MENTAL HEALTH SERVICES FOR OLDER ADULTS COMMISSIONED BY SURREY PCT

Transcription

1 Page 53 Agenda Item 6 MENTAL HEALTH SERVICES FOR OLDER ADULTS COMMISSIONED BY SURREY PCT STRATEGIC REVIEW 2007 Professor K.V. Wilson WSS Consultants

2 Agenda Item 6 Page 54 SPCT OPMH REVIEW 2 CONTENTS Key Findings 3 Section Summaries 4 Introduction 9 National and Local Context 10 Principles of Service Development and Delivery 13 Needs Assessment 15 Investment Overview 19 External Benchmarking for Service Range and Scale 25 Older People s Mental Health Whole System Model 29 Service Review Tier 1: Health Promotion 33 Service Review Tier 2: Community and Primary care 34 Service Review Tier 3: Intermediate Care 42 Service Review Tier 4 Inpatient Assessment and Treatment Services 44 Service Review Tier 5: Continuing Needs 51 Summary of Strategic Implications and Recommendations 52 References 55

3 Page 55 SPCT OPMH REVIEW 3 Agenda Item 6 KEY FINDINGS A carer support strategy should be developed in conjunction with carers. It is feasible to commission fewer acute assessment beds without having a deleterious effect on the service - providing that sufficient developments in out-of-hospital services are implemented. Investment in an intermediate tier of care for older people with mental health problems would benefit service users and carers, facilitate earlier discharge and reduce admissions to acute wards. Unless the capacity / productivity of out- of- hospital care increases, it is likely that more acute beds will be needed by to meet demands caused by an increase in the prevalence of dementia and severe depression, associated with an ageing population. Commissioners should seek to understand the marked differences in the level of services between localities, with a view to equalising access to services across Surrey over the strategic period. Memory services, which follow NICE Guidelines, should be commissioned in every locality. A crisis intervention service should be commissioned specifically for older people with mental health problems. Further investment should be made in liaison psychiatry Priority should be given to strengthening support for primary care in the diagnosis and management of early stage dementia. Many of the proposals made in this report, particularly for dementia services, might be achieved more effectively if elements of older people s mental health services were commissioned jointly with Surrey CC Priority should be given to improving information systems and exchange between SABPT and Surrey PCT current arrangements are inadequate for effective commissioning

4 Agenda Item 6 Page 56 SPCT OPMH REVIEW 4 Introduction SECTION SUMMARIES 1. The review, commissioned by Surrey Primary Care Trust (PCT), focussed on levels of investment and the scale and design of older people s mental health services in Surrey This report summarises the review findings, proposes a service model and describes the strategic implications of the review findings. 2. The findings reported from this more detailed review concur with an earlier interim report submitted by WSS Consultants ie net investment in older people s mental health services is needed and there is a marked variation in investment in different localities. 3. Mental health information systems, generally, are notoriously poor. Priority needs to be given to improving systems between SABPT and Surrey PCT if commissioning is to ensure value for money together with quality and accessibility for service users and carers. National and Local Context 4. Dementia and mental ill health in older people is a cause of much suffering and distress, with massive direct financial consequences for the NHS and Social Services and indirectly for the wider economy. These consequences will increase significantly because of demographic change. 5. There is no shortage of policy guidance on implementing older people s mental health services and most of it is not contentious. National guidance emphasises joint strategic planning for older people s mental health services. The DH has announced a national strategy on older people s mental health to be launched in The challenge everywhere, including Surrey, is how to prioritise investment in the service and implement guidance. Service Principles 7. There is strong emphasis on services promoting independence. 8. Services should be needs led, constantly guided by the experiences of users and carers and delivered at home or as close to home as possible. 9. Whole system planning and whole system working is necessary if services are to be delivered cost effectively and seamlessly. Needs Assessment 10. The two main mental health problems in the over 65s are depression and dementia and the prevalence of both in Surrey is likely to increase by around 10% over the strategic period to 2012 and carry on increasing significantly beyond Estimates of prevalence for severe depression are imprecise but suggest that prevalence in Surrey is between 1800 and 5000.An estimated older people suffer with dementia (with an estimated further 260 people aged under 65yrs). 12. An estimated 59% of patients with dementia have two or more co-morbidities. Length of stay in acute general hospital is significantly increased when dementia exists as a secondary diagnosis

