Guidance for commissioners of older people’s mental health services 1Practicalmental healthcommissioningGuidance for commi...
Joint Commissioning Panelfor Mental HealthCo-chaired by:Membership:www.jcpmh.info
2 Practical Mental Health CommissioningContentsIntroduction04What are olderpeople’s mentalhealth services?Why are olderpeo...
Guidance for commissioners of older people’s mental health services 3Ten key messages for commissioners1 Older people will...
The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal Colle...
Guidance for commissioners of older people’s mental health services 5What are older people’s mental health services?Older ...
6 Practical Mental Health CommissioningWhat are older people’s mental health services? (continued)TABLE 1PROFESSION ROLENu...
Why are older people’s mental health servicesimportant to commissioners?1 People are living longer,including older peopleI...
8 Practical Mental Health CommissioningThe NHS Mandate provides a cleardriver to assist in addressing some of thechallenge...
What do we know about currentolder people’s mental health services?SERVICE MODELSThe National Service Framework for OlderP...
10 Practical Mental Health CommissioningWhat do we know about current older people’s mental health services? (continued)Gi...
What would a good older people’smental health service look like?In considering what a goodservice might look like,there ar...
What would a good older people’s mental health service look like? (continued)• a good service will support thedevelopment ...
Guidance for commissioners of older people’s mental health services 13approaches60. Multi-professional in nature,these may...
14 Practical Mental Health CommissioningWhat would a good older people’s mental health service look like? (continued)Publi...
Guidance for commissioners of older people’s mental health services 15• people with diagnosable physicalillnesses, especia...
Supporting the delivery of the mental health strategyThe JCP-MH believes thatcommissioning which leads togood older people...
Guidance for commissioners of older people’s mental health services 17Expert Reference Group Members• James Warner(ERG Co-...
1 Office Office for National Statisticswww.statistics.gov.uk/hub/population/ageing/older-people2 Audit Commission (2002). In...
31 Penninx BW, Leveille S, Ferrucci L, vanEijk JT, Guralnik JM. (1999). Exploringthe effect of depression on physicaldisab...
20 Practical Mental Health Commissioning60 Department of Health (2004).Organising and deliveringpsychological therapies.61...
A large print version of this document is available fromwww.jcpmh.infoPublished May 2013Produced by Raffertys
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Guidance for commissioners of older people’s mental health services

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This guide is about the commissioning of mental health services which can improve the mental health and wellbeing of older people.

This guide has been developed by a group of older people’s mental health professionals, people with mental health problems, and carers. The content is primarily evidence and literature-based, but ideas deemed to be best practice by expert consensus have also been included.

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Guidance for commissioners of older people’s mental health services

  1. 1. Guidance for commissioners of older people’s mental health services 1Practicalmental healthcommissioningGuidance for commissioners ofolder people’smental health servicesJoint Commissioning Panelfor Mental Healthwww.jcpmh.info
  2. 2. Joint Commissioning Panelfor Mental HealthCo-chaired by:Membership:www.jcpmh.info
  3. 3. 2 Practical Mental Health CommissioningContentsIntroduction04What are olderpeople’s mentalhealth services?Why are olderpeople’s mentalhealth servicesimportant tocommissioners?05 07What do weknow aboutcurrent olderpeople’s mentalhealth services?09What woulda good olderpeople’s mentalhealth servicelook like?11Supporting thedelivery of themental healthstrategy16References18Ten key messagesfor commissioners
  4. 4. Guidance for commissioners of older people’s mental health services 3Ten key messages for commissioners1 Older people will form a largerproportion of the population. By 2035the number of people aged 85 andover is projected to be almost 2½ timeslarger than in 2010. The populationaged 65 and over will account for23% of the total population in 20351.Commissioners will need to ensurethat accurate modeling of their localpopulation is conducted as part of theirJoint Strategic Needs Assessment andplan sufficient capacity in local services.2 Older people’s mental health servicesin particular benefit from an integratedapproach with social care services.Most patients in older age mentalhealth services have complex socialneeds. Commissioners should ensureservice providers across agencies worktogether if they are to meet people’sneeds and aspirations effectively2.A whole system approach that drawstogether the expertise of healthand social care agencies and thosein the voluntary sector will delivera comprehensive, balanced rangeof services, which places as muchemphasis on services that promoteindependence as on care services2.3 Older people’s mental health servicesneed to work closely with primarycare and community services.Models that include primary care‘in-reach’ or joint working withcommunity physical health careservices, provide more co-ordinatedcare and should be the norm.4 Services must be commissioned onthe basis of need and not age alone.Older people’s mental health servicesshould not be subsumed into a broader‘adult mental health’ or ‘agelessservice’. The needs of older peoplewith functional mental illness (forexample depression) and/or organicdisease such as dementia and theirassociated physical and social issues areoften distinct from younger people.5 Older people’s mental health servicesmust address the needs of peoplewith functional illnesses such asdepression and psychosis as well asdementia. The majority of the mentalillness experienced by older people isnot dementia and there is significantcrossover between dementia andfunctional illnesses such as depressionand psychosis.6 Older people often have a combinationof mental and physical healthproblems. Commissioners and serviceproviders need to seek and exploitopportunities for joint working andservice delivery that can address bothphysical and mental health needs. Olderpeople with long-term health conditionsmake up the greater proportion of thiscare group. Having more than onelong-term condition greatly increasesthe risk of depression3. Planning anddelivering an integrated service tomanage service delivery to this groupthrough joint working protocols will bethe best and most cost-effective way tomanage care.7 Older people’s mental health servicesmust be multidisciplinary. Medicaldoctors are important because ofthe complex physical and treatmentissues common in older people, butgiven the complex needs of thisgroup, integrated input from nurses,psychologists, physiotherapists,occupational therapists and speech andlanguage therapists is necessary.8 Older people with mental healthneeds should have access tocommunity crisis or home treatmentservices. With extended hoursof working and intensive crisismanagement, home treatment workershelp to reduce the need for admission,facilitate early discharge and reducetransfer to residential care.9 Older people with mental health needsrespond well to psychological input.Evidence shows that response ratesamongst older people are as good asthose of younger adults. The spectrumof psychological service provision at alltiers needs to reflect this4.10 Older people should have dedicatedliaison services in acute hospitals.Over 60% of older people in acutehospital wards have a serious mentaldisorder which is often unrecognisedand delays rehabilitation anddischarge5. Commissioners mustensure appropriate specialist liaisonservices are in place with relevantdischarge care plans and support fromsecondary care mental health teams.
