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Mental Health: Age Discrimination

My Lords, it is customary to thank the initiator of the debate, but I urge your Lordships not to thank me. This debate was initiated by the persuasion and at the insistence of the noble Baroness, Lady Neuberger, to whom I am grateful. I have always been rather reticent about raising this topic as a subject for debate, simply because it seemed like special pleading from someone who has spent her life in old-age mental health services, but this is a timely point to have this debate—particularly this week, because of the appointment of the new national tsar for dementia, Professor Alistair Burns. He is a canny, delightful and exceptionally talented man and I know that he will go at it with aplomb, if I may say that. Let us face it, he will have a bit of an uphill struggle, given the National Audit Office’s recent interim report on the capacity of the Government, the National Health Service and local authorities to implement the national dementia strategy. However, I am sure that he will get a great deal of support from parliamentarians in his new role. Before I get into my "Disgusted of Tunbridge Wells" mode, I want to remind everyone how terrible things used to be. Before the 1960s, there were no separate services for older people with mental health problems, which meant that older people with profound mental illnesses stayed in acute hospitals, often for a long time, and just withered away at the end of the ward. They ended up either in Part III homes with the local authority, struggling to cope, or they went to a long-stay asylum or geriatric hospital, depending on whether their modus vivendi was largely horizontal or vertical. It was as simple as that; it was pretty awful. In the 1960s, a few pioneers started to develop services. It was a marvellous time to be sent to one of the specialist units for training, as I was. It was an exciting time, because we felt that we were in the vanguard of a developing specialty and that we were showing our fusty old colleagues in general mental health services how community mental health services should be working in conjunction with the local authority. It was tremendous fun and very exciting. I fear that, as much needed funding has gone into general mental health services, services for older people have lagged behind. We used to be more advanced in the UK than anywhere else in the world. I used to travel all over the world talking about our wonderful services. People were amazed at how far we had been able to come. I am ashamed to say that, nowadays, the situation is better in many other countries. That is a real cause for concern. Let us come to the shocking statistics, so clearly set down in the Royal College of Psychiatrists’ position statement published last year, about which the noble Baroness, Lady Neuberger, asked a Question in the House. There is no doubt that many tens of thousands of people over the age of 65 are missing out on specialist services simply because of the way in which we configure them. This is a tragedy, as many of them risk serious deterioration and will die early as a result of a lack of treatment. That is in spite of the fact that mental health problems are common in older people. Depression is the commonest disorder in old age. Its prevalence in women tends to stay the same after middle age, but in men it goes up and up. Of course, dementia is almost entirely a disorder of the very aged. Psychosis, which many of us associate with a young onset, is 50 per cent commoner in older people. Suicide is twice as common in people over 65 as it is in people under 25 and we know that at least 80 per cent of people who commit suicide are suffering from depression. However, half of young people with a major depressive illness are referred to a specialist psychiatrist, whereas only one in six older people is so referred. As treatment, by and large, has as great an efficacy among older people as among younger people, and as maintenance treatment can prevent relapse and decrease mortality, this favouring of younger adults makes no clinical sense. In the past 30 years or so, services have been configured by age. A strict demarcation line was perceived as the only way to carve out the finances necessary to establish a new service. It makes clinical sense, of course, because of the special characteristics of the disorders, which tend to co-exist with physical health problems and are more likely to have an obvious organic medical origin. Also, pharmaceutical treatments are far trickier for them. I was one of those who supported this age discrimination. I used to tell my colleagues, "Don’t you dare treat anyone over 65", because I could then say that the proportion of the budget that went to older people was mine and that all the resources that went to this group of people belonged to my service. It was quite a convincing strategy for getting fair shares. That is how it started. However, this model has been interpreted far too rigidly. Now we have the tragedy that someone aged 64 can access a wide range of support services through adult mental health services, but only one year later, regardless of their need, they will be placed in an old-age service where the same support is not available. If you are under 65 and you have a mental health crisis or attempt suicide, you can have an immediate assessment, treatment at home and a 24-hour specialist team. Over the age of 65, you are barely eligible for anything; you are put on an out-patient waiting list. Over-65s are usually denied access to psychological therapies, early intervention, rehabilitation and addiction services, which nearly all have a strict age cut-off. The recent imbalance has happened by default. In 1999, the establishment of the National Service Framework for Mental Health saw the beginning of much needed investment in mental health services and the creation of new specialist teams. Two years on, the National Service Framework for Older People had one small section only on this. The difference was that the NSF for mental health came with money and performance management directly from the Department of Health, whereas mental health services for older people came with no money and no performance management from the centre. Clearly, not only have these services been excluded from investment and developments but the increasing numbers of older people have not been matched by extra resource. A report commissioned by the department in 2006 confirmed the failure to make progress. I and many others have pointed out the inequity of this, but it has taken 10 years to acknowledge that permanent leadership in the department is crucial for at least one important disorder. However, the leadership vacuum in other mental health services remains unresolved. It has been calculated that it would take an extra £2 billion to £4 billion to even up access. This is not going to happen—I am not asking for it—but it points to a deep cultural shift in commissioning towards equality of opportunity for older people, which will mean shifting the resources away from other areas, probably within mental health. What are the Government doing to respond to some of those critical reports that have pointed out the shortfall? Our ageing population is the biggest challenge, but I am still not convinced that we have leadership within government to tackle it. As part of their ageing strategy, the Government have created the UK Advisory Forum on Ageing, which has ministerial leadership from the DWP and the Social Care Minister. It does not refer anywhere on its website to health. Who will be responsible for driving the equality that we need? I am hopeful that, if the sections of the Equality Bill related to ageing are enacted, a few test cases will help no end, because exhortation never has. There are many issues that I could raise today, but I point to the need for fair access to and distribution of resources, because what needs to be done is fairly obvious. I ask when it really will be done.