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A couple of years ago, shadow home secretary David Davis observed that Tony Blair "seems to appoint a tsar every time he encounters bad press" - a strategy that might explain why we now have tsars for every conceivable health and social issue, from antisocial behaviour to cancer.

However, since Davis made his comments, Blair's government seems to have fallen somewhat out of love with its tsars. The cascade of new appointments has slowed to a trickle and one - the high-profile but ultimately disappointing drugs tsar, Keith Hellawell - has been unceremoniously dumped.

True, social care tsar Kathryn Hudson took up her appointment earlier this month (news analysis, page 16, 1 July). But other recently appointed tsars have been publicly referred to as "national programme directors" when earlier both terms were used. Now, the government, and many of the national directors themselves, seem keen to distance themselves from the title tsar.

A tsar's job is to drive forward changes, advise government on policy and act as a high-profile public "champion" for their specialist area. Most in England are secondees, which means they stay on their original salary. As a result, most of the national programme directors are earning substantially less than the average director of social services (at least on paper). But are they value for money?

Here we look at the main social care tsars, what they've achieved, and what people in their sector think about them.

Older people's tsar: Ian Philp  
Appointed: November 2000  
Remit: England   

When Ian Philp was appointed, former health secretary Frank Dobson advised him "not to be a pointy-headed academic". Philp seems to have taken him at his word, developing a reputation as a hands-on tsar. 

Philp was heavily involved in developing the National Service Framework that he is now charged with implementing. There was criticism at the time that, unlike other frameworks, the older people's version had no clear funding attached. But Philp says: "I like to think of my budget as the £1bn spent on the health service." 

Philp cites three key achievements. First, driving the development of a clear sense of direction for older people's services. 

Second, developing capacity in the community and tackling delayed discharges. "Anything that means older people don't spend unnecessary time in beds in acute hospitals is a good thing. We're doing well on delayed discharges." 

And third, championing the importance of a healthy and active life for older people. "It's less easy to quantify than delayed discharges but I feel we have made good progress."  

One frustration is the segregation of mental health services for older people from the changes taking place in adult mental health. "It's the antithesis of what I've been trying to achieve," he says. "We have to ensure people are treated on the basis of their needs, not age. I've asked Louis Appleby (see below) to take leadership of joining together the two strands."   

What people say about him

Philip Hurst, health policy officer, Age Concern 
"We're very positive about him. The fact that he's a clinical director and can speak to other clinicians in their own language has been valuable. But also he is enthusiastic and energetic, and has spread a lot of that enthusiasm round the country. He has found ways to identify and share good practice, giving practical help to people. Services to older people have improved as a result. The people on the receiving end of improvements wouldn't know or care that he was responsible and I don't think he'd want the credit either. He's one of the most effective tsars, given that the NSF for older people had no money attached."    

An older people's champion (lay, based at a primary care trust, north of England, wishes to remain anonymous) 
"He's doing quite a good job considering the NSF didn't come with any money. It helps that he's a personable, youngish consultant who gets on well with older people. He has been pretty hot on standard eight, which is about healthy living. Also this year he's been talking a lot more about older people's mental health, which is a Cinderella service. But I'm not convinced he has influenced government policy on older people much. Things are still systems-driven. I think the voice of older people as individuals is still being lost."   

Martin Green, chief executive, Counsel and Care 
"The NSF set ambitious goals, and the appointment of a tsar was essential in moving the agenda forward. From the beginning he was open to engagement with all stakeholders and understood that to succeed he had to engage with older people and the voluntary sector as well as the health care system. There is still more to do to improve services, but we should acknowledge how far we have come in a short time. Much of the credit for this can be attributed to his commitment."

Mental health tsar: Louis Appleby   
Appointed: April 2000 
Remit: England    

A psychiatrist by training, Louis Appleby chairs the Mental Health Taskforce set up to implement the NHS Plan. He is also professor of psychiatry at the University of Manchester.  

It being August, this tsar was on holiday, so we could not speak to him. But according to a Department of Health spokesperson, his achievements include leading on the creation of the National Institute for Mental Health in England, and extending the institute's work beyond working-age adults to include older people and children. He has developed the first integrated mental health research strategy, and contributed to the development of a core curriculum for mental health staff. 

