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In addition to all this, older people have had very little access to psychological therapies. The improving access to psychological therapies programme, which is now being rolled out across the country, is age-neutral-again, in theory. However, in primary care I understand that older people suffering with depression or anxiety, disorders that are very susceptible and respond well to NICE guidance-recommended psychological treatments, will not be referred to those services. One reason for that, according to the guru on this subject, David Clark, is that therapists need specialist training in order to apply those treatments to older age groups. So far, there has been no provision of specialist training for people with IAPT to enable them to provide the services to older people.
I understand the Government's commitment to the IAPT provision as a route back into employment. My worry is that that commitment, which any incoming Government, of whatever colour, would no doubt replicate, would inevitably lead to IAPT following the other services in precluding older people from access in practice. In theory they have access, but I do not believe that they will in practice unless something specific is done.
The question then is: can we afford to continue ignoring this problem? The evidence suggests that we cannot. I pay tribute to the excellent report by the Royal College of Psychiatrists, The Need to Tackle Age Discrimination in Mental Health, which I will draw on quite heavily in giving noble Lords a few figures; others have quoted different figures, but there may be a tiny bit of overlap.
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First, there is the size of the problem. In the UK, 40 per cent of older people attending their GP have mental health problems. Fifty per cent of older patients in general hospitals have mental health problems-I have to say that I did not know that figure, which is colossal and terrifying-as do 60 per cent of people in care homes, which is slightly less extraordinary. The whole set of figures is just amazing. The situation is only going to become worse. The number of people over the age of 75 with depression will increase by 30 per cent and of those over 85 by 80 per cent by 2026. Depression in later life is strongly linked, as the noble Baroness, Lady Murphy, said, to physical ill health and disability.
I am sure that the rationale behind limiting the national service framework to working-age people was purely economic: as these people are not contributing to the economy, the urgency of treating them is less, so let us leave them out. You can sort of understand that. However, even on economic grounds, the case now for addressing the needs of the elderly is irrefutable. Delivering older people's mental health services to care homes not only improves the quality of life for the individual but reduces the prescribing of antipsychotic drugs, the use of GP time and days spent in hospital. Someone needs to work out those figures-in fact I am sure that someone has, but I do not have them before me-but there must be considerable savings in that area alone.
The provision of older people's psychiatric hospital liaison services could achieve considerable savings through reducing the length of hospital stays and reducing readmission rates. Despite the fact that these liaison services are recommended by the Department of Health, the National Institute for Health and Clinical Excellence and the Royal College of Psychiatrists, only 27 per cent of trusts provide even the most basic of these liaison services. I believe that only with a very clear commitment from the Department of Health and a requirement on PCTs to fund those services will they be provided, albeit that the economic arguments are very strong. If PCTs were a bit more sophisticated, surely they would provide those services.
According to the Royal College of Psychiatrists, preliminary evidence suggests that crisis home treatment teams for older people reduce hospital admission rates by up to 31 per cent. They also reduce the length of hospital stay, unplanned admissions and admission to care homes. The potential savings must be colossal. The New Horizons strategy, which replaced the national service framework in 2009, provides a good framework to start reversing the age discrimination. It makes it clear that provision needs to be made to enable groups that have lagged behind to catch up.
I will jump to the end. I hope that the Minister will be able to give the Committee an assurance that research funding in this field will be given priority and that the Department of Health will ensure that rational decisions are made by PCTs to invest in mental health services to cut the huge waste of resources in placing people with mental health problems in acute hospitals when they can be far better cared for at home.
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5.21 pm
Baroness Neuberger: My Lords, I am enormously grateful to the noble Baroness, Lady Murphy, for instigating this debate. Despite her compliment to me-it was a bit of a plot that we cooked up in the wake of the launch of the Royal College of Psychiatrists' report-it seemed to me that this issue requires cross-party thinking. It is wonderful, with her expertise and lifelong working experience in the field, that she should lead the debate. I am really grateful to her for doing so.
We have heard a lot about the statistics in the Royal College of Psychiatrists' report, but this is an issue that we as a House address all too rarely. The report pointed out the worrying statistics about which we have already heard. We all know that the National Service Framework for Mental Health was for working-age adults only. I agree with the noble Baroness, Lady Meacher, that the Government have made huge strides-we as a society have made huge strides-in the treatment of mental illness of people of working age, but that has led to what seems to be an extraordinary discrimination against older people. The National Service Framework for Older People deals only with dementia and depression, not with other conditions that are common among older people, including psychosis, which people think belongs to young men but is common among older people, and delirium, which is very common.