  5. 5. The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• people with mental healthproblems and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities(prior to April 2013)• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.The JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health6.IntroductionThe JCP-MH has two primary aims:• to bring together people with experienceof mental health problems, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioning• to integrate scientific evidence, theexperience and viewpoints of people withmental health problems and carers, andinnovative service evaluations in orderto produce the best possible advice oncommissioning the design and deliveryof high quality mental health, learningdisabilities, and public mental health andwellbeing services.The JCP-MH:• has published Practical Mental HealthCommissioning7, a briefing on the keyvalues and principles for effective mentalhealth commissioning• provides practical guidance and adeveloping framework for mental healthcommissioning• has so far published twelve other guideson the commissioning of primary mentalhealth care services8, dementia services9,liaison mental health services to acutehospitals10, transition services11, perinatalmental health services12, public mentalhealth services13, rehabilitation services14,forensic services15, drug and alcoholservices16, community specialist mentalhealth services17, acute care (inpatientand crisis home treatment)18, eatingdisorders19, and child and adolescentmental health services20.WHO IS THIS GUIDE FOR?This guide has been written to provideinformation and practical advice ondeveloping and delivering local plans andstrategies to commission the most effectiveand efficient older people’s mental healthservices.Based upon clinical best practice guidanceand drawing upon the range of availableevidence, it describes what should beexpected of an older people’s mental healthservice in terms of effectiveness, outcomesand value for money.The guides will be of particular use to:• Clinical Commissioning Groups• General Practitioners (GPs) andcommissioning leaders• Commissioning Support Organisations• wider local authority commissioners,voluntary and independent sectororganisations.HOW WILL THIS GUIDE HELP YOU?This guide has been developed by agroup of older people’s mental healthprofessionals, people with mental healthproblems, and carers. The content isprimarily evidence and literature-based, butideas deemed to be best practice by expertconsensus have also been included.By the end of this guide, readers should bemore familiar with the concept of effectiveolder people’s mental health services and bebetter equipped to:• understand what an effective range ofolder people’s mental health servicesshould look like• know the sorts of services andinterventions that should be on offer• understand how those interventionscan contribute to achieving recoveryoutcomes and make improvements inpublic mental health and wellbeing.4 Practical Mental Health Commissioning
  6. 6. Guidance for commissioners of older people’s mental health services 5What are older people’s mental health services?Older people’s mental healthservices are concerned withthe care and treatment ofpeople with complex mixturesof psychological, cognitive,functional, behavioural, physicaland social problems usuallyrelating to ageing.These specialist mental health services aimto meet the needs of people with mentalhealth problems and their carers in manysettings including:• primary care• their own homes and via community-based services and inpatient facilities• acute general hospitals• residential care homes and nursinghomes• hospices• prisons (this is rare but mayincrease given rising numbers ofolder prisoners)21.Services should be person-centred,accessible, culturally appropriate andabove all needs-based.Not just dementiaThere are some misconceptions aboutwhat constitutes ‘mental health’. It isoften assumed to be mental ill healthand in particular, with older people, justdementia. Mental health is not just aboutthe absence of ill health but the promotionof positive health and wellbeing.Mental ill health in older people doesnot just mean dementia but also otherdisorders such as depression, anxiety,schizophrenia, suicidal feelings, personalitydisorder and substance misuse. Servicesin health and social care should notsimply be focused on those people whoare known to have mental ill health andhow to support them. They should alsobe concerned with the identification,diagnosis and appropriate treatmentof older people who develop mentalillness for the first time in older age,perhaps, but not necessarily, in reactionto consequences of ageing (e.g. physicalissues such as stroke, Parkinson’s, falls orsocial isolation).Older people’s mental health servicesshould therefore provide a range ofassessment and treatment services formental disorders. These will include:• depression• bipolar disorders• anxiety disorders• schizophrenia and psychosis• dementia• alcohol and substance misuse disorders.For further information on dementia,please see the JCP guide on commissioningdementia services9, as well as the resourceslisted on page 17.Who should receive old age services?The Royal College of Psychiatrists hassuggested needs-based criteria, outliningfor which people the interventionsprovided by older people’s mental healthservices would be most relevant. Theseare outlined below:• people of any age with a primarydementia• people with mental disorder andsignificant physical illness or frailtywhich contribute(s) to, or complicate(s)the management of their mental illness– exceptionally this may include peopleunder 60• people with psychological or socialdifficulties related to the ageing process,or end of life issues, or who feel theirneeds may be best met by a service forolder people22.How are old age services provided?Older people’s mental health servicestypically provide a community-based (i.e.seeing a substantial proportion of patientsat home) multidisciplinary model. Suchmodels are particularly useful for peoplewho are frail or cognitively impaired andcannot easily travel to hospital or othersettings. Furthermore assessing andfollowing-up people at home provides farbetter scope for accurate assessment andclinical and risk management.Access to crisis services and inpatientunits that are specific to the needs of thispopulation is also important.Who works in old age services?Community mental health teams andward-based inpatient services need toinclude a range of health and socialcare professionals. Table 1 shows theprofessional groups and their primary roles.
