Older Mind Matters

Getting old age psychiatrists out of their secondary care silos

I recently attended the International Psychogeriatric Association conference in Cairns, Australia. Partly I felt I should go as a member of the Board of Directors of the IPA, but mostly the IPA conferences are a delight (and it was an excuse for a holiday too). There are always lots of good quality presentations to listen to and interesting people from around the world to meet. I think 29 countries were represented in Cairns.

I took part in a symposium about the global challenges to developing old age psychiatry. We wrote it up as a short piece for the IPA website (see link here) and it got me thinking about how the specialty might or should develop in the future. Two other strands of thought also seem to be relevant to this. One is getting involved in the Gnosall memory clinic (see previous blog post here). The other is a talk I went to which was really about developing services for Torres Strait islanders: the speakers talked about the seagull and pelican models. The seagull model is where the ‘bird’ flies over and (at best) drops a crust on you. The pelican model involves getting in and staying in as part of a community. (I apologise for the over-simplification).

These strands made me wonder - how would old age psychiatrists work if they saw themselves as workers in primary rather than secondary care? Could we be the servants of GPs? Would that improve the service to families?

If as a society we are to meet the challenge of being able to support everyone living with a dementia, to continue to treat other mental illnesses in late life, and to make specialist knowledge and skills available to those who need them, then old age psychiatrists will have to be better at working in partnership with primary care, secondary care, social care, voluntary organisations and families. The trouble with secondary care is that it puts walls around and between services and teams so that people can’t easily move between them. What would happen if old age psychiatrists got out of their secondary care silos?


Note: I wrote a short piece in 2004 entitled What is old age psychiatry? (link here) - we still need to reflect on the nature of the specialty.

1 comment (Add your own)

1. David Jolley wrote:
Silos and Tiers

Thanks for this – absolutely great

From the beginnings, as exemplified by the Goodmayes service, Psychogeriatrics was characterised by being out and about – taking its expertise, usually as a consultant psychiatrist, to places where there were old people with mental health problems and offering help and treatment in their natural habitat.
The outreach then was from a massive, outdated, poorly equipped and sited Mental Hospital.
There have been wonderful changes since that time: there are specialist services throughout the UK, mostly working in and from general hospitals or community hospitals but perversely managed within a segregated Mental Health Trust.
Our recent survey of work patterns suggests less activity at base and more outreach. Your suggestion is to take this movement further and to become part of the planets which are visited: primary care, general hospital etc. This will be as members of specialist teams.
I do not think this means the base of specialist in patient, day hospital and even long-stay care is not necessary – All these components have value – properly used they allow optimal use of other resources

Ian and Nicola Greaves, Lesley Greening and I wrote about services arranged in Tiers – published in brief by the Journal of Dementia Care – It may be useful and appropriate now to share the full version of that paper via this blog and with acknowledgement of the formal publication

See what you think

Three tier memory service for a Region: responsible, rational and affordable



A paper for the Journal of Dementia Care:

Journal of Dementia Care 18 (1) 26-29


David Jolley, Ian Greaves, Nicola Greaves and Lesley Greening

Gnosall Health Centre
Brookhouse Road
Gnosall
Stafford
ST20 0GP
Tel 01785 822220
Fax: 01785 822776


David Jolley is also Consultant Psychiatrist Penninecare NHS Trust and Honorary Reader PSSRU Manchester University M13 9PL
David.jolley@manchester.ac.uk





Background: It is common ground that mental health problems, including dementia, amongst older people are of increasing importance as all countries see more people surviving into their sixth, seventh, eighth decades and beyond (1,2,3). Within England and the other nations of the United Kingdom a series of reports has reviewed the current situation in terms of the prevalence and incidence of dementia and related conditions, best practice in terms of their identification, investigation, treatment and care including support to the family (4,5,6). The latest in the series is the National Dementia Strategy (7). This begins with an appreciation that current services do not meet the needs of patients or carers at an acceptable level. It suggests that the situation in this country is amongst the poorest in Europe (8, 9, 10) though acknowledging the benefits of its having ‘a nationwide structure of specialist old age psychiatry services with the skills to make diagnoses of dementia, and to provide co-ordinated treatment and care of people with dementia’ (8). The strategy’s three-fold ambition is to raise awareness of dementia (and related conditions), facilitate early investigation, diagnosis and treatment, and improve services for people with dementia and their families.
It is a major plank of the Strategy that people with dementia and their families require ongoing, flexible, responsive and robust support throughout the course of their condition, including episodes of care in hospital or care homes and their final weeks and death. Yet the emphasis of the implementation is upon investment in secondary tier specialist memory clinics modelled on that described at Croydon (11) with rapid throughput and discharge. An additional novel suggestion is the appointment of ‘dementia advisers’ who will also be characterised by rapid throughput and no case load responsibilities.
There are very substantial cost implications to adopting the Croydon Model nationwide and more than a few unknowns regarding medium and long-term outcomes. Three years on and the majority of patients known to that service were engaged by the Community Mental Health Team for the Elderly (CMHTE) rather than the Memory Clinic. There is limited description of how the Clinic and CMHTE relate. The clinic’s successes in recruiting particularly from its target groups of younger people with dementia, people with mild impairment and people from ethnic minority groups can be attributed to groundwork done with local Primary Care and culture leaders and centres. Yet there is an implication is that Primary care is there and has responsibilities but is less effective in modes of identification, investigation, treatment and support than it should be. One response to this might be to re-designate roles into Secondary Care. This is not a scenario supported by the Strategy, other than for short-term investigation and treatment. What is needed is a robust model of service which will identify people early in their career of difficulties and see them through whatever is to follow.