Over the past decade, partly as a result of the national service framework and partly, as the noble Lord, Lord Crisp, said, because of the way in which we commission services, things have actually got worse. Everyone knows that they have got worse. The Department of Health has commissioned two reports and has considered what would be needed if we were to make older people's access to services equal to that of younger adults. The sum involved is vast-something like £2 billion to £4 billion, as the noble Baroness, Lady Murphy, mentioned. That seems to be especially evident around the area of depression and anxiety disorders. This is information that the department itself has brought into the public domain.
We are an ageing society. One could argue that the Equality Bill, which we are debating at the moment, should help, but we need to be very clear about the statistics, which others have mentioned, on the prevalence of mental illness among people aged over 64 in the UK. As I am about to hit 60, I am getting a bit concerned. This will affect quite a lot of us quite soon. We know that the incidence of mental disorder among people aged over 64 in the UK is between 20 and 25 per cent and that dementia comprises between 20 and 25 per cent of that. The noble Baroness, Lady Meacher, cited the extraordinary figure that, for older people, there are mental health problems among 40 per cent of people who go to their GP and 50 per cent of those who are in hospital. I agree that the figure of 60 per cent in care homes seems a mere bagatelle by comparison. The King's Fund showed that, by 2026, the only increase in the number of people with mental disorder will be by virtue of ageing, which is why this is such an enormously important cultural issue.
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The Deputy Chairman of Committees (Lord Brougham and Vaux): My Lords, we have a Division in the House. We will adjourn for 10 minutes and add 10 minutes on.
5.24 pm
Sitting suspended for a Division in the House.
5.34 pm
The Deputy Chairman of Committees: We shall finish this debate at five minutes to six. The noble Baroness, Lady Neuberger, may continue.
Baroness Neuberger: My Lords, I was in full flow. I shall now cut some of what I was going to say.
We have already heard that there is a huge incidence of depression among people over 75, that it is likely to increase by 30 per cent by 2026-by 80 per cent among people over 85-and that it is three times more common than dementia, especially among people who are living alone and in isolated circumstances. We know that it is a major risk factor for suicide, we know that it increases natural mortality by a factor of two to three and we know that it impairs independent function. It also worsens the outcomes of other medical conditions and it costs a lot. The consequences are therefore serious. What it really says is that society does not care much. This kind of discrimination reflects cultural attitudes on the value of older people versus the value of younger people. The noble Lord, Lord Crisp, is right: we need to take this seriously. I could say much more about this.
I wish to draw two other issues to the Committee's attention. In the national audit of violence, there were far higher rates found in wards for older people than among younger people. Also, the sudden unexplained deaths in patients were highest among those aged 65 to 74, particularly where dementia was involved. That is eight times higher than among those aged 45 or less. That suggests, again, that something odd is going on. We cannot track it exactly, but it looks peculiar. This must be cultural. It is a form of discrimination; the noble Baroness, Lady Greengross, is right about that. Older people are seen as making less fuss and as being less likely to cause a row. That is why we need to take this seriously in a cross-party way.
I would like to ask the Minister five questions. First, as there is already discrimination against older people in mental health services, will funding for older people be protected against any forthcoming financial constraints, or will older people be penalised equally with younger people, which would compound discrimination? Secondly, will lack of funding be used as a justification for not addressing age discrimination in mental health services? Thirdly, can she confirm that there will be investment in specialist services for older people to match demographic change, or will discrimination be allowed to escalate by increasing demand exceeding lack of supply? Fourthly, can she confirm that legislation will protect the need for age-appropriate specialist mental health services-the need, for example, for specialist training and provision for CBT-or will this have to be an exception in a law to ban age discrimination? Finally, because depression is
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5.37 pm
Earl Howe: My Lords, it is with particular feeling that I express my gratitude to the noble Baroness, Lady Murphy, for tabling this Question, to which she spoke, as ever, so compellingly. I add my thanks to the noble Baroness, Lady Neuberger, for the conspiracy that she entered into with the noble Baroness, Lady Murphy.
