Hong Kong J Psychiatry 2001;11(2):19-22

REVIEW ARTICLE

T Dening

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THE GOVERNMENT’S STRATEGY FOR OLDER PEOPLE

The current administration in the UK is a Labour Government, which has been in office since 1997. Their election victory followed 17 years of Conservative governance. Tony Blair and his Ministers have been keen to set an active policy agenda, with particular emphasis on modernising Government and embra- cing technological advances. In this context, the Government has developed several general policy initiatives for older people aimed at helping them to play their full part in society.

Better Government for Older People was a 2-year programme aimed at developing new ways of working across traditional organisational boundaries and creating innovative solutions to problems. This report, All Our Futures, made a series of recommendations for action related to the need to:

• combat age discrimination
• improve engagement with older people
• improve decision making
• better meet older people’s needs
• promote a strategic and integrated approach to an ageing population.

Another important development for older people is the Inter-Ministerial Group (IMG) on Older People, a cross- government group designed to coordinate government policy for older people. The IMG is chaired by Alistair Darling, Secretary of State for Social Security. The group published Life Begins at 50, a programme of action to tackle the issues raised in the Gover nment’s recent Listening to People exercise. This programme highlights:

• lifelong learning and leisure
• work and volunteering
• a good life at home — social care, housing, and security
• health, income, and transport
• consultation and involvement.

Other recent publications are intended to improve the employment position of people older than 50 years and to provide practical guidance to the law relating to older peoples’ rights to healthcare, pensions and benefits, housing, safety, and leisure.

HEALTH AND SOCIAL CARE FOR OLDER PEOPLE

Many problems can arise from trying to provide appropri- ate and well coordinated care for older people and such difficulties are encountered worldwide. Planning between health and social care services may not be sufficiently inte- grated. Some services function badly, while others such as preventative and rehabilitative services are insufficient. Availability of services may be inadequate. Older people may have difficulty in accessing services, and may not feel fully involved in decisions made on their behalf. Family carers, many of whom are elderly themselves, may also have difficulty in accessing support.

Several important policy initiatives address these issues, many of them first outlined by the Government in their white papers on the National Health Service (NHS) and Social Services. First and foremost, both mental health and older people’s health are among the priorities highlighted in the Government’s National Plan for the NHS, published last year. The plan emphasises the Government’s determination to eliminate ageism in health care, so that services are available on the basis of assessed need and not allocated according to arbitrary criteria such as age.

At a local level, health authorities and social services departments are drawing up health improvement programmes in collaboration with other local partners, including NHS trusts and primary care groups. These are aimed at improving health and reducing inequalities for the whole population, including older people. Joint investment plans are an integral part of this process. The new budgetary flexibilities introduced by the 1999 Health Act permit pooled budgets to commission and provide services, lead commissioning, and integrate provision arrangements. Health and local authorities will have to put the needs of service users firmly at the centre of services and public funds will be used more efficiently and more effectively.

There is a new long-term care charter — Better Care, Higher Standards — to ensure that better information about local health and social services is available so that older people can more easily obtain access to services. The policy on eligibility criteria for continuing health care is also being revised in the light of a recent legal case. Guidance on fair access to care services will introduce greater consistency to the application of eligibility criteria for adult social care. The Government has this year extended the system of direct payments for purchasing services to older people, a step to help promote their independence.

The Government has also made money available through its Promoting Independence Partnership Grant, amounting to £650 million over 3 years, to improve rehabilitation services and avoid unnecessary hospital admissions, and to develop contingency plans for handling the winter burden. The Prevention Grant, to promote independence through preventive approaches to community care, will amount to £100 million over 3 years.

Effective services for older people must entail effective support to carers. The Government recognises the vital role of carers and greatly values their work. The Carers and Disabled Children Act 2000 was published last year and includes a range of commitments to give carers better information, support, and care. A special grant of £140 million over 3 years will enable local authorities to provide a wider range of services to carers and will promote the availability of short breaks for carers and those they are looking after. Work to implement the carers’ strategy is now well underway. This includes raising awareness of carers’ issues when planning, delivering, and evaluating services. Carers’ issues will need to be included in undergraduate and postgraduate education in the NHS.

