Mental Health Care (Older People in Lincolnshire)
(10 years, 8 months ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Stephen Phillips (Sleaford and North Hykeham) (Con)
World Health Organisation figures show that mental illness is responsible for the largest proportion of the disease burden, at just over 22%, in the UK. That is greater than that of cardiovascular disease or cancer, each of which stand at about 16%. In our society, mental health simply does not receive the same attention as physical health. People with mental health problems frequently experience stigma and discrimination, not only in the wider community but from services they need to access. This is exemplified in part by lower treatment rates for mental health conditions and an historical underfunding of mental health care relative to the scale and impact of mental health problems.
However this problem may have arisen, it is persistent and the consequences are plain. People with severe mental illness have a reduced life expectancy of 15 to 20 years, even though the majority of the reasons for this are entirely avoidable. I cannot be the only one to think that this can no longer be tolerated in the 21st century. I am glad that the Government have made real progress in promoting the principle of parity of esteem with their commitment to put mental health on a par with physical health in the NHS. Central to this approach is the fact that there is a strong relationship between mental health and physical health, and that the influence works in both directions: poor mental health is associated with a greater risk of physical health problems, and poor physical health is associated with a greater risk of mental health problems.
I sought this debate to raise the particular issue of mental health care for older people in my county, an issue that can only continue to grow in importance as our population ages. The UK is experiencing a significant population shift, with both the size of the older population and projected life expectancies rising considerably faster than previously expected. Significant growth is expected amongst those over 65 in the next few decades, with the oldest age group of those aged 85 and above growing proportionally the fastest. As the population aged over 65 increases, the number of older people with mental health problems will also, inexorably, increase. The largest increase in numbers of any mental health problem will be seen in the rise of the numbers of people with depression, but there will also, undoubtedly, be significant increases in the number of people with dementia.
Surprisingly, perhaps, this will be compounded by co-morbidity with substance misuse in this age group. Although usually regarded as a problem affecting younger adults, abuse is overlooked in the elderly. In the next few decades, there are likely to be increasing numbers of older people exhibiting co-morbid symptoms, as alcohol and drug users from the baby boomer generation reach and pass retirement.
One of my constituents, a community nursing assistant at the Manthorpe centre in Grantham, has spoken to me about his concerns for the future. Although the centre is not in my constituency but in that of my hon. Friend the Member for Grantham and Stamford (Nick Boles), it provides mental health services for older people from all over Lincolnshire. As such, concerns have been raised with me about the reorganisation of services at the centre and elsewhere in the county. The job of a community nursing assistant, as my hon. Friend the Minister will know, is to provide the emotional and practical support needed by elderly patients. Assistants thus deal with a large number of lonely, isolated and vulnerable people. It is not only the mental health diagnoses of those in this group that cause problems, but the simple loneliness. Often, their health care workers are the only people they see or talk to on a regular basis. Indeed, my constituent has told me that he and his colleagues can be the “nearest relative” at funerals, which gives some sense of the acuity of the problem.
It used to be the case that families and communities looked after their older members and supported them, but sadly, as we all know, that is all too often not the case. The disestablishment of those community posts in Lincolnshire is thus causing real concern. Those who fill them save the NHS money by helping those in need directly, without their needing to be admitted to hospital, which is far more costly than being supported while living at home. Yet when I contacted the Lincolnshire Partnership NHS Foundation Trust to ask about these posts, I was told they were intended to provide social intervention rather than health care per se—a function that the trust feels should be carried out by local authorities through their social care staff. So it is that a lack of funding from one part of the system that does not regard itself as responsible for the establishment of these posts runs the risk of costing itself and other parts of the NHS more money in the long term.
I understand from more recent discussions that the trust is now working closely with our local authorities to ensure that patients remain supported, but I understand and share the concerns of many that elderly folk in need may fall through the cracks despite good intentions. Indeed, that is too often the case where NHS care and social care interact—an issue that I know has been raised on numerous occasions in the House by colleagues on both sides. I would therefore be grateful if the Minister told the House what steps his Department is taking to work with trusts that are reducing provision to ensure that robust support networks are maintained and improved for patients with mental health needs.
