Access to old age psychiatry services

To access the old age psychiatry services, service users usually consult their GP first. Elders and their families from several Black and minority ethnic groups have high awareness of GP services (Reference Bhalia and BlakemoreBhalia & Blakemore, 1981; Reference BarkerBarker, 1984; Reference McCallumMcCallum, 1990) and make good use of them (Reference DonaldsonDonaldson, 1986; Reference Balarajan and YuenBalarajan et al, 1989; Reference Gillam, Jarman, White and LawGillam et al, 1989; Reference Lindesay, Jagger, Hibbert, Peet and ModelinaLindesay et al, 1997b ; Reference Livingston, Leavey, Kitchen, Manela, Sembhi and KatonaLivingston et al, 2002). However, the number of Black and minority ethnic elders in contact with old age psychiatry services is low (Reference Shah and Dighe-DeoShah & Dighe-Deo, 1997). This discrepancy between high general practice consultation rates and low take-up of old age psychiatry services exists despite the community prevalence of dementia and depression being similar or higher among Black and minority ethnic elders than among indigenous elders. There needs to be more research in this area, as it is likely that this situation is caused by a number of related factors, for example the relationship between service users and their families, general practice and old age psychiatry services, stigma. Professionals and the community also need to be more aware of services for this group of users. Service providers in particular need to consider the way in which structures and processes can affect access.

There is some evidence that poor access to old age psychiatry services of ethnic minority elders is changing in some UK services. Since the publication of the 2001 College report, one London study reported that Polish elders have equitable access to health and social services at the same frequency as indigenous elders (Reference Bhatkal and ShahBhatkal & Shah, 2004). This finding was consistent with identical findings from two earlier studies of elders of Indian origin in the same locality of London (Redlinghuys & Shah, 1997; Reference Odutoye and ShahOdutoye & Shah, 1999). Also, a population-based study of a mixed group of ethnic minority elders in Islington, London, reported similar findings for the use of primary care, secondary care and social services, but old age psychiatry services were not included (Reference Livingston, Leavey, Kitchen, Manela, Sembhi and KatonaLivingston et al, 2002). The Count Me In survey (Commission for Healthcare Audit and Inspection, 2007) of all psychiatric in-patients in England and Wales on 31 March 2007 reported that the standardised admission ratios (the standard being the rate for England and Wales) for those over the age of 65 were: higher in the White Irish, Other White, Other Asian, Black Caribbean, Black African and Other Black groups; lower in the White British and Chinese groups; and not significantly different in the Indian, Pakistani and Bangladeshi groups.

Black and minority ethnic elderly groups are not homogeneous and therefore the temptation to amalgamate all such groups together should be avoided.

Core training and education - cultural capability

The CR103 report highlighted the need for greater improvements in cultural capability for mental health services for older people. Clinicians working in mental health services should receive regular and rigorous formal training in cultural capability, awareness, appropriateness and sensitivity to improve their knowledge, skills and attitudes (Department of Health, 2005). This should include training on local policies for racial harassment and discrimination, and legislation relevant to racial discrimination (Reference Patel, Winters, Bashford and BingleyPatel et al, 2003; Department of Health, 2005). Such local training should be complemented by workshops and seminars conducted by the College, the Race Equality and Cultural Capability Programme that is being developed by the National Health Service Institute for Learning, Skills and Innovation (Department of Health, 2005), the common skills set for mental health practitioners that is being developed by the National Institute for Mental Health in England (NIMHE; Department of Health, 2005) and the emerging training manuals (e.g. a manual on cultural capability due to be published by the College).

The College should promote the need for training in the ascertainment, recording and monitoring of ethnicity, stressing the importance of using such data to identify discriminatory practices, service user needs and new service developments. It should also emphasise the importance of ongoing discussions with local Black and minority ethnic organisations, service users and carers as a means of understanding and auditing service delivery.

Promoting access to services for users and carers

There are significant issues related to access to mental health services for Black and minority ethnic elders, particularly lack of awareness and understanding about services and lack of appropriate information (Royal College of Psychiatrists, 2001). Thus, the College has called for a database of services including information about good practice, accredited interpreters, educational meetings, screening tests and, where possible, access to translations of essential information for Black and minority ethnic users and carers (Royal College of Psychiatrists, 2001). This could be held by the College Faculty of Old Age Psychiatry, with input from the Transcultural Special Interest Group.

