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16 Dec 2009 : Column 277WH—continued
Inevitably, debates such as this-I am sure that the Minister has experienced this on many occasions-turn on what is wrong and needs to be put right rather than dwelling on what is good and wonderful. I make no apology for that, as I hope that he understands that this debate is about raising concerns. I accept that the present Government have not been idle. National service frameworks, "New Horizons", psychological therapies and the national dementia strategy are just a few of the initiatives that they have taken. However, I am concerned that insufficient attention has been paid to the mental health needs of older people. That lack of attention is
not just harmful to the individuals concerned; it wastes taxpayers' money on late and inappropriate interventions and treatment.
To illustrate, in a typical 500-bed district hospital, an average of 330 beds are occupied by older people, 220 of whom have a mental illness. A shortage of trained staff and age-appropriate services mean that those patients remain in hospital for longer and are more likely to be readmitted as emergencies later. The Government have focused on dementia, with good reason; I have no objection whatever to that. The national strategy is welcome, as was the recent announcement on anti-psychotic drugs. I thank the Minister for getting in touch with me on the day of that announcement. However, a much broader approach to the development of age-appropriate mental health services is required in order to drive change.
The World Health Organisation forecasts that depression will be the second biggest contributor to health costs by 2020, just 10 years from now. The rate of depression is set to rise by 30 per cent. among over-75s, and by 80 per cent. among over-85s by 2026, just 16 years from now. Depression is three times more common than dementia and it increases with age, with the poorest most at risk. It is linked to a greater reduction in health than any other long-term condition, and it leads to a sharper decline in overall health when combined with any other long-term condition.
Nevertheless, just one in six older people with depression receives any treatment, compared with one in two younger people with depression. It is a major risk factor for suicide and the cause of 80 per cent. of suicides. Although it is good news that the suicide rate has fallen in the past decade, it has not changed among older people. As a result, the suicide rate in people over 65 is double that of people under 25. Research evidence also shows that older people with mental illness stay in hospital longer and are more likely to die in hospital or to lose their independence and be discharged to a care home.
Mr. Stephen O'Brien (Eddisbury) (Con): I have been listening to the hon. Gentleman's remarks, and I accept that he might be about to develop this point. However, does he agree that one concern, which I suspect we share, is that the amount of research effort, particularly into dementia, Alzheimer's and the mental health of the elderly, needs to match the demographic curve? We need to put the research effort behind where things are going. At the moment, there is some question in most people's minds about that. Is he equally concerned?
Mr. Burstow: The hon. Gentleman is absolutely right to raise that concern, which I hope is shared by all parties. He is two pages ahead of me, but I will return to that point, if I may.
One study found that a person suffering from undiagnosed dementia is three times more likely to die in hospital than other older people. The same research also found that a large number of admissions were inappropriate and could have been prevented by prompt medical care in the community. Lack of specialist assessment is a recurring theme linked to poor-quality care, poor outcomes and waste of taxpayers' money.
Why are things like this, and what needs to change? The introduction of a national service framework on mental health in 1999 kick-started change and investment
in new services, but the drafting of the frameworks reflects an age bias. One need only look at the fact that 149 pages in the NSF for mental health are devoted to the mental health of people of working age, compared with just 17 pages on mental health in the older people's national service framework. What does that tell us about relative priorities a decade ago? The national directors of both mental health and older people's services accepted in 2004 that not as much progress had been made in developing new mental health services for older people, and I am told by the Royal College of Psychiatrists that little has changed since then.
As I said earlier, the progress made for working-age people means that older people with mental health issues are worse off now in relative terms than they were 10 years ago. A serious lack of equity remains in access to mental health services. My point is not to claim a lack of good intent on the Government's part; policy initiatives and national guidelines exist. However, the evidence is compelling that none of that has gained any traction on resource allocation and practice. The National Audit Office has documented how older people have been denied access to assertive outreach, crisis resolution, home treatment and early intervention services available to adults of working age. Other research has revealed a similar pattern of exclusion from hospital liaison, rehabilitation and psychotherapy.
What needs to be done? As I said, the national dementia strategy is welcome. It is an essential although insufficient response to the mental health needs of older people. The Minister and the hon. Member for Eddisbury (Mr. O'Brien) will know that I have a keen interest in dementia research. Only yesterday, I had the pleasure of receiving an answer to a written question to the Minister about the new ministerial taskforce on dementia research. I was fascinated by the answer:
"The remit of the group will be to maintain the momentum begun at the summit by developing a new vision for the future of dementia research and advising on practicable ways to achieve that vision."
Visions are all well and good. They are useful because people can be pointed towards them. However, a taskforce on research must assemble the building blocks of the additional cash that needs to be invested in the area.
The answer goes on to say that the first part of the body's remit is
"to devise ways to use available resources more effectively to help increase the volume and impact of high quality dementia research".-[Official Report, 14 December 2009; Vol. 502, c. 739W.]
That implies that existing cash is to be used, rather than that more will be allocated, and we know that there is a huge gulf between the amounts committed to dementia research and to conditions such as stroke, heart disease and cancer. Finally, the answer states that membership of the body has yet to be finalised. It was announced in July. Five months on, it has not met and its membership is not yet set. Will the Minister say when it will begin its task?
