Published: 17/03/2005, Volume II5, No. 5947 Page 24 25 26
Despite big promises from the DoH, mental health services for older people are simply not up to scratch. William Little hears the calls for a renewed focus on a neglected area
Despite having its own standard in the older people's national service framework, mental health services for the over-65s are failing them significantly. Voluntary sector organisations working on the ground claim none of the milestones that should have been met last April - including the establishment of multi-disciplinary care teams and single assessments of mental and physical health needs - have been achieved.
By its own admission, the Department of Health admits progress is 'patchy' and acknowledges a serious shortage of care homes and few services to help people with dementia live at home.
And a report published last month by Leeds University's Nuffield Institute for Health and Help the Aged revealed that, while depression is the most common mental health problem among older people, 'problems of accessing help arise at every stage'.
Depression affects about one in eight older people living at home and 40 per cent of those in care homes, yet nearly two-thirds have never discussed their condition with their GP. Only half of those who see their GP will receive a specific therapy.
Barriers to specialist mental healthcare are higher still. The report showed that fewer than 10 per cent of older people with a depressive illness are referred to specialist services.
The Commission for Health Improvement's final report into mental health trusts, published in late 2003, pinpointed the reason for the failure.
It showed that 'development of older people's mental health services has been poor because the focus of policy, local priorities and the national performance indicators remain centred around adult mental health services'.
Its clinical governance reviews also found a lack of priority given to services for older people, with many users and carers reporting inadequate staffing levels and frequent shortages.
'There remain wards where older people with mental illness and dementia are mixed. There is a lack of capacity in nursing and residential homes and a lack of intermediate care. The performance management of older people's services is immature and trusts have limited information to satisfy themselves that they are providing high quality care, ' the review found.
'Age discrimination is entrenched within mental health services, ' says Philip Hurst, health policy adviser for Age Concern. 'Key actions and milestones for standard seven of the NSF such as getting GPs treating and diagnosing mental health problems in older people didn't become a must-do target for the NHS.' The fact that this did not feature in the recent GP contract negotiations is a clear indication that these services are not a priority, he says.
Susan Benbow, National Institute for Mental Health in England fellow in ageing and mental health, agrees that older people's services have not seen the level of development that has gone into services for adults of working age. She points out that the older person's NSF has only one standard for mental health, whereas people of working age have a whole NSF to themselves.
And while the NSF for older people puts the multi-disciplinary community team at the cornerstone of better engagement with older people, most teams, says Ms Benbow, still contain only a social worker and a psychiatric nurse.
Echoing the CHI report, she also says that 'there is no way of ensuring that trusts meet the standard, so there are no drivers for change'.
'If trusts do not want to implement it, there is nothing stopping them.' Funding is also an issue. 'There wasn't a requirement to use money dedicated to the mental health NSF for older people's services. The older people's NSF came without any ring-fenced funds or dedicated resources. It is a stark comparison between the levels of investment and focus behind the different groups, ' says Mr Hurst.
The other difficulty is the way services are configured. Mental health for older people falls between the gap of older people services, which focuses mainly on physical health, and mental health services that are not fully developed, reveals Ms Benbow. 'Older people's mental health services have got to fall in both physical and mental health services. Services need to bridge the gap between the two, ' she says.
Mr Hurst agrees: 'There needs to be more significant focus on training of health professionals to spot problems in later life. Nurses working in a hospital will come across people with mental health problems, although they may be in hospital for a physical illness. They need to be able to spot those problems.' Ms Benbow says that older people need assertive outreach, community mental health teams and crisis teams just as much as people of working age. 'Services have to be based on need, not on age, ' she says.
An empty assessment?
There is also concern within NIMHE that the single assessment for older people is in danger of becoming a bureaucratic exercise, and that many mental health teams are not having any input.
'The principle is good but the way it is being taken forward is undoing that, ' Ms Benbow says.
'It shouldn't be about different agencies ticking a piece of paper to show one kind of assessment has been carried out. It should be a way of bringing everyone together. We must go back a step and work out how services interrelate.' Janice Holbrey, chief executive of Five Boroughs Partnership trust, a mental health services provider, believes commissioning needs to move beyond specifics and into wider services that support older people's general wellbeing.
She says depression does not have to be seen as a natural consequence of old age. 'We can protect older people's mental health through supportive networks and relationships. We know that works for people of working age.' Yet for those with severe mental health problems and dementia, 'some people are saying that there is an emerging crisis, ' says Janice Robinson, senior advisor on health and social care at the King's Fund. 'The pressure of numbers is growing but the provision is not keeping up.' She says research is showing a 'clear consensus that services are simply not good enough'.
