Professor Adrian James, President of Royal College of Psychiatry

AUTHORS:  Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov 

In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.

Here the subject is Professor Adrian James, a consultant forensic psychiatrist in Devon and president of the Royal College of Psychiatrists. Professor James has held a series of senior leadership roles and has also been heavily involved with the royal college, bringing a quality improvement approach to workforce wellbeing. 

A podcast of this interview is available here:

 

What has your journey been to where you are today? 

I'm a south-east London boy and I was lucky enough to get into a grammar school there. To be honest I wasn't massively interested in school. I didn't really get a lot out of it, but I wasn’t bad at science and if you were good at science people thought you should consider medicine.

Around the same time my father was quite physically unwell. He had a lot of heart and stomach problems and one of my memories of my childhood was him being blue-lighted several times into hospital. He had lots of operations and they often went wrong, and he became very unwell. So I ended up visiting him a lot in hospital and spending time by his bedside and I thought what amazing places they were. 

I think that somehow lodged in my mind and, not being bad at science and having that link with the medical world, I just thought, well, why not have a go at medicine. I was never at that point driven to be a doctor; I wasn't driven to be a psychiatrist, so I kind of fell into it really. I actually applied to Guy's Medical School where my dad had been a patient.

Again I didn't get a massive lot out of medical school, particularly early on. I wasn't really into basic sciences but I did a lot of sport. I was in the athletics team; I was captain of rowing, so I loved that. And I met my future wife. We're still fortunately together and that's been a richness beyond compare in my life. 

I did all the various firms and when I came to do psychiatry I thought it was fascinating and it became my career choice. I found it very stimulating. I enjoyed the time with psychiatrists and the psychiatrists were really interested in us as medical students.

They actually asked our opinion, 'Well, what do you think about this situation?' We actually went out to see patients in their own home which didn't happen in any other branch of medicine. I found myself just being drawn into psychiatry and here I am. 

 

Is there anything else that attracted you to psychiatry? 

Well, I enjoyed sitting down with patients and hearing their stories and not just processing people through the hospital, actually sitting down and saying, 'Tell me why you're here. Tell me what's happening in your life.' I got to hear about all aspects of somebody's life, not just about their illness, and I found those stories fascinating.

It also required the application of science to try to help with the challenges that they faced and all the things that we could contribute to help them achieve their overall objectives in life, not just their health objectives. 

I also enjoyed being with psychiatrists and other mental health professionals. I found them very interesting people. They had lots of fascinating things going in their lives which they were happy to talk about. I found that psychiatry reached out into so many aspects of life, into the arts, politics, and the interface with law, perhaps more than other branches of medicine.

We were much more interested in things like capacity, although there was no capacity legislation in those days, but it was at least a concept that we recognised. You had to ask somebody what they felt about the treatment that they were getting and whether they understood it and what they felt about whether they wanted it.

So it was a dialogue we had in psychiatry that you didn't really have in any other branch of medicine. So I just enjoyed the work and I found that you could really make a difference. 

 

What are your clinical interests?

I did general, intellectual disability, child and adolescent, older adults, and forensic psychiatry as part of what would now be called my core training. The forensic psychiatry was very stimulating; that interface with the law and seeing people who had the most severe forms of mental illness, such as schizophrenia, bipolar, personality disorder, and people who then find themselves in conflict with the criminal justice system.

They might have killed somebody or committed an act of serious violence and there was the interplay between their illness and their criminal activity. 

So we assess people to see if they're unwell and whether they should come to hospital for treatment rather than go to prison for punishment. I was meeting people at their lowest possible ebb; very unwell, often on the front page of the local - or sometimes national - paper.

They were often being criticised and were estranged from their families. Sometimes their criminal activity had involved their families. And I could say, 'I can help you through this. I can actually make a difference to your life, and this is how we're going to do it.' I thought that was just the most amazing privilege. 

We could acknowledge their pain, acknowledge where they were, and really spend a lot of time with them. I found in some other branches of psychiatry you had a very brief interaction with a patient whereas in forensic psychiatry you would have them under your care for many months, sometimes years, so you could really get to the bottom of people's problems and challenges and really pick them off one by one.

