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The NHS at 70 – time for an honest debate about the future

 

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5th July 2018 will mark the 70th anniversary of the establishment of the NHS. It remains the most enduring testament of the collective will of the people of this country to tackle the need and suffering of their fellow citizens. As such it will be an occasion which deserves celebration, but I hope it is also an anniversary which provides a focal point for some critical debate about its future.

By this I do not mean challenging the basic principles of the NHS. Britain is not unique in providing universal access to healthcare but it’s system is distinctive and, on the whole, is relatively efficient and fit for purpose. However, the last 8 years of austerity have highlighted weaknesses which, if not addressed, will undermine the sustainability of what is able to be offered for future generations given an inevitable increase in demand with an ageing population and advances in medical technology.

I would highlight five priorities for the New Year.

The first is workforce where we have now woken up to the scale of the short and long-term challenges we face. In the short term the big pressure is numbers, for instance, in mental health, we need 19,000 extra members of staff by 2020/1 to replace staff we are losing and to meet the extra demands of the Five Year Forward View for Mental Health. In the long term there are bigger challenges about reenvisaging the health and care workforce and rethinking career pathways along the more flexible lines which will appeal to a younger workforce less likely to buy the old paradigm of a profession for life.

We also need to be much smarter at looking after the workforce we have got. The recent Farmer/Stevenson report on mental health at work positioned the NHS as one of the sectors of the economy with the highest annual costs of poor mental health at work (estimated at between £2,028 and £2,174 per head). We need more than a sticking plaster approach to addressing this, taking account of the fundamentally traumatic nature of working in healthcare and any remedy must be a fundamental part of the calculations make about efficiency and productivity in the NHS.

The second priority is to be honest about the money. All I have seen in the last couple of years is of a system, which despite some heroic efforts from providers and commissioners, is seriously struggling to keep up with the demand it is facing within the resources available, let alone being able to address key priorities for development and transformation such as those for mental health. I am, of course, not alone in that view with similar opinions being voiced by the Kings Fund and most of the leading health think tanks. While I accept that there are no easy answers to the pressures on public finances there are major consequences of the current position. First there is stress of dealing with the fallout on the frontline staff and who can often feel held personally responsible for the failings of the system. Second a constant focus on short term efficiency distorts priorities, making it harder to make investments in new models of care which often require some element of double running but which, in the long term, are central to the delivery of a sustainable system of care.

These dilemmas have made me a supporter of proposals to take decisions about the long-term funding of the NHS and social care out of day to day political decision making with funding pegged to an agreed proportion of GDP. There would still be difficult choices to be made but, at least, the basis for those choices would be less arbitrary.

My third priority is prevention in its wider sense. It is the most obvious economics that intervening early is less expensive than waiting to deal with issues when they have reached crisis point. However again and again in the years of austerity we have cut those services which prevent demand or help to seriously reduce its impact. Some of this recognises the limited role which health services play, on their own, in improving health outcomes. It also reflects the distortion caused by the short-term nature of funding which can lead to the exclusion of initiatives which deliver a very robust return on investment but where payback will be over years if not in some cases, decades. From my perspective there would be very powerful case for treating elements of public health spending as capital investment with upfront investment justified in terms of its longer-term impact on health outcomes and utilisation.

Linked to this is the need for a much greater sense of urgency in tackling health inequalities which needs to be a much greater focus of national policy making and local commissioning decision. In an era where what we can do is being rationed, either explicitly or implicitly, the impact on health inequalities should be a key criterion for any assessment made by NICE of new treatments.

My fourth point is the need to continue to resist the temptation to default to organisational change as a kind of “magic thinking” to address the problems of funding. I think STPs have, in general, been helpful and the principles of Accountable Care provides opportunity to take a paradigm of integrated care further. But let’s not again make the old mistake of putting form before function. From my experience organisational development is best as a means of supporting and extending those areas which are already well on a journey towards more integrated working and any wider roll out must be justified in terms of clear evidence of benefit in a UK setting. We must also be bold in constructing approaches which go beyond the traditional boundaries of the NHS and ensure social care, housing and the voluntary a key seat at the table.

