This edition of the BJPsych sees the publication of an important article by Abdul-Hamid et al, assessing the quality of care of people with mental illness who grow old and transfer to an older adults service vis à vis those who remain in general adult services. Reference Abdul-Hamid, Lewis-Cole, Holloway and Silverman1 I cannot overemphasise the importance of this paper. The notion of specialist psychiatry services for older people, who have very different psychological, medical and social needs to adults of working age, is rather like having lifeboats on a cruise ship; intuitively a good idea, but there is little evidence to support the presence. This evidence is becoming increasingly important because, over the past few years in the UK, and indeed around the world, we have seen specialist old age services being dismantled and integrated into ‘ageless services’. Before we look at the reasons and consequences of these changes in more detail, it is perhaps worth tracing the development of old age psychiatry as a specialism.
The development and decline of the specialty
The first specialised old age psychiatry services began in the late 1950s. Reference Hilton2 They were much needed! Prior to that, there had been scant regard for the mental health needs of older people. Those who had necessitated admission to hospital were often cared for on ‘back-wards’ with little regard to their mental health, physical needs or social welfare. Notwithstanding these pioneering services, the development of the specialty was slow, despite the fact that there had been a number of policy reports identifying the gap, and recommending solutions. However, during the 1970s and 80s, the specialism gained ground with the development of dedicated, consultant-lead, multidisciplinary teams serving both community patients and providing in-patient and day hospital facilities. Reference Hilton3
By 1980, the Faculty of the Psychiatry of Old Age had been established at the Royal College of Psychiatrists in the UK, and the specialty gained its own postgraduate training programme and specialist postgraduate qualification. There are nearly 600 old age psychiatrists practising as consultants in the UK currently, and a recent survey, which represented 95% of National Health Service providers in the UK, found all delivered core old age mental health services. However, this survey revealed some worrying trends. Reference Warner and Jenkinson4 In total, 11% of respondents identified that whole sections of core services had gone ageless, so an 18-year-old and an 80-year-old would be treated on the same ward or by the same community mental health team. A further 7% of trusts were considering making such a move. These results suggested that the discipline of old age psychiatry was under threat.
Such a threat would have significant consequences. Respondents who had experienced transition to agelessness reported significantly detrimental effects in the quality of care, patient safety, service efficiency and staff morale. Reference Warner5 Contemporaneous with the development of ageless services, there was a significant reduction in uptake of training posts in old age psychiatry. Without the next generation of old age psychiatrists being trained, the specialism would soon wither. Finally, since 2010 there were disproportionately more cuts in funding in old age services compared with adult services. The vultures were circling!
There are probably a number of reasons for this shift to ageless services. First, at around this time, both England and Scotland introduced equalities acts. Although careful reading of these acts would reaffirm that specific age-related services were appropriate and lawful, my suspicion is that some providers were shifting to ageless services for fear of falling foul of the legislation. The second reason is that these changes also occurred at the same time as one of the most severe periods of health austerity the UK has witnessed. Combining teams can be seen as an easy way of saving money, although the unintended consequences that may accrue from such changes are usually not factored into these equations. A third factor is a pervasive and pernicious institutionalised ageism still prevalent within the health sector. Reference Anderson, Connelly, Meier and McCracken6 One piece of evidence to substantiate this statement is the substantial (over £2 billion annually) relative underfunding of old age psychiatric services relative to adults of working age – a disparity that resulted from the differential introductions of the national service frameworks over a decade ago but continues today. Reference Anderson, Banerjee, Barker, Connelly, Junaid and Series7
Action to protect old age services
In response to this, the Faculty of the Psychiatry of Old Age of the Royal College of Psychiatrists set about trying to protect remaining old age services and restore those that have gone ageless. After extensive stakeholder consultation new service criteria defined around the needs of the older people that the old age teams serve, rather than a criterion based on a patient passing a specific birthday, were developed. The new needs-lead criteria are as follows.
(a) People of any age with a primary dementia.
(b) People with mental disorder and physical illness or frailty that contribute(s) to, or complicate(s) the management of their mental illness. This may include people under 65.
(c) People with psychological or social difficulties related to the ageing process, or end of life issues, or who feel their needs may be best met by a service for older people. This would normally include people over the age of 70.
The Faculty also undertook a broad publicity campaign, writing to politicians, publishing a joint commissioning guide that was sent to all healthcare commissioners in the UK. We also sent a letter, co-signed by several national organisations including the Royal College of Nursing and British Geriatrics Society, to all chief executives and medical directors of mental health trusts, advising against moves to ageless services.
One difficulty we faced in this task is a lack of sufficient evidence that old age services do confer benefits for older people. The paper by Abdul-Hamid et al provides such evidence. Reference Abdul-Hamid, Lewis-Cole, Holloway and Silverman1 They found that older people who had graduated (a horrible word in this context) from working age adult services to specialist old age services had significantly fewer unmet needs than those who continue to be looked after in adult psychiatry, despite the total needs not being significantly different between the two groups. Particularly when service planning is so devoid of any robust evidence, and so many service changes are made based on intuition and heuristics rather than any evidence, this paper is very welcome in supporting old age services going forward.
The erosion of old age services in the UK has been watched closely by our colleagues around the world, who, it seems, are beginning to face similar difficulties. Reference Warner, Graham, de Mendonça Lima and Brodaty8 The good news is, at least anecdotally, some mental health trusts that have converted to ageless services are now reintroducing specific old age services. In the coming year the Faculty will repeat its national survey to better map the current service provision and future trends. In the meantime, it is imperative that we garner more evidence in the form of research like the paper by Abdul-Hamid and colleagues to support our arguments with commissioners and healthcare providers.