Older Mind Matters

One size doesn't fit all - age discrimination in mental health

I’ve recently had two emails from people concerned about proposed changes in their services to form a “purely dementia service on one hand and a one size fits all functional service on the other.”

The terms “age-inclusivity” and “age-integration” have been used to describe the requirement to ensure that services are based on need, not on age, and that policies and plans address the needs of people across the age range. In practice this means that general adult psychiatry services are now more flexible and will keep on people they know well and are caring for appropriately, rather than expecting an individual’s 65th birthday present to be a transfer to older adult services. The expertise and specialism of old age psychiatry lies in complex admixtures of physical and mental health problems, often complicated by social and psychological disadvantage, and this is now seen to be applicable to some people earlier in life.  “Age-inclusivity” should mean that people’s mental health needs are important, regardless of age, and everyone must have access to appropriate services with no rigid age-divide governing access, development, or level of funding. Service models developed for working aged adults (eg crisis intervention, home treatment teams) should not be the exclusive property of general adult services: there is a need to investigate how these sorts of service are best provided to older people.

Unfortunately some people have misunderstood this to mean that specialist old age services are ageist and need to be done away with. Documents produced by the Department of Health make clear that the vision for older people with mental health needs is a vision of age appropriate services with access to properly resourced and designed specialist services addressing the particular and complex needs of later life which are the core business of older people’s mental health. The National Dementia Strategy (Department of Health, 2009) says:

‘specialist services have a role that extends beyond dementia alone – they have responsibility for older adults with schizophrenia, depression and mania, as well as for those with dementia that is complicated by mental and/or behavioural disorders. However, they are also a vital component part of service provision for people with dementia. An effective system of dementia care requires strong, well resourced and effective specialist older people’s mental health services.’ (p73)

This means that where older adults’ needs can be met by general psychiatry services then they should have access to general psychiatry, and that, where people earlier in life have cognitive impairment or complex physical and mental health needs which are better met in old age psychiatry services, they should have access to old age psychiatry. It also means that services across the life span should be equally well resourced, developed and supported and that older people are included and appropriately prioritised in policy and service development. It is blatant age discrimination to argue that older adults shouldn't have access to specialist services tailored to their needs (see the Royal College of Psychiatrists Position Statement on Age Discrimination, 2009) and, in my view, proposals to move to a “one size fits all functional service” are being explored by organisations purely as a cost cutting measure. Such changes will disadvantage the most vulnerable who are least likely to be able to protest and oppose  cuts which are disguised under a banner of doing away with so-called discrimination (curiously it isn't discrimination to have services aimed at the special needs of children or women). 

The Public Sector Equality Duty (2011) states that it may involve treating some people better than others and

‘positive action provisions in order to provide a service in a way which is appropriate for a particular group’.

The consultation on the Equalities Act (Government Equalities Office, 2011) makes the following point:

‘When developing our approach for health and social care, our intention has been to eliminate harmful discrimination, whilst preserving the use of age where it is right to do so – for example, treating an individual based on his/her needs and providing age-appropriate services as necessary’. (p7)

The people who come under the care of older people's mental health services are people with complex comorbidities. They would be gravely disadvantaged on wards for younger adults. Also there is no clear boundary between cognitive impairment and functional illness. For example people with depression often have memory problems whilst they are depressed and people with dementia may be depressed in addition to their dementia. The most ill older people will be the ones who suffer most if services are forced to move towards a 'one size fits all' service. But of course I guess it doesn't matter - they're old aren't they?

2 comments (Add your own)

1. Michael Hurt wrote:
It is so helpful to see such experienced, well published and very qualified people from older peoples' mental health write about this subject. There is clearly is a big misunderstanding with managers and some commissioners around the age discrimination argument and indeed the need to fit people into care clusters.

Let's hope that this blog helps enlighten managers and local policy makers!

Tue, March 22, 2011 @ 5:24 PM

2. DJ wrote:
One size etc: How old am I and does it matter?

The problem as I see it is the wish to go along with as many people as possible – leaving the world with fudged boundaries or no boundaries at all. Big biological systems require a cellular structure and specialisation of parts for optimal function and the delivery of complex outcomes. This is most clearly demonstrated in human beings as individual organisms.

The question then is not if to subdivide but how to subdivide large and complex organizations such as those aiming to promote multi-dimensional, multi-purpose health and welfare. The currently pc mantra that age appropriate services equate to ageism is illogical and, in my view, represents a particularly cynical version of ageism itself: special services for children and adolescent are good – youngsters are valued and deserve the best. Indeed professionals must not attempt to provide services for individuals in these age groups unless they are appropriately experienced or licensed. In the same way special facilities for women, special services for ethnic minorities etc are welcomed and encouraged.
Special provision for older people is evident in several aspects of our society, for instance in retirement, pensions, reductions in charges for travel, entertainment or education. Most Local Authorities divide their Social Services sections between ‘children and adolescents’, ‘elderly’, ‘mental health’ and ‘young disabled’.