My final point relates to culture. The NHS has many strengths and it is full of many very committed and inspiring individuals. The way it works together as a system can, sometimes, leave something to be desired.  Part of the problem is the public and political nature of the service and to the way in which it is portrayed in parts of the media, some of it relates to the way in which different constituencies, especially when under external pressure, react to each other.  We need a culture which is tough on problems and supportive of individuals and when things go wrong does not automatically try to find someone to blame.  We need to call time on aspects of the persecution and bullying of staff which sadly remain all too visible in the way the NHS, at times, goes about its business.

So, 2018 will be the time to celebrate the 70th birthday of a remarkable British institution. Its remarkableness, however, will be even more reason for an honest debate about its future.

 

 

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Just like the ones we used to have – the two sides of nostalgia

 

 

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Whether we’re dreaming of a white Christmas or a blue passport, nostalgia is a widespread feeling at this time of year. First coined in the 17th century by a Swiss medical student to describe the distress of mercenary soldiers fighting away from home the word has come to mean, more generally, a sentimental longing or wistful affection for a period in the past.

Nostalgia often has a benign connotation. It is a feeling which allows us to capture and reflect on beautiful and pleasurable moments of the past, stripped of their contemporary difficulties. Such moments of nostalgia can bring us much pleasure and comfort, but it is worth reflecting on the darker and more disturbing side of this emotion.

The origins of the word relate to issues of distress, for individuals, who as mercenaries, were dislocated from the surroundings of home, of their fellow countrymen, of familiar customs and the like. This distress could affect wellbeing, harmed individuals’ ability to recover from their wounds and, sometimes, be a cause of suicide. We know from more modern science that that the cultural dislocation experienced by some immigrants can be a trigger for severe mental health problems. Like most psychological issues nostalgia sits on a spectrum, for many of us, a manageable set of symptoms but for some a source of distress.

I am no stranger to nostalgia myself. The Welsh have their own word for this phenomenon “hiraeth” and as the son of a welsh exile I was surrounded, as a child, by a lot of nostalgic affection for the country of my ancestors, its language and the values and sense of community of the Valleys. I built on that with my own sense of nostalgia for the beautiful countryside which I visited each summer, so different from the suburban drabness which I grew up in. Such feelings are easily aroused when I return now to Wales and provide a well of comfort from which to draw in facing some of the challenges I face in life.

There is a wealth too of nostalgic writing, often at least semi-autobiographical, which I have always enjoyed. How Green was my Valley by Richard Llewelyn, captured for me as a teenager a romantic and inspiring view of the South Welsh Valleys. Books such as Lark Rise to Candleford and Cider with Rosie described evocatively the English countryside before the modern world fully intruded on century old patterns of living.

As yesterday’s debate about the post Brexit colour of our passports demonstrates, questions of nostalgia are playing an increasingly large role in public discourse in our country. These are not trivial or superficial issues but rather relate to a deeper reaction to the scale and pace of change which is happening in the modern world. This is most acute for those groups most left behind by economic and social change and technological development and for those places and communities whose sense of identity and purpose have been marginalised in a more globalised world.

For Britain there is an added narrative of national decline, related to unresolved issues about the loss of empire and related sense of our own importance. Nostalgic yearnings whether for blue passports, the heroism of the Dunkirk evacuation, evensong and afternoon tea, brass bands and old-fashioned football teams are all part of a national narrative, however false at times, which demonstrates a nation, at least in part, not comfortable with its position in the world.

Inevitably nostalgia is a bigger issue for the older generations. One of the saddest features of the Brexit referendum was how it emphasised a division of outlook between young and old. Such a division has many historical precedents but in our own time it is further exaggerated by the scale of demographic change and the shifting balance between the generations.

So, what we should think of nostalgia, comfort or curse? As with many things it is probably both.