5 Page 57 SPCT OPMH REVIEW 5 Agenda Item The proportion of older people from Black and Ethnic minority communities is considerably less in Surrey than the national average (2.8% cf 9.1%). The risk of experiencing discrimination may be higher in areas where numbers of BME elders are small Investment Overview 14. Benchmarking by South East Coast SHA indicates that in three of the former Surrey PCTs, expenditure on dementia services was below both the national average and ONS group average and in two PCTs it was well below. 15. In real terms there has been a small reduction in investment on older adult mental health services commissioned from SABPT since 2004/ Investment on different types of older people s mental health services varies markedly from locality to locality. Differences in investment in acute assessment and treatment beds and in memory services is particularly marked. These differences cannot be explained on the basis of identified need. Benchmarking Scale and Range of Services 17. DH/CSIP benchmarking of older people s mental health services was available for 2007 but Surrey data was incomplete and sometimes evidently invalid. 18. The useable benchmarking information suggests that the range of services available in Surrey is more limited than indicated for England as a whole, which in turn is regarded as having poorly developed mental health services for older people. 19. There is little in the way of carers services per se and poorly developed community and primary care based services (as everywhere). Surrey appears to be lacking in the provision of intermediate treatment beds, psychological therapies for older people and organised dementia services for younger people. 20. On the other hand there is relative over-provision of acute beds and outpatient clinics and memory services are provided to a greater extent than the England average. Whole System Service Model 21. There is currently no coherent service model of care applied consistently across Surrey. 22. A five tier model is proposed by this report (Health Promotion, Primary and Community Care, Intermediate Care. Inpatient Services and Continuing Needs provision.) 23. Development of the intermediate tier is seen as key to the successful working of the whole system 24. The essence of whole systems is that a change in one part will produce a change in another which may or may not be predicted. Specifically, any reduction in bed numbers needs to be carefully modelled in terms of displacement of care into the community and investment made to provide that care. Health Promotion 25. Health promotion in later life is addressed in the Surrey draft mental health promotion strategy but requires a delivery mechanism.

6 Agenda Item 6 Page 58 SPCT OPMH REVIEW A dedicated multi-agency health promotion approach should be developed with support from public health, to ensure that older people are considered in health promotion strategies and health promoting activities. 27. The information and signposting service developed for adults of working age (First Steps) should be revised or developed separately to include the special information requirements of older adults. Primary & Community Care (General) 28. Neither the DH benchmarking exercise nor the Review identified any carer-specific services. 29. Surrey PCT should have an effective mechanism for engaging with carers on an ongoing basis and consideration should be given to specifically resourcing the development of a carer support strategy and programme. 30. Full implementation of the single assessment process is central to delivering older people s mental health services in the community. 31. Consideration should be given to providing specific support for primary care practitioners to achieve earlier diagnosis and intervention in dementia. 32. PBCs should be encouraged to develop comprehensive, locally based dementia services. 33. The benefits of having a primary care older people mental health service separate from the CMHTOP (North Surrey) should be evaluated. 34. Neither the review nor the DH benchmarking exercise identified psychological therapy services tailored to older people s needs. Older people should have equal access to psychological therapies and the PCT should examine referral data to assess whether this is happening. The views of clinical psychologists should be sought on their role in preassessment and diagnostic counselling. 35. The range of primary care based provision being made for younger adults should be tailored and accessible to older adults Community Mental Health Teams for Older people (CMHT OP) 36. CMHTs represent the second largest category of spend on older people s mental health services in Surrey ( 6,423,688). 37. CMHTsOP are not all fully integrated and the PCT with Surrey CC should take steps to ensure that integration is achieved in line with policy. 38. The resource envelope for CMHTsOP seems adequate but the PCT may need to consider commissioning a programme of redistribution across localities. 39. Surrey PCT should satisfy itself that CMHTsOP are fulfilling the role anticipated of them by DH Guidance and commission a service which is fully integrated with other out-ofhospital services.

7 Page 59 SPCT OPMH REVIEW 7 Agenda Item 6 Memory Services & Day Hospitals 40. There is an acknowledged evidence base to justify investment in memory services conforming to NICE Guidance They may be provided as part of a another service or as a separate service if the latter they need to be designed and commissioned as part of a whole system which includes CMHTs OP and day hospitals. 42. Surrey PCT should commission a single model of memory service in each locality, firmly based on NICE guidelines. 43. Commissioners and SABPT need to clarify which memory services are included in the SLA. 44. The overall costs of day hospitals in Surrey is over 1million but there is great variability in cost between them, suggesting variability in function. 45. Surrey PCT should commission day hospitals only as part of a coherent service complementary to other parts of the service and, in particular, complementary to Surrey CC commissioned day services. Residential and Day care 46. Surrey County Council provides around 130 beds in residential homes across five boroughs and commissions around 980 beds along with a large number of day places for older people with mental health problems, from mainly two independent sector providers. 47. There is marked variation in level of service provided in different localities as with almost all PCT services. 48. A joint strategy between Surrey PCT and Surrey CC would lessen risk to both that might arise if Surrey CC experiences supply shortage when the prevalence of mental health problems in older people rises. Intermediate Care 49. Intermediate care can have a pivotal role in any mental health system for older people. Specialist services for people with dementia should be developed as well as ensuring access to mainstream intermediate care. 50. Experience has shown that older people with mental health problems are often excluded from mainstream intermediate care services, possibly because staff do not have requisite skills to cope. 51. Steps have been taken to provide access to mainstream intermediate care and a rapid response service for older people with mental health problems in east Surrey. These developments have taken place within generic service development for older people. 52. Surrey mental health commissioners should consider investing in and developing an intermediate tier of services, including a crisis intervention service as part of the CMHT OP service. Acute Inpatient Assessment & Treatment Services 53. Population based estimates of the number of acute mental health beds required vary widely because requirement depends on capacity in the rest of the mental health system. CSIP/DH benchmarking indicates that Surrey has around 16 more beds than would be expected compared with England as a whole.

