| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
Several noble Lords raised the question of impunity in relation to Congolese army personnel, some integrated and some in the militias. Bosco Ntaganda was mentioned. Our ambassador has discussed with the UN Secretary-General's special representative Alan Doss the arrest warrant required and has received assurances that the UN mission will support the DRC Government in carrying out the warrant. The Government of the DRC have accepted the indictment and are committed to arresting Bosco, but they are concerned to ensure that the timing of this does not derail the fragile
3 Feb 2010 : Column GC53
I am running into the point when my time is up, although I have probably dealt with only seven of the 47 questions that I have been asked. A voluminous document answering all the remaining questions will be winging its way to all noble Lords who have participated. I repeat my assurance that I shall bring the debate and its contents, suggestions and criticisms to the attention of my noble friend Lady Kinnock before she visits the DRC towards the end of the month.
Mental Health: Age Discrimination
Question for Short Debate
4.45 pm
To ask Her Majesty's Government what action they are taking to eliminate age discrimination in mental health services for older people.
Baroness Murphy: My Lords, it is customary to thank the initiator of the debate, but I urge your Lordships not to thank me. This debate was initiated by the persuasion and at the insistence of the noble Baroness, Lady Neuberger, to whom I am grateful. I have always been rather reticent about raising this topic as a subject for debate, simply because it seemed like special pleading from someone who has spent her life in old-age mental health services, but this is a timely point to have this debate-particularly this week, because of the appointment of the new national tsar for dementia, Professor Alistair Burns. He is a canny, delightful and exceptionally talented man and I know that he will go at it with aplomb, if I may say that. Let us face it, he will have a bit of an uphill struggle, given the National Audit Office's recent interim report on the capacity of the Government, the National Health Service and local authorities to implement the national dementia strategy. However, I am sure that he will get a great deal of support from parliamentarians in his new role.
Before I get into my "Disgusted of Tunbridge Wells" mode, I want to remind everyone how terrible things used to be. Before the 1960s, there were no separate services for older people with mental health problems, which meant that older people with profound mental illnesses stayed in acute hospitals, often for a long time, and just withered away at the end of the ward. They ended up either in Part III homes with the local authority, struggling to cope, or they went to a long-stay asylum or geriatric hospital, depending on whether their modus vivendi was largely horizontal or vertical. It was as simple as that; it was pretty awful.
3 Feb 2010 : Column GC54
In the 1960s, a few pioneers started to develop services. It was a marvellous time to be sent to one of the specialist units for training, as I was. It was an exciting time, because we felt that we were in the vanguard of a developing specialty and that we were showing our fusty old colleagues in general mental health services how community mental health services should be working in conjunction with the local authority. It was tremendous fun and very exciting.
I fear that, as much needed funding has gone into general mental health services, services for older people have lagged behind. We used to be more advanced in the UK than anywhere else in the world. I used to travel all over the world talking about our wonderful services. People were amazed at how far we had been able to come. I am ashamed to say that, nowadays, the situation is better in many other countries. That is a real cause for concern.
Let us come to the shocking statistics, so clearly set down in the Royal College of Psychiatrists' position statement published last year, about which the noble Baroness, Lady Neuberger, asked a Question in the House. There is no doubt that many tens of thousands of people over the age of 65 are missing out on specialist services simply because of the way in which we configure them. This is a tragedy, as many of them risk serious deterioration and will die early as a result of a lack of treatment.
That is in spite of the fact that mental health problems are common in older people. Depression is the commonest disorder in old age. Its prevalence in women tends to stay the same after middle age, but in men it goes up and up. Of course, dementia is almost entirely a disorder of the very aged. Psychosis, which many of us associate with a young onset, is 50 per cent commoner in older people. Suicide is twice as common in people over 65 as it is in people under 25 and we know that at least 80 per cent of people who commit suicide are suffering from depression. However, half of young people with a major depressive illness are referred to a specialist psychiatrist, whereas only one in six older people is so referred. As treatment, by and large, has as great an efficacy among older people as among younger people, and as maintenance treatment can prevent relapse and decrease mortality, this favouring of younger adults makes no clinical sense.
In the past 30 years or so, services have been configured by age. A strict demarcation line was perceived as the only way to carve out the finances necessary to establish a new service. It makes clinical sense, of course, because of the special characteristics of the disorders, which tend to co-exist with physical health problems and are more likely to have an obvious organic medical origin. Also, pharmaceutical treatments are far trickier for them.