Proposal: Thus we propose an alternative model which takes account of the strengths of Primary Care, supplements them with the specialist skills of a District Memory Service Staff and ensures that even the most complex cases are appropriately investigated and managed by acknowledging the expertise of Regional and academic centres as a tertiary resource.



Memory Clinic in Primary care:

We have found over a three year period that it is possible to provide a Memory Service within a Practice of 8,000 by offering a one session per month ‘In-Practice’ clinic with specialist Old Age Psychiatry/memory Clinic presence (12,13). Patients are recruited from within the Practice with referrals from GPs or other clinicians who encounter people with memory problems during their routine contacts, or when screening or reviewing patients with vascular problems. The clock drawing test and BASDEC are used to identify abnormality of cognition or mood (14,15). Further enquiries and organisation depend on the Practice-Based Health Visitor who works to an agreed protocol and makes use of her professional skills and local knowledge (16, 17). The referral rate to this facility is sustained at 18 per 1000 aged 65 years per annum which is higher than that achieved in Croydon taking into account the work of the Croydon Memory Clinic and CMHTE (fig 1). Assessment at the clinic, which has a nil percent DNA rate, is greatly helped by the immediate availability via Practice computer records of in depth, multi-dimensional details of the patient’s previous and current health encounters and treatments. This contrasts with the substantial delays and difficulties encountered when seeking such information from a clinic within a Mental Health Trust. Communication of findings and their interpretation is immediate with patient, carer and Practice and confirmed in a letter. Our experience is that all but three from sixty referrals have managed entirely within the Practice without involvement of the local Old Age psychiatry service or secondary level Memory Clinic. The work has been well received by patients, carers and colleagues in the Practice and Social Services and the Practice has played a role in generating a local voluntary support group and Alz Café. No one has required referral to a regional specialist centre. A costing exercise by the PCT has suggested this model of service is less expensive than the equivalent standard service utilised by other Practices with savings of the order of £300,000.00 per annum

Never-the-less it is clear that Primary Care memory services such as this require support and input from a secondary care/specialist level. In the Gnosall clinic the input is from a consultant psychiatrist for one session per month. This copes with referrals at a rate equivalent to the predicted incidence of dementia for the Practice population (Figures 2,3,4). The consultant is used to working within a specialist team and the multi-disciplinary skills of administrator, nurses, clinical psychologists, occupational therapists, social workers and other doctors. The Croydon clinic papers describe the elements of such a team and demonstrate that initial contact, information gathering and assessment may be undertaken by team members of any of the professions. Findings are then shared within the team so that all aspects are considered in making a diagnosis and management plan which can then be implemented.
An amalgam of the Gnosall/Croydon models suggests that all Practices should be provided with specialist in-house memory clinics supported by sessions from the District Memory Service. This will include contributions from a consultant psychiatrist (or equivalent) but front-line clinics might be conducted by trained members of the team from other professions. Many straightforward cases will be dealt with within the Practice with discussion by the District Team if needed and with particular members of team (Psychiatrist. Psychologist etc) as is indicated (figs 5 and 6).

It will be appropriate for a proportion of patients presenting with complex problems to be seen within the ‘base’ District Memory Service – we suggest 10per cent is a reasonable estimate: 70 per annum which should be comfortably managed and most returned to Primary Care support once the complexities have been better understood and resolved as far as is possible.

Secondary Tier (District) Memory Service:

The District Memory Service thus becomes seen as a well informed and skilled team with a base usually within Old Age Psychiatry. Its functions
Include activities at the base – but the majority of clinician time will be devoted to work within Primary Care (figs 4, 5, 7, 8, 9). The District Memory Team will play a major role in spreading knowledge about memory problems and dementia, teaching, training, audit and research. Its members will relate to patients and carers directly within Primary Care – and within the clinic base for the proportion of patients needing more intense and detailed multi-disciplinary work.