8 Agenda Item 6 Page 60 SPCT OPMH REVIEW On SABPT older people s acute wards in 2006/07 average (mean) length of stay was 102 days (compared with 80 England), occupancy was 86% and DTsOC was 21% of all discharges. 55. With achievable reductions in LoS (to levels at or above what already exist on some wards) and reductions in DTsoC (to levels already achieved in first quarter 2007/08) and occupancy levels slightly higher than current (at 90%), significant bed reductions could be achieved. 56. A reduction of beds would release an estimated million for modernising the whole system of care. 57. If the estimated increase in the prevalence of dementia and severe depression during the strategic period is taken into account, then an additional 12 acute beds would be needed by 2012 assuming no change to current practice and no change to the system outside hospital. 58. An effective psychiatric liaison service could have a large impact upon the excess length of stay associated with dementia for people on acute general hospital wards. The current PCT investment of 89,000 is well below that required to implement a comprehensive liaison service. Consideration could be given to acute hospitals commissioning this service directly from SABPT. Continuing Needs 59. A small increase in continuing needs beds is likely to be required over the strategic period but commissioners should keep the situation under continuous review.

9 Page 61 SPCT OPMH REVIEW 9 Agenda Item 6 INTRODUCTION 1. Surrey PCT invests in excess of 23 million in mental health services for people over 64 years of age, of which there are in Surrey some 175,000 (16.3 % of the total population). A review of these services for older people was undertaken for Surrey PCT by WSS Consultants in mid part of a wider review of adult mental health services. 2. The review looked at levels of investment and the scale and design of services, drawing on information provided by Surrey PCT and Surrey and Borders Partnership Trust (SABPT), the main provider of specialist services. Because the PCT is responsible for services across a very large geographical area (previously the responsibility of five separate PCTs) variations in investment and in scale and design of services across different localities within Surrey were also investigated. 3. Assessment of the quality of service provided was outside the scope of the review though the review identified a number of services where further, more detailed review would help understanding of the nature of services provided. Mental health services in Surrey are not jointly commissioned and the remit of the review was a focus on NHS commissioned and provided services. However, references are made to Surrey County Council s role and contribution in general terms, where information was readily available and relevant. 4. As with the wider review of adult mental health services, it proved very difficult to obtain consistent and accurate information and data about the services under review. This is undoubtedly partly due to the changes made to the organisation of the NHS in Surrey over the past eight years. Since the publication of the Mental Health National Service Framework in 1999, two Health Authorities became five PCTs, which have now become one. The new PCT commissions its services across three localities, which do not match exactly the areas covered by the previous PCTs. Neither did the previous five PCT areas match the (four) local implementation team areas for Surrey. 5. Meanwhile three mental health NHS Trusts have become a single Partnership Trust. Information systems in mental health are relatively poorly developed everywhere but all of the above will have compounded the problem. 6. Similarly, benchmarking, notoriously difficult in older people s mental health services is made more difficult by all of the above. Inconsistencies were evident between the recently introduced benchmarking data supplied by the DH 1 and locally provided information (which should have informed the national data) and also between both sources and information provided as part of a recent SEC SHA benchmarking exercise 2 These difficulties were addressed as pragmatically as possible by use of internal benchmarking within Surrey and by comparisons with generalised norms and indicative estimates from reports and published literature.. 7. Prior to undertaking this part of the review, a headline review of investment and performance in SABPT was undertaken and reported upon. 3 The findings of that interim report are drawn upon in this report but are not documented in full. The interim report found that investment on older people s mental health services provided by SABPT had reduced in real terms in the period since it was established. The benchmarking exercise carried out by SEC SHA also indicated that investment in Surrey s older people s mental health services was below the national average. The findings of the current, more in depth, review echo the findings of the interim report. 8. This report provides a brief needs assessment, states the purpose of individual service components, summarises the findings of the review of individual service components, suggests a model for delivery for older people s mental health services and makes recommendations for change or further investigation within a five year strategic period. In keeping with best practice, the strategic implications should be discussed and recommendations consulted upon, at least with carers and service users, before converting into a final strategy.