I was one of those who supported this age discrimination. I used to tell my colleagues, "Don't you dare treat anyone over 65", because I could then say that the proportion of the budget that went to older people was mine and that all the resources that went to this group of people belonged to my service. It was quite a convincing strategy for getting fair shares. That is how it started.
However, this model has been interpreted far too rigidly. Now we have the tragedy that someone aged
3 Feb 2010 : Column GC55
The recent imbalance has happened by default. In 1999, the establishment of the National Service Framework for Mental Health saw the beginning of much needed investment in mental health services and the creation of new specialist teams. Two years on, the National Service Framework for Older People had one small section only on this. The difference was that the NSF for mental health came with money and performance management directly from the Department of Health, whereas mental health services for older people came with no money and no performance management from the centre. Clearly, not only have these services been excluded from investment and developments but the increasing numbers of older people have not been matched by extra resource. A report commissioned by the department in 2006 confirmed the failure to make progress.
I and many others have pointed out the inequity of this, but it has taken 10 years to acknowledge that permanent leadership in the department is crucial for at least one important disorder. However, the leadership vacuum in other mental health services remains unresolved. It has been calculated that it would take an extra £2 billion to £4 billion to even up access. This is not going to happen-I am not asking for it-but it points to a deep cultural shift in commissioning towards equality of opportunity for older people, which will mean shifting the resources away from other areas, probably within mental health. What are the Government doing to respond to some of those critical reports that have pointed out the shortfall?
Our ageing population is the biggest challenge, but I am still not convinced that we have leadership within government to tackle it. As part of their ageing strategy, the Government have created the UK Advisory Forum on Ageing, which has ministerial leadership from the DWP and the Social Care Minister. It does not refer anywhere on its website to health. Who will be responsible for driving the equality that we need?
I am hopeful that, if the sections of the Equality Bill related to ageing are enacted, a few test cases will help no end, because exhortation never has. There are many issues that I could raise today, but I point to the need for fair access to and distribution of resources, because what needs to be done is fairly obvious. I ask when it really will be done.
4.56 pm
Baroness Greengross: My Lords, I thank my noble friend Lady Murphy for initiating this important debate; I thank also the noble Baroness, Lady Neuberger, for being so instrumental in bringing it about. I shall
3 Feb 2010 : Column GC56
It is estimated that, for every 10,000 people over 65, 2,500-or 25 per cent-have a diagnosable mental illness, 500 of whom will have dementia. That figure is taken from the position statement of the Royal College of Psychiatrists, which the noble Baroness, Lady Murphy, quoted.
The noble Baroness mentioned depression. We know that, on an average day in a 500-bed district general hospital, 330 beds will be occupied by older people, 220 of whom will have a mental disorder. We also know that depression is the most common health problem in later life, affecting 15 per cent of older people. However, 85 per cent of older people with depression receive no help from the NHS, which is blatant discrimination. It cannot be excused, however much progress we make. Depression is the cause of 80 per cent of suicides. It doubles natural mortality and it is the major reason for admission to care homes. Those figures again come from the Royal College of Psychiatrists' position statement of last October.
We know that, if you are under 65 and have a mental health crisis, you will almost certainly receive immediate assessment and treatment at home from a 24-hour specialist team. I have personal experience of this from the past few months. I saw a crisis team go to everybody who was younger before arriving at nine o'clock at night-having been called at 7.30 in the morning-to see an elderly person who was in a very bad state. An immediate move is made to the younger person, not to the older person.
If you are under 65 and have been admitted to a general hospital, you will probably receive an assessment of your mental health, but if you are over 65, you most likely will not. However, if you have a mental health problem, you are more likely to stay in hospital for twice as long or be discharged to a care home instead of to your own home-again, the Royal College of Psychiatrists has made that clear.
I turn to an issue very close to my heart-dementia. Yesterday, the Alzheimer's Research Trust produced a report that demonstrated that one person in five over 80 is affected by dementia and that every patient costs the UK economy more than £27,000 a year. That makes £23 billion a year overall. However, in the UK, for every £10 spent on research into health and social care, the princely sum of 5p is spent on dementia. Although dementia accounts for over 50 per cent of the combined health and social care costs of cancer, heart disease, stroke and dementia, it receives 6 per cent of research funding. A survey of several thousand people with dementia found that almost 50 per cent of carers said that being in hospital had a very negative effect on the person with the condition. The average length of stay, which is about a week, more than doubles for people with dementia.