  7. 7. 6 Practical Mental Health CommissioningWhat are older people’s mental health services? (continued)TABLE 1PROFESSION ROLENurses Inpatient physical and psychiatric nursing care, community assessments and interventions,care coordination, Mental Health Act / Mental Capacity Act assessments, nurse prescribing.Clinical leadership, initial assessment; ongoing assessment; support planning, follow-up;care programme approach (CPA) coordination/case management; discharge planning.Consultant Psychiatrists Mental Health Act / Mental Capacity Act assessments, complex assessments and interventions,prescribing, supervision and advice to team members. Clinical leadership; initial assessment; adviceon difficult clinical issues; monitoring of team function (including metrics). Minimal role in follow-up.Ensuring seamless transition when junior medical staff change.Other doctors Initial assessment; ongoing assessment, specialist assessment/management follow-up advice ondifficult clinical issues and diagnosis.Psychologists Clinical leadership; initial assessment; specialist assessment and management follow-up;discharge planning. CPA co-ordination/case management of complex cases. Will be involved witha range of psychological interventions based on the initial formulation and activities, includingneuropsychological assessment and rehabilitation; from face-to-face client work with individuals andfamilies, group work, Mental Capacity Assessments. Co-working, skills-sharing, teaching, workingwith practice development facilitators, supervision, audit, research and service developments.Social workers Initial assessment; ongoing assessment, specialist assessment/management follow-up;CPA coordination, discharge planning, safeguarding, Mental Health Act assessments.Support workers Physical health care; therapeutic interventions; monitoring role functioning; providing emotionaland practical support; encouraging social participation.Occupational therapists Initial Assessment; specialist assessment/management follow-up; CPA coordination;discharge planning.Note: this is not an exhaustive list and someservices may also include other professionalsincluding speech and language therapistsand physiotherapists.
  8. 8. Why are older people’s mental health servicesimportant to commissioners?1 People are living longer,including older peopleIn 1901, there were just over 60,000people aged 85 and over in the UK. Todaythere are 1.5 million, a 25-fold increase23.In 2008, there were 18.3 million peopleaged 60 and older in UK. By 2033, thenumber of people in the UK aged 75 andover is projected to increase from 4.8million to 8.7 million. For those aged 85and over, the projected increase is from1.5 million in 2011 to 3.3 million in thesame period24.The number of peoplein care homes is projected to rise from345,000 in 2005 to 825,000 in 204125.As a result of this demographic changepublic expenditure on long-term care isprojected to rise by more than 300% inreal terms over that period24.This demographic change is not a newphenomenon; it has been widely reportedand plotted in recent years, includingin the Dilnot report23. It will requirecommissioners to consider carefully theconsequences of an ageing population.2 Older people aredisproportionately highusers of health and socialcare servicesAlthough age-related decline in mentalwellbeing should not be seen as inevitable,older people form the majority of peopleusing health and social care services. Weknow that mental health problems increasewith age, for example, dementia affectsover 5% of those aged over 65 yearsand 20% over 80 years26,27. Moderateto severe depression occurs in 3-4% ofthe older adult population28. The highestprevalence of depression is found inthose over 7529. Indeed, contrary to someperceptions, the majority of the morbidityin older people is not dementia, but otherfunctional illnesses such as depressionand psychosis though these can, andfrequently do, co-exist with dementia.Historically older people were at greaterrisk of suicide, but more recent datasuggests a similar risk compared toyounger adults30. A suicide attempt in anolder person is more likely to be successfulthan in younger people, and must neverbe dismissed. Expert advice should besought on all cases.When it goes untreated, depressionshortens life and increases health andsocial care costs31. It is a leading causeof suicide among older people.Depression, pain and physical disabilityare all associated with suicide. When olderpeople are treated for depression, qualityof life improves32. Higher suicide ratesmay not be a characteristic of old agedepression but rather a consequence of afailure to diagnose and treat it.There are significant co-morbidities witha range of physical health needs. Forexample, 50% of people with Parkinson’sdisease suffer depression33, 25% followingstroke34, 20% with coronary heartdisease35, 24% with neurological diseaseand 42% with chronic lung disease36.Depression is often difficult to diagnoseand treat in these groups and requiressustained, expert management.The impact of older people’s mental healthneeds is therefore wide ranging, having aneffect not only on the person themselves,but also on their family, friends andcarers. The demand for services islikely to increase given the predictionsof demographic changes and higherprevalence.This will mean that commissionersand providers will continue to face thechallenge of providing high qualityspecialised services, to a larger numberof people, and within a more constrainedeconomic environment. This will challengeexisting funding priorities for both healthand local authority commissioners. Theywill need to consider the potential interms of effectiveness and efficiency fromjoined-up, integrated services includingdeveloping partnership models that enableolder people and their carers to managetheir long-term conditions better.3 Older people and publicmental healthOlder people’s mental health is nowrecognised as a significant public healthissue. The wider relationship of mentalhealth and physical health problems andageing upon an individual is clear:• ageism and other forms of age andmental health related discrimination andstigma• social isolation and loneliness –maintaining relationships with friendsand family• financial difficulties• access to affordable, safe and securehousing• fuel poverty• difficulties with tasks of daily livingsuch as cooking, cleaning, personalhygiene etc• poor mobility• physical illness and frailty.Older people with high support needsplace particular value on:• personal relationships• support/good relationships with carers• self-determination/involvement indecision-making• social interaction• good environment/home• getting ‘out-and-about’• information about services and helpavailable• financial resources37.4 Policy objectivesGuidance for commissioners of older people’s mental health services 7
  9. 9. 8 Practical Mental Health CommissioningThe NHS Mandate provides a cleardriver to assist in addressing some of thechallenges that physical and mental healthproblems bring. It sets out five objectivesfor the NHS where the Governmentexpects to see improvement:• helping people live longer• managing ongoing physical and mentalhealth conditions• helping people recover from episodesof ill health or following injury• making sure people experiencebetter care• providing safe care.The Mandate also includes someadditional objectives in relation to olderpeople and mental health:• improving standards of care and notjust treatment for adults includingolder people• better diagnosis, treatment and carefor people with dementia• putting mental health on an equalfooting with physical health – this meanseveryone who needs mental healthservices having timely access to the bestavailable treatment38.In order to achieve parity of esteem,commissioners will need to strengthenlinks between physical and mental healthprofessionals, with the aim of benefittingpatients by providing more integratedservices that can address the twin impactsof mental and physical health issues.Final Report of the Independent InquiryInto Care Provided By Mid StaffordshireNHS Foundation Trust (known as theFrancis Report)This report was published in February2013 following Sir Robert FrancisQC’s public inquiry into the role ofthe commissioning, supervisory andregulatory bodies in the monitoring ofMid Staffordshire Foundation NHS Trust.The report made 290 recommendationsfor the NHS and government. Many ofthe issues investigated related to the careand treatment of older people and issuesof discrimination in relation to their care.The Inquiry’s main message was thatlistening to, and understanding, patientsmust come first, at all levels of the NHScommissioners and providers must worktogether to ensure the implementationof the relevant recommendations toensure high quality services that are safe,responsive and effective.Why are older people’s mental health services important to commissioners? (continued)Any Qualified Provider/Section 75regulationsAlthough the NHS has traditionallybeen the predominant provider of olderpeople’s mental health services, a numberof independent and voluntary sectororganisations have played a part indelivering specific services to complementthose in the NHS and social care.‘Section 75’ regulations place requirementson commissioners to improve the qualityand efficiency of services by procuringfrom the providers most capable ofmeeting that objective and deliveringbest value for money39. In doing so,commissioners must be aware of the needfor boundary-free integration of carepathways between providers to ensure themost seamless service possible.Specialist older people’s mental healthservices form an intrinsic element of therange of services that should be expectedto be available. Where they are adequatelyinvested in, and of high quality, they canachieve good outcomes, not just in mentalhealth, but across the wider health andsocial system.