10 Agenda Item 6 Page 62 SPCT OPMH REVIEW 10 NATIONAL AND LOCAL CONTEXT 9. There is no shortage of evidence of need, policy drivers, reports and plans to indicate the direction that a Surrey strategy for older people s mental health should take. Some are summarised below and all are referenced for more detailed reading. 10. National Service Framework for Mental Health (Department of Health,1999) 4 Documents seven standards of care for adults with mental health problems and links to the National Service Framework for Older People. Although its focus is adults of working age, the principles and standards are all applicable to adults of any age. Includes standards to address stigma and social exclusion and the key role of primary care. 11. National Service Framework for Older People (Department of Health, 2001) 5 Comprises eight standards with one (standard seven) dedicated to the delivery of high quality services for people with mental health problems. A number of the other standards are directly applicable to developing a high standard of care for older people - in particular those focussing on person centred care, dignity and the single assessment process. Establishes the need for the implementation of care pathways in relation to older people s mental health care. A key objective is the development of an integrated mental health service between NHS and Local Authorities. 12. Forget me Not (Audit Commission, 2000; revisited in 2002) 6 The result of a study carried out in twelve areas of England and Wales. Identified significant shortcomings in service planning and delivery. Emphasised the need for health and social care services to work in a more strategically and operationally integrated fashion to deliver better quality services for older people with mental health problems. 13. Between Two Stools: Psychiatric Services for Older People in General Hospitals (University of Leeds, 2002) 7 Identifies by survey that older people occupy two thirds of general hospital beds and that a significant number will have a co-existing psychiatric problem. The general hospital staff that provide care to these patients have received little or no training to deal successfully with the co-morbidity that they encounter. 14. General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia ( University of Stirling, 2004) 8 Although there is ample evidence in support of the benefits of early diagnosis and intervention in dementia, this survey identifies that a significant proportion of GPs are not confident in their diagnosis of dementia nor in the capacity of specialist services to provide the necessary support when a diagnosis is made. The implications are for potential delays in diagnosis and effectiveness of interventions. 15. Securing Better Mental Health for Older Adults (Department of Health, 2005) 9 This document marks the start of a new initiative to combine forces across mental health and older people's services to ensure that older people with mental illness do not miss out on the improved services that younger adults or those without mental illness have seen. It provides a vision for how all mainstream health and social care services, with the support of specialist services, should work together to secure better mental health for older adults, and describes how the Department of Health is aiming to help deliver this.

11 Page 63 SPCT OPMH REVIEW 11 Agenda Item Everybodys Business (Care Services Improvement Partnership, 2005) 10 A comprehensive service development guide which sets out the key components of a modern older people s mental health service. Draws upon the principles and aims established in the above documents. 17. Supporting People with Long Term Conditions. An NHS and Social Care Model to support local innovation and integration (Department of Health, 2005) 11 The Government set Public Service Agreement targets for improving outcomes for people with long term conditions. These targets include offering personalised care plans for vulnerable people at risk, reducing emergency bed days by 5% by 2008 (by improving primary and community care) and increasing by 1% the number of people aged 65+ supported in their homes by 2007 and The document sets out a new Care Model designed to help local NHS and social care organisations improve care for people with long term condition including those with mental illness and dementia. 18. Raising the Standard (Royal College of Psychiatrists, 2006) 12 Identifies the key components of an older people s mental health service, describes models of care and proposes levels of service which may act as guides and benchmarks to local service development. 19. Dementia Guideline on supporting people with dementia and their carers in health and social care ( NICE-SCIE, 2007) 13 States the principles of care that should apply to people with dementia and their carers, states the evidence base for interventions both medical and psychological and like all earlier documents re-states the need for integrated planning and working between health and social care agencies in order to achieve better care and better value for money services. 20. Improving Services and support for people with dementia (National Audit Office, 2007) 14 Reviews the scale and impact of dementia and the recommendations of earlier reports and evidence. Concludes that services are not currently delivering value for money to taxpayers or people with dementia and their families. It concludes that with the rapid ageing of the population will come increased costs and that services are likely to become increasingly inconsistent and unsustainable without redesign, that there is an urgent need for action and makes recommendations for the action to be taken. 21. National Strategy for Dementia (in progress) (Department of Health) 15 The DH in August 2007 announced its intention to produce the first ever national dementia strategy, which should be published in In so doing it recognised the need for improving public and professional awareness, ensuring early diagnosis and intervention and improving the quality of care for dementia. In view of the consistent messages from a range of Governmental and other authorative bodies about what is needed in a strategy for dementia, there is little likelihood that the Surrey PCT and Surrey CC would be unable to anticipate the requirements of a national strategy.