I am delighted that the Government recently held a research summit on dementia, which I was privileged to chair. A ministerial advisory group has now also been set up. We just hope that, regardless of who wins
3 Feb 2010 : Column GC57
There is blatant ageism in accessing mental health services. The Healthcare Commission's report Equality in Later Life, which examined six mental health trusts, found that older people were excluded from mental health services received by young people, that there were very low levels of referrals from GPs to specialist units for mental health sufferers who are older and that there was a lack of age-appropriateness throughout. Two out of the six trusts have made a lot of progress towards eliminating ageism but they have taken very different paths in terms of structure. A common feature was the role of clinical and managerial leaders in bringing about change. A lot can be done.
The same report demonstrated that many mental health providers have organised their services into working-age and older adult services, which is reinforced by policy divisions between the mental health and older people national service frameworks. Reaching the age of 65 does not mean that you change very much, but suddenly your services are completely different. In my view, that is very difficult to understand, let alone accept. The unintended effect is definitely a disparity between older and working-age adults. Surely the goal must be that services are based on need, not age, as was made clear by the report to the Secretary of State by Sir Ian Carruthers and Jan Ormondroyd in October this year.
We must aim to achieve age equality partly by taking up the recommendation in the Royal College of Psychiatrists' position statement:
"All professional regulatory organisations will need to review and, if necessary, revise their standards",
and codes of conduct. The statement recommends:
"Comprehensive specialist mental health services for older people must be reconfigured and developed, with an urgent need to provide: access to crisis home treatment ... early diagnosis and intervention ... care home liaison ... general hospital liaison",
and, as my noble friend Lady Murphy emphasised,
Surely the biggest discrimination of all in dementia is that a terminal illness experienced mostly by older people is generally treated as being eligible only for social care funding, rather than NHS care. Why is that? Nothing in the proposed national care plan or the Personal Care at Home Bill will radically alter that, so far as I can see, but we must be fair. An Equality Bill is going through the House, intended to achieve fairness in our society. We need the same fairness, whatever our age.
5.05 pm
Lord Crisp: My Lords, I thank both noble Baronesses for raising this important subject. It is rather humbling to be part of this group from your Lordships' House who are discussing this, because it seems to me to be a group that understands these issues profoundly. I suspect that many of your Lordships, like me, have personal experience of family members who have experienced these problems. People are bringing a great deal of experience to this debate.
3 Feb 2010 : Column GC58
I wanted to pick up some points that perhaps go a little wider: how health services are delivered, why we have this problem and what I think those with the political and policy power can do to move it on. I shall make two big general points, which are pretty obvious, and then pick up three more specific points.
The two big general points lie behind what has been said but have perhaps not been spelt out quite like this. The first issue-this is not a personal point-is that this is our future; this is what it will increasingly be about in future. We suspect that there will be more older people with mental illness and co-morbidities. That is another big issue, but those co-morbidities can be lost in people's view of older people with mental health problems. It is our future. It is a growing issue because it will cost us more, whether we plan for it or not-the reality of care will be there.
The second issue is also big and obvious: this will grow in political sensitivity. That is partly because we are all ageing and partly because we now have more relatives in their 80s. As the noble Baroness, Lady Greengross, said, we need only to consider the average age in hospital. In my experience in the NHS, when the average age in the entire hospital went above 72, we were in real trouble. That context is fundamental to the future of health services in the country.
Let me pick up the three specifics. First, there are some treatments that work, which people do not always realise, and there is a research agenda, which I know that the Government have recently promoted, to find more treatments. That is vital, because there is sometimes a sense of hopelessness when one thinks about the subject as a member of the general public. That research is not just about drugs; it is also about understanding how we deliver services. As the Nuffield Trust brought out very well in its recent study on dementia, that is about understanding the nature of dementia and what it is like from the point of view of the person with dementia. A great body of understanding and research still needs to be developed and given higher priority if ageism and other problems are to be tackled.
