Managing mental health services is 'lots of fun, very challenging and as intellectually demanding as any other senior management job in the NHS', says Peter Reading, chief executive of Lewisham and Guy's Mental Health trust in London. But, he adds, it can also be frustrating because it does not carry the status of managing an acute trust and 'because the services we deliver are not universally welcomed, either by users or by the general public'.
Mr Reading has worked in mental health services at the trust for more than nine years, but is shortly to become chief executive of University College London Hospitals trust. 'I am now ready for another challenge,' he says. 'But I have stayed here so long because the job just kept on growing - it has now trebled in size from when I started - and the service has gone through so many changes.'
He believes there are probably only about 25 purely mental health services trusts in the country, compared with over 150 providing mental health services in part. But, he argues, there is 'no question' that a single focus mental health services trust is the best way to run the service, 'particularly in the inner cities where higher levels of morbidity and spend can achieve a critical mass across a much smaller territory'.
John Boyington, chief executive of Leicestershire Mental Health Services trust, begs to differ. 'The average size of acute trusts is set to grow over the next few years which will mean that, in relative terms, mental health trusts will get smaller. This presents great problems when you are vying for funds,' he says.
'You are also in danger of creating a professional ghetto. Yes, there are certain things that are special about mental health services. But there are also lots of things that are not special. We have to stop seeing mental health services as a single entity provided through a single point... You need to integrate mental health services into lots of other services.'
For Duncan Selbie, chief executive of Pathfinder Mental Health Services trust in south London, a distinction has to be made between providing mental health services in a city, 'where to be joined with other services means something will get no airspace' and outside cities, where the demands are likely to be different. 'There can be no single model,' he insists. Services 'need to fit round the needs of the local population'.
Mr Selbie came to Pathfinder trust from 'a traditional, general background'. 'I have been through every grade in the NHS since I joined 18 years ago,' he says, 'from clerical officer to chief executive'. He moved into psychiatry seven years ago: 'It was the most exciting thing I have ever done.' It combines the 'interesting and sexy' bits of acute work with dealing with 'real people trying to live decent lives', he says.
But it can be tough, with money and maintaining morale the perennial problems. 'We have to go
on fighting to make sure that our mental health services are not treated worse than our acute neighbours,' he says.
'And we have to make sure that we celebrate a confident service which is - for the most part - doing things people can be justifiably proud of.'
Mr Boyington's background was in nursing, where he worked in mental health services for 12 years, before moving into general management. He took up the chief executive post a year ago. Many people stay in mental health for life, he says.
'More and more people are recognising that managing mental health services is about managing a complex agenda, and you need to be as competent to do this as manage any other part of the NHS.'
He says his pay is 'the equivalent of that of colleagues running acute trusts'. Nor does he feel particularly isolated, although he acknowledges there are less well-developed professional networks for mental health.
There are plenty of challenges, however, not least 'keeping clinicians on board' and the continuing concerns about public protection. 'You have to balance these with the rights and needs of the individuals who need help with mental health problems,' he says. 'Clinicians, in particular, feel themselves to be at the sharp end of this - they feel accountable for making some extremely difficult decisions.'
Mr Reading believes the management tasks of mental health services managers are broadly the same as for career general managers, with two exceptions - the stronger emphasis on partnership working and the amount of time spent on trying to influence other agencies.
For him the biggest issue facing mental health services managers is that 'service users have been distributed into the community, but we are struggling to manage the health services provided for them because the system is only half built'. Part of this problem is that managers have influence but do not control the services in the way they did in the past, he says.
'We will be unpicking and changing this system over the next 15 years as we try to design something sustainable.'
This can leave managers feeling 'fragile and vulnerable', he says. 'Mental health services management can be a great career move, but you have to be able to live with these challenges.'