  10. 10. What do we know about currentolder people’s mental health services?SERVICE MODELSThe National Service Framework for OlderPeople, published in 2001, made specificreference to the need for improvementin services in England. One of its keystandards was that older people whohave mental health problems should haveaccess to specialist older people’s mentalhealth services with integrated socialservice elements, provided by the NHSand councils to ensure effective diagnosis,treatment and support, for them, and fortheir carers40.Everybody’s Business41, a servicedevelopment guide, was published in 2005to improve health and social care practiceat the front line. It made clear that olderpeople’s mental health spans health andsocial care, physical and mental health andmainstream and specialist services.In 2008, the Care Quality Commissionfound that there was still limitedavailability of good quality nationaldata in relation to the quality of specialistolder people’s mental health services42More recent moves to outcomes-based commissioning and performancemanagement have sought to address thegaps in information about how services areperforming.Age is an important personal characteristicenshrined in law. The main tenet of parityof esteem is that all people are entitledto the best care available, whatever theirdiagnosis or personal characteristics (suchas age or gender). Older people withmental disorders are entitled to havetheir care and treatment managed byprofessionals who have specific expertisein that area. This principle is supported byNICE, the Department of Health, the RoyalCollege of Psychiatrists, and the BritishPsychological Society.Due to differences in the nature oftreatment and care needs of olderpeople with mental health problems, anddifferences in what having mental healthproblems can mean to different age groups,older people often have different care andtreatment needs from younger peoplewith mental health problems. Meeting thecomplex needs of older people requiresspecific professional skills and an awarenessof the social, familial and historical contextto which that person belongs. In addition,services have to be structured in such away that they can respond to this complexmix of social, psychological, physical andbiological factors43.No Health without Mental Health6expectsservices to be age-appropriate and non-discriminatory. A recent trend of mergingold age and adult services potentially risksbreaching the Equality Act by causingindirect discrimination and reducing patientchoice (see page 17 for resources onaddressing this risk).Older people should not be precluded fromaccessing services provided for adults ofworking age where it can appropriatelymeet their needs. It is essential that servicessensitive to different needs continue to beprovided, and that specialist older people’smental health services (who have uniqueexpertise in meeting a particular set ofneeds characteristic of later life) continueto be provided comprehensively in allcommissioning areas44.The expertise of older people’s mentalhealth services lies in the care andtreatment of people with complex mixturesof psychological, cognitive, functional,behavioural, physical and social problemsusually relating to ageing. Although notrestricted to older people, the presence ofan increasing number of these domains inan individual is characteristic of the mixtureof problems associated with the ageingprocess. Specialist old age services are bestequipped to diagnose and manage mentalillness in our ageing population.InvestmentIn common with all public services,the NHS is operating within a moreconstrained financial environment. Twentybillion pounds of savings must be madeby 2015 through a range of measuresgrouped under the heading of Quality,Innovation, Prevention & Productivity(QIPP). All commissioners are seekingto ensure that financial resources aredeployed to deliver effective, outcome-based services that provide value for thepublic purse.Investment in older people’s mental healthhas never had parity with adult services,and if reductions are applied equally willbe further disadvantaged. Nationally olderpeople’s services are currently underfundedby as much as £2.3 billion compared withservices for younger adults45.The most recent audit of investment inolder people’s mental health services waspublished in August 2012. This showedthat the total reported overall cashinvestment in older people’s mental healthservices fell by 1% from £2.859 billion in2010/11 to £2.830 billion in 2011/12.Taking inflation into account, the overallreal term investment in older people’smental health services fell by 3.1% from£2.921 billion in 2010/11 to £2.830 billionin 2011/1246. This is a significant shortfallgiven the pre-existing funding gap, andis made worse by the fact that thesereductions have taken place against abackdrop of rising demand for services.The national investment per weightedhead of population for 2011/12 was£341. Investment within Strategic HealthAuthorities (now disestablished) variedbetween £269 and £483 investment perweighted head45.Guidance for commissioners of older people’s mental health services 9
  11. 11. 10 Practical Mental Health CommissioningWhat do we know about current older people’s mental health services? (continued)Given the fall in investment, theacceptance of the need for specialisedservices and rising demand means thatin future, targeted investment anddevelopment is required for older people’smental health services compared to othermental health specialties. Parity of esteemwith adult services remains an ambitionthat commissioners should be aiming toachieve, working alongside primary careand voluntary sector agencies in order tobuild service capacity.PREVALENT PRESENTING CONDITIONS• depression – depression is common inpeople over the age of 65. There arecurrently up to 2.4 million older peoplewith depression severe enough to impairtheir quality of life47. Recognition ratesare lower than for younger people andwhen recognised, fewer than half canexpect appropriate pharmacologicaltreatment. Only-one third of olderpeople with depression discuss theirsymptoms with their general practitionerand less than half of these will receiveadequate treatment48.• schizophrenia – psychosis is commonin older people, with 20% of peopleover 65 developing psychotic symptomsby age 85, and most are not aprecursor to dementia49. These rates ofhallucinations and paranoid thoughtsremain high in people of 95 years of agewithout dementia. Older people withschizophrenia include those who havegrown old with the condition and thosewho have developed the illness in laterlife. Paranoid ideas and delusions canalso occur with a dementing illness, andpeople with these needs require carealong the same lines as other peoplewith dementia.• memory services – approximately800,000 people are known to beliving with dementia in the UK. Thisis expected to almost double within30 years, and only 40% of cases ofdementia are currently diagnosed50.Memory assessment services specialise inthe diagnosis and initial management ofdementia and are often the single pointof referral for people with a possiblediagnosis of dementia51. Ideally theseservices should be multidisciplinary andinclude pre-diagnostic counselling andpost-diagnostic support for the personwith dementia and their family, includingpsychosocial interventions as well asmonitored medication, if required. TheRCPsych and Memory Services NationalAccreditation Programme resourceoutlining standards for memory servicesassessment and diagnosis is a valuabletool for commissioners to refer to52.• working with carers – older people withmental health problems may have anincreased requirement for care. Thisis often provided by family carers, themajority of whom are old themselves41.It is estimated that up to 1.5 millionpeople care for someone with a mentalhealth problem. Thirty percent of carerswill suffer from depression at somestage, and carer breakdown has beenfound to be a major trigger for long-term care53,54.The mental health and wellbeing ofcarers is therefore paramount in theaim of maintaining older people in thecommunity for as long as possible. Carerswant to have:– information– respite– emotional support– support to care and maintain theircarers own health– a voice55.4. Demand and capacityThe rising number of older people inthe population is likely to result in anincreasing demand for the whole rangeof health and social care services.Commissioners will need to work closelywith public health colleagues in localauthorities to ensure robust Joint StrategicNeeds Assessment (JSNA) and demandmodeling so that provision can beappropriately developed to address therising need for services. These JSNAsneed to consider data and outcomes forolder people’s mental health, and not dataaggregated simply for mental health withno accompanying age information.