12 Agenda Item 6 Page 64 SPCT OPMH REVIEW 12 Local context 22. As is the case with mental health services for adults of working age, this review finds that strategic planning of mental health services for older people has suffered badly from a lack of co-terminosity of NHS organisations, County Council and Local Implementation Teams (LITs). Although the re-organisation of NHS organisations has brought a single mental health trust and a single PCT, the process of re-organisation itself has created something of a hiatus in strategic planning for older people s mental health services. 23. The lack of co-terminosity and subsequent organisational change has created very significant difficulties in establishing a consistent picture of the services that are currently provided and commissioned and this has proved problematical for the review process. Issues remain to be addressed in that geographical localities and clusters established for Practice Based Commissioning are not aligned with the previous LIT areas. The nature of older people s mental health services makes it an absolute requirement that NHS commissioning is integral and aligned with the planning and commissioning of a number of other agencies required to deliver a modern redesigned service. LITs were established under the NSFs to ensure the integrated planning and delivery of services involving involved multiple commissioners and providers. The new commissioning arrangements need to develop to ensure that the problems associated with a lack of coterminosity do not continue. 24. In 2004 the report of the CSCI inspection of Surrey CC social care services for older people 16 commented we had some concerns about the lack of strategic direction for services for older people experiencing difficulties with their mental health and their carers. Services lacked strategic co-ordination and as a consequence availability was inconsistent across the county. The findings of the current review echo exactly the CSCI findings of three years ago. 25. Amongst the documentation provided to the review was a draft strategy document entitled Modernising Mental Health Services For Older Adults in Surrey 17 dated August Whilst the document contains a number of elements of a strategy, and it has been helpful to draw on the social care information in particular, it is acknowledged to be far from complete and this review has started from first principles.

13 Page 65 SPCT OPMH REVIEW 13 Agenda Item 6 PRINCIPLES OF SERVICE DEVELOPMENT AND DELIVERY 26. There is a strong consensus in the literature and national policy and guidance about the principles which should underpin the development of strategy and delivery of services for older people and specifically for older people with mental illness and dementia. Optimising opportunities for independent living 27. This should be the guiding principle of the service. The concomitants of this principle are that services should be: Home based services whenever possible ie services that avoid the necessity to receive care away from home and services that help to get people home as soon as possible when they have been admitted to hospital Person centred - because working in partnership with the service user and their carers is the most likely way of providing services that address the issues that matter in promoting and maintaining independence Working in Partnership with Carers 28. NHS and social care agencies need to help carers to optimise the support they give by offering timely and adequate information and sign posting to services along with advice and support for the care they give. 29. NHS and social care organisations need to fully commit to working in partnership with carers. Assessment and support to meet carers personal needs is essential to their own health and well being as well as that of the individual being cared for. 30. Unpaid carers (mainly female family members) provide the majority of care in the community and it is currently estimated that they save the taxpayer over 5 billion per year the personal cost to them is inestimably more. Evidence Based/ Best Practice 31. Services should be evidence based, reflect best practice, consistent and systematic in their application and reviewed and evaluated for their effectiveness Access to Services 32. Services need to be accessible and culturally sensitive, underpinned by shared values which place service users and carers at the centre of activity. They should be delivered as locally as is possible without compromising the quality and effectiveness of the service. Availability of Services 33. A service that meets the needs of services users and carers cannot be delivered solely in office hours in the working week. Some services need to be available 24/7 eg crisis intervention and support services, general hospital liaison services. Other services need to be tailored so as to meet peak demand. Equitable access to evidence based/ best practice services 34. Service users should have fair access to effective services of the same standard wherever they live and without discrimination. Provision of a range of services

14 Agenda Item 6 Page 66 SPCT OPMH REVIEW A comprehensive range of services should be provided, which promotes positive health, tackles exclusion and stigma, empowers service users and carers to access services that promote independence and improve quality of life through high quality care and evidence based interventions. In order to expand the range of effective options, specialist services should extend their support to other organisations dedicated to the support of service users and carers Cost Effectiveness/Best Value 36. Commissioners of services need a clear understanding of their expenditure on mental health services as a prerequisite for assessing cost effectiveness and to ensure that services are delivered within the resources available. They should be able to demonstrate best value through greater emphasis on efficiency requirements, identification of success indicators and a comprehensive approach to evaluation of services. The views and experiences of users and carers should have a major input into assessing value for money. (The National Audit Office review of dementia services in 2007 concluded that health and social care services are spending significantly on dementia but services are not currently delivering value for money to taxpayers or people with dementia and their families 14 Whole System Strategies 37. The scale and nature of service needs of older people with mental illness and dementia is such that a whole system approach to strategic planning and implementation is essential to the delivery of an effective and cost effective service. The responsible agencies need to work in partnership to deliver seamless services. Service users and carers should be fully part of the partnership approach. Supported Staff and Environments 38. Commissioners should ensure that the services they commission for older people with mental health problems are provided by organisations who can demonstrate that their staff are carefully selected (having regard to the additional vulnerability of people with mental health problems), appropriately trained, skilled and motivated and that there is evidence of ongoing development and updating. Services should be delivered in and from appropriately equipped, safe, hygienic and well maintained environments.