The first point I would make is that while nostalgia can provide moments of comforting reflection the reality is that history, like a river, flows in one direction. While there are always echoes of the past in future events, it is not possible to “turn the clocks back”. When we try to do so we do not recreate the past, only a different version, and not necessarily better, version of the future.  Furthermore if we are to apply the past in our consideration of the future we have to face up to the reality of past events and not just our rosy tinted recollection of them.

The second point is to recognise that shared ideas and symbols of historical identity do matter, and matter, in particular, in times of stress and disruption. In a more globalised world we need to celebrate and cultivate more local customs and sources of identity, whether geographical or representing other expressions of shared identity. This needs to be done in an open and tolerant way not to provide another source of repression and control.

Finally and to echo the theme of my last blog there is a need to find ways, at a time of a worrying lurch to the extremes, to find ways of creating a dialogue which connects, rather than divides, the majority of opinion.

So, in dreaming of white Christmases or green Valleys we can find comfort and common cause with our fellow citizens. Let’s celebrate nostalgia as long as we remember we must live in the present and not the past.

 

Holding the Middle of the Road

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Confucius’ famous curse feels a bit superfluous these days. There is little to doubt that we do live in “interesting times”. Whether it be Brexit, Donald Trump and the rise of populism, austerity, terrorism, the impact of automation or climate change the last decade has seen a convergence of challenges to the established order of things in the Western World which, in my life time, feel unprecedented. Disturbingly we face these issues in a political and social environment which has become increasingly extreme and polarised. Social media, which doesn’t always lend itself to subtly, has epitomised this phenomenon.

These trends are disturbing and don’t, I feel, bode well for the health of our democracy and for the social cohesiveness which is so central to our sense of collective wellbeing. For many the term “middle of the road” is off putting, symbolising, perhaps, unsatisfactory compromises and the abandonment of more comforting oppositional positions. However, for me, the middle of the road is the place where we need, more than ever, to be if we are to make genuine progress in resolving the challenges which face us as individuals and as a society.

There are four aspects to this.

The first is the willingness to listen, with respect, to a range of opinions and views beyond one’s own. It is one of the real problems of our current times that the polarisation of opinion has limited our ability to have a constructive dialogue with those who don’t share our views. It has been one of the things I have always valued about mental health that it has been an issue which has united so many people from different backgrounds and social and political perspectives. By contrast it was one of the tragedies of the Brexit referendum that it exposed the extent to which we had become two nations, impervious to each other’s’ experiences and concerns.

The second principle is the ability to respect evidence and to change one’s mind as a consequence. Truth is rarely black and white, and we need to be able to tolerate the nuances of intelligent debate and the possibility that the evidence will not always support the position which we are taking. Some of this relates to our respect for experts although, in my opinion, experts can also be blinkered in their outlook, especially when they have a lot staked, as individuals, on a particular position. It is more to do with an openness of mind and sense of humility which allows us to admit that we have been mistaken in our views and are able to move on.

The third attribute is perseverance. Vision and a clear sense of direction are important in any endeavour, but I would rather have ten small changes which make a practical difference to peoples’ lives than a grandiose promise of change which has little chance of success or can only come at an enormous cost. With perseverance must come patience and a trust that small actions can lead to real change and that long-term commitments are necessary if we desire to transform society. Short termism is a particular British curse, nowhere more evident than in the planning of the NHS where, too often, there is a desire to promise enormous change in the short term while we remain unable to resolve the problems that have been with us for thirty years or more.

The final point is that how things are done matters as much as what is done. The quality and tolerability of life is a function of how we behave with each other. Courtesy, tolerance and respect are essential requirements of civilised life which need to be championed. Where people are held to account for their actions due process must be paramount and everyone, wherever they sit on the political spectrum, is innocent until proven guilty. Justice and good administration need to be nurtured and ends do not always justify means. As every conflict in my lifetime tells me one of the biggest dangers of extremism is that it somehow justifies an equal and opposite reaction. When terrorism triumphs over civilised values it really has won.