Sir Edward Leigh (Gainsborough) (Con)
The people in Lincolnshire will be grateful to my hon. and learned Friend for raising these issues. Does he agree that they are exacerbated by the rural nature of our county? Frankly, people in a deeply rural county such as Lincolnshire sadly get a worse service than people living in urban areas.
Stephen Phillips
I am extremely grateful to my hon. Friend, who makes an important point. All too often, and not just in this area of public service, as he knows, but in so many others, we get a much worse service in rural communities—particularly, it seems, in Lincolnshire —than many other places. That is in part made up for by the fact that we have extremely strong communities, with strong ties between neighbours and families, but as I know he knows, far too often we seem to draw the short straw in this and other areas.
That is in part why I also want to raise with the Minister the apparent disconnect between services for those aged over 65 and those under that age, given our ageing population in the county. In that regard, I have been told that the care provided by the community mental health team in my part of Lincolnshire for those under 65 has been fairly extensive, including a lot of support for those settling back at home after a hospital admission, but that such services are not so readily available for those aged over 65. Why the disconnect and what can the Minister do about it?
I am aware, of course, that the Equality Act 2010 has been vital in shifting mental health services towards age inclusiveness. The Minister will know, and has no doubt acted on the fact, that there is now a duty on health and social care services not to discriminate on age grounds. That ought to mean that older people with mental health problems should have the same access to mental health services that had previously been available only to people under the age of 65. Is this working? No doubt the Minister can tell the House, for there is a great deal of concern, at least in Lincolnshire, that it is not. I understand that the Department of Health has acknowledged the under-representation of over-65s in the IAPT—improving access to psychological therapies—initiative and has made a commitment to undertake various corrective actions to address that in line with the provisions of the 2010 Act. I would be grateful if the Minister could tell the House what his assessment is of the current state of mental health services for those aged over 65 and what steps he is taking to ensure improvements in provision and access in Lincolnshire and elsewhere.
The Royal College of Psychiatrists has said that to integrate older adults’ mental health services into “ageless” services makes no sense. Older people have very different physical, social and psychological issues, which require specialist old-age psychiatrists working in specialist services for older adults. Older people tend to have multiple physical co-morbidities or frailties, which often complicate their mental health treatment. Many older people also have specific cognitive problems, social issues or end-of-life concerns, which may precipitate or sustain mental illness.
It would seem that the key element is flexibility of access. We need to ensure that people do not automatically become ineligible to continue to be treated by a service once they pass the age of 65, so that someone under that age with, for example, early-onset dementia can gain access to the expertise of comprehensive older-adult mental health services. I should be grateful for the Minister’s comments on those points.
The Royal College of Psychiatrists has also identified a “mental health treatment gap”, exemplified by lower treatment rates for mental health conditions, premature mortality among people with mental health problems, and the underfunding of mental health care relative to the scale and impact of mental health problems—the problems that I described at the beginning of my speech. Annual statistics published by the Department of Health on investment in mental health have shown that in 2011-12 there was a 1% decrease in overall investment and a 3% decrease in investment in older people’s mental health services. I know that addressing the funding gap will be challenging—particularly as such underinvestment tends to be exacerbated during times of austerity, when mental health services risk being cut in preference to physical health services—but I venture to suggest to the Minister that things should not go on as they have been.
Given the current challenge to address the high levels of both identified and unmet need, an increasing ageing population will have significant resource consequences for mental health and social care services for older people, which are already struggling to provide care at present. Unless there are major breakthroughs in new cost-effective treatments, or prevention and promotion initiatives succeed in reducing the incidence and prevalence of mental health problems among older people, services will need significant extra resources to meet that demand. In practice, however, mental health spending has in the past followed an erratic pattern nationally, with cuts in some areas and investment in others.