  12. 12. What would a good older people’smental health service look like?In considering what a goodservice might look like,there are some key principlesthat should underpincommissioning activity:• older people and their carers should beable to access general and mental healthpromotion and education services, andinformation from community accesspoints, through primary care to acuteinpatient and continuing care. All shouldwork to promote the social inclusionand independence of older people withmental health difficulties.• the expertise of older people’s mentalhealth services lies in the care andtreatment of people with complexmixtures of psychological, cognitive,functional, behavioural, physical andsocial problems usually related to ageing.• older people and their carers need tofeel heard, safe, engaged and respected.Services should promote and maximiseopportunities for co-production.Commissioners need to meaningfullyconsult and involve older people,including those with mental illness andtheir carers in the development andplanning of local services. Carers must berecognised and engaged with as partnersin care delivery, as well as people whohave needs of their own.• a good service will have a strong valuesbase. In particular, it should draw on therecently published Nursing Vision whichemphasises person-centred approaches(the six C’s: compassion, courage,communication, competence, care andcommitment)56.• choice should be a key element inservice delivery for older people withmental health problems. The right tochoice will take effect from April 2014and commissioners should plan for this.People who are detained under theMental Health Act will not be entitled touse the provisions of the choice policy.• a good service will recognise thatalongside specialist provision, colleaguesin primary care do most of the workto support people with mental healthproblems, given that the majority ofpeople with a mental health problemare seen in primary care only. Workingin partnership with primary care must beseen as a central part of the way in whichspecialist services operate.• services must be commissioned on thebasis of need and not age. Older peopleare as entitled as any other group to highquality age-appropriate services. Servicesshould ensure the same standard of careas services for younger people, includingspeed of response and choice57. Theseshould be delivered in a timely way andprovided comprehensively by teams ofprofessionals specifically trained andqualified in the management of olderpeople with the right range of knowledgeand expertise in teams specificallycommissioned for older people’s mentalhealth. The workforce should haveequal access to high quality training inappropriate interventions.• older people’s mental health servicesneed to be integrated with social careservices. Integration is a single system ofneeds assessment, commissioning and/or service provision that aims to promotealignment and collaboration between thecare sectors58.• older people’s mental health servicesneed to provide care in a seamless way.There need to be clear pathways to avoidpeople falling between service criteriaboundaries across:– specialist community physical healthteams for older people– memory services– crisis intervention services– acute hospitals– residential care.• staff across all health and social careorganisations working with older peopleshould have skills in recognising andcaring for mental health needs, andin working with specialist mentalhealth services.• older people whether livingindependently, or in differing forms ofsupported, residential or nursing homeaccommodation, who are in need ofmental health assessment or interventionshould have access to intermediate andinpatient care services. These shouldinclude a full range of evidence-basedpsychological, social, medical andpersonal care interventions deliveredin a culturally sensitive manner andaiming to support the individual in themost independent living circumstancespossible.• an effective older people’s mental healthservice requires a managed networkof services across a wide spectrum ofcare, and the exact components ofthe care pathway provided should bedetermined by local need. This needshould be established through a JointStrategic Needs Assessment that can helpto determine the range of services andproviders that should be in place. Thesecould comprise:– information services– psychological interventions– liaison services in general hospitals– community-based teams– inpatient services.• a good service should providecomprehensive psychiatric, psychologicaland social input to older people.Adequate inpatient, memory clinic andcommunity-based teams should formthe central elements of the services,complemented by a clear presence ingeneral hospitals, primary care andcare homes.Guidance for commissioners of older people’s mental health services 11
  13. 13. What would a good older people’s mental health service look like? (continued)• a good service will support thedevelopment of diagnostic andmanagement skills among GPs andact as a learning resource for practiceteams, through use of attached staff,regular case reviews and readily accessibleadvice from senior staff.• a good service must be appropriatelyand permanently staffed to allow safe,effective management in all locations inwhich old age mental health services aredelivered.• a good service needs to providecontinuity of care for an older person,no matter what their diagnosis, needsor location might be. It will be wellintegrated, with no need for formal cross-referral between disciplines or agencies.• a good service will engage in sharedplanning and management of anolder persons needs with colleagues inmedicine for old age, colleagues normallyworking with younger adults, and thoseworking in sub-specialities such assubstance misuse, learning disabilities,forensic psychiatry and medicalpsychotherapy.• a good service will plan and respondappropriately to demographic andcultural changes in the population.Putting principles into practiceTo achieve this, commissioners shouldconsider commissioning a range ofservices to meet the needs of older people,including:• preventive public health interventions• support and engagement with familiesand carers• provision of psychological therapies thatis equitable with those for adult services• provision of acute hospital liaison services• services that are delivered in bothcommunity and inpatient settings• memory assessment services• specialist mental health assessment,diagnosis and intervention services forolder people that are distinct from thosefor younger adults.Using the right leversCommissioners should make use of therange of levers available to create andimprove local services. These includeCQUINs, as well as contract and servicespecifications. Detail of these can be foundon the JCP-MH website (www.jcpmh.info).Community-based servicesCo-morbidities or multi-morbidities arethe norm in later life. A multi-agencyand multi-professional approach is key toidentifying and intervening early in high-risksituations where there are vulnerable peopleand unsupported carers under high levelsof stress.Community Mental Health Teams (CMHTs)for older people are regarded as pivotalto the delivery of an integrated service59.Delivering