At a time of such existential threats it is easy to understand why some people have rejected the politics of compromise and consensus. All through history there have been politicians who have been prepared to “trim” their positions to further their own personal advantage. However, it is in the middle that real movement and progress is possible. I am not advocating a world without values and principles which are strongly held, they after all define the terms of what is possible to achieve through compromise with others. I am advocating that we are willing to reach out from where we are comfortable to engage with others and to put the common good above all.

When the traffic is speeding rapidly in both directions it takes some courage to hold the middle of the road.

Thanks for the Memory

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A trip, last month,  to North Wales where I spent most of my childhood summer holidays and where, in turn, I had taken my own family, gave me the chance to indulge in some special memories. The experience made me pause to reflect on this most distinctive of human gifts and what it means for how we define ourselves and experience our lives.

I also enjoyed recently listening to some of Radio 3’s excellent series of programmes on music and memory. There were some fascinating insights onto how our memories work and some inspiring stories of how music can help in improving the quality of life of those affected by neurological conditions such as dementia or strokes.

I have been blessed (there are occasions when my family might say cursed) with a retentive memory, able to recall, without too much difficulty, facts and experiences. As a historian I am particularly good with dates and events, less good with plots and stories, which my wife is much better at. I am also good a retaining a sense of where I have been and while I often get lost on the way there, I rarely do on the way back.

I am also keen on things which help maintain memories. I’ve intermittently written a diary for much of my life, love taking photographs and keep notes on the more complicated things I read. I enjoy going back to those secondary sources from time to time, and like a cow with a second stomach, redigesting my memories.

However, my feats of memory are nothing compared to others. I am always amazed by how a musician like the pianist Andras Schiff can play from memory the whole of a piece as long and complicated as Book 1 of Bach’s Well Tempered Clavier. In previous ages powers of oral retention were inevitably greater than now. As a student I was fascinated to learn about the Yugoslav wedding singers of the early 20th Century who were capable of memorising a poem as long as the Iliad.

Memories can take different forms. For the most part my memories are visual but there are some which can be triggered by sounds, music, smells or just the recollection of feelings. I think about the experience of my older brother, who has been blind since birth, and who also has a good memory, and how his memories, sometimes of the same events as mine, must be cast in a very different currency.

Memories of course can also be a source of distress which cast a long and damaging shadow over future life. Forgetting and avoiding memories can be a natural way of dealing with painful and difficult experiences such as abuse. However, while consciously forgotten, painful memories can leave a deep and painful unconscious imprint on feelings and behaviour. The ability to process previous memories is central to being able to deal with the consequences in the present and lies at the heart of many psychotherapeutic disciplines.

Memories can be partial and it can be difficult sometimes to remember too much. The brain does an amazing job in filing and editing memories and using them to support different narratives in our lives. It is fascinating how, especially older people, can remember clearly the events of their childhood. I remember being staggered listening to my grandmother, at the end of her life, recalling with vivid lucidity, at a distance of ninety years Queen Victoria’s Diamond Jubilee when she would have struggled to remember what had happened earlier in the same day.

The loss of memory is a source of anxiety. The modest difficulties I now experience in being able to recall information, names or events (it always seems to come back just after I need it) bother me. There is no illness I fear more than dementia and it has been devastating to see its effects on family members and others. Listening to some of the programmes on Radio 3 reminded me of how little we still now about these conditions and, just as much, of the experience of those who are affected by them. The programmes also reminded me of the importance, not just of biological research and interventions but of the positive value of social and cultural responses, such as musical therapy and activities.

Memory is a crucial part of what defines us as individuals. This is also true for groups, societies and nations who often define themselves through shared memories including those second-hand memories which have been shared across generations. It is part of the complexity of making sense of the contemporary world to try to give proper respect, at a time of enormous change, to the bank of common memories which underpin intellectual and cultural identity without, at the same time, being locked in an unhealthy obsession with the past and without privileging one set of memories over another.

Good memories enrich life and experience and support good mental health. So indeed, thanks for the memory.