What, ultimately, I want to hear from the Minister tonight is an assurance that he is focusing on this issue, and that enough is being done to ensure that mental health services receive proper funding, in Lincolnshire and throughout the country.
The Minister of State, Department of Health (Norman Lamb)
I congratulate my hon. and learned Friend the Member for Sleaford and North Hykeham (Stephen Phillips) on securing the debate, and on his speech. I do not think that I disagreed with anything he said. He was absolutely right to highlight the fact that when finances are tight in the NHS it always seems to be mental health that loses out. That happened in the middle of the last decade, and it has happened again now. There is what I describe as an institutional bias against mental health in the NHS, and it must be combated. That is why, as my hon. and learned Friend said, we have legislated for parity of esteem.
The levers—the financial incentives—in the NHS are unbalanced, and that disadvantages mental health. On the physical health side of the divide is the politically powerful guide relating to the 18-week period between referral and treatment, but there is no equivalent on the mental health side. Moreover, payment by results operates in the case of physical health. The combination of those two things sucks money into acute hospitals—it increases investment at the acute end of the spectrum—but takes money away from mental health, which depends on block grants negotiated locally. We must change that, and next year we shall introduce access standards to mental health services so that we can start to address the imbalance in the system.
As my hon. and learned Friend pointed out, the fact that we are all living longer makes the increasing prevalence of these problems inevitable, and, although we have legislated to make age discrimination unlawful, it cannot be eradicated overnight. Because of the way the system works, older people still lose out, such as in access to IAPT—improving access to psychological therapies—cognitive behaviour therapies.
Dementia and Specialist Older Adult Mental Health Services, which is part of the foundation trust in Lincolnshire, provides a range of specialist community and in-patient services and contributes to all key care pathways for older adults with dementia and mental health-related needs. As Members will be aware, these services are designed and commissioned locally so that they can be closely matched with the needs of the population they serve. That does not always happen, but it is the principle.
Crucially, local GPs are ideally placed to know local health needs and they now play a key role in commissioning health services. Lincolnshire Partnership is therefore working with four GP clinical commissioning groups in Lincolnshire and with other providers to improve the services it offers. Aims include reducing unnecessary hospital admissions, facilitating hospital discharge, and delivering more home and community-based services. There is a range of initiatives within this programme, such as having mental health nurse-led clinics in GP practices and care pathways. That is a very important advance. Bringing mental health back into primary care is a necessary reform because very often people get stuck in long waiting lists, waiting for referral to treatment and support. Other initiatives include CCG-aligned community teams with functional mental health and dementia-specific clinical pathways and skills, nursing home support, and developing behavioural psychological support services in the community for people with complex behavioural needs.
In October 2012 we announced a £50 million capital investment fund to support the NHS and social care in improving dementia care. The funding is aimed at expanding the range of health and care services, offering supportive environments to help the growing number of people with dementia get the best possible care. My hon. and learned Friend will be aware of the Prime Minister’s dementia challenge, which was issued in 2012 and which focuses on improving health and care services, making our communities more dementia-friendly and increasing research into dementia, both trying to find a cure and gaining a better understanding of how we care for people with dementia.
Lincolnshire Partnership NHS Foundation Trust was awarded £250,000 from that programme to transform the care environment at the Manthorpe centre, to improve care for people with dementia in Lincolnshire. The Manthorpe centre is a 20-bed assessment and treatment unit located on the district general hospital site at Grantham that offers specialist care to older people suffering from dementia or functional conditions. This is a high-level service provided in hospital to allow for a needs assessment by a range of professionals who provide an appropriate bespoke treatment plan.
Local services always need to be alive to the need to change and improve so that they can meet the needs of the people they serve. Of course this can sometimes be unsettling for staff, and organisations need fully to engage with them in achieving improvement. It is good that the health worker at the Manthorpe centre went to speak to my hon. and learned Friend to raise his concerns directly so that they could be debated here in Parliament. This is all the more important when, as I will discuss in a moment, we are focusing on mental health and older people as never before.
