Has the shine worn off the tsars?

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.