The other specifics are what my noble friend Lady Murphy referred to as the cultural shift: how do you make change and what are the barriers? I agree that part of it is a leadership issue. It is great to see that a new tsar has been appointed and good to hear the noble Baroness's comments about the original national service frameworks coming with money. So there is a leadership issue, but there are other issues as well. The first is, simply, that we still have a health service that is just not configured for patients with these sorts of needs. They are similar to a lot of other patients with continuing care needs, but we still have a health system that is based around hospitals and doctors and has funding and payment mechanisms that reinforce the notion that health is about GP referral to hospital, treatment in hospital and going home. There is a fundamental barrier to paying for good mental health services. Incidentally, this is not an argument against payment by results-for a whole range of areas, payment by results seems to me to work very well-this is an argument for finding some other way to pay for another range of services. That is a fundamental cultural problem about health, not just in the UK but in all developed countries.
3 Feb 2010 : Column GC59
The second point, which came out in what my noble friend Lady Greengross said, is that this is also about people. It is not just about telling the Government and the policy-makers that they should pay more attention to this; it is about staff and how people think. We have all seen elderly patients who have come into hospital with a stroke. You know that they should have had a scan as soon as possible, but they may be there for 48 hours before something happens. Some of that is benign neglect, if I may put it like that. It is not necessarily about money-sometimes it may be misplaced kindness in not intervening-but it happens all the time.
The third point, which I stress strongly, is that if the Government-the policy-makers-are going to move this up the agenda, it is not just about more money or more leadership but about staff training. I mean staff training within the specific service but even more within the acute hospital. It is certainly true that 5 per cent of our patients spend 65 per cent of the money and that most of those patients have continuing care needs. One wonders whether 65 per cent of medical education is devoted to people with continuing care issues. I suspect that it is not; I see my noble friend nodding at me.
These are big changes. My contribution to this debate is to say that this is real and it is going to get bigger. The political salience will grow. We will be confronted by this more and more. The efforts to solve it are about supporting what the Government have started with their research programme and developing it further; taking further the attempts to change the model of care and service in the NHS more generally so that it accommodates the needs of an increasing number of older people; and pushing forward with the professional bodies and trainers to make some changes in the way that we all, I guess, behave when we work in these services.
5.11 pm
Baroness Meacher: My Lords, I support my noble friend Lady Murphy. That will not be a surprise to many people. As someone who has worked in the mental health services for the best part of a quarter of a century, I feel very conscious of the plight of older people with mental health problems.
Until the national service framework in 1999 introduced a plethora of community services for the working-age mentally ill population, the plight of older people today was shared by anybody with a mental health problem. What has changed is that the younger age group has finally received some services. Since 1999 there have been enormous strides in meeting the needs of people aged 18 to 64. Most particularly, as others have mentioned, multidisciplinary crisis teams go into people's homes when they face a severe mental health problem. I emphasise that these teams go into people's homes maybe three times a day in the early stages, supporting those people, monitoring the effectiveness of medication and making sure that they can manage in their own homes. It is these crisis teams, perhaps more than anything else-there are of course other teams, as my noble friend Lady Murphy mentioned-that have had a major impact in reducing the flow of people into in-patient beds.
3 Feb 2010 : Column GC60
If one is to be brutally honest, the savings to the economy from this reduction in mental health in-patient beds has been very significant. It is very much the success of the national service framework combined with the failure of government to provide the funding and performance management system for the National Service Framework for Older People that has created the gap in services and generated the age discrimination. In speaking in this debate, I applaud the Government for the incredible success of the national service framework over the last 10 years. We should not forget that in this debate.
A national survey in 2006 showed that only 8.8 per cent of mental health providers had a crisis team service specifically for people over 65. Others, such as the trust that I chair in east London, I am sad to say, in theory extend the crisis service to people over 65. I was talking to my medical director and found that, in practice, what happens is that these crisis services will carry out an assessment in the middle of the night if somebody over 65 is referred to them but will not prepare a package of home treatment care for the person over 65. The same applies to assertive outreach teams. We do not say, "People over 65 can't go to an assertive outreach service". It is open to people over 65, in theory. The fact is, though, that the assertive outreach team is overwhelmed with people aged 18 to 64, so it will not take on someone of 65-plus, so people in that age range are simply not referred. The problem is that these teams have not been funded to deal with the whole community and the decision has been made to squeeze out the elderly.
| Next Section | Back to Table of Contents | Lords Hansard Home Page |