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No scope for complacency: time to improve healthcare for older people

  • Claire Hilton (a1)

The Equality Act 2010 should prevent age discrimination in the provision of healthcare and other services in the UK. The Royal College of Psychiatrists' Faculty of the Psychiatry of Old Age and General & Community Psychiatry Faculty have offered constructive guidance to help achieve this. However, there are pitfalls. First, legislation does not guarantee enforcement. Second, discrimination in the form of persisting negative attitudes of society towards older people and their ability to benefit from health interventions is associated with a deficit in funding old age services that has accumulated gradually during the 60 years of the National Health Service. These difficulties will need to be overcome to achieve effective implementation of the Act.

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Claire Hilton (
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1 Faculty of the Psychiatry of Old Age, General and Community Psychiatry Faculty. The Equality Act 2010 and Adult Mental Health Services: Achieving Non-Discriminatory Age-Appropriate Services (Occasional Paper OP82). Royal College of Psychiatrists, 2011.
2 Faculty of the Psychiatry of Old Age. In-Patient Care for Older People within Mental Health Services (Faculty Report FR/OA/1). Royal College of Psychiatrists, 2011.
3 Help the Aged. Half of doctors say NHS is ageist. BGS News 2009; March: 8.
4 Macmillan Cancer Support. The Age Old Excuse: The Under Treatment of Older Cancer Patients. Macmillan Cancer Support, 2012.
5 Rowntree, BS. Old People: Report of a Survey Committee on the Problems of Ageing and the Care of Old People. Oxford University Press, 1947.
6 Spence, D. Baby boomers go bust. BMJ 2012; 344: e2191.
7 Parsonage, M, Fossey, M. Economic Evaluation of a Liaison Psychiatry Service. Centre for Mental Health, 2011.
8 Greaves, N, Greaves, I. The Gnosall project: setting new benchmarks for dementia care. J Care Serv Manag 2011; 5: 4952.
9 WRVS. Gold Age Pensioners: Valuing the Socio-Economic Contributions of Older People in the UK. WRVS, 2011 (
10 Beveridge, W. Social Insurance and Allied Services (Cmnd 6404). HMSO, 1942.
11 British Medical Association. The Care and Treatment of the Elderly and Infirm. BMA, 1947.
12 Ministry of Health. Report of the Committee of Enquiry into the Cost of the National Health Service (Cmnd 9663). HMSO, 1956.
13 Bosanquet, N. New Deal for the Elderly. Fabian Society, 1975.
14 Lancet. Mental health of elderly people. 1979; i: 395.
15 Department of Health. Living Well with Dementia: A National Dementia Strategy. Department of Health, 2009.
16 Burns, A. Introducing the national dementia CQUIN. Department of Health, 2012 (
17 BBC News. Dementia: PM promises push to tackle 'national crisis'. 26 March 2012 (
18 Ministry of Health. Care of the Aged Suffering from Mental Infirmity. HMC (50)25, 1950.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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No scope for complacency: time to improve healthcare for older people

  • Claire Hilton (a1)
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Re:Risk of transforming old age psychiatry to dementia only service

James Warner, Chair- Old Age Faculty
21 January 2013

Dr Sikdar's letter is a timely reminder of the issues facing old age psychiatry and I welcome the opportunity to outline what the faculty is doing to meet the challenges. Firstly, we must accept that defining entry to a service by age alone is simply not logical and now probably unlawful;services which continue to do so need to think urgently about this. Possibly as a consequence of the definition vacuum, some Trusts are movingto "ageless services". Older people with mental disorders (not just dementia) are entitled to have their care and treatment managed by professionals who have specific expertise in that area. This principle is supported by NICE, the Department of Health, the Royal College of Psychiatrists and the British Psychological Society. In January the faculty sent a letter to all Mental Health Trust CEOs and Medical directors requesting a pause in conversion to ageless services pending agreement of new criteria.

The faculty of Old Age Psychiatry is also leading work on re-definingservice criteria based on need rather than age. Draft criteria are:

1. People of any age with a primary dementia. 2. People with functional mental disorder and significant physical illness or frailty which contributes to, or complicates the management of their mental disorder. 3. People with psychological or social difficulties related to the ageing process, or end of life issues, or who feel their needs may be bestmet by an older adult's service. This would normally include people over the age of 70.