15 Page 67 SPCT OPMH REVIEW 15 Agenda Item 6 NEEDS ASSESSMENT Population profile 39. People over the age of 65 represent around 16% of the population nationally and use a disproportionate amount of both physical and mental health services. The two main mental health problems in older people are depression and dementia although other problems such as anxiety and phobias are at least as common. Additionally people who developed severe and enduring mental illness at a younger age, for example schizophrenia, are living longer and may have additional physical care needs. Some of the more salient aspects of the Surrey population include: The population of Surrey comprises 2.2% of the national population. The proportion of people aged 65+ living in Surrey at the time of the 2001 census was slightly more than in the nation as a whole (E&W 15.9 %, Surrey 16.3%). 18 The age cohort contributing mainly to the slightly larger than expected older population in Surrey is the 85+ group. In the national population, 12.2% of over 65s are aged 85+ whereas in Surrey the proportion is 13.9 % or an excess over national expectation of almost 2900 people aged 85+. Despite the slightly older population the proportion of unpaid carers is very slightly less in Surrey (9.4%) than in England overall (9.9%) 19 Table OP:1: Older Population Profile England& Surrey 2001 POPULATION (% 65+) England (52.5%) (% 65+) (35,2%) 85+ (% 65+) (12.2%) All 65+ (% all ages) (15.9%) All ages Surrey (51.1%) (35.0%) %) (16.3%) Depression 40. This is the most common mental health problem in older people, with women more likely to suffer than men. Depression is a relatively common disorder in people over 65 living in the community, with between 10% and 15% of the population affected. The prevalence however is considerably higher in care homes and hospitals with rates of 30-40% and 15-50% respectively being quoted. 20 Applying these rates to the Surrey projected population 21 (177900) the number of people over 65 suffering with depression would be between and 26,685. Given the relative mental health needs index for Surrey is low, it might be anticipated that the lower figure is closer to the actual. Prevalence 41. The prevalence of severe depression, which is more likely to encounter intervention by the specialist services is between 1% and 3%. In Surrey this amounts to a prevalence of between 1779 and Again allowing for the overall low mental health need in the Surrey population the lower figure would perhaps be closer to the actual. The table shows the expected increase in prevalence over the next ten years.

16 Agenda Item 6 Page 68 SPCT OPMH REVIEW 16 Table OP2: Estimated Prevalence of depression and severe depression in people 65+ in Surrey Surrey estimated prevalence Depression Severe depression Inpatient activity can be used as a proxy for incidence but it may be a poor indicator as it is an indicator of a combination of need and service response. Inpatient admissions to SABPT following a depressive episode (per 100,000 weighted population) are shown in the exhibit below 2. As can be seen they are generally below the national average (allowing for weighting). Exhibit OP1: Depressive episode admissions to SABPT per 100K weighted population Dementia 43. Dementia is a term used to cover a range of progressive terminal organic brain diseases. Symptoms include a decline in memory, reasoning and communication skills and ability to carry normal daily activities, loss of control of bodily functions all caused by structural and chemical changes in the brain. The emotional impact of the disease on sufferers and carers is immense with depression and levels of stress and anxiety common. Although old age is the main risk factor it can also affect younger people and there are implications for service design for the different age groups. 44. The cost of dementia nationally is estimated to be greater than the cost of heart disease, stroke and cancer combined. And yet Surrey, like many other places, has no strategy to tackle it. If national estimates for the direct costs to the NHS 14 and social care are crudely applied to the Surrey population the annual cost is likely to be in excess of 60,000 million. If the national estimate of overall economic cost is applied to Surrey, the cost rises to over 286,000 million. The prevalence of dementia in the UK is estimated to increase by 34% by 2020 with significant implications for NHS and Social Care resources. Prevalence 45. There are different methods of estimating dementia prevalence rates. The prevalence rates used below are taken from the Alzheimer s Society Report (The Medical Research Council s (MRC) cognitive functioning and ageing study (CFAS) 20 produces slightly larger estimates based on the 2001 census population). The table indicates that the prevalence of dementia in Surrey will increase by 19% over the next ten years. This increase will need to be taken into account in service redesign.

17 Page 69 SPCT OPMH REVIEW 17 Agenda Item 6 Table OP 3: Forecast Prevalence of Dementia in Surrey by District Surrey Districts Elmbridge Epsom & Ewell Guildford Mole Valley Reigate & Banstead Runneymede Spelthorne Surrey Heath Tandridge Waverley Woking Surrey Total Co-morbidity 46. Most people with dementia have at least one co-morbidity. In a recent study carried out by the NAO 14, 59% of patients with dementia had two or more co-morbidities. Apart from the additional distress this brings for people suffering with dementia and their carers, the impact on inpatient activity in general hospitals is very significant. As an example, shown in the exhibit below (OP2 ) 2 are the lengths of stay for a sample of named conditions at one of Surrey s general hospitals (Royal Surrey County). there are significant implications here for service design in relation to liaison psychiatry and staff training. Exhibit OP2: Average length of stay for Patients with Dementia in a secondary Diagnosis (by primary diagnosis): Royal Surrey County

