Background

This study addresses the urgent need for better evidence to inform the provision of care for older people with mental health problems, a significant and growing group whose care costs constitute a substantial proportion of the health and social care budget. Entitled National Trends and Local Delivery in Old Age Mental Health Services, the research explores the most appropriate and cost-effective ways of organising and delivering care for this client group at the macro (strategic planning) and mezzo (provider unit) levels, locally and nationally.

The rising number of older people in the UK presents a considerable challenge to policy-makers, commissioners and service providers nationwide. More than 10 million people in the UK are aged ≥ 65 years, and this figure is anticipated to rise by almost two-thirds in the next 20 years. Moreover, the fastest growth in numbers will be among the ‘oldest old’, the biggest users of care services. Population projections suggest that by 2033 the number of people aged ≥ 85 years will have doubled.^1,2

Although many older people will lead healthy, fulfilling lives, increasingly involving work or roles as volunteers or carers,^3,4 this demographic change will have a significant impact on the ability of services to meet the needs of older people with mental health problems, not least because the prevalence of dementia increases exponentially with age. Some 5% of the population aged > 65 years and 20% of those aged > 80 years have dementia, while approximately 15% of all older adults have depression. Others are affected by anxiety, schizophrenia, paranoid states and substance misuse.^5–7

Such disorders carry very high costs, both personal and economic, for many are subject to relapse or of long duration. Mental health problems can affect every aspect of a person’s functioning, exacerbate physical ill health and cause significant personal and family distress.^7,8 They are also associated with increased service use.^9,10 Relatively conservative estimates suggest that 40% of older adults visiting their general practitioner (GP), 50% of general hospital inpatients and 60% of care home residents have a mental health problem,¹¹ and older people with mental illness make greater demands on home care services than the older population as a whole.^12–14 Indeed, the total economic costs of dementia have been put at £23B per year,¹⁵ more than the annual cost for stroke, cancer and heart disease combined.¹⁶ This provides a marked incentive to make the best use of resources, particularly in a climate of economic constraint.¹⁷

Although old age psychiatry was not formally recognised as a specialty within the NHS until 1989, the need for specialist services for older people with mental health problems was first recognised in the 1940s, prompted by the already increasing number of older people, the differentiation of clearly demarcated syndromes of psychiatric disorder in later life and the inadequacies of care in long-stay institutions.^18–21 Until then older people with mental health problems had generally been cared for by general psychiatrists, but in the late 1960s and early 1970s the first consultant psychogeriatricians were appointed and reports of specialist services began to emerge.^20,22,23 Steady service development followed, and by 1980 there were approximately 120 consultant psychiatrists with a substantial time commitment to the care of older people. Many of these staff were based in hospitals, with beds in long-stay wards and a high proportion of chronically ill patients.²⁴

The pattern of service development over subsequent decades reflects a move away from the medical assessment of patients in largely hospital-based services towards the multidisciplinary assessment, treatment and support of patients in predominantly community-orientated services.²⁵ This shift was in keeping with the growing policy imperative for community care,^26–28 and was stimulated by a variety of considerations including costs and cost-effectiveness,^10,29 with institutional care generally perceived to be more expensive than care in the community.³⁰ There was also a growing belief that most older people, including those with complex needs could, and would rather be, cared for in their own homes.^10,31 However, such preferences are themselves likely to be influenced by the relative availability and quality of care in different settings, the availability of informal care, and cultural expectations about family obligations and personal cost.³²

As the number of NHS hospital beds fell throughout the 1980s, the care home sector grew, boosted by a paradoxical financial incentive whereby people eligible for supplementary benefit could have their care in private and voluntary sector homes funded through income maintenance support with no medical or social work assessment required.^33–35 The resulting concerns about service funding and organisation led to the 1990 NHS and Community Care Act,³⁶ which stressed the role of local authorities as arrangers/purchasers rather than providers of care and highlighted the need for a comprehensive review of individuals’ health and social care needs before admission to long-term care. Mechanisms to increase choice and flexibility, match services with need, and promote accountability and quality were described, and a special transitional grant was made available to fund community care packages as well as care home placements.^{33,35,37–39} Designed as a corrective to the institutional bias of the previous decade, by the mid-1990s dependency levels in residential settings were considerably greater than in the mid-1980s⁴⁰ and have risen further since.^41,42

Despite little government guidance on the role of mental health services for older people, specialist services continued to grow rapidly throughout the 1980s and 1990s.^43,44 The dominance of ‘the medical model’ declined further, and an increasing emphasis was placed on the need for health and social services to work together.³ By the end of the twentieth century, localities aimed to offer mental health services that were ‘comprehensive, accessible, responsive, individualised, multidisciplinary, accountable and systematic’.⁴⁴ However, many areas could not live up to such aspirations, and variation in service practice was deemed likely to have a negative impact on equity, efficiency and patient outcomes.^43,45–47

The publication of the National Service Framework for Older People (NSFOP) in 2001³¹ and a string of linked initiatives^11,48,49 were widely welcomed as an attempt to address these inconsistencies and improve the quality of care. Outlining a 10-year programme of reform, the NSFOP aimed to deliver fair, integrated and high-quality services based on eight national standards, one of which concerned the provision of care for older people with mental health problems and their carers. Integrated health and social care services, including a broad range of hospital- and community-based facilities, were to deliver effective diagnosis, treatment and support.³¹ Multidisciplinary community mental health teams for older people (CMHTsOP) were given a key role in the provision of specialist care for people with severe or complex mental health problems at home, as well as providing support and advice to staff working in primary, care home and general hospital services. In comparison with the previously published framework for adults of working age, however, the framework contained less prescriptive models of service and no dedicated resources.⁵⁰