I would encourage my hon. and learned Friend to continue to raise these points with the chief executives of local authorities and NHS organisations in his area. As I mentioned earlier, the success of the managed care network in his area has recently been independently recognised, which is good.
My hon. and learned Friend asked what the Government were specifically trying to do on national policy. We now know much more about the causes of some of the most common mental disorders, such as depression and anxiety. We also know what can, in many cases, prevent them, and we are focusing on raising awareness of the interventions that we know work—for example, reducing isolation in older people. Loneliness and isolation affect people with mental health problems. We know that loneliness has a very negative impact on physical and mental health. The mental health of people who are on their own and not seeing anyone deteriorates, and they may also start to drink too much—that is a common feature of loneliness and it exacerbates the problem. Loneliness is associated with conditions such as cardiovascular disease, dementia, poor sleep and depression. Loneliness and social isolation are problems that government alone cannot solve.
Many of the solutions to combating loneliness lie within local communities themselves, but government has a part to play. One thing that I always stress is that if we are to combat loneliness and focus on well-being, which is the principle at the heart of the Care Bill we have been taking through Parliament, there has to be a richer collaboration between statutory services and the wider community. My hon. and learned Friend mentioned the strong communities in Lincolnshire. One potential solution to the challenges he highlighted is the fact that there are growing numbers of people in retirement. Although some have care needs, many of them are fit and healthy and often they want to give something back but do not know how to do so. The question of how we can unleash the power of our communities and those people who do have time on their hands and want to contribute suggests to us part of the solution to the challenge we face.
By bringing people together, giving them the right tools and increasing the evidence base on loneliness, we can encourage local commissioners to tackle this important problem. I agree with the points made by my hon. and learned Friend on both parity of esteem and the links between physical and mental health—as he made very clear, one so often causes the other. We have taken action to try to address these problems. We have enshrined in law the equal status of mental and physical health in the Health and Social Care Act 2012. We know that people living with significant and persistent mental health problems have significantly reduced health and quality of life, and that they live on average 16 to 25 years less than the general population—that is extraordinary and, as he indicated, it is avoidable. The reasons people with mental health problems die earlier could be addressed and we could reduce this outrageous gap in life expectancy.
That is why reducing premature death in people with serious mental illness is identified as a priority area in both the public health and NHS outcomes frameworks, and it is why the NHS operating framework specifically focuses on the physical health of people affected by mental illness for the coming year. Let me explain the purpose of the outcome frameworks. That is horrible jargon, but the point of such frameworks is to try to focus on what the results are for people and to measure the performance of organisations across the country in what they achieve for people and whether their performance is improving over time. That starts to enable us to hold the system to account.
We are investing more than £400 million to give hundreds of thousands of people, in all areas of the country, access to psychological therapies. We are supporting local organisations in taking effective action to improve mental health. Our mental health strategy and the implementation framework that goes with it, and our suicide prevention strategy, focus on specific actions that local organisations can take to improve mental health across the life course in their areas. In June last year, we announced the better care fund, and from April 2015 councils and the NHS will get £3.8 billion to work with each other and the voluntary sector. Plans are now being assured—they have been submitted in draft form—and challenged at local and national level. In 2015-16 the fund will receive an additional £2 billion from clinical commissioning group budgets and £800 million from existing health and social care funding streams. This fund is about a new way of working, with joint decisions made locally to deliver joined-up care, pooling the resource that is available, for people who need it most.
My hon. and learned Friend gave an example of one organisation saying, “It’s not our responsibility; it’s somebody else’s.” That sort of silo working has to end. We know that if we harness the public resource that is available, join up more effectively the efforts of different public sector organisations and work collaboratively with the wider community, we can make much better use of our available resources. It really should be a thing of the past that we hear organisations saying, “It’s not our responsibility; it’s somebody else’s.” They must resolve their problems collaboratively. I was encouraged to hear that that now appears to be starting to happen.