18 Agenda Item 6 Page 70 SPCT OPMH REVIEW 18 Black and Minority Ethnic Service Users and Carers 47. There are important issues around the particular needs of Black and Minority Ethnic users and carers in all parts of the service The population of elders from Black and Ethnic minority communities increased nationally by almost 153,000 between the censuses of 1991 and At the time of the 2001 census, the proportion of people from a BME background in Surrey was lower than the national average (2.8% compared with 9.1%) According to the 1991 Census (the latest data available on ethnicity), 28,786 people, or 2.8% of the Surrey population, are from black and minority ethnic groups. Proportions vary considerably across the 11 boroughs and districts. 49. The highest number of residents from black and minority ethnic communities live in Woking, 5.4% of the local population. In Epsom and Ewell 5.7% of residents come from black and minority ethnic communities. The majority of these residents come from Indian or other Asian communities. Overall, people from Indian communities comprise the largest minority ethnic group living in Surrey, with 6,716 residents and 0.65% of the population. 20% of these residents live in Spelthorne, 15% in Elmbridge and 13% in Epsom and Ewell The point of making the above observation is that the DH report Delivering Race Equality 23 points out that the risk of experiencing discrimination may be higher in areas where numbers of BME elders are small and it is particularly important that in such areas local policies are proactive in countering these risks. 51. The DH Report From Lip Service to Real Service 24 recommends that in achieving equal access for BME elders to services, councils should be mainstreaming services in such a way as to meet the needs of BME elders. The National Director for Mental Health 25 has identified the needs of BME communities as being the area of mental health where there is the greatest need and where the least has been done. The Royal College of Psychiatrists 26 recommends that in assessment and treatment services for BME elders, the emphasis should be placed on: ethnic awareness and sensitivity in staff training, recruitment of a racial mix of multidisciplinary staff members and providing continuing care services in the community appropriate to the user group. 52. In the face of an increasing number of people aged 65+ in the BME community and an increasing prevalence of mental illness in the Surrey population overall, it would be important for the Surrey strategy for OPMHS to be explicit about how any particular needs of BME elders might be addressed.

19 Page 71 SPCT OPMH REVIEW 19 Agenda Item 6 INVESTMENT OVERVIEW 53. Benchmarking of older people s mental health services is notoriously difficult. It is a sign of the general neglect suffered by these services that until very recently the DH has never routinely required data to be collected on older people s mental health services though they have done so for younger adult mental health services. ( The results of the first round of DH sponsored financial benchmarking are awaited at the time of writing this report). 54. The South East Coast SHA recently undertook a mental health benchmarking exercise of its own 2 including a comparison of expenditure based upon outputs from programme budgeting. Programme budgeting is in its relative infancy but it is the only opportunity currently available to make comparisons on mental health investment. The SHA exercise does not single out investment associated with services for older people with depression but does so for dementia. Benchmarking of net expenditure on dementia indicates the need to look closely at the adequacy of provision for older people in Surrey 55. The Exhibit (OP3) below shows the expenditure on dementia services by each of the former PCTs (data for the newly formed Surrey PCT not yet available). It compares Surrey NHS spending with national average NHS spending and spending by PCTs in the ONS cluster group to which the respective Surrey PCTS belonged. Three of the former PCTs had expenditure below the national average and group average and in two areas well below (East Surrey and Guildford and Waverley). Both of the other PCTs were below their ONS Group average for Dementia. Mental health Commissioners in Surrey believe that this is an artefact related to commissioning arrangements and coding of expenditure. Nonetheless, taken in the round the impression is one of below average investment. Exhibit OP3: Dementia Services Net Expenditure per 100,000: Surrey PCTs (weighted population), National and ONS Group averages (2005/06) 56. A detailed review of Surrey County Council expenditure on dementia care fell outside the scope of the review but the report of the inspection of older people s services in 2004, carried out by the Commission for Social Care Inspection (CSCI), indicated that social services spending on older people services was amongst the highest in their ONS Group (see Exhibit OP4 below)

20 Agenda Item 6 Page 72 SPCT OPMH REVIEW 20 Exhibit OP 4: Surrey CC PSS Budget allocated to older people per population aged 65+, An earlier report 3 from this strategic review showed that there had been a real terms significant reduction in spending on adult mental health services overall in Surrey since 2004/05 ie since the establishment of SABPT as a single NHS provider of mental health services. The impact on expenditure on older people s services has been less than on younger adults services but none the less there has been a real terms reduction in investment. 58. Surrey NHS investment in Older People s Mental health since 2004/05 has increased from 18.4m to 21.6 m 27 (Mental health commissioners quote 23m) but in real terms there has been a decrease of 2%. Spending on community based mental health services for older people has reduced in real terms by 6% and inpatient investment increased by 4% relative to 2004/05 (Figure OP1 below). Strategically, an increase in community and reduction in inpatient spending might have been anticipated. A real terms reduction in investment in older people s mental health services (in the context of a service benchmarked as spending less than average and an ageing population with increasing prevalence of dementia) is clearly not a strategic approach that can be supported. Furthermore, as indicated later in this report, the out of hospital services for older people in Surrey look to be poorly developed even by comparison with the national norms, which in themselves are generally regarded to be insufficient. A reduction in community expenditure against an increase in inpatient expenditure is against the grain of national policy. 59. Relative expenditure on different aspects of the older people s MH services for Surrey overall is shown in Figure OP2 below (based on latest version of SLA financial information supplied to the Review) 28.