Making things work for mental health

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The word landmark is overused but I think was appropriate for Paul Farmer and Dennis Stevenson’s report last week “Thriving at work” on the steps which need to be taken, to improve workplace mental health. It was a compelling call to action which highlighted the clear moral and economic case for improving mental health at work.  If implemented, it would not only address the immediate challenges implicit in 300,000 people with mental health problems leaving work each year it would also be symbolic of a fundamental shift in attitudes towards mental health in our society.

In the ten years or so I have worked in the field of mental health I have been aware of the importance work has in transforming perceptions of mental health.  It is already one of the areas where, in those ten years, significant change has taken place.  In 2007 you could count the organisations who took workplace mental health seriously on the figures of one hand.  There is now recognition of the issue, if not action, across the economy.  However, there is still a lot more to do.

My first exposure to mental health at work came before I joined the sector.  At a time of organisational change two of my team with historic, but at the time undisclosed, mental health problems became unwell and had extended periods of absence from work.  As their line manager it was a tremendously unsettling experience and on which I had no training on how to deal with.  Luckily, with positive help from HR, both returned to work and have continued successfully with their careers.  It could have been different.

In line with many of the recommendations in the Farmer/Stevenson review there are, in my view, a number of critical issues which need to be grasped if we are to create genuinely mental health friendly workplaces and realise the personal and economic benefits associated with that.

The first relates to mindset. By that I mean that organisations and their leaders genuinely value the contribution of employees who may have had or who may develop mental health problems.  It is a mindset that believes that, a history of mental health problems, does not devalue the skills and competences that those people bring to the job.  Indeed, that in some cases, the experience may add something additional in terms of commitment and insights.  As with physical health issues support and reasonable adjustments can be enacted which help people affected to continue to carry out their role.

The second covers organisational commitment to develop a strategy to support workplace mental health, to invest in the identified interventions and to monitor performance. As in other areas of change this agenda needs time round the board table if it is to be taken seriously and prioritised over other issues which can easily soak up management time.  An organisational strategy needs to be specific to the organisation and, while some generic interventions are appropriate, there needs to be analysis of the specifics of the organisational context.  The presentation of mental health stressors and the level of problems vary between organisations.  The four fold variation in the costs of mental health problems between different sectors was one of the fascinating facts from the Farmer/Stevenson report.

Above all strategies must mark long term commitment to this issue. At its heart this is a question of a cultural change, and as any of us in senior positions of management are aware, cultures don’t change without perseverance and sustained commitment over a period of time.  There is a strong message here for the NHS, amongst others, whose work on staff wellbeing and resilience has tended to be piecemeal and inconsistent.

The third focuses on the crucial role of line managers in supporting staff who have or may develop mental health problems. Their skills and competency in helping keep someone well or managing a situation when someone becomes unwell is often the biggest single factor in determining a successful outcome for an individual experiencing mental health problems.

Line manager training in mental health crucial but this must go beyond Mental Health First Aid, excellent starting point though that is. I would argue strongly that we need to build in a psychologically informed focus on wellbeing into a much range of management training, in particular in areas such as performance management and change management which are so often create potent stressors which can impact on the development of mental health problems.

Disclosure is an important factor in enabling line managers to carry out their role. As I know from my own experience situations are so much harder to deal with when the first conversation about mental health is when someone becomes unwell.  Organisations can help, in both formal and informal ways, to encourage employees to disclose issues but it is also easy to understand, given years of stigma and discrimination, why people don’t.   Initiatives such as BT’s mental health passport which allow a standard format for individuals to document, in discussion with their line manager, the nature of their issues, early warning signs of developing problems and the best strategies for supporting them are a very helpful way of normalising the issue.

My final point is that an agenda mental health at work cannot sit in isolation from a wider debate about the quality of working experience. While, on the whole, I accept the argument that work is good for one’s mental health, there are times when it is not.  A lack of work/life balance, constant and badly handled change, bullying and harassment, lack of value or appreciation of employee’s contributions, lack of autonomy in people’s roles are all casual factors for poor mental health.  As a Chief Executive I know all too well that it is impossible to shelter an organisation from all the pressures of the external environment but leaders can not absolve themselves of thinking of what the impact of that environment are on the people who work for our organisations.  The debate must be both about how we create resilience in the workplace but also how we create workplaces which require less resilience.