I started school at 5 years old because that was the rule and the arrangement.
I took an examination at 11 plus and another at set of exams at 16 years and more at 18 years – that was how it was. Then I left school. Those were the regular times to be doing things.

It is nice to know you can go to colleges, night schools, workers’ education classes and whatever to learn and gain qualifications at other times, but it is good to have a mainstream system that caters for most and in a cost-effective way. Flexibility and allowance for individual needs and preferences must be right, but works best alongside a framework which caters well for most.

Specialist services for older people disabled by multiple pathologies began in this country as a response to the plight of people stored without therapy or hope in the long-stay wards of chronic sickness hospitals of the 1940s. The pioneers of Geriatric Medicine demonstrated that much could be done to help individuals recover some abilities and to open up prospects for richer last months and years. Enlightened therapy and rehabilitation earlier in their experience of accumulating pathology and potential disability reduced the likelihood of secondary handicaps. Thus warehouses to death were replaced by multi-faceted services integrating with Primary Care, General Hospitals, Social Care and Mental Health. This enlightenment drew its strength from taking a positive approach to the challenges which are associated with chronological and biological ageing. Before that initiative the health component of services had been content to accept that age per se meant that prognosis for most conditions was limited and attempts to achieve recovery would be unrewarding. This was the outcome of intuitive ageism, institutionalized in medicine and accepted my most members of society, including older people themselves.

The internationally acclaimed achievements of Geriatric Medicine in the UK have been squandered and lost or emasculated during the past 20 years. Recruitment of larger numbers into the Specialty has been associated with diversion away from its original purpose and focus, and dilution of its energies by re-assimilation into ‘General Medicine’. Elements of the triumphant services of the 1970s remain and are celebrated in many areas, but the comprehensive sweep from prevention, domiciliary work, acute care, rehabilitation, day hospital and continuing care has faded to a memory. It is has been broken up into economic units driven by self interest which threaten to deny people access to optimal care, leaving them to await death alone at home until their needs are graded as extreme. Only then will they be placed along with others in similar extremis to spend their last few months beyond hope and at their own expense.

Geriatric Medicine never aimed to provide all specialist medical services to people over 65 years of age. Perhaps it should have. The numbers of people in that age-band requiring specialist help, including admission to hospital were and are so large that this was deemed impossible.

That has not been the case in Mental Health: special services for older people with mental disorders, including dementia began to appear in the UK 20 years after the first Geriatric Medicine services. Working from Mental Hospitals (in the main), or other centres, they were usually successful when taking a comprehensive view of their responsibilities to the population over 65 years. All services have included people with dementia, many extending their remit to younger people with dementia. Most services included people developing mental health problems or relapsing when over 65 years. Increasingly old age services have welcomed people with enduring mental illnesses for the staffing and resource situation improved and the provision of the alternative care afforded by the ‘back wards’ of Mental Hospitals has been taken away.

From a situation where mental health care for older people meant an assessment followed by allocation to a very long waiting list and admission, if you were still alive, to a long-stay single sex, 50 bedded dormitory ward, the picture has been transformed. The unity diagnosis ‘senile psychosis’ has been subdivided into the range of pathologies defined by Martin Roth, Felix Post and others. New therapies have appeared and new approaches practiced. Early intervention and integration of services across the Primary Care/Specialist Care, Physical Health/Mental Health, Health Care/Social Care interfaces have been achieved to marvelous effect.

Ageism has informed cynical constraint and disadvantage of specialist services for older people by inequitable funding. There have been generous increases for people of working age but no parallel increases for services devoted to older people, sometimes reductions despite the population pressure of increasing numbers of the very old. It is this ageism which is the problem to be acknowledged and to be overcome.

Providing services for older people with mental health problems staffed by motivated, enthusiastic, devoted and well-informed staff has worked and still works. Demolishing this model on the false premise that it is designed to disadvantage older people and their families is utterly wrong-headed. Returning all older people to find their share within unstructured all-age services would be a return to the unpoliced lottery in which they were losers before the salvage operation which the Psychogeriatricians began in the 1960s.

My view is that the success of Age Appropriate/Age Related services for older people is established and that model should be retained. The services for older people, people of working age and younger people including children, must be funded equitably. This requires a readjustment now and agreement on a formula which ensures that fairness will be preserved through future decades.

Dave Jolley
PSSRU Manchester, Gnosall Health Centre and Willow Wood Hospice

April 5th 2011

Tue, April 5, 2011 @ 9:10 AM

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