I was shocked when I looked at this subject closely. We owe it to the Royal College of Psychiatrists and to the former Healthcare Commission for publishing the evidence of what is little short of a national disgrace. In using that phrase I am not necessarily pointing the finger at the Government, for reasons that I shall explain in a minute, but, nevertheless, I am sure that the Minister will agree that the systemic failings highlighted in the debate cannot now be ignored. They require action both at the centre and at every level of the health service. Her reply today will be listened to and noted with more than usual attention.
I am the first to say that mental health services in general are a lot better than they were a few years ago thanks to the investment that has been made in them. However, it is sadly all too clear-the noble Baroness, Lady Greengross, gave some statistics-that those services are not available to nearly the same extent for older people. I am not going to repeat the statistics; we all have as our bible the compendium of evidence assembled by the Royal College of Psychiatrists, which will be our point of reference for the foreseeable future.
The evidence assembled by Age Concern should also pull us up short. While I shall not repeat some of its figures, a few have not been mentioned today. They are figures that fall on the other side of the equation-what all this is costing us as a country. According to Age Concern, if we do not satisfactorily meet the mental health needs of older people over the next few years, the UK economy will suffer to the tune of £245 billion per year in lost consumers, £230 billion in lost workers, £15 billion from the absence of lost carers, and so on. Therefore, there is an imperative of a purely economic kind, never mind the one that we first think of-the cost in human terms.
If as an elderly person you are seriously mentally ill and you find yourself in hospital, your prognosis is particularly poor. You are likely to stay in hospital longer. You are more likely to lose independent function. You are more likely to die. To my mind, admitting an elderly person to hospital because of their mental state is to admit that the system outside has failed them. What is going wrong? The royal college points to several things. One is the arbitrary cut-off at age 65 between adult mental health services and health services for older people. That cut-off, to which other speakers have referred, is less the result of deliberate action on anyone's part than an unlooked-for consequence of the way in which services have been configured to conform to, on the one hand, the National Service Framework for Mental Health and, on the other, the National Service Framework for Older People. The
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The other main factor underlying this picture relates to professional training-the lack of training combined with misplaced cultural attitudes towards the elderly. The problem that the noble Baroness highlighted cannot be solved overnight or by passing an Act of Parliament. It is quite clear that the needs of older people are too often not properly understood at primary care and community level and, because of that, they are not being correctly addressed.
Older people's mental health needs are different from those of the young, which is why we have to think about how to meet those needs in a way that also looks at the older person's total circumstances, including their physical illnesses. I was glad that the noble Lord, Lord Crisp, mentioned co-morbidities. It is not enough just to identify depression in an older person and then treat it. We need to look at the causes. Very often older people feel isolated and lonely. There can be all sorts of reasons for that. Someone who is incontinent may be afraid to go out. Someone whose toenails need cutting may find it painful to walk. Someone whose eyesight is poor may not be able to manage in the street. Yes, we need specialist mental health services for the elderly, but this is also about holistic care of the elderly in the community, and the services required to deliver that are often neither complex nor particularly expensive.
We rightly hear a lot in the news about the increasing incidence of dementia, but the World Health Organisation is warning that, in 10 years' time, depression will be the second highest health burden that we have to deal with. The number of people who live alone is steadily increasing and the availability of informal care is shrinking. Although we talk about wanting to keep elderly people in their own homes for as long as possible, we have to remember that a care home can provide an older person with company and stimulation. Delivering primary care services direct to care homes, as the noble Baroness, Lady Meacher, was right to tell us, is also very cost-effective in terms of patient outcomes and the use of professional time. However, with rising numbers we must invest in people. The way ahead lies in having clinical teams with the right skill sets, which are capable of providing age-appropriate services, including mental health services in the community. Age-appropriateness is important.
There are examples of good practice and there are some good government initiatives, including New Horizons and the national dementia strategy, but if there is one message that we need to take from this debate it is surely that time is now of the essence.
5.45 pm
Baroness Thornton: My Lords, I have slightly less time than I was told that I would have because of the way that the debate went, but I will do my best to address all the remarks that were put to me. I start by thanking the noble Baroness, Lady Murphy, for giving us the opportunity to debate an issue that is of such
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Unfair discrimination of any description, including by age, is unacceptable. It is alien to the principles that sustain our National Health Service and it is vital that we do everything that we can to eradicate it, not just in health but across every part of public services. It is unfortunately the case that many older people live with mental health problems. There is also, as many noble Lords have said-the Government agree with this-strong evidence that older people experience discrimination at all levels of mental health care, as described eloquently by the noble Baroness, Lady Murphy. The 10-year National Service Framework for Mental Health, which ended last year, covered only adults of working age. I say to the noble Baroness, Lady Meacher, that it was directed at working-age adults not because of economic need; it was, more likely, because of the kind of issues that were outlined by the noble Baroness, Lady Murphy, in her introductory remarks about addressing the needs of the elderly. Mental health for older people was confined to the National Service Framework for Older People, which has indeed added to the widening of age discrimination.