Again that's seeing people as real people to say, 'Well, what do you want to achieve in your life in terms of your relationships, your occupation, your interests, your physical health, and work through each of those.'

I found that immensely rewarding and I like the challenge of the interface with the law. You sometimes have to go to court, and you'd be cross-examined by an eminent barrister who would be trying to make you look ridiculous.

So it really sharpened you up. You really had to think: do I know what I'm talking about? Have I got the evidence, and can I present it? I found that a really positive challenge and it sharpened me up as a clinician. So I became a forensic psychiatrist. Within forensic psychiatry there are super-specialisms.

I've done a bit of work with intellectual disability and forensic psychiatry, and I've done a bit with child and adolescent forensic psychiatry but I would say I'm a generalist really. Mostly I see patients with schizophrenia, bipolar and personality disorder. 

 

Have attitudes changed towards forensic psychiatrists and psychiatrists in general? 

I think they have. As President of the Royal College of Psychiatrists I sit on groups with all the other presidents of royal colleges and actually we've become quite a close-knit community.

Because of Covid we meet several times every week. We meet with the Secretary of State, we meet with the Chief Medical Officer, we meet with NHS England and we've all got to know each other really well. The others actually want to hear about psychiatry; they're talking about mental health on these calls and I'm not having to bring it up.

Within the leadership there is an acknowledgment that psychiatry is an important specialty, it's got something to give, it's evidence-based and actually they want more of it. They say, 'Secretary of State, you've got to do something about mental health.' So that's a really good thing. 

But there are still some people within medicine who say, 'Well, shouldn't you have done something other than psychiatry?' I think that's disappointing, but it's receding because people see the value of psychiatry.

I think one of the most powerful developments has been in liaison psychiatry. These are psychiatrists who go into general hospitals and interface with paediatricians, geriatricians, physicians, and surgeons and they see people who come in with a physical illness but they’ve also got a mental illness and they see the difference that it makes to the lives of their patients.

That's been hugely beneficial and very important. We've got a way to go but it's got a lot better. 

 

What are the biggest changes you've experienced within psychiatry during your career? 

The biggest change would be the huge reduction in beds in psychiatry. When the NHS first came into operation, the overwhelming majority of beds were mental health beds which is an extraordinary thing really. The number of beds has come down, that's been generally a very good thing.

There were always things that could be provided in the community that by default were provided as an in-patient setting. There was a programme to close those beds - a massive, massive reduction - and the development of community services.

Where they've developed, been properly funded and had a proper workforce plan around them, they've been hugely successful and very well-liked by patients. 

But a lot of the money that had been invested in beds didn't go into community services. We're now beginning to invest more but community services are not cheap and you need to provide them in a robust way.

The other big change has been really engaging patients in their treatment and seeing patients as partners and patients seeing us as partners. There was a time in psychiatry where I think the psychiatrist was almost seen as the enemy and I think we do have a complex relationship with our patients, particularly as we are the only branch of medicine where if somebody has capacity and they don't consent to treatment we can actually say that you must have treatment.

Actually Public Health can too but that's a law that's very rarely used, even with Covid. So we have a unique relationship with our patients and that sets up understandable tensions and that's part of the challenge.

Another change has been in the partnerships we have with the big patient organisations like Mind and Rethink. We now have a shared agenda to improve services for people with mental illness rather than sitting on different sides of the table with one lot criticising the other. That's been a massive improvement. 

 

What makes a brilliant psychiatrist? 

You have to enjoy it to start with and be enthusiastic about it, you can't just treat it as a sort of process-y thing.  That doesn't mean that every day fills you with joy -  there are huge challenges - but overall you have to have a feel that it's worthwhile.

You do have to be a listener. You have to be an active listener and you have to hear what people say. You have to acknowledge and accept people's pain even if you sometimes can't understand where that comes from. That's really important for a psychiatrist. 