services through multidisciplinaryCMHTs ensures that the needs of localcommunities are both at the forefront ofservice provision, and creates a serviceidentity that can be easily recognised andaccessed by patients and referring agencies.CMHTs provide continuity, and are often thelynchpin, providing coordination betweenother services within mental health (inpatientwards, hospital liaison, memory services) andbeyond (acute geriatric medicine, ImprovingAccess to Psychological Therapies – IAPT.The multi-agency, multidisciplinary teammembership can harness local expertise,knowledge and skills, and enable theteam to network with those other relevantservices that may need to be engagedin the individual care plan (e.g. housingand leisure). A single team approach todelivering services will streamline referralsources and use common assessment andcare planning processes that will improveaccess and continuity.The JCP-MH has also published resourcesfor commissioners on community mentalhealth services and acute care for adultsof working age which can be accessed viawww.jcpmh.infoIt is important to state that the range andscale of challenges that older people withmental health needs and their familiesand carers face, means that continuityof care usually remains with the GP.Specialist services should provide support,information and advice, including educationsessions not only to the patient and theircarers, but also to other professionals,including those in primary care.Crisis resolution and home treatmentCrises amongst older people arise fordifferent reasons than in working ageadults, and intensive support may berequired for longer, particularly where aperson is living alone. Service configurationneeds to be able to respond in thesecircumstances.This guide supports the developmentand delivery of crisis resolution and hometreatment, providing that the service can bedelivered solely or in part by people withspecific expertise in the problems faced byolder adults.Psychological servicesSpecialist psychological (or talking)therapy services for older people aim toalleviate psychological distress and promotepsychological wellbeing and health of olderpeople with mental health problems andtheir families and carers.People with mental health problemsconsistently place access to psychologicaltherapies as an unmet need, both in earlyand later stages of the care pathway.The term talking therapies can cover a widerange of models such as: psychodynamic,cognitive behavioural, cognitive analytic,systemic, narrative and arts-based12 Practical Mental Health Commissioning
  14. 14. Guidance for commissioners of older people’s mental health services 13approaches60. Multi-professional in nature,these may be provided by psychologists,psychiatrists, nurses, counsellors, socialworkers and others who have undertakenappropriate training in specific models ofpsychological intervention.The effectiveness of psychological (andpharmacological treatments) for olderpeople with mental health problems iswell recognised61, but these are often notfully provided or funded. Commissionersshould explore the fullest range ofevidence-based interventions to ensure thatlocal services are able to provide a broadset of services across both community andinpatient settings.An effective older people’s mental healthservice will include access to psychologicaltherapies across all elements of theservices, from primary care (includingIAPT) to inpatient wards. In particular,the IAPT programme for older peopleprovides a key means by which to achieveimproved outcomes by providing a highquality, measurable preventative servicein primary care.Inpatient servicesInpatient services remain an integral partof any effective older people’s mentalhealth pathway. Sometimes older peoplewill require a period of time in hospitalfor assessment and/or treatment ofcomplex conditions. It is imperative thatcommissioners ensure that an adequatenumber of inpatient beds is available fortheir local population.In comparison with working age adults,older people are less likely to have co-morbid substance misuse or personalitydisorder, but more likely to have significantphysical co-morbidity, frailty and somedegree of cognitive impairment. Theirlength of stay is likely to be longer as aconsequence.To ensure the highest standards, this guideadvocates that commissioners work withproviders to deliver inpatient services thatbest meet the needs of the local population,but that emphasis is placed on:• inpatient services that specificallymeet the needs of older people andare separate from wards for adults ofworking age• where possible, separate ward spacefor functional and organic disorder• gender separation guidance for inpatientservices being properly applied.General hospital settingsOld age liaison should be provided byolder people’s mental health services,distinct from those provided by adultteams for working age patients (althougha single point of referral may beappropriate). The profile of an olderperson referred to a liaison service from ageneral hospital is substantially differentfrom that of a younger adult. Deliberateself-harm in older people results in arelatively greater risk of completing suicide.Depression, dementia and delirium are allcommon, often undetected and will delayrehabilitation, lengthen stay and increasecare costs. Effective treatment of psychiatricmorbidity in acute hospitals reduces lengthof stay and care costs62.The Rapid Assessment Interface &Discharge (RAID) philosophy of keepingoverall liaison provision as uniform aspossible (e.g. single point of referral) hasbeen successful63and provides a helpfulmodel for commissioners to consider. Theservice needs of older people with mentalhealth problems referred from generalhospitals is different to that from youngeradults. However, old age services providingliaison input will benefit from being co-located with other liaison services.Black and minority ethnic (BME) eldersOlder people from BME groups whoexperience mental health problems are nowrecognised to be one of the most sociallyexcluded groups in our society. Minorityethnic elders are under-represented as usersof specialist mental health services, butthere is no evidence that elders from blackand minority ethnic groups have reducedmental health needs.This form of social exclusion is not just dueto the direct impact of mental illness but isa result of stigma, prejudice and a lack ofaccess to services that could aid recoveryamongst this group.The older BME population is growing fastand was expected to increase by 170%between 2005–2012, according to theUK Inquiry into Mental Health and Well-Being in Later Life, a rise that if validatedwill have been significant and may besustained. The same inquiry, led by AgeConcern (now Age UK), warned thatolder BME people are among the groupsmost likely to experience mental healthproblems64. It is clear that older peoplefrom ethnic minority backgrounds withmental health problems can potentiallyface issues of discrimination arising fromtheir age, their sex, their ethnicity and theirpsychological ill health.Planning of services for older people fromBME groups needs to begin early and thereis a need to develop and improve ethnicmonitoring and to disseminate evidence ofgood practice.