Investment in improving psychological therapies is welcome. However, time will tell whether we will see an equitable roll-out. One in five older people's mental health services report having no access to clinical psychology and one in three community teams do not include clinical psychologists. The British Association for Counselling and Psychotherapy commissioned an independent review on counselling older people, which
concluded that counselling is effective with older people, particularly in the treatment of depression.
It is disappointing that mental health services are not included in the Government's new entitlements regime that replaces the existing framework. For example, if a person is waiting for cognitive behavioural therapy and the 18-week milestone is passed, there is no redress. There is no funding to allow them to get the provision elsewhere. Why were mental health services left out of the entitlements approach? I am sure that will be of interest to many people outside the House.
An evidence-based approach to developing age-appropriate mental health services would save money and deliver better outcomes for older people. Older people's hospital liaison services save money. They reduce the length of hospital stays, cut readmissions and result in better outcomes. For example, a Liverpool hospital that had a high readmission rate for older people set up a specialist liaison mental health team for older people in 1999. An analysis of 324 high-risk people who were referred to the team's social worker because they had complex needs found that they had a 7 per cent. lower six-month readmission rate than the hospital's older patients in general. It also found that 96 per cent. of referrals were assessed on the day of referral and, of the readmissions, only 13.5 per cent. were considered inappropriate.
Care home liaison can save time and money. It can also help to reduce anti-psychotic drug prescribing-something on which I have campaigned for many years, so I welcome the recent announcements. It is estimated if we made the changes needed in that area we would save £55 million a year. A specialist older people's mental health care team in Doncaster runs a home liaison team to provide services to care homes. That has helped to reduce admissions to hospital, improve the quality of care and provide training to care home staff. In its first year, the team received 460 referrals and admissions to hospital reduced by 75 per cent.
Crisis home treatment teams can cut hospital admission rates by a third, reduce the length of hospital stays and reduce admissions to long-term care. In west Suffolk, a crisis resolution home treatment team for working-age adults was extended to include over-65s. Older people had previously had no alternative to being admitted to hospital. Most people with whom the team dealt were suffering from depression. The number of older people admitted fell by 31 per cent. as a result of the extension of the scheme, without any loss in patient or carer satisfaction. There is huge potential to unlock resources and reallocate them to services that deliver better outcomes for patients.
Delivering age-appropriate mental health services requires a more informed work force in primary care, general hospitals, care homes and social care, as they must be able to tailor services to fit individual and age-specific needs. The last remaining barriers within and between health and social care need to be torn down. Integration of services is essential to delivering equity and efficiency. Mechanisms such as local area agreements should play a part in ensuring that we have seamless services with integration and multi-agency working on the ground.
Older people's mental health should be a national priority in the NHS operating framework. I was disappointed to read today in a written answer from the Secretary of State that the new operating framework for
2010-11 is silent on that and that mental health services do not register as a national priority. Not even the dementia strategy registers as a national priority. That is a missed opportunity and a great shame. If guidance, policies and strategies are to get traction, they need to be backed up.
Mr. Stephen O'Brien: I did not spot the written answer, as I was engaged on something else this morning. However, if the framework suggests that mental health, let alone dementia, is not a national priority, does the hon. Gentleman think that that is an admitted change from what was promulgated under previous Secretaries of State, which was that cancer, cardiac and mental health services were the three priorities that the Government were seeking to address?
Mr. Burstow: That was my reading of the Secretary of State's written answer. If there is a misunderstanding, I would rather the Minister cleared it up today. Certainly, my reading of the written answer that was published today is that mental health services, including dementia services, do not feature at the top level of the operating framework. They have to be placed at the top level to get the traction that I assume the Government and the Department want the national strategy to have. I know that there is a debate over whether such decisions should be devolved locally. However, the Government clearly intend to drive change in dementia services. The only way to signal that intention is by making it clear in the framework. I want to get that on the record, and I hope that the Minister will clarify this matter in his response.
In conclusion, the biggest challenge to our health and social care system is the ageing population, as it has been for a decade or more. In particular, the challenge is the mental health of our ageing population. Currently, need is not being meet and evidence is not being translated into practice. There must be a shift in Government policy to the health needs of older people and a comprehensive approach must be developed. That must be a clear and unambiguous national priority. It is unsustainable to do nothing. There are huge opportunities in unlocking resources to make improvements. The case for concerted action is unanswerable. I look forward to the contributions of other hon. Members and to the Minister's response.
2.47 pm
Greg Mulholland (Leeds, North-West) (LD): It is a pleasure to serve under your chairmanship, Mr. Cook, and to speak in this important debate on the last day before the House rises. I congratulate my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) on securing the debate and on his consistent and vigorous leadership on older people's issues. Long may he continue to be such a champion for older people.