You have to instil hope for patients. That's really important and often what people are really looking for. Sometimes they don't want all the answers straight away. Sometimes it's a bit of a mistake to say, 'We'll do this, this and this and it's all sorted.'

We think that patients expect that and we overplay our hand. But you do have to instil hope and at least a way forward. You do have to understand the science around psychiatry and also the psychological and the social side. One of the richnesses of our speciality is how the science, the psychology and the social side all come into play. We need to do more of all of it, not veer from one to another.

So you have to have a feel for that, and you have to have a feel for the patient as a whole person and all aspects of their lives. Actually we've got a lot to teach the rest of medicine in this. If you're presented with a hip that's very painful, you can just say, 'I can examine your hip and we'll do an operation and thanks, goodbye.' Actually often what's more important is how that affects the individual and their life. 

 

What made you run for the presidency of the Royal College of Psychiatrists? 

If you'd asked my friends when I was a medical student, they would all have a very good laugh. I never went into psychiatry thinking that I would become the President, I never had a plan to do it. It wouldn't be true to say that I fell into it but I took on a number of leadership roles within medicine. I always had a college role, and I just got more and more immersed in it, and I became more interested in policy. 

 

What are your key priorities?

So I stated right from the beginning that I had four priorities, one was parity of esteem, so that's seeing mental illness in the same way as you see physical illness. So ensuring that people with mental illness have the same access to care, that their experience is as good, and they have equally good outcomes.

There is a staggering statistic that if you've got a mental illness you have a one in three chance of accessing evidence-based treatment. If you've got cancer you've got a 98 percent chance of accessing treatment. Some of that is because of stigma and people not coming forward for treatment, but another big chunk is that services are not available.

So my priority has been getting funding into services, getting the structures right, making sure we've got the workforce. For example we mounted a Choose Psychiatry campaign, and our recruitment has gone up from 67 per cent at core training levels, so the first rung of our training in psychiatry was 100 per cent full last year. It's probably going to be 100 per cent this year as well and we've increased the numbers. So that's been enormously successful.

My second priority was equality, diversity and inclusion. Too many of our patients don't have the services that they recognise as meeting their needs and too many people are suspicious of mental health services. They don't see people who are like them working in those services, particularly not in leadership positions and so we don't provide a good enough service for people from diverse backgrounds.

We've got a programme or work around that but the statistics are very clear: if you're from a black, Asian or minority ethnic community you have to work twice as hard to get to certain positions. If you look at leadership, people are underrepresented. We got a group of people together, we looked at all the work that's been done on this over the years, the things people said they were going to implement that they didn't implement.

We have an equality action plan with 29 clear actions, one of which is that I'm held to account for following through on these actions. I actually have to report every year to our trustee board to say, 'We said we'd do this, this is what we did.' 

This is really important because if everybody who works in an organisation is not empowered to give of their best, that's bad for them, it’s bad for the organisation, and it's bad for patients. 

Third is workforce well-being. We've attracted more people into psychiatry but, once they're in, we need to look after them more. We are doing work with NHS England at the moment on the wellbeing hubs across the whole of medicine. 

Fourth is sustainability and so we've got a sustainability action plan. We declared a climate and ecological emergency and we've set a plan for the college to go carbon neutral by 2040. I'm hoping we can do it before then. In fact, climate change is a core mental health issue.

The evidence base around climate change and causation of mental illness is growing all the time, and we know that if you have access to fresh air and green spaces your recovery is better. And that’s not just in mental health but in physical health as well. The NHS is eight per cent of the carbon footprint of the UK. 

 

Tell us about your workforce wellbeing and quality improvement initiative 

With the Wellbeing Committee, when I spoke to trainees, to SAS doctors, and to consultants early in their career there was a feeling of hopelessness, sometimes, about the environments they were working in. There were some very simple things that they felt could make a real difference but nobody seemed to be able to sort them out. I thought this was really a win-win.

So I got a group of people together to look at the evidence base around workforce wellbeing, the impact on performance, the impact on morale and the impact on keeping people in their jobs. So we got a group of experts together and as part of that we developed a quality improvement initiative, using quality improvement science around workforce wellbeing. 