The provision of long-term care has attracted much public attention and debate. The Government has responded to the recommendations of the Royal Commission on Long Term Care and decided that, in England, nursing care should be provided free of charge in nursing homes. There is still concern that continuing to charge for personal care, as opposed to nursing care, will discriminate against people with dementia. The implications of this are currently being examined. The situation in the UK is made more complicated by the fact that the Scottish Assembly has pledged to provide funds for personal as well as nursing care.

However, the Gover nment has accepted the Royal Commission’s other major recommendation to establish a National Care Commission. It is right and proper that the quality of long-term care is an area of public concern. The Care Standards Act 2000 will ensure that care homes for older people are regulated by new national minimum standards, set out in the document Care Homes for Older People. A General Social Care Council will be established, to raise professional and training standards for the million-strong social care workforce. This will do much to reassure older people that the people who support them are safe, skilled, and competent. The document No Secrets, on prevention of and responses to abuse of vulnerable older people and other adults, has recently been published for consultation.

MENTAL HEALTH SERVICES FOR OLDER PEOPLE

Specialist mental health services for older people were first established in the UK during the 1960s in reaction to the poor care then available, which was usually limited to long- term care beds in old hospitals. There are now approximately 400 Consultants in old age psychiatry across the UK. Services are centred on multidisciplinary teams, which aim to be comprehensive, community orientated, accessible, responsive, and flexible. The emphasis upon community is vital for 2 reasons.

Firstly, it provides a service tailored to the needs of the local population. Secondly, domiciliary assessment and treatment is offered, where possible, enabling a comprehensive assessment of a person’s needs to take place without having to attend hospital clinics. Although the community focus is important, access to hospital beds for acute admission, and respite and continuing care is also necessary.

Partnership working is also about staff working together as a team. Hospital specialists, such as geriatricians, for example, need to liaise closely with old age psychiatrists because of the frequent association of physical and mental ill health in older people. The British Geriatrics Society and the Royal College of Psychiatrists have recently established a special interest group in this field, a welcome indication of interest.

In addition, mental health services must recognise the vital role of informal carers in looking after older people with mental health problems. The Carers Act sets out what needs to be done to support carers in their role. There is also the contribution of the voluntary sector. Several organisations champion the cause of older people, providing support and advice to patients and carers that complements the specialist services. Particularly important in this regard is the Alzheimer’s Society, which addresses the needs of people with dementia and their carers. However, there is a gap in supporting the interests of older people with functional disorders.

Another important area is the mental health needs of older people within ethnic minority groups. The number of older people from ethnic minorities is rising rapidly in the UK as people who immigrated in the 1940s and 1950s reach retirement age and beyond. Older people from ethnic minorities are a particularly vulnerable group since they are often socially and economically disadvantaged and may be at particular risk of becoming isolated if they do not speak English fluently.

The impact of moving into a different society may profoundly affect family culture, and traditional patterns of support may be changing. We must understand these changes in order to provide appropriate services and assistance.

Research is another key area where the Government provides support, mainly through the Medical Research Council, which spends more than £6 million per year in this area, but also by funding other studies, for example of carers and their economics, and of hormone replacement therapy in dementia.

Many local mental health services are excellent, but there are unacceptable inconsistencies between different areas, as highlighted by the Audit Commission in their recent report Forget Me Not. The Gover nment’s National Service Framework (NSF) for Older People will be critically important in this area.

THE NATIONAL SERVICE FRAMEWORK FOR OLDER PEOPLE

The NSF for Older People is aimed at improving the quality of and reducing variations in services for older people. It follows the NSFs for Mental Health and Coronary Heart Disease published in September 1999 and March 2000, respectively. It will focus on those parts of the NHS that are particularly important to older people and will set national standards and define service models for the care of older people. The NSF will establish strategies to support implementation, and establish performance measures against which progress within an agreed time scale will be measured.

An External Reference Group (ERG) co-chaired by Ian Philp, Professor of Health Care of the Elderly at Sheffield University, and Denise Platt, Chief Inspector of the Social Services Inspectorate, was set up to advise Ministers on the development of the NSF. The Group included members from a variety of professions and organisations.