Despite such high ambitions, recent years have witnessed several reports expressing profound criticism of the care received by older people with mental health problems, including the ongoing difficulties of getting services to work together.^50–53 Although specialist mental health services have continued to grow, there remains significant disquiet about the degree of variation in practice and investment, whereas the ongoing efficiency savings demanded from local authorities have led to tighter eligibility criteria and fewer people receiving services.^2,54–56 The National Dementia Strategy was designed to address at least some of these concerns, and early priority has been given to the need to provide good quality diagnosis and intervention for all; improve the quality of care in general hospitals and care homes; and reduce the use of antipsychotic medication (a particular concern in care homes).^57–59 Although it has been argued that the primary function of long-stay facilities is to provide care for people with advanced dementia⁶⁰ and the proportion of residents with depressive symptoms is also high,^61–63 evidence suggests that care home staff are often ill equipped to meet such needs and that many mental health problems go undetected and undertreated.^63,64

The need for new research

Although a consensus exists on the need to improve mental health care for older people, and on its underlying principles, evidence on the relative clinical effectiveness and/or cost-effectiveness of different service models is sparse.^7,65,66 Relatively few studies have made useful service comparisons enabling inferences to be drawn about the best ways of delivering care, and evidence from other countries with different service arrangements is not always transferable to the UK.^7,49 In the absence of clear evidence, local service development and commissioning have reflected both historical funding patterns and individual enthusiasm and commitment.^66,67 There is then an obvious need to help health and social care commissioners and providers make informed decisions about resource allocation and address any unwarranted variation in supply.^68,69 The programme of work detailed in this publication seeks to contribute to that process focused on three fundamental concerns at different levels of the health delivery system in England:

• to refine and apply ‘the balance of care (BoC) approach’ (a systematic framework for choosing between alternative patterns of support by identifying people whose care needs could be met in more than one setting, and comparing their costs and outcomes) to the care of older people with mental health problems
• to identify whether, how and at what cost the mix of services provided for this client group might be more optimally developed in a particular locality
• to enable other health and social care decision-makers to apply the BoC framework independently
• to identify core features of national variation in the structure, organisation and processes of community mental health teams (CMHTs)
• to examine whether or not different CMHT models are associated with different costs and outcomes
• to identify core features of national variation in the nature and extent of specialist mental health outreach services for older care home residents
• to scope the evidence on the association between different models of outreach and resident outcomes; and
• to disseminate the findings and service development tools from the work to NHS trusts, commissioners, local authorities and national policy-makers.

First, at the macro level, the programme examines the combination or mix of inpatient, residential and community services, health and social care, provided for older people with mental health problems, and whether or not the balance between them can be altered beneficially (workstream 1). As noted earlier, the configuration of supply and investment in localities varies and is subject to debate. However, there is relatively little evidence about the characteristics of those people who benefit most from different services or the relative cost-effectiveness of institutional and non-institutional care.^7,65,70 Against this background, Chapter 2 reports the findings of a systematic review of the past use of ‘the balance of care’ approach, which offers a systematic framework for choosing between alternative patterns of support by identifying people whose care needs can be met in more than one setting and comparing the costs and outcomes of different options.^71,72 Building on this, Chapters 3–5 outline the results of a new development to this approach and demonstrate its utility in planning care for older people with mental health problems through a detailed evaluation of the mix of services needed in three areas of north-west England.

Second, at the mezzo level, the programme explores the factors which make for the effective working of CMHTs for older people (workstream 2). The provision of integrated, multidisciplinary CMHTs has formed a central plank of mental health policy for older people with mental health problems.^11,31,48,57 However, although there is a modest evidence base to support a range of individual-level interventions undertaken by staff in such teams,^7,65 comparatively little is known about the service design features or models of teams associated with better outcomes, or their relative costs.^49,70 To this end, Chapter 6 details the findings of a systematic literature review to establish the known nature and extent of variation in teams’ structures and processes over time, and the strength of the evidence-base linking variations in team approaches to service user, staff and service outcomes. This is complemented by the results of a national survey of the composition and working practices of contemporary CMHTs, and the findings of an evaluation of the relative costs and outcomes of different team models using a multiple case study approach (see Chapters 7–11).

Lastly, the programme provides a detailed picture of the support available to meet the mental health needs of older care home residents (workstream 3). Improving access to specialist care and advice for this population has recently become a prominent concern^11,57 and many specialist services already provide support for care home staff.⁷³ However, relatively little is known about the quality and availability of the services they offer. This work seeks to address that gap and reports the findings of a systematic literature review that examined how the structure, organisation and activities of specialist mental health services vary in their provision of outreach to older care home residents, as well as the impact of such services on resident outcomes (see Chapter 12). This is augmented by the results of two national surveys, one of CMHTs outreach services, and one of care home managers (see Chapters 13 and 14). Although a proposed trial of depression management for older care home residents was not funded, this work provides a valuable scoping of a critically important area in old age mental health services.

In summary, the programme presents both national data that will act as a benchmark for future service development and monitoring, and new information on the most cost-effective ways of organising and providing services to facilitate evidence-based development. As befits complex evaluations, it displays a concern for both measurement and meaning, process and outcomes,^66,74 and draws on a combination of quantitative and qualitative approaches. Given the breadth and depth of this programme, the material presented necessarily covers only a proportion of the work undertaken and forms just one element of a comprehensive dissemination strategy. Nevertheless, the findings will be useful to a range of different stakeholders, including service providers, commissioners, policy-makers, carers and older people themselves.