This is really about getting the leaders in an organisation signed up to say, 'We're going to be doing this stuff, we're going to be empowering people at the front line to make some changes.' All within a governance framework but then getting those groups of people together to say, 'What's the evidence around wellbeing? How could it apply to your position? What are the things that could really make a difference in your working environment?'

Making some small changes and testing to see if they've really made a difference and if they do, spreading the learning locally and nationally and revisiting and just checking what you've done. So we've started, we've got a pilot with 40 teams looking at the quality improvement initiative around workforce wellbeing. 

Health Education England and NHS England are really signed up to it. Two of my children are trainee doctors, one in general practice, one in obstetrics and gynaecology and I speak to them and say, 'Well, how was your day?' It's those basic things that just are never really sorted, and this is something we really can crack. 

With the Quality Improvement Committee, I did a lot of work with the Institute for Health Improvement in Boston around some of the massive changes they have made. People used to think that pneumonia was kind of inevitable when you had lots of people being ventilated.

The view was: it's just going to happen; you've got sick people and lots of tubes. But then people used quality improvement science to break it all down to say, 'Well, actually how does this happen? How can we change it?' And I thought well why can't we apply that in psychiatry? To be honest there was a bit of resistance in the college to start with and I couldn't persuade the groups I thought should be doing it.

So I thought, well, I'll do it and I'll chair the group and so I did it for about two years and then brought in a real expert, once we had shown the college was serious about it. We've now got a whole lot of quality improvement initiatives around violence, around sexual safety on wards, around suicide prevention and around workforce wellbeing. 

 

You hit the headlines when you said COVID had been ‘the biggest hit to mental health since the Second World War.' Tell us more 

That was interesting. Sometimes you say things to journalists and you know when you say them what's going to happen. I thought long and hard about it and I knew what I was doing - and I think it's absolutely right. At that stage in the pandemic you could see the impact.

I had lots of discussions with people throughout the world, my equivalents, and they could all see the impact on people's mental health. And the other presidents of royal colleges were seeing it.

First of all COVID has a neurological effect, you find it in the brain in post-mortem samples, and so there are studies going on looking at the direct impact on mental illness and new cases of dementia and psychosis for example. 

Then you have other direct effects such as people being ventilated, and we know people being ventilated are much more likely to get post-traumatic stress disorder. Then you have all the people who have died from COVID in the UK, very often under tragic circumstances, and you had complex grief reactions.

People couldn't even say goodbye and you couldn't have a proper send-off, so there are ripples from those deaths. And you have children who had their schooling disrupted, their social networks disrupted, spending more time online than ever before. 

And then you have all the social determinants of mental illness.  You look at all the uncertainty, you look at issues to do with housing, employment, finance. You look at people's connections; connections are really important to people's wellbeing and a lot of those were severed.

So, all the dials were going the wrong way and then people began to do research around this. The Centre for Mental Health estimated that there would be an extra ten million people presenting with mental illness over five years (1.5 million children and 8.5 million adults) as a result of COVID.

Earlier on some people felt you shouldn't be frightening people but it is my job to say what I think's going to happen, so people can prepare. It is my job to warn people. 

One thing with COVID is that we haven't reacted fast enough. The evidence is really very clear, particularly in the first wave and actually the second wave as well, we could have done more sooner. And I didn't want that to be what happened in mental health. We needed to have early warning and be prepared.

Now everybody accepts it and it is obvious; we've had a huge increase in urgent and acute referrals of both children and adults. And we’ve had a huge increase in routine referrals and an increase in bed occupancy, which is near 100 per cent in many areas. Episodes of care have gone up hugely.

So unlike some other branches of medicine which, through no fault of their own, have not been able to do work, we've actually been working harder than ever. Actually demand has gone up so much that we haven't been able to keep track of it. That demands a response from government and policymakers. Our predictions have been proven to be true. 

 

Are you worried about the emergence of a two-tier system where people who can afford to go private? 

