Professor Philippa Garety, Clinical Director and Joint Leader, Psychosis Clinical Academic Group

Philippa Garety sounds like she ought to be quite a cosy, girlish, slightly old fashioned, innocent granny in a rocking chair. You couldn't be more wrong. She is a ground breaker, albeit in a polite, non-ball breaker way. She is not really interested in self-promotion. And was slightly anxious, and wanting to check my copy before it went out. She does not want to make waves, certainly not destructive ones, and is deeply serious about her role and responsibility, without any grandiosity.

Her preferred modus operandi is harmonious: she leads, jointly, the biggest clinical academic group in one of the biggest mental health trusts in the UK (South London and Maudsley NHS Foundation Trust; there are approximately 5000 patients under the care of recovery teams, about 1000 under early intervention, and another 1000 in complex care/rehabilitation, Trust-wide). Her style rests on negotiation, mutual respect, scientific evidence, consensus. But make no mistake, she is not a pushover and has the ideas, vision and the ‘intellectual self-confidence’ (as she put it) to have taken on this new and high-profile role.

Instinctively collaborative, she was attracted to the job by the triumvirate power-sharing. She is the clinical lead, with an academic lead, Professor Philip McGuire, and a service lead, Lucy Canning, and they work closely together. The shared leadership model attracted her as a way of getting away from a medical director with clinical responsibility often ‘keeping distance from the service director in order to be able to critique the service director’. She genuinely believes that the new collaborative style of leadership is ‘more supportive of innovative and excellent clinical practice with a strategic focus’. They are trying to improve delivery of mental health services across the psychosis spectrum, from early onset, first episode, through longer term and recovery. The approach is non-doctrinaire, pragmatic, aiming for excellence in a cash-strapped health environment, not a task for the faint hearted. It has meant convincing staff, managers and finally commissioners that continual cutting of funding has the perverse consequence of increasing costs, by increasing instability and bed usage, and overwhelming staff who in turn become less effective. They have pulled off a piece of magic, successfully persuading local commissioners that investment is more effective at cost containment than disinvestment: boosting community services, along the lines successful with early intervention for psychosis, with a view to reducing bed usage and thus costs in the longer term – ‘It's early days, but bed usage is going in the right direction’. Strategy needs to be logical: ‘I know data can be used in different ways, and that there is no simple identity between data and reality, but over the years we have seen decisions being made which are highly politicised and/or pragmatic, without really looking for the information.’

There is ‘some evidence’ for early intervention ‘when case-loads are sensible, there is good leadership, the best range of interventions is available and staff are sufficiently skilled, and supervised to offer them’. She also emphasised the need for ‘understanding about the importance of engagement, working with families and carers, excellent medical intervention, vocational specialists’. And how often is that the case on the ground, I wondered?

We talked about the evidence for supportive generic outreach versus more specific and formal structured interventions. She acknowledged the importance of continuity in the relationship between service user and service deliverer, whatever they think they are delivering. She also agreed that the sophisticated nurse, psychologist or psychiatrist actually uses a range of therapeutic skills within any one consultation, which are difficult to measure.

Nevertheless, it is clear that she respects scientific research methodology: it may be difficult to ask the right questions, and to deliver robust answers to questions about what is most useful and why, but this does not obviate the need to try to get the most reliable answers we can, and base policy on those rather than on mere hunch.

Over the course of our conversation, I came to the conclusion that her drivers are simple and unfashionable: compassion and a passion to provide the optimum treatment (psychological, social or pharmacological) for people with psychosis, who, as we all know, suffer enough without incompetent service delivery. Philippa Garety is not preachy, and she certainly did not directly state this motivation. But it shone through her lack of vainglory.

She was brought up in Mill Hill, in North London, and was sent to a convent by her Catholic parents. Her Christian roots have moved to the Church of England, and although it felt too intrusive to press her on theological matters, I got a sense that this is solid and important to her. At Cambridge, she studied philosophy for 2 years, with the intention of becoming a lawyer, but decided it would be ‘too boring’. She came to the (then) Institute of Psychiatry to become a clinical psychologist in 1979, and perhaps it is not entirely coincidental that this institution has recently been renamed the full mouthful of the Institute of Psychiatry, Psychology and Neuroscience.

I wanted to know how philosophy had informed her thinking as a psychologist. She has described her curiosity being piqued, when, as a young psychologist, a patient stated baldly, ‘You put my mother in the washing machine’.

She brings epistemological questions to bear on psychotic experience – ‘how can we claim to know what we know?’ Wittgenstein and linguistic philosophy was the hot area during her time in Cambridge, but she was drawn to the philosophy of science and epistemology; how different models of understanding arise, how meaning is attributed. Personally, she is a flexible thinker, able to see different perspectives, and is allergic to the doctrinaire: ‘one can operate within certain frameworks, as long as they seem useful, but they don't have to be seen as representing single notions of reality’. Perhaps this flexibility has enhanced her interprofessional capacities? Working, as she does, constantly, with psychiatrists, described as ‘my closest colleagues’.