21 Page 73 SPCT OPMH REVIEW 21 Agenda Item 6 Figure OP1: Investment in SABPT community and inpatient OPMH services 2004/5 07/8 (adjusted for inflation) Mental Health Direct Costs (65+),community/inpatient 2007/08 cf 2004/05 (adjusted for inflation) Millions IP actual IP 04/05 adj Com actual Com 04/05 adj / / / /08. Figure OP2: Investment in individual OPMH services 2007/08 Surrey Total Expenditure OPMH by Servce Type (2007/08 SLA SABPT) Millions community teams Day hosp Memory Servc Acute beds respite beds ext care beds 60. Figure OP3 shows the relative spend on services by former PCT area. Large variations in spend are evident and particularly in acute hospital beds. To take account of differences in population size in each area the spend per 1000 population has been calculated for the services. (time did not allow for an exercise in weighting for mental health needs to be undertaken but variations in mental health needs across Surrey are known to be relatively small)

22 Agenda Item 6 Page 74 SPCT OPMH REVIEW 22 Figure OP3 : Investment in individual OPMH services by Surrey locality Millions Surrey Locality Expenditure OPMH by service type (SLA 2007/08 SABPT) S.Heath &W N.Surrey E.Surrey EEMS Guid&Wavly 0 community teams Day hosp Memory Servc Acute beds respite beds ext care beds Figure OP4: Investment in Acute Assessment and Treatment Beds / 100K population by Surrey locality (2007/8 SLA) Surrey Assessment & Treatment Beds Spend /1000 population Expenditure( ) SHAW N Surrey E Surrey EEMS G&W

23 Page 75 SPCT OPMH REVIEW 23 Agenda Item Figure OP4 shows relatively large differences in expenditure on acute inpatient beds in each locality. Mental health commissioners advise that there is little net flow of patients between the former PCT areas and this being the case the question arises as to why some areas can provide services with a relatively low expenditure on inpatient services whilst others appear to need to spend much more. This is a very important question in the context of a service which appears to have underdeveloped out of hospital services. 62. Everybody s Business 10 describes the Community Mental Health Team as the backbone of the modern specialist older people s mental health service. Not all of Surrey s community teams are CMHT OP teams, some are CPN teams (an issue returned to later in this report). For purposes of examining investment in this key service area across Surrey, the cost of CPN and CMHT teams has been aggregated and the differences in investment across Surrey localities are illustrated below in Figure OP5. Again the picture is one of inequitable expenditure on older people mental health services. Figure OP5: Investment in CMHTs/CPNs /100K population by Surrey locality (2007/8 SLA) Surrey Expenditure on CPNs/CMHTOPs/1000pop 65+ (2007/08 SLA SABPT) Expenditure (1000s) Surrey Heath&Woking North Surrey East Surrey EEMS Guidford Waverley Average 63. Similarly there is disparate expenditure across Surrey on Day Hospitals and Memory Services. Explicit expenditure on memory services occurs in only two areas (the SLA indicates that Woking has a service and also that services are being provided in areas where they are not commissioned). it is possible that day hospitals are providing some element of memory services. To allow for this the investment in day hospitals and memory service in each area has been aggregated (Figure OP6). It is evident that sizeable differences in investment apply across Surrey.

24 Agenda Item 6 Page 76 SPCT OPMH REVIEW 24 Figure OP6: Combined Investment in Day Hospitals/Memory Services/ 100K population Surrey Expenditure Day Hosp/Memory Services /1000 pop 65+ (SLA SABPT 2007/8) Thousands Memorys Svcs DayHosp Figure OP7 0 below aggregates all of the key out of hospital services (day hospital, memory services, CMHTs Surrey/CPNs). North This Surreyshould East Surrey reduce the EEMS effect of Guildford differing service Average content/definitions but as can Heath&Woking be seen differences in investment in out-of-hospital Waverleyservices persist. Figure OP7: Combined Investment in Out-of-Hospital Services/ 100K population Surrey Expenditure CMHTOP/CPNs &Day Hosp/MemServices /1000 pop 65+ (2007/08 SLA SABPT) Expenditure (1000s) Thousands Surrey Heath&Woking North Surrey East Surrey EEMS Guildford Waverley Average