It is concerning and inequality is a big issue for me. It's true through the whole history of medicine that people who needed services most find it more difficult to access services. The independent sector within psychiatry is very small and the largest chunk of it is the NHS actually paying for beds within the independent sector and that's slightly different.

My priority is that everybody who needs a service, gets it and it's free at the point of delivery. If some people can pay for it, well, good luck to them. We just need to make sure that everybody can access the services they need and it's my job to lobby for those services. 

 

What have you learnt about leadership? 

You have to listen to people; you have to be connected to what's happening in the most important part of the system, which is that interface between a clinician or a team and a patient. You have to know what's happening and what the challenges are. If you're not connected to that - and I'm still an active practising psychiatrist - you can lose touch.

One of the most important things I've learnt is that, when you are dealing with those who are higher up the hierarchy - the Secretary of State or the head of NHS England - your messages must become more simple rather than more complex. 

It's very easy to think you've got to go into meetings knowing all the facts and figures. But you find that that isn't actually what's necessary. You do need to be able to underpin what you're saying, but you need to go in with clear messages about what the issues are. You do have to accept things from other people's perspectives, the challenges that they face. There's a reality around the world politicians work in and you have to present them with solutions they could actually follow through on.

Keeping it simple is really important. And you have to be prepared to use the press because sometimes that's the only way you can get your messages across. Sometimes politicians don't like it but they do listen but be very careful that you're not saying different things to different people. Consistency is really important in leadership. You have to be clear about what your priorities are and get people behind you on those priorities. People have to want to work with you, they have to see the value of what you're doing so there's a reason to follow you.

You have to be sincere and mean what you say and always your guiding principle has to be; what's in it for patients? Sometimes there are tricky dilemmas between different decisions you might make and you say, 'Well, the bottom line is, what's going to have the best value for patients?' 

 

What are your proudest achievements? 

I'm immensely proud of my children and their achievements and the people they are and the values that they have. And I’m very proud of my very successful marriage. Those things underpin absolutely everything else.

Professionally I'm very lucky that I still enjoy my clinical work - being in a room with a patient who is really suffering, is upset, sometimes very angry, and being able to do something about it. It was the honour of my life to become President of the Royal College and to be able to have that position and be able to really make a difference. It's not really for me to say but I would like to think that I've got the same values now that I had when I went into medicine.

That might be my proudest achievement - even though I've had senior positions, I don't think I've ever really changed my perspective on medicine. It's still the same, it's just applied in a different way. 

 

What advice would you give to aspiring psychiatrists? 

Enjoy it. Try to go into every interaction and into every meeting or clinic thinking, ‘This is a privilege.’ Sometimes I might feel a bit all at sea but I have the skills to make a real difference here. You have to actually actively enjoy what you're doing rather than see things as a process to be got through. It might sound a very simplistic thing, but I almost had to teach myself.

I was very process-oriented. You've got to get through this. I've done that, get through that. Rather than thinking about what I was actually doing and the intrinsic fulfilment and enjoyment of being in the moment. 

It's a bit like clinical mindfulness. It's appreciating what's happening in the room rather than saying, 'I've got to get out of the room and at least I've done that, I'll go onto the next thing.' You can teach yourself to do that. 

Always put patients at the centre of everything that you do, always listen to patients, never underestimate the impact of just being in a room with a patient. You don't have to have all the answers, you do have to instil some hope and not only hope for patients but the teams that you're working with. 

Sometimes people in our teams can get into a hopeless situation and it's our job as senior leaders to actually instil hope and keep teams going. Look after yourself.  You have to clinically manage things, but you also have to have a bit of time to manage yourself.  Otherwise, if you're not careful, it'll all go to pot. 

 

What's your favourite book? 

I would probably say The Lord of the Rings actually. I'm not a great reader outside work but what I like about reading with my work is it is so interesting and I'm applying it in every single meeting. This might sound incredibly shallow, so I apologise, but I don't really have much time to actively concentrate on other reading.

I cycle which gives me some physical activity and I watch a bit of football and that just gets me away from everything. When I'm not working, I don't really want to have to concentrate on something else. I want to just get away and do something which is relatively mindless. 

 

Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.