The College has a register of psychiatrists with fluency in different languages, often updated. Audiotapes, videos, CDs and diagrammatic representation of management and service-related issues can complement the use of interpretation services and may be particularly helpful for illiterate service users and carers (Reference Lindesay, Jagger, Hibbert, Peet and ModelinaLindesay et al, 1997b ). Educational videos on dementia have been developed internationally (e.g. by Alzheimer's Disease International, www.alz.co.uk), nationally (e.g. PRIAE, Policy Research Institute on Ageing and Ethnicity, www.priae.org) and locally (e.g. Alzheimer's Concern Ealing, www.alzheimersconcern.co.uk). Additionally, translated versions of all information leaflets should be made available to service users and carers who can read their mother tongue.

Screening instruments for dementia and depression are emerging in several languages for Black and minority ethnic elderly groups, but there is a paucity of diagnostic instruments. However, there are some fundamental problems. The appropriateness and validity of some translated scales in this age group has to be considered. All existing screening instruments for dementia and depression for Black and minority ethnic elders have been developed in the target participants’ language. As translated versions of instruments have questions in the participant's language, the clinician cannot directly administer the instrument unless they are fluent in that language. Moreover, the clinician cannot solely rely on the interpreter to accurately administer the instrument because the clinician will not be able to ascertain the accuracy of this mode of administration. There is an urgent need to develop instruments for use in day-to-day clinical practice, whereby the interpreter can administer predetermined and standardised set of translated questions given by the clinician to the patient. Furthermore, the development of self-rated screening instruments, like the Geriatric Depression Scale (Reference Yesavage, Brink, Rose, Lum, Huang and AdeyYesavage et al, 1983), is problematic in individuals who are unable to read their mother tongue. For this group there is a need to develop interviewer-administered instruments.

For everyday communication on in-patient units, day hospitals, day centres and residential and nursing homes, it may not be practical to have an interpreter present all the time and bilingual staff are uncommon. Appointing bilingual staff should be encouraged both to aid communication with service users and as an information source on cultural issues.

A manual of translated versions of commonly used key phrases (e.g.‘please come and have breakfast’, ‘please come and have your medication’, ‘would you like to go for a walk?’), together with a paraphrased version in English, needs to be developed. In this way, the user could read the staff's request or, where they cannot read their own language, staff can read the paraphrased version to them. Common responses should be available to the staff to ensure communication and appropriate care.

Consultation with Black and minority ethnic users and carers

The evidence on consultation with Black and minority ethnic elders tended to be mainly anecdotal. Over the past few years, well-attended national conferences have been held by organisations such as PRIAE and NIMHE, which have highlighted issues already identified on the local level. This has included the problems of institutional racism affecting access and delivery of care. The assumption that Black and minority ethnic communities in a particular area are homogeneous often leads to perpetuation of inappropriate services.

Black and minority ethnic service users and carers should be consulted on such matters as appropriate communication, language, religious and ethnic diversity and transport. Ways of working with Black and minority ethnic elders should be established so as to empower them to articulate their concerns themselves rather than through others. The College review of the 2001 report could investigate ways of disseminating information about good practice in this area, for instance through links with NIMHE.

Research: inclusion and focus

The College's CR103 report acknowledges the relative dearth of the mental healthcare needs of Black and minority ethnic elders. Although subsequent studies remain scarce, their number is growing. The College is committed to ensuring that Black and minority ethnic groups are included in all research programmes.

It is important not to assume that findings from epidemiological studies from the country of origin of Black and minority ethnic elders are applicable in the UK, because the process of migration, fluency in English, the degree of assimilation and acculturation into the host culture and other environmental changes are likely to influence the findings in the UK.

In general, population-based epidemiological studies and studies evaluating the effectiveness of treatment interventions often exclude Black and minority ethnic elders and therefore findings from such studies cannot readily be applied to this group. Black and minority ethnic elders need to be included in these studies. There is also an urgent need for population-based epidemiological studies of different Black and minority ethnic groups to examine the prevalence of mental illnesses, their severity and the resultant disability, as well as risk factors, natural history, clinical features and clinical presentation and issues related to carers, including stress and strain. These studies should be complemented by others designed to identify barriers in the pathway to secondary care, for example using the Goldberg & Huxley's (Reference Goldberg and Huxley1991) model of pathways into care. The elderly should be included in studies which use the traditional limit of 65 years - clinical issues do not change on the 65th birthday. Such exclusion particularly disadvantages Black and minority ethnic elders as they are generally in the ‘young:old’ (65-80) range (Reference ShahShah, 2007).