Older people are often excluded from key mental health services

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					                                                                                                                         Draft 31/0309
                                   Devon Health and Social Care Forum
                                   Working Paper 14
          Healthcare Commission Report on Mental Health Services for the over-65s
                                    (31 March 2009)
     1.           In a worrying report published on the final day of its existance , the Healthcare Commission
     reports that older people are often excluded from key mental health services because of their age. The
     Commission studied services for older people at six specialist mental health trusts (about 10% of the
     total number). It met with over 600 people at six mental health trusts including: chief executives; senior
     managers; ward staff; service users; carers; social workers and commissioners. It held interviews and
     workshops with people at each Trust to build a picture of what was working well and what needed to
     improve in mental health services. The Commission's study covered four themes: age discrimination in
     mental health services; quality of inpatient care; how comprehensive services are; and, how
     organisations work together to provide services.

     1.1           It found evidence of some good practice with some evidence of high quality inpatient care,
     where there was good integration of health and social services, and of service users and carers being
     involved in developing services, although there is room for improvement at some trusts. It found good
     support and training for carers at some trusts. Most trusts had also made some progress in identifying
     issues of age discrimination. Two trusts made an effort to deliver services based on need rather than age,
     with anti-discriminatory policies embedded throughout the organisations. Staff showed pride in services and
     felt strongly that their services were seen as being equal to others. Four trusts had made progress in
     identifying issues of age discrimination and taken some action towards making their services accessible on
     the basis of need. Three of the four had a transition procedure in place for patients transferring between
     services for people under 65 to those for the over 65s, respecting need rather than age in deciding when
     patients should be transferred.

     1.2           Where health and social care services were integrated at both team level and management
     level, it was more likely that services offered a higher standard of care and a greater range of services. This
     means the people who use services and their carers could access the help they need and were more
     satisfied with their care. Carers in less integrated services said they could often spend a large amount of
     time and energy trying to find out who they needed to go to for what problem.

     1.3          In trusts where the Commission found evidence of high quality care, there was a sense of
     strong clinical and managerial leadership. These trusts tended to have old age psychiatrists with
     managerial roles at senior levels who were able to provide leadership and bring issues relating to the
     care of older people directly to the trust's board. In the trusts with divided or joint clinical leadership there
     appeared to be a lack of robust progress in service improvements.

     1.4          But, the study also showed that mental health services for over 65s need "urgent attention",
     stating that people over 65 are often denied access to the full range of mental health services available to
     younger adults. The Study showed older people were often unable to access the full range of services,
     including: out of hours services; crisis services; psychological therapies; drug and alcohol misuse services.
     The Commission also expressed concern there is limited national data available on the quality of specialist
     older people's mental health services, which would allow performance in key areas to be analysed more

    1.4            The findings of the Study show that older people were often prevented from accessing care
    because of stretched services or a lack of age-appropriate care. Some staff said patient groups
    considered to be of high risk to the public or where government targets were applicable, were often
    prioritised, leaving older people's services lagging behind with little funding.

   2.            On the downside, the study found that out of hours and crisis services were often not open
   to older people and only took referrals for people under 65 or for conditions other than dementia. There
   appeared to be a reluctance to refer and a reluctance to accept referrals, due to workload and the age-
   appropriateness of the service offered. There was no clear justification for this. Staff at several trusts also

1 From 1 April 2009, the Care Quality Commission will bring together the work of the Commission for Social Care Inspection, the
Healthcare Commission, and the Mental Health Act Commission. The new commission will regulate the quality of care in health and
adult social care and look after the interests of people detained under the Mental Heath Act. This is the first time that independent
regulation of health, mental heath and social care has been brought together in this way.

2 Healthcare Commission, Equality in later life (A National Study of Older People's Mental Health Services) 31 March 2009

said some older people had difficulties in gaining access to services for alcohol and substance misuse.
Even when services were available they were either not offered in an age-appropriate way or were not
available when staff attempted to refer to them. Many were geared towards younger people, usually
males, and were felt not to be appropriate for older people who may feel vulnerable in the atmosphere.

2.1           Provision of psychological therapies for older people was poor in most of the trusts visited.
One trust reported that in an audit of 1,300 referrals to psychological therapies from GPs, only 49 were for
people over 65, revealing a lack of awareness among GPs of the older age group's need. One trust also
reported a waiting list of six months for an assessment. Integration of health and social care services was
also patchy, and this impacts on the quality, range and availability of services for patients and their carers.

2.2          Some commissioners struggled with the boundary that separates the over and under 65s in
mental health services and were unsure about the different models of service required. The Commission
urges services to focus on assessing people according to need rather than age in order to provide the
most appropriate services for the individual.

2.3            Service users and carers were particularly positive about the support groups available for
carers and training courses for them to learn about their loved one's illness. They said services were
better at involving them in decisions about their own care, but there are still lessons to be learned to make
sure patients are consulted when planning services and that they are given basic information about how
they can access them in an emergency and for routine help. But, some people said they felt they were
sometimes pushed ‘from pillar to post' when attempting to contact someone.

2.4          According to interviews with some carers, they were concerned about the closure of some
services and the care relatives received on general wards in acute hospitals. Some trusts did not provide
day services at all and the alternatives to this were not apparent. Carers also said some staff in general
wards at acute hospitals were not being trained or were not equipped to deal with patients with mental
health problems, especially dementia.

3.            The Report makes 14 recommendations to the government, the Care Quality Commission,
trusts and service providers to ensure there is a coordinated approach to improve mental health services
for older people. It is very concerned that nationally available data does not provide a robust basis on
which to compare the performance of different areas in meeting older people's mental health needs, or to
allow the boards of trusts to assure themselves about the extent to which they are providing good quality
non-discriminatory care. Where data was found to be reliable, it did not shed light on the most important
themes identified for the study. The Commission recommends the government, the Information Centre for
Health and Social Care and regulatory bodies should review the quality and focus of national data sets, to
enable more effective monitoring and evaluation of these services.

3.1            The Commission recommends the Government should steer the strategic direction for
mental health services towards making sure older people's rights are upheld by having equal access to
services withoput discriminated by age. It believes the Department of Health's ‘new horizons' project,
which will implement a new framework for the delivery of mental health services in 2010, would be a good
vehicle for this. It is also calling for the Royal College of Psychiatrists and other relevant organisations to
develop models of care based on assessment of need rather than age.

4.              Anna Walker, the Commission's chief executive, said: "Improving mental health services for
older people is an important priority for the NHS, which the government has already recognised. This
study has revealed some areas of good practice. Where health and social services are working well
together we found high quality care and a wide range of services available to older people. At some trusts,
carers told us that they had good support and training to help them cope with their loved one's illness. This
is to be welcomed. But trusts are not always providing appropriate mental health services to the over 65s.
It is truly unacceptable that out of hours and crisis services were often not available to older people. There
needs to be a fundamental shift towards providing care based on a person's clinical need rather than their
age. Considering a quarter of admissions to mental health inpatient services are over 65, this issue needs
urgent attention. "

3 The number of people over 65 is projected to increase by 15% by 2019 and the number of people with dementia is estimated to
rise to one million by 2025. This is the reason why services for this group of people needs to be fully accessible and robust enough
to cope.

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