(District) Community Mental Health Teams for the Elderly:

Community Mental Health Teams (CMHTEs) represent key components of services for older people with mental health problems including dementia (18, 19). The relationship between the work of CMHTEs and Memory Clinics has not been much explored. Early Memory Clinics were designed to attract people suitable for research – with mild, uncomplicated symptoms which might be measured and followed when exposed to therapeutic interventions (20). Later clinics have sometimes been skewed to identify and treat patients thought likely to benefit from medication or other licensed therapies (21). But increasing Memory Clinics have been equated with concepts of high quality assessment and early intervention for anyone presenting with memory problems. This positions them as essential components to be encountered early within the mainstream of care rather than an option reserved for a privileged few (22, 23). This is certainly implied within the Dementia Strategy and will require regulated symbiosis between Memory Clinic and CMHTE (24). It is reasonable to hope that early interventions from Memory Services will reduce the need for help later from a CMHTE. Our experience at Gnosall has been that there has been minimal call upon the local CMHTE over a three year period. That is not to say that patients and carers do not require help and support, but much of this can be best provided within Primary Care. It may be possible to consider a re-modelling of CMHTE activity toward that of outreach and involvement within Primary Care which we are encouraging within the tiered Memory Service scenario.




Tertiary Tier (Regional) Memory Service:

Just as there are some patients whose problems are beyond the competence of Primary Care – even when supplemented by specialist outreach, there are some patients who present with features which puzzle the District Service. Most Regions have latterly generated one or more specialist or academic centres which have developed cutting-edge skills in the investigation, diagnosis and pioneering research of such cases (25,26). In this they provide a useful and important contribution to science and knowledge, but are also supportive of the holistic service to a Region (figs 3, 4, 10)



Discussion: There can be no question that strategies must be developed nationally and internationally to meet the needs of older people who develop mental health problems including memory disorders and dementia. One approach being explored in India and other countries builds on local strengths by providing training and support within communities (27, 28). Our suggestion is that working within Primary Care, rather than whisking people away into secondary/specialist mental health services is a logical equivalent of this given the structure of services in England and the UK. It reduces some of the inevitable expense and stigma which are associated with the specialist services and avoids overloading them with follow ups which they cannot sustain. Instead it offers a sound system of in depth support for patients and families and colleagues in Primary Care who will be better informed and equipped for their tasks. At Gnosall it has been the Health Visitor who has taken on the central co-ordinating role which has allowed Primary Care and specialist to work together to best effect. This is an interesting deviation from the recent thrust which has seen Health Visiting almost equated with child care (16,17). Perhaps the wider potential of Health Visitors for whole-family care could be revisited. It is possible that other Primary Care professionals, nurses, CPNs or others would be interested in this work and comfortable and competent within it. Primary care will need to identify an individual from one profession or another to fulfil this role for the system to function.
The wider vision, of a three tiered service, draws on models such as that used within Child and Adolescent Psychiatry (29). It has not been fully realised as such in practice with dementia – but the elements are there in most Regions and the formalisation of flow patterns and referral rates identified here are thought to be reasonable extracts of the situation which has grown rather than been planned. There may be considerable advantages to follow from such a formalisation of roles and expectations.



Conclusions: We have proposed an alternative approach to the identification, investigation, treatment and ongoing support of people with memory disorders including dementia, to that espoused by the Dementia Strategy. It will be encouraging if this and other proposals can be considered and their strengths and weakness assessed in comparative studies.

References:

1) Grundy E: Demography and old age. Journal of the American Geriatrics Society, 1983: 31(6) 325-332

2) Ferri CP, Prince M, Brayne C, Brodaty H, Fratiglioni L, Ganguli M, Hall K, Hasgawa K, Hendie H, Huang Y, Jorm A, Mathers C, Menezes P, Rimmer E, Scazufca M, for Alzheimer’s Disease International: Global prevalence of dementia: a Delphi consensus study. The Lancet 2005, 366: 2112-2117

3) Prince M, Livingston G and Katona C: Mental health care for the elderly in low-income countries: a health system approach. World Psychiatry 2007, 6: 5-13

4) Audit Commission: Forget-me-not. Mental Health services for older people 2000, HMSO, London. Whole report

5) Knapp M and Prince M: Dementia UK. Alzheimer’s Society, London. 2007 whole report

6) National Audit Office. Improving services and support for people with dementia. 2007 HMSO, London

7) Department of Health. Living well with dementia: a National Dementia Strategy, 2009 HMSO, London