Appleby continues to chair the National Suicide Prevention Strategy Advisory Group, and he has overseen the implementation of the 2002 National Suicide Prevention Strategy for England, which led to a significant reduction in the number of in-patient suicides. 

The DoH says: "Professor Appleby has championed the mental health cause through his leadership, his research and his personal engagement with professionals, service users and carers.  

"More than a figurehead, he has been an active and central player in the most significant period of change in the history of mental health service delivery in England." 

However, while few doubt the tsar's commitment, he has overseen a troubled time for mental health services. There are complaints that little of the £700m allocated to the NSF has filtered down to services, the mental health bill has been repeatedly delayed and, in July, mental health trusts were among the worst performers in the star ratings allocations.   

What people say about him 

Andrew McCulloch,  chief executive, Mental Health Foundation 
"Louis Appleby has had some notable successes. As a distinguished psychiatrist with a track record in psychiatric research, he has been successful in arguing the case for mental health research. He deserves praise for the suicide prevention strategy, and his effective leadership has ensured regions outside the South East are equal partners in policy and practice development.  

"However, it would be difficult for one person to make the paradigm shift we need in mental health policy in England. He is in a particularly difficult position as a special adviser, policy adviser and national clinical director. Add to this the government's undoubted desire to appoint a doctor to lead an area where many of the interventions are not medical, and things become complicated. Nevertheless, his recent focus on anti-stigma work has shown that his non-medical instincts are sound. 

"Unfortunately, his time has been blighted by the fact that he has had to defend the draft mental health bill. This would be damaging to anyone's credibility. Mental health also appears to have slipped down the government's agenda. While it would be unfair to expect one person to turn this particular tide, the failure of mental health to permeate the government's public health agenda seems an obvious miss."   

Gill Hitchon, chief executive, Maca 
"We all had great hopes of him because of the way he went about tackling the job. Much of the subsequent policy development has been positive, even though we can't see where the extra resources have gone. In more recent times, however, it feels that he has been caught up in the inter-departmental issues between the Home Office and the Department of Health over the draft mental health bill.  

"It's difficult to know whether, without his involvement, the previous draft bill would have been even more retrogressive - but when the new version is published on 15 September we will be much clearer on whether the emphasis is really about public safety or a better way of helping people with serious mental health needs. If it's the former, I would consider him to have failed."

Learning difficulties tsar: Rob Greig  
Appointed: September 2001 
Remit: National director of Valuing People support team    

Rob Greig and his team have the task of  implementing the objectives in the white paper Valuing People, which are designed to bring independence, choice and control to the lives of people with learning difficulties. Two years into the job, how does he think he is faring? 

"If I were to claim anything, it would be that I have kept Valuing People on the agenda, particularly with those in mainstream services who wouldn't necessarily think of it as their responsibility, for example the Learning Skills Council and the NHS. I have been a bit of a nag.  

"The role opens doors and encourages people to listen who might not otherwise do so. It's sad that you need that kind of status-linked job label to do that. But the label has helped to achieve things.  

"The role keeps the momentum going. I think people with learning difficulties would be substantially forgotten if there wasn't someone championing their cause within government and at a national level. I'm in no doubt that without the role there would still be long-stay hospitals that weren't planning to close. 

"I leave it up to others to judge whether I am value for money. My salary is less than if I were a senior public sector manager. The team's annual budget is £2m - that includes all salaries and national and regional programmes. That's £2m to deliver a programme dealing with £4bn of public expenditure."   

What people say about him 

Andrew Holman, director of Community Living, a support body for people with learning difficulties
"It's been useful having a slightly separate policy branch from the Department of Health. Greig and his team have done a lot of good work, produced good documents and put on good conferences. We probably need somebody in that role but they need to bring about change quickly. We are still seeing too many finance-driven services rather than person-centred ones. 

"When we look back at this period I wonder whether people will be asking whether anything really changed for them. We still have few people using direct payments, few are in work and the long-stay hospital issue is still around."   