  15. 15. 14 Practical Mental Health CommissioningWhat would a good older people’s mental health service look like? (continued)Public health commissioning tosupport older people’s mental healthPublic health is about improving the healthof the population through preventingdisease, prolonging life and promotinghealth13. The Foresight Report highlightedthat “the increasing prevalence of cognitivedecline, particularly due to dementiawill be critical. However, other mentaldisorders, notably depression and anxietywill also be important: addressing therelatively poor access of older adults totreatment (compared with younger adults)should be an immediate priority.”65This highlights the need for commissionersto consider the impact of public healthcommissioning and its relationship to thedevelopment of services for older peoplewith mental health problems.According the to JCP-MH publication,Guidance for commissioning publicmental health services, public mentalhealth involves:• an assessment of the risk factors formental disorder, the protective factorsfor wellbeing, and the levels of mentaldisorder and wellbeing in the localpopulation• the delivery of appropriate interventionsto promote wellbeing, prevent mentaldisorder, and treat mental disorder early• ensuring that people at ‘higher risk’ ofmental disorder and poor wellbeing areproportionately prioritised in assessmentand intervention delivery.Although there is a shortage of robustevidence for the effectiveness and cost-effectiveness of interventions to improvethe mental wellbeing of older people66,particular interventions to increase socialparticipation, physical activity, continuedlearning and volunteering can help preventdepression, particularly in older people.Public health intelligence can assist indecisions about which interventions andservices to commission. They must workclosely with colleagues in public health inthe conducting of Joint Strategic NeedsAssessments and the development ofcommissioning strategies to ensurecoherent linkages that will lead to effectiveand efficient services.HousingGood quality, affordable, safe housingunderpins mental and physical wellbeing.Without a settled place to live, accessto treatment, enabling recovery andgreater social inclusion can be impeded67.Housing provides the basis for individualsto recover, receive support and return toan independent life in the community68.Mental ill health is frequently cited asa reason for tenancy breakdown67, andhousing problems are frequently given asa reason for a person being admitted orre-admitted to inpatient care69or in delaysin leaving hospital.Support with housing can improve thehealth of individuals and help reduce overalldemand for health and social care services.Specialist housing and housing-relatedsupport helps people to live independentlyin the community, reducing the need forcare and preventing poor health. Timelyhome adaptations and reablement servicesaid timely discharge and prevent hospitalreadmissions, helping people to recovertheir independence after illness70.From specialist housing through toaccessible general housing, dementia careservices through to handyperson services,commissioners must ensure a full rangeof care and accommodation solutionsare offered to enable independence forlonger71.Long-term conditions commissioning tosupport older people’s mental healthPeople with long-term conditions frequentlyhave more than one condition. Around halfof this population will have more than onemajor health problem, and around a quarterwill have three or more problems72, with thechances of having more than one problemincreasing with age. As people grow older,their health needs become more complex,with physical and mental health needsfrequently being inter-related and impactingon each other. Examples include:• both physical and mental healthdifficulties can affect an individual’s abilityto care for themselves independently, andpotentially have major implications fortheir way of life – for example, surveysindicate that 25% of people receivinghome care services are depressed73.• physical health difficulties can bothcontribute to, and be compoundedby, depression and anxiety, as well asacute and chronic confusion. Conditionsassociated with chronic pain, and thoseleading to the loss of independence,and possibly the loss of the family homeif a move is necessary, are commonlyassociated with depression.• a persons ability to look after their ownhealth, by taking a good diet, keepingactive both mentally and physically,managing medication correctly andco-operating with treatment, can beadversely affected by depression ordementia.• many older people receive multiple typesof medication. Any medication has thepotential to cause adverse effects aswell as benefits. Any new or changedtreatment to help a physical conditioncan lead to, or worsen, mental healthproblems. Similarly, treatment for mentalhealth problems can adversely affectphysical health in vulnerable older people.