'Two things are happening in residential care, ' she says. 'Many older people are having to find care homes out of London because there are so few in the capital, adding to the suffering of people who are already in a confused state.' The second is that care homes will not take people with dementia following the introduction of national requirements for better care provision.
'Care homes will not take people with dementia because they will not make the registration, ' says Ms Robinson. 'They are struggling to get staff because they do not have the right qualifications.' However, other observers have recently noticed an increase in momentum around older people's mental health. Mental health czar Professor Louis Appleby stresses the importance of such services, and lessons from around the country are beginning to filter through to other areas.
Bolton, Salford and Trafford Mental Health trust is helping to train staff in the West Midlands to help spot mental health problems earlier. It is implementing the lessons learned from an earlier joint review by Salford Mental Health Services and Salford and Trafford health authority.
The review identified the need to develop more services for older adults with mild to moderate mental health problems, and to enhance the awareness of primary care staff.
Gita Bhutani, a consultant clinical psychologist from the trust's Salford psychology services, says it now offers clinical services to all GP practices in the area allowing for better access to clinical psychologists, counselling, occupational therapists and community psychiatric nurses.
'In addition we also offered training to primary care teams on the grounds that if they were not picking up any problems there wouldn't be any work for us to do.' Salford now has accredited training for primary care nurses in the identification and initial management of mental health problems in older people, including dementia, depression and other conditions. They have also introduced basic protocols to assist primary care staff in making appropriate referrals.
'There is a sense of urgency at the national and local level. They are now recognising services are not good enough and are in dire need of improvement, ' says Ms Robinson.
'There is now an excellent opportunity to create an excellent NSF for older people.'
Find out more
Depression and Older People: towards securing wellbeing in later life, by Mary Godfrey and Tracy Denby of the Nuff ield Inst itute, is available f rom Marston Book Serv ices on (01235) 465500 or d i rect. firstname.lastname@example.org. uk (£14.99 plus£2.75 p&p).
www. nimhe. org. uk/priorities/olderpeople. asp
www. publications. doh. gov. uk/nsf/olderpeople
THE VOLUNTARY CONTRIBUTION
The Age Concern Oxfordshire flexible carers service aims to bridge the gap between the help offered by statutory and voluntary agencies.
It improves the quality of life of older people with mental health needs by offering home-based active support in direct response to the individual's needs and wishes.
Trained care staff provide individual support to older people with significant mental health needs who are reluctant to accept help.
They also assist in rehabilitation, improve levels of functioning, prevent further deterioration, enhancing quality of life and enabling the individual to remain in their own home.
'Over 90 per cent of our referrals come from mental health teams. We work very closely with the statutory sector, ' says Steve Corea, head of mental health services at Age Concern Oxfordshire.
While mental health services only make a small number of visits a week and cannot provide long-term home care, the flexible working scheme ensures the gains they make with patients do not come undone.
'We worked with one gentlemen who started neglecting himself and stopped taking his medication when he came out of hospital, ' says Mr Corea.
'He needed someone to engage with him in an individual way to get him back living independently in the community.
'We supported him in going out to garden centres and to start working on a shared allotment.
'He has now been discharged from the flexible scheme, but without it he could have ended up back in hospital.'
THE 65-YEAR ITCH
One of the major problems defining mental health services along age-related lines, says Age Concern's Philip Hurst, is that services people have accessed for their entire lives can be withdrawn once they reach 65.
'We know one man with a long-term mental health problem who had a good relationship with his psychiatrist and was attending a day centre.
'Yet as soon as he reached retirement age he couldn't use the same psychiatrist and day service any longer.
He had to use services that for older people that were predominately for people with dementia, when he had bi-polar disorder.' NIMHE fellow in ageing and mental health Susan Benbow says that while this is definitely a problem, it occurs in patches rather than being widespread. In many areas services will respond to an older person's need.
'You shouldn't be losing the services that have met your needs on your 65 birthday. You shouldn't lose the staff that you have known all your life.
'Services should be based on need, not on your age. Going over to older people's services at 64 is frowned on these days.' But she knows that older people have been excluded, for instance, from assertive outreach because it only operates for those aged up to 65.
'There needs to be equivalent services that are tailored to the needs of older people, ' she says.
Mental health serv ices for older people tend to be neglected by pol icy in favou r of general adu lt mental health services.
Inadequate staff ing, lack of capacity and insuff icient intermediate care are all contributing factors.
Salford and Trafford trust now has accredited training for primary care nurses in the identification and initial management of mental health problems in older people.