion for users of mental health service that some of the other clinical directors have been in their areas. I believe it is so essential that—using a recent phrase from political life—the quiet man should turn up the volume.