At an annual cost to our economy in terms of lost output of as much as £99 billion and thousands of ruined lives this is not an issue we can ignore.

Martin Luther – A man who changed the world

DSC_2921This Tuesday marks the 500th anniversary of one of the most significant events in European and, indeed, the whole of Western history.  On 31st October 1517 Martin Luther nailed his 95 theses on the power and efficacy of indulgences to the door of the Castle Church in Wittenberg and set in train the set of events which led to the Protestant Reformation, and it could easily be argued, the emergence of western thought and values in the form we know today.

Having studied the Reformation and the 16th century as part of A Level history I took the advantage, earlier this year, to reacquaint myself with the story of Luther, both by visiting Wittenberg as part of my cycle trip on the Elbe and by reading an excellent modern biography of Luther by Scott Hendrix.

In our post religious age the figure of Luther is less familiar than it would have been for most of the last 500 years. Many people would more likely think of the American Civil Rights Leader Martin Luther King than the German religious reformer, although the former was named after and inspired by Luther.  However, whatever one’s approach to formal religion, Luther is a man whose story has a much wider historical and intellectual importance.

Luther is a wonderful example of the interaction between the actions of individuals and the wider forces and trends which generate historical change. In 1517 the ingredients for the Protestant Reformation were all in place.  There was a deep seated dislike of the Catholic Church and, in particular, the corruption of its leadership.  Wider social changes were happening, such as the introduction of printing, which made it easier for new ideas to spread and take hold.  Nonetheless it took the actions of one man to make it happen and, in this case, the actions of that one man over the next 30 years were more than usually significant in influencing events. When I was doing my A level history I came across a wonderful analogy comparing the actions of Luther to Beethoven’s 4th Piano Concerto, where uniquely for that musical form at the time, it was the pianist who played the opening theme on their own before the orchestra joined in.   In the same way in the first years of the Reformation Luther’s personality and actions were crucial in determining what happened.

There were a number specific attributes which made Luther’s contribution so special. He was a brave individual who was prepared to stand up to the most powerful men in the world and stick to his principles under duress and under threat to his life, being forced to spend a year in hiding in the Wartburg Castle in Eisenach. Similarly, while not always prepared to compromise, he had a broader view than many had at the time about how his changes might go with the grain of popular belief. Unlike other reformers he did not argue for the abolition of all traditional practices such as the veneration of images. He was prepared to work with secular supporters while not losing the ability to challenge them.

More than anything else it was his power as a communicator which was at the heart of Luther’s success as reformer. Luther’s written and spoken output, in particular in German, was phenomenal and he out wrote his Catholic opponents by a margin of 2 to 1.  By 1520 250,000 copies of his writing were in circulation, a massive number for the time.   Luther’s communication also embraced a range of forms.  Unlike other Reformers, he believed strongly in the value of music as an adjunct to religious worship and wrote a number of hymns including the famous “Ein feste Burg ist unser Gott.”  We have much to thank him for that as it was the Lutheran tradition which spawned some of the greatest work of J.S. Bach (in one of those lovely historical coincidences they both attended, at 200 years remove, the same school in Eisenach).

Luther has his detractors. He could be an obstinate and angry man.  His views on some issues, in particular the anti-Semitism he expressed in his later writings are unattractive.  However what also came over from my reading and visit is man of great human warmth, who loved the company of others, who developed strong relationships and partnerships with others.  He was a man who was aware of his own faults and short comings, famously saying of himself “At the same time saint and sinner” and was someone who was acquainted with mental distress, suffering from periods of depression.

Luther, despite the depth of his religious beliefs, struggled in the cold celibacy of the cloister and his marriage to Katharine von Bora was based on a deep and mutual respect for each other and for the comfort and mutual support a married couple can bring each other. Katarina’s comments on Luther’s death are genuine and moving  “If I had owned a principality or empire I would not have felt as bad had I lost it as I did when our dear Lord God took from me, and not only from me but form the whole world – this dear and worthy man.”