The ERG was supported by several task groups looking at the system of health care for older people from different perspectives. These included:

• locations of care — acute hospital care and primary and community care
• process issues — assessment and transitions to, from, and within hospital
• conditions prevalent among older people — stroke, mental illness, dementia, and falls
• a users’ group and a carers’ group to ensure that the process was informed by those who matter most.

The Mental Health Task Group was chaired by Alistair Burns, Professor of Old Age Psychiatry in Manchester. The group had wide representation from other professionals including psychiatrists, nurses, clinical psychologists, speech and language therapists, and senior managers in both health and social services, as well as from the voluntary sector.

The Task Group gave results of their deliberations to the ERG, which has now submitted its final advice to Ministers who are considering the information. At the time of writing, it is too early to say what the NSF will include but the ERG has developed a number of principles to underpin the NSF, which include:

• promoting health and well being — not assuming that being ill is an inevitable part of ageing
• preserving older people’s dignity and respecting their autonomy — how a service is delivered is important and just because people are old does not mean that they can’t be involved in and make decisions about their care
• recognising that informal carers such as spouses and children should be partners in the care process
• ensuring a coordinated approach to service delivery both within the NHS and between the NHS and its partners, particularly those involved in social care
• ensuring that older people have fair access to NHS services — this means access being determined solely on the basis of health need not dependent on age or other factors
• ensuring that staff have the skills and competencies that they need to care for older people.

The Government expects to publish the NSF imminently. It is not intended to be issued to the NSF for consultation since the ERG has already adopted an inclusive process in the development of its advice by engaging a full range of views. The task groups have been central to this as have informal discussions with key bodies such as the relevant medical Royal Colleges and the Local Gover nment Association.

There are some specific points to be made about the NSF in relation to mental health issues. First, it is worth noting that mental health for older people is considered with older people’s health in general and not with mental health. Conversely, the NSF for Mental Health only goes up to the age of 65 years. The reason for this is probably the same as that for separate mental health services for older people. In the years before the development of old age psychiatry, older people would be admitted to the same wards as younger, disturbed patients with psychotic illnesses. They would often be overlooked by the more strident claims to attention of younger patients.

Similarly, the separation of policy along the lines of age means that the needs of older people are not forgotten amidst the headline issues of younger patients with psychotic illness and severe personality disorders. However, it is important that mental health services remain integrated since they have important areas of common ground, for example training programmes and the application of the Mental Health Act.

Second, early onset dementia is covered in the NSF for Older People and not the Mental Health NSF. This reflects the fact that, increasingly, old age psychiatrists and their teams are seen as having the most appropriate experience in this field because of their community ethos and their experience with dementia. It is the linkage of service provision with mental health services for older people that leads early onset dementia to be considered in the Older People’s NSF. Nonetheless, some separate facilities such as day care and respite care may be needed because some younger people with dementia are physically robust and do not integrate easily with frail older people who also use specialist mental health services. Such services specifically for younger patients are beginning to be established.

Third, the NSF will not make any specific recommenda- tions about the availability and prescribing of antidementia drugs. There is no need for it to do so since the Government’s National Institute for Clinical Excellence has recently recommended that cholinesterase inhibitors should be made more widely available across the NHS. Fourth, the NSF will include the full range of mental health problems for older people. There is, however, a particular emphasis on dementia and depression since these 2 conditions are highly prevalent, and are often not well recognised or treated. These are areas of major potential health gain if they are managed more consistently.

CONCLUSIONS

The UK Government has a broad approach to policy for older people. This includes many health and social care initiatives which affect the field of mental health. Among these, the NSF for Older People will be particularly important for everyone involved with mental health and older people.

Acknowledgement

The paper is based on a talk given at a conference in Oxford in June 2000. The full text of many of the documents referred to in this paper can be found at the UK Department of Health website (http://www.doh.gov.uk).

Dr T Dening, MA, MD, MRCPsych, Consultant Psychiatrist, Addenbrooke’s NHS Trust, Cambridge, UK, and Professional Adviser, Department of Health, London, UK.

Address for correspondence: Box 311
Fulbourn Hospital Cambridge CB1 5EF UK
E-mail: tdening@doh.gov.uk