Philippa Russell, member of the learning disability task force, and NCB policy adviser for disability 
"Greig and his team have made an immense contribution to Valuing People. We needed positive leadership and he has been a public champion for people with learning difficulties, an advocate at the highest level."

Antisocial behaviour tsar: Louise Casey 
Appointed: January 2003 
Remit: England and Wales   

As national director of the Antisocial Behaviour Unit, Louise Casey has completed her "poacher turned gamekeeper" conversion. Formerly an outspoken deputy director of homelessness charity Shelter, Casey moved to government to head the Rough Sleepers Unit in 1999, where she became mired in controversy over the methods used to meet her targets for cutting rough sleeping.  

She decamped to the Home Office 18 months ago to head the new Antisocial Behaviour Unit. The unit has a three-year lifespan and a budget of £75m to reduce antisocial behaviour. The focus is on action and listening to communities.  

Casey has built a formidable reputation for plain-speaking, but it has been little in evidence since the move, leading some to conclude that in effect she has been gagged by the media-sensitive department. However, on this occasion, she was on holiday.   

What people say about her 

Anthony Lawton, chief executive, homelessness charity Centrepoint 
"We are pleased that tackling antisocial behaviour is a priority for the government as part of its commitment to regenerating and sustaining communities. Yet we are concerned that the emphasis is on punitive measures at the expense of prevention and rehabilitation and that young people are all too often seen as the perpetrators rather than the victims of crime.  

 "We are concerned that the government's headline approach to antisocial behaviour is not compatible with the work being done by the Social Exclusion Unit, Department of Health and Neighbourhood Renewal Unit to reduce inequalities and reintegrate disadvantaged groups into society."   

A spokesperson for Turning Point, a drugs and alcohol misuse voluntary organisation 
"We're a bit wary of the antisocial behaviour agenda because we should be tackling the underlying causes rather than the symptoms. How do you tell the difference between nuisance neighbours and someone with a mental health problem, for example? When Casey was made homelessness tsar everyone thought her targets were huge. If she could manage that there's no reason why she can't have some success with antisocial behaviour.  

"It is to be hoped she can bring some of the lessons from tackling the underlying issues of homelessness to antisocial behaviour. The only danger of creating a tsar is that there's a risk that everyone else lets go of the issue."

Scotland

Unlike England, Scotland does not have an abundance of tsars. Despite this, a story in a Scottish newspaper last week claimed that the executive was spending more than £330,000 a year on its tsars. Over the past five years the Scottish executive has established several co-ordinator posts for a range of subjects.    

Mental health: Gregor Henderson 
Appointed: 2002  Henderson is the executive's first national programme director for mental health and well-being. He oversees a £24m national programme action plan for 2003-6 with four key aims. First, to raise awareness and promote mental health and well-being. Second, to work to eliminate the stigma and discrimination people with mental health problems face. Third, to prevent suicide and cope with the aftermath of suicide. And fourth, to promote and support recovery. Scotland is preparing for the April 2005 implementation of the Mental Health (Care and Treatment) (Scotland) Act 2003.  The executive is pleased with the progress on tackling attitudes towards mental health, says a spokesperson.    

Richard Norris, director of policy,  Scottish Association for Mental Health 
"There has been a flurry of activity in Scotland over mental health in the past few years. It's been surprising because it has not traditionally been a high political priority. The executive's new initiatives, such as the suicide reduction strategy, are welcome. Taking five years to change attitudes towards mental health problems is realistic. There are no overnight quick fixes." 

Edinburgh antisocial behaviour tsar: Donald Urquhart  Appointed: May 2004Edinburgh Council is Scotland's first local authority to create two posts to specifically address antisocial behaviour and drugs and alcohol. The new head of the city's antisocial behaviour division, Donald Urquhart, had been a police officer for 32 years.  What are Urquhart's plans? "The biggest thing is to get the agencies to work together. There is some good partnership working but it has been based on individuals' personalities and when they leave it ends." His role is necessary, he says, because antisocial behaviour has not been the priority the public sees it as. "My aim is to reduce antisocial behaviour through partnership working." So is he worth the approximate £50,000 a year he earns? "Yes and I'm worth much more than that, I'm a very good package!" he says, laughing.