8) Knapp M, Comas-Herrera A, Somani A and Banerjee S. Dementia: international comparisons. A summary report for the National Audit Office. 2007 PSSRU, London School of Economics, London

9) Bond J et al, Inequalities in dementia care across Europe: Key finding of the facing Dementia survey. International Journal of Clinical Practice 2005, 59 (supplement 146) 8-14

10) Waldemar G et al Access to diagnostic evaluation and treatment for dementia in Europe. International Journal of Geriatric Psychiatry 2007, 22: 47-54

11) Banerjee S et al Improving the quality of care for mild to moderate dementia: an evaluation of the Croydon Memory Clinic. International Journal of Geriatric Psychiatry 2007, 22 782-788

12) Greaves I, Greaves N, Greening L and Jolley D. Reaching and keeping dementia in Primary Care. Journal of Dementia Care 2008, 16(4) 18-19

13) Greening L, Greaves I, Greaves N and Jolley D. Positive thinking on Memory problems and dementia in Primary Care: The Gnosall Memory Clinic. Community Practitioner In press

14) Shulman K, Gold D, Cohen C and Zucchero C. Clock-drawing and dementia in the community: a longitudinal study. International Journal of Geriatric Psychiatry, 1993: 8; 487-496

15) Pitt B. Loss in late life. British Medical Journal, 1998: 316; 1452-1454


16) Department of Health. Facing the future: a review of the role of Health Visitors. Department of Health, London. 2007


17) Department of Health. The government response to Facing the Future. Department of Health, London. 2007


18) Benbow S and Jolley D. Organisation of services in Geriatric Psychiatry p 1163-1171 in: Pathy M, Sinclair A and Morley J (eds) Principles and Practice of Geriatric Medicine (4th edition) John Wiley and Sons. Chichester

19) Royal College of Psychiatrists. Raising the standards 2006. Royal college of Psychiatrists London

20) Jolley D and Moniz-Cook E. Memory Clinics in context. Indian Jornal of Psychiatry 2009, 51: 570-576

21) Lindesay J. Marudkar M. van Diepen E. and Wilcock G. The second Leicester survey of memory clinics in the British Isles. International Journal of Geriatric Psychiatry 2002: 17 (1) 41-47.

22) Luce A. MacKeith I. Swann A. Daniel S. and O’Brien J. How do memory clinics compare with traditional old age psychiatry services? International Journal of Geriatric Psychiatry 2001; 16: 837-845.

23) Simpson S. Beavis D. Dyer J. and Ball S. Should Old Age Psychiatry develop memory clinics? A comparison with domiciliary work. Psychiatric Bulletin. 2004; 28, 78-82

24) Grizzell M, Fairhurst A, Lyle S, Jolley D, Willmott S and Bawn S. Creating a community-based memory clinic. Nursing Times 2006 102(28) 32-34

25) Mann D, South P, Snowden J and Neary D. Dementia of frontal lobe type: neuropathology and immuno-histochemistry. Journal of Neurology, Neurosurgery and Psychiatry 1993, 56(6) 605-614

26) Hodges, J.R. Berrios G. and Breen K. The multidisciplinary memory clinic approach. Chapter 6, p101-121 in Berrios G. and Hodges J.R. (eds) Memory disorders in psychiatric practice. 2000. Cambridge University Press, Cambridge


27) Prince M, Graham N, Brodaty H et al: Alzheimer’s Disease International’s 10/66 Dementia Research Group: one model for action in developing countries. International Journal of Geriatric Psychiatry 2004, 19: 1787-181

28) The 10/66 Dementia Research Group: Care arrangements for people with dementia in developing countries. International Journal of Geriatric Psychiatry 2004, 19: 170-177

29) Royal College of Psychiatrists (2006) Building and sustaining specialist Child and Adolescent Mental Health services: Council report (CR137) Royal College of Psychiatrists, London







































Figure 1: comparative referral rates



Figure 2: Regional over view - Staffordshire








Figure 3: Prevalence of dementia: Practice base, District base, Region:




Figure 4: The three tiers in numbers of referrals per annum










Figure 5: Central District core and outreach to Primary Care


Figure 6: Primary Care









Figure 7: District Service:

Figure 8: Staffing of District Memory Service (250,000)







Figure 9: Allocation of time to Primary and Secondary level work




Figure 10: Regional Service:







Acknowledgements: Thanks to several people who have read and improved on previous drafts of this paper including Michael Clark and Susan Jolley

Conflicts of interest: Nil

I find the figures do not come out - If people want a copy directly please ask

david.jolley@manchester.ac.uk

Fri, October 5, 2012 @ 6:12 PM

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