At the heart of Luther’s world view is the importance of individuals, all equal before God, all responsible for their own actions and beliefs. This, for me, is Luther’s greatest legacy to western thought and as important today as it was that day 500 years ago when he nailed his 95 theses to the church door in Wittenberg.

 

Why I work in mental health

 

_64128011_de27-1As you will have seen from this blog, I have been concerned, over recent months, in issues about the mental health workforce. The health of the workforce, both in terms of numbers and morale is central to the achievement of any ambitions we have about the development of mental health services. As I described in my last post there are many challenges facing us currently in respect of the workforce.  However as the stigma about mental health begins to recede there are also opportunities to promote working in mental health to a growing body of young people who see mental health as a motivating and central issue in their lives.

For this year’s World Mental Health Day I wanted to respond to this and, with the aim of encouraging others, write about what makes working in mental health for me such an inspiring vocation.

I came into mental health more than 10 years ago, first as Chief Executive at Rethink Mental Illness and subsequently in my current role at the Tavistock and Portman. I had previously had some engagement with the issues while a civil servant and at NHS Direct.  Not everything in those roles in mental health has, like any other job, been brilliant but I do not regret for a moment a decision to work in this field, in particular, at this time.  There are a number of reasons.

Mental Health has been a fascinating area to work in, intellectually.  This relates both to the understanding of the problem of mental illness and its impact on individuals, families and society but also in working on the interventions which might make a difference.    I have been repeatedly struck by the important shadow mental health casts over so many other areas of life:  work, education, the criminal justice system to name but a few, and the prospect of what changes we could make if we recognise properly the burden of mental ill health and invest effectively and prevention and treatment.  Having some role in making the case for change and supporting the delivery of services has been exciting and rewarding.

Mental health is not only intellectually satisfying, it is emotional engaging. Mental health is about people and how they think and how they feel.    The most effective therapeutic interventions I have seen and heard about in mental health rest on the value of empathy and relationships.  Those work in the front line of mental health services understand the direct and powerful role they play, as individuals, in supporting the recovery of the people they are helping.  Those values also matter for those running mental health organisations.

It has also been the right time to work in mental health. It is now ten years ago since the Time to Change programme started in England to challenge stigma on mental health and change public attitudes.  In that decade Time to Change has been the forefront of a sea change in public attitudes which has spread over many areas of public life such as the worlds of business, sport and politics.  With that change in attitudes has come a much greater openness across society about the experience of mental health problems and a greater recognition in all sorts of walks of life of the importance of supporting those affected.  Ten years on it is incredibly uplifting to have had a small part in making that programme happen.  I am unlikely to do anything more significant in my career.

The recognition that this is a special time for mental health also increases the urgency of finding the right things to do to make a difference to lives and collecting the evidence that those things work in practice. That is not easy at a time of austerity when almost any case for investment relies on the ability to make an economic argument that the costs of the new intervention will be, at least, covered by savings elsewhere. Political support may have arrived but there is much work still to do to sceure the necessary resources.

Mental health can be hard in other ways. It has brought me much closer to distress and suffering.  For all the need to be positive and hopeful there are days of profound sadness as when as you hear that someone you have known or are responsible for as a patient has taken their own life.  It has made me more angry than I have ever otherwise been in my career about injustices such the inhuman work capability assessment.

Working in mental health has, I believe, made me a stronger person.  It has opened my eyes to mental health issues outside work and the manifestations of mental health problems amongst my own family and friends.  Working in the field has not made me, necessarily, any better at managing such issues but I hope it has made me more understanding.

The best aspect, however, of working in mental health is the people. In 10 years I have met some truly wonderful and inspiring individuals whether clinicians, researchers, campaigners, service users or family members.  Above all I have met individuals who have experienced tremendous distress in their lives or those of their families but who have been able to direct those experiences towards wanting to make the world better for others.  That’s a great team to be part of.