By 2035 there will be 2.5 times as many people in the UK aged over 85 as there are now; 23% of the total population will be aged 65 and over. Their health problems, including their mental health problems, are going to loom large. Is current policy well adapted to meeting this need?
Older people are prone to two distinct kinds of mental illness: organic (i.e. due to physical changes in the brain, and especially dementia) and functional (i.e. illnesses that have no clear organic basis affecting people’s ability to function, especially depression and psychosis). Perhaps surprisingly, the majority of the mental illnesses experienced by older people are functional, and the physical health and social difficulties associated with these illnesses are often distinct from those experienced by younger people.
Depression, with low mood, feelings of worthlessness, hopelessness and loss of enjoyment is common in older people; up to 2.4 million already have symptoms severe enough to impair their quality of life. Recognition of depression is not as good as it is with younger people. Only one third of older people discuss the problem with their GP and less than half receive appropriate treatment. Psychosis, where people develop firmly held bizarre beliefs and/or hear voices, is also common among older people, occurring in 20% of people over 65 by the time they reach age 85. In most cases it is not related to dementia.
In the past older people often experienced ageism when their mental health problems were treated within hard-pressed services for the adult population at large. As a result specialist health services were developed and for 40 years the UK has been one of the world leaders in recognising this need and developing comprehensive (dementia and functional illness) mental health services specifically for older people, with specialist training for doctors, nurses and psychologists, and dedicated wards and teams set up as “ring-fenced” resources for their care.
Some new mental health initiatives have not addressed the needs of older people and tend to force them back into competing for care in ‘ageless’ services where experience shows that their distinctive needs are often not met. For example the introduction of ‘improved access to psychological therapies’ (IAPT) in 2006 did not consider older people at its inception, as its funding was linked to its success in returning adults of working age to employment. The introduction in 2008 of a national dementia strategy and implementation plan for England, with the development of stand-alone memory services for people with dementia, unfortunately leaves the remaining specialist mental health services for older people poorly resourced and facing probable dissolution.
The driver behind this is service line management (SLM), developed in the United States in the 1980s and now championed by Monitor to support financial and performance governance in foundation trusts in England. In SLM, trusts – including mental health trusts – are divided into specialist areas based on disease “clusters” that are then managed as distinct operational units. The trust can then collect data on financial performance, activity and staffing for each cluster to plan services, set targets, and manage performance.
All service lines are compared by volume of activity and profitability. ‘Benchmark setters’ generate high volumes and good profitability, ‘potential growth’ areas have good profitability but low volumes, larger specialties can be managed to reduce costs and improve efficiency, while small and unprofitable service lines can be reviewed for their viability. The argument for this is that effective management is more important than ever if the NHS is going to meet current funding challenges. What in essence these changes do is develop a “good business environment” where packages of treatments for patients’ problems can be put out to tender, to be bid for by either public or private providers.
SLM is increasingly being adopted in psychiatry where, in order to fit this business model, patients are now “clustered” with others whose care costs are the same. Dementia services create a good service line. However older people with depression or psychosis do not cluster with those with dementia, but with working age adults. This means older people are being moved to ‘ageless’ services. An impressive array of international old age psychiatrists are clearly very concerned about this and what may be lost for older people in the UK as stated in a recent letter to the Times.
A recent survey of psychiatrists specialising in old age in 81 organisations providing mental health care for older adults in the UK found that 47% of the organisations were currently developing some elements of ageless services. Of these, 17% were planning to convert to wholly ageless services.
Current spending projections suggest that health and social care services will face further significant financial pressures in the next 20 years. Organisations will compete to run services on cost and performance indicators. In psychiatric services, time with patients and the number (and experience) of staff are the major costs. Both have already been reduced, and pressures can only increase. Previous experience should have taught us that with a return to ‘ageless’ services older people are likely to be the first to lose out. Is this what we want for them – including ourselves?