For people under the age of 60, it would be unusual for Old Age Psychiatry services to have a lead role, though the provision of expertiseto individuals under conjoint management arrangements would be welcomed inappropriate cases. For people between the ages of 60 - 70, conjoint management should be explored, particularly where co-morbidity dominates the clinical presentation. The principles of conjoint management are that one team takes responsibility for the overall care and treatment of the patient, but draws upon physical support from other services rather than simply opinions. Patient choice is pivotal and patients in crisis should not be transferred from one team to another except in exceptional circumstances.

These criteria allow for local variation (for example whether Korsakoff's is included in criterion 1) and are based on judgement rather than reductionism. Consequently they may lead to disagreements about individual patients which are probably best addressed through conjoint management. On the whole however they are seen as logical and utilitarian.Modelling suggests workload of OA services would be similar to now if theyare implemented.

I agree with Dr Sikdar that it is really important to preserve management of functional illnesses in OA teams. Almost 50% of my directorate's workload is non-organic and the cross over between dementia and functional illness is very common and complex. Many people with dementia present with functional symptoms and many more will develop severe functional symptoms once dementia is established (psychosis 25%, depression 40%). Many people with long-established functional illness willgo on to develop dementia. For these reasons the only way it is possible to preserve continuity of care is to have OA teams providing care across the spectrum.

The disproportionate funding gap (Old Age Services are underfunded byover ?2bn compared to adult services) is an outrage, especially as we facereal growth in demand due to demographic change. The fact that Trusts' Cost Improvement Plans are equally applied to Old Age services is unconscionable and illogical; but would be up to local clinicians to arguethis point.

The faculty has done much over the last few months to address these issues through a) a National Survey of faculty members to establish baseline service provision and map changes b) lobbying politicians and Trusts and c) development of new service criteria. There is much still todo and the support of our members in this work remains pivotal.

James Warner

Chair- Old Age Faculty, Royal College of Psychiatrists

... More

Conflict of interest: None declared

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Risk of transforming old age psychiatry to dementia only service

Sudip Sikdar, Clinical Director, Consultant psychiatrist for older people, Regional Advisor
16 January 2013

I read Hilton's Editorial with interest and write as a practising old age psychiatrist and clinical director for adult and older peoples' mentalhealth service in my trust as well, as local dementia lead and Regional Advisor for the Mersey region.

While a lot of development has rightly taken place and is taking place in improving dementia services across the Merseyside region and the country as well, weare in danger of neglecting the important issue of providing functional mental health services for elderly. And even though the old age faculty is to be applaudedfor doing a huge amount of work in raising the issue of discrimination andneed for age appropriate services, it has not clearly defined what an older person's need is and how it varies when a patient newly presents with first episode of functional mental health problems beyond the age of 65 years. On-going work in Primary Care Trusts and shadow Clinical Commissioning Groups in Long Term Care and Integrated Care Pathways between primary and secondary care also focuses primarily on dementia in older people.

Trusts across the country have taken different approaches to solvingthis problem with some adult mental health services having raised the cut off age from 65 years to 70 to 75 years for functional illness while others combining adult and older peoples' functional mental health teams thus trying to give access to Crisis Resolution Home Treatment (CRHT) or Assertive Outreach Team (AOT) services to older people for example.

The problems with either of the approaches are that Department of Health Policy Implementation Guidelines for specialist services like CRHT,AOT etc. are still age defined (16 to 65 years); social services still workon the age boundary of 65 years, general adult colleagues are reluctant to accept new referrals for functionally ill patients over the age of 65 years citing that their CCT is in general psychiatry and the national experiencethat current adult CRHTs are poor at dealing with functionally ill older patients who often have a combination of physical, cognitive and social care needs and often do not have the capacity to pick up extra demand, however small it may be.

There is no money in the system to develop new specialist CRHT type services for older patients with functional and organic illnesses (our recent Quality Innovation Productivity Prevention (QIPP) bid to develop such a service in our trust was rejected while general hospital and care home liaison bids attracted new money as these services primarily deal with patients with dementia).

As adult mental health services are much larger in size compared to older adult services in most mental health trusts, senior non-medical managers tend to over-represent the former group and faced with an annualCost Improvement Plans of 4%-5%, it is tempting for them to try and convert old age services to dementia only and combine the functional mental health services for adults and older adults in one team. While thismay create financial efficiency; the actual needs of functionally ill older adults are increasingly getting neglected. Morale in existing Community Mental Health Teams in older adults who traditionally have provided extended hours of services for all older patients across the diagnostic groups (including crisis resolution, home treatment and managing urgent social care needs) is at an all time low as many are getting dis/rebranded thus losing/ diluting their skills.

It is time to wake up to these challenges and the old age faculty would do well to articulate clear views and provide directions in this area.

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Conflict of interest: None declared

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