I will start by talking about the Equality Bill; I am working on it at the moment, so it is high in my mind. Many of the points that were made left me thinking that the Equality Bill will help. The Equality Bill and the age equality review are important milestones in the Government's long-standing commitment to anti-discrimination. The Bill will give real bite to much of the work that is already under way. It will sharpen minds across the NHS and social services when the age discrimination ban comes into force in 2012. The Bill is not the beginning but the continuation and embodiment of our efforts. We can credibly talk about ending unfair age discrimination, although there is plenty to do.
The noble Baroness, Lady Murphy, mentioned test cases. She may well be right, but the contemplation of test cases might do much to change the culture. The recommendations set out in the review of age discrimination in the health and social care sectors by Sir Ian Carruthers and Jan Ormondroyd are sensible pointers to what we need to do next to create services that fully meet older people's needs.
In December 2009, we launched New Horizons: A Shared Vision for Mental Health, our comprehensive programme for improving the mental health and well-being of the whole population and the services for those with poor mental health. It takes a lifespan approach, from laying down the foundations of good mental health in childhood, through promoting and protecting continued well-being into adulthood, to supporting and maintaining resilience in older age. New Horizons comes on top of significant, real-terms investment in mental health services. Since 2001-02, spending has grown by £2 billion, or by 50 per cent in real terms. This means a two-thirds growth in the number of psychiatrists, a fifth more psychiatric nurses and over 700 new teams providing specialist mental health services in the community.
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New Horizons is about making the most of the fruits of almost a decade of investment. It is about focusing on prevention, early intervention and innovating and collaborating for the best possible results. I take on board the point made by the noble Lord, Lord Crisp, about reconfiguring the NHS with regard to this issue.
We are committed to ensuring that mental health services move away from the traditional explicit discrimination between adults and older adults. In 2009, the Healthcare Commission reviewed six mental health trusts. It found that two were delivering services based on need, not age, but that the other four still had to address the issue. The two trusts had approached the issue differently but both had required strong clinical and managerial leadership to be successful. Again, to echo the point made by the noble Lord, Lord Crisp, this is about leadership. The need for specialist older people's services should be recognised, but with access based on need, not date of birth.
We are working with the Royal College of Psychiatrists to develop an appropriate toolkit for mental health services and to assist it in developing age-appropriate, non-discriminatory services. As a first step, New Horizons provides the descriptors of such services to assist in this work. The providers of these services will be able to assess themselves against the toolkit to ensure that they are meeting the mental health needs of older people in their communities.
We are also working with the Royal College of Psychiatrists, the Royal College of General Practitioners, the Royal College of Nursing and the British Psychological Society to develop training initiatives to improve the rate of identification and the treatment of depression in older people both in the community and in residential care-again echoing the points made by the noble Lord, Lord Crisp. Psychological therapies are available to adults of all ages who experience depression or anxiety disorders. Age should not form any barrier to access to those services and we expect positive outcomes for individuals who may approach those services.
The noble Baronesses, Lady Greengross and Lady Murphy, referred to the need for specialist services for older people. We absolutely agree. New Horizons supports equal access to services. The noble Lord, Lord Crisp, talked about the characteristics of services for older people. I shall need to write to him with more detail about what New Horizons says about that, but he may well be familiar with that.
This Government have a track record of working with the NHS and I take on board the need to change the culture in this area. The first national dementia strategy, launched in February last year, is driving real change in the quality and scope of services for people affected by dementia. We very much welcome Alistair Burns, who has been mentioned, as the new national clinical director for dementia to lead this work. We are also doing vital work across social care, including through the Putting People First programme, which is slowly changing the one-size-fits-all culture of services to embrace a more personalised approach.
The noble Baroness, Lady Neuberger, asked about exceptions relating to mental health in legislation. We are determined to end age discrimination in the provision
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