  16. 16. Guidance for commissioners of older people’s mental health services 15• people with diagnosable physicalillnesses, especially chronic or recurrentconditions commonly show higherrates of mental health problems thanthe general population. Recovery from,or the management of, for examplediabetes and coronary heart diseasecan be compromised as a consequenceof mental health problems, especiallydepression74.• rates of depression in severe and chronicdiseases can be high. It has been shownthat up to 60% of people who havesuffered a stroke can be depressed, upto 40% of people with coronary heartdisease, cancer, Parkinson’s Disease andAlzheimer’s can also be suffering fromdepression75.Personal health budgets andpersonalisationA personal health budget is an amountof money to support a person’s identifiedhealth and wellbeing needs, planned andagreed between the person and their localNHS team. The vision for personal healthbudgets is to enable people with long-term conditions and disabilities to havegreater choice, flexibility and control overthe health care and support they receive76.Direct Payments are intended to creategreater flexibility in the use of social carebudgets, giving greater control to peoplewho use services and enabling them todetermine the nature and provision oftheir care. Older people and their carers,especially those living with dementia,may need support from the specialist teamto use and manage personalised budgetsfor themselves.These payment systems introducethe requirement for greater personalresponsibility, and for individuals to use theirown resources, as well as the chance for theNHS and social care to continue to reshapetheir approach to both the commissioningand delivery of care services. Commissionerswill need to be mindful of the increasinguse of personal health budgets and directpayments when developing local strategiesfor service change and development, andwork to overcome potential barriers forolder people.TechnologyInformation technology is having anincreasing impact on the delivery of mentalhealth services to older people. The IAPTprogramme has shown that computerisedCBT (cCBT) programmes can be usedeffectively by older people if they are wellsupported in the first instance to gainconfidence in the use of the technologyand materials77.Similarly, telephone therapy and emailfollow-up sessions work well, providedthe person and their therapist have hadsome initial face-to-face meetings.This can reduce need for outpatientappointments not only for therapy butalso for memory clinic settings. This cande-stigmatise and normalise contact withmental health professionals and reduceanxieties about travel. It needs to beoffset against the positive gains fromface-to-face contact in terms ofrelationship building and reduction ofsocial isolation. Although the evidence foruse of telehealth and telecare is somewhatequivocal, as seen in the ‘Whole SystemDemonstrator’ site review conductedby the Nuffield Trust78, commissionerswill need to explore the ways in whichtechnology can assist it the provision ofeffective and responsive services.Special SettingsCare homesDepression occurs in 40% of people livingin care homes and often goes undetected79.Very few care homes provide solely for thecare of older people with mental healthproblems which are not dementia. Usuallypeople with mental health problems areparticularly isolated in the care homesetting. The special needs of those incare homes need to be recognised ina commissioning process. In particular,training care staff to identify possiblesymptoms of depression can improvedetection80.The National Mental HealthDevelopment Unit produced a resource,‘Let’s Respect’ which is primarily aimed atstaff working in care homes who want toknow about the mental health needs ofolder people in order to improve practiceand standards of care81.It can be accessedat: www.nmhdu.org.uk/silo/files/lets-respect-toolkit-for-care-homes-.pdfPrisonsAlthough the current old age populationin prisons is small, sentencing policy overthe last two decades will ensure that itwill rise. The physical health of prisonersis poorer than the general population andthey are more prone to vascular disease82.Depression and dementia are both morecommon in the older prison population.Commissioners of services need torecognise this in their local planning anddevelopment.Learning disabilityMental health problems are more commonin this group than the general population.Although transition arrangements willbe required for people who have been incontact with learning disability servicesthroughout their life, service provisionis required for the minority of learningdisabled people who develop mental healthproblems for the first time in old age.
  17. 17. Supporting the delivery of the mental health strategyThe JCP-MH believes thatcommissioning which leads togood older people’s mentalhealth services as describedin this guide will support thedelivery of the No Healthwithout Mental Health strategyin a number of ways as setout below:Shared objective 1:more people will have goodmental healthCommissioning effective older people’smental health services will enable theidentification of associated mental healthproblems and ensure access to appropriateassessment, diagnosis treatment andsupport.Shared objective 2:more people with mental healthproblems will recoverImproved older people’s mental healthservices will ensure that older people withmental health problems have their needsmet so that their quality of life, choicesand independence are enhanced.Shared objective 3:more people with mentalhealth problems will have goodphysical healthEnsuring the provision of effective olderpeople’s mental health services will enablethose people who have co-morbid mentalhealth problems to have their physicalhealth needs properly assessed andtreated. The identification of these needsand action to address them will result inimproved physical health.Shared objective 4:more people will have a positiveexperience of care and supportOlder people are disproportionately higherusers of health and social care. Goodquality services, and especially ones thatintegrate and support the other health andsocial care services, will have a positiveimpact in improving people’s experience ofcare and support.Shared objective 5:fewer people will sufferavoidable harmDepression in older people remains asignificant issue. Effective diagnosis andtreatment is likely to have a positiveimpact on levels of self-harm and suicide.Shared objective 6:fewer people will experiencestigma and discriminationIn the commissioning and provision ofolder people’s mental health services it isessential to avoid both direct and indirectage discrimination.16 Practical Mental Health Commissioning
  18. 18. Guidance for commissioners of older people’s mental health services 17Expert Reference Group Members• James Warner(ERG Co-chair)Consultant and Honorary Readerin Older Adults PsychiatryCentral North West LondonFoundation TrustChairFaculty of the Psychiatry of Old AgeRoyal College of Psychiatrists• Peter Connelly(ERG Co-chair)Consultant Old Age Psychiatrist(NHS Tayside) and Co-Directorof the Scottish Dementia ClinicalResearch NetworkImmediate Past ChairFaculty of the Psychiatry of Old AgeRoyal College of Psychiatrists• Polly KaiserConsultant Clinical PsychologistPennine Care NHS Foundation Trustand member of The Facultyof Psychology of Older People• Andy BarkerConsultant in Old Age PsychiatrySolent NHS TrustLord Chancellor’s Special(Medical) VisitorOffice of the Public Guardian• Cath BurleyChair of The Faculty of Psychologyof Older PeopleDivision of Clinical PsychologyBritish Psychological Society• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Steve IliffeProfessor of Primary Carefor Older PeopleUniversity College LondonDevelopment processThis guide has been developed by agroup of older people’s mental healthexperts, in consultation with patientsand carers. Each member of the JointCommissioning Panel for Mental Healthreceived drafts of the guide for reviewand revision, and advice was soughtfrom external partner organisations andindividual experts.Final revisions to the guide were made bythe Chair of the Expert Reference Groupin collaboration with the JCP’s EditorialBoard (comprised of the two co-chairs ofthe JCP-MH, one user representative, onecarer representative, and technical andproject management support staff).AcknowledgementsThe external reference group developedthis guide under the leadership of JamesWarner and Peter Connelly, who wouldlike to thank Andy Barker, Cath Burley,Polly Kaiser, Steve Iliffe and Sheena Foster(service user and carer committee chair forthe British Psychological Society) for theirinvestment of energy, time and expertise.It was written and edited by SteveAppleton (Contact Consulting) andChris Fitch (Research and Policy Fellow,RCPsych).Steve AppletonSteve Appleton is Managing Directorof Contact Consulting, a specialistconsultancy and research practice workingat the intersection of health, housing andsocial care.He has held operational and strategic postsin local authorities and the NHS, with aspecialist interest in the health, housingand social care needs of people withmental health problems, substance misuseneeds, learning disability, older people andoffender health.Department of Health –Dementia Challengehttp://dementiachallenge.dh.gov.uk/National Development Team for Inclusion(NDTI): resources on achieving ageequality in mental health serviceswww.ndti.org.uk/publications/ndti-publications/a-long-time-comingResources
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  22. 22. A large print version of this document is available fromwww.jcpmh.infoPublished May 2013Produced by Raffertys

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