According to leading older people's organisations, age discrimination remains the most common form of discrimination in this country. We must take it much more seriously. Perhaps this point is for a different debate, but that is largely due to the failure to put age discrimination on the same footing as other forms of discrimination. Although there are attempts to address that, concerns exist that there will not be the same
clarity regarding age discrimination that there rightly is for other forms of discrimination. In a less obvious way, prejudice plays a part in the health and social care systems. Unfortunately, we still hear examples of older people facing neglect, receiving second-class services, being socially segregated and having restricted opportunities. Far more needs to be done to address that.
The figure to which my hon. Friend referred is shocking: almost half of all geriatricians think that the NHS's failure to provide older people with the level of care to which they are entitled amounts to institutional ageism. That is according to the leading geriatricians in the country, and we should all be deeply concerned about such comments. More than half of those same geriatricians-55 per cent.-said they were personally worried about their own prospects for receiving adequate care from the NHS when they are over 65. Alex Mair, chief executive of the British Geriatrics Society, was quoted in The Guardian as saying
"the NHS is currently failing older people".
The figures show that people over 65 already account for more than 60 per cent. of hospital bed days, and therefore are responsible for the greatest proportion of expenditure on health and social care. In 2007, 8.2 million people were aged over 65 in England and Wales. That figure is projected to increase to 11.6 million by 2026, which is an extraordinary increase of 46 per cent. Similar rises are projected for the prevalence of disability and dependency. The burden on the health and social care system will therefore increase.
A number of reports are worth mentioning: first, the report on the barriers facing older people, which was undertaken by Sir Ian Carruthers, the chief executive of NHS South West, and the Bristol council chief executive, Jan Ormondroyd. It found that older stroke patients received less adequate care than young sufferers, and that almost half of doctors who cared for older people believed that the NHS was institutionally ageist. I was concerned to see that the report goes on to show in some detail the treatment that my hon. Friend has outlined, particularly regarding mental health. The report "Equality in Later Life" also demonstrates that older people are discriminated against regarding access to out-of-hours and crisis services, psychological treatment and alcohol services.
I am afraid that there still appears to be institutional ageism within some of the main NHS services. On cancer, women aged over 70 are not automatically called for breast cancer screening, despite firm medical evidence of a clinical need for that service. Older women with breast cancer receive a lower level of care than younger women, and are less likely to be diagnosed via needle biopsy and triple assessment. They are also less likely to undergo surgery or receive radiotherapy than younger women. When compared with a 65 to 69 year-old woman, a woman aged 80 or older is five and a half times less likely to receive triple assessment for operable breast cancer, and 40 times less likely to undergo surgery. Even women as young as 70 or 74 are more than seven times less likely to receive radiotherapy following breast conservation surgery.
Department of Health figures suggest that compared with other comparable countries, the UK experiences 15,000 extra deaths from cancer a year in the over-75 age group. In relation to that figure, the gap between the
UK and other countries appears to be widening, as does the gap between older and younger age groups in UK.
On stroke treatment, older people are less likely to receive cholesterol-lowering treatments recommended for the secondary prevention of stroke, despite the treatment being equally medically effective across all age groups. Although rates of secondary drug prevention are generally low-26.4 per cent. of patients aged 50 to 59 received treatment compared with 15.6 per cent. of patients aged 80 to 89, with a figure of just 4.2 per cent. for those aged 90 or over-there are lower rates of treatment to prevent stroke in older people, and substantial under-investigation in routine clinical practices for patients aged 80 or over.
On cardiology, according to Age Concern and Help the Aged, 46 per cent. of GPs and care of the elderly specialists and 48 per cent. of cardiologists treated patients aged over 65 differently from other patients. People aged over 65 were less likely to be referred to a cardiologist, given an angiogram or given a heart stress test. Cardiologists were less likely to recommend operations to open up blocked coronary arteries for older patients, and older patients were less likely than younger people to be prescribed cholesterol-lowering statins.
I make those points before coming to the main topic covered by my hon. Friend: mental health. According to Age Concern and Help the Aged, mental health is the clearest example of age discrimination in health and social care policy. A report published in 2009 by the Royal College of Psychiatrists states that tens of thousands of people over the age of 65 are being denied access to specialist mental health services because of arbitrary age limits. That is primarily because the national service framework for mental health extends only to working adults up to the age of 65. There is simply not enough cross-over between such frameworks for mental health and older people. What steps will the Minister take to try to ensure that the frameworks work together more coherently, to ensure that older people cease to get a rough deal by apparently falling outside those frameworks and falling between two stools?
In a survey carried out by the Royal College of Psychiatrists, members of the old-age faculty reported having been
"told of evidence that specialist services for older people with mental health problems, including dementia, are being cut purely to meet the financial pressures created elsewhere in the NHS, and to meet the demands of the Secretary of State that financial balance must be achieved".
Will the Minister say whether that survey finding is correct, because clearly that is of real concern? We are having a debate about already inadequate mental health services for older people, yet the Royal College of Psychiatrists survey shows that concern exists that services will be cut further.
The Government have of course invested extra money to fund working-age adult mental health services up to the age of 65 during the past three years. Clearly, that is welcome, and I think that people would say that services are improving. However, why should that stop at 65? If the framework is going to stop at 65, why is there not more of a mental health strategy for older people from the age of 65 onwards?
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