Last year, we announced 14 integrated care pioneers to work on ambitious and innovative approaches to delivering person-centred co-ordinated care and support. The pioneers are supported by national partners. They draw on international expertise and work with senior sponsors within the sector, allowing them to innovate, break down the barriers that exist to joining up care and lead the way on integrated health.
My hon. Friend the Member for Gainsborough (Sir Edward Leigh) mentioned the rural nature of Lincolnshire. Well, Cornwall is rather similar, as indeed is my own county of Norfolk. In Cornwall, the integrated care pioneer has a fantastic collaboration between volunteers and GPs. The volunteers give companionship to people who are living on their own, and work collaboratively with GPs. GPs recognise that the volunteers help them in their work and reduce the isolation that so many people feel, and they have seen significant reductions in hospital admissions. So, if we improve lives, we save money, and that must be what we are all after.
Each pioneer is focusing work on its own priorities, which is bringing specific progress on issues. Many of the pioneers, in both rural and urban areas, face the same issues. Partners are coming together and overcoming difficulties for everyone. We want to disseminate, as quickly as possible, the learning from those areas so that everyone can gain the benefit of this exciting pioneering work. We aim to make integrated care and support the norm and to improve the experiences of patients, service users and carers.
“Closing the Gap”, which we launched in January, indicates the importance of equity between mental and physical health for this Government. It outlines 25 priority areas where people can expect to see, and experience, the fastest changes. One priority area is tackling inequalities in access to mental health services.
Older people typically use mental health services much less often than their working-age counterparts. According to IAPT data, only 6% of people who use psychological therapies are over 65. In response, we supported the advertising campaign delivered through Age UK and Carers UK to raise awareness of psychological therapy services among older people.
NHS England is promoting psychological therapy services for adults who have depression or anxiety disorders through the national IAPT programme and, as part of this work, is paying particular attention to access for people over 65 years of age. It funded the advertising campaign to promote IAPT services. The promotional campaign challenges views that depression is natural in older people—that is an old assumption that people make—and encourages GPs to refer older people to IAPT services and older people to self-refer.
Another strand of IAPT development is a project that aims to ensure that psychological therapies are routinely available to people with long-term physical health conditions and medically unexplained symptoms. Given that many older people have such physical health conditions, this project will lead to greater use of IAPT services where necessary. We have also developed a new curriculum for psychological therapists that trains them to work more effectively with older people.
The hon. and learned Gentleman raises a point about substance misuse in the elderly population. We should not be surprised that people who have used illegal substances or alcohol earlier in life do not suddenly stop when they reach 65; better training for all professionals will ensure that help is based on actual need, and not on outdated images of older people.
“Closing the Gap” supports all the objectives set out in the Government's mental health strategy, which is a cross-Government mental health outcomes strategy for people of all ages. It was launched in February 2011 and sets out a clear vision for improving mental health and well-being in England for people of all ages, including older people.
The hon. and learned Member for Sleaford and North Hykeham spoke of the apparent disconnect between services for the under and over-65s and quoted the Royal College of Psychiatrists. We are committed to making sure that adults of all ages are treated fairly, with access to services based on their needs, not on any assumptions about what they might need. When we are developing local services, commissioners and providers have the opportunity to consider how mental health services can be user-led rather than service-led, while recognising the specialist service requirements of some older people with mental illness.
The number of older people in the UK is projected to rise substantially over the coming decades as a result of a combination of rising life expectancy and the large number of births in the period following the second world war—the baby boomer generation. Despite the demographic and additional economic pressures, the Government’s ambition is to make this country a great place in which to grow old. There is an awful lot of work still to do and we have not combated the lack of parity yet, but we are totally committed to doing so. A lot of the things we are doing will help us achieve that.
Question put and agreed to.