Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0121The Pattern of Psychogeriatric ServicesJohn P. WattisLeeds Community and Mental Health Services, Leeds, UKHISTORIC BACKGROUNDThe roots of the National Health Service (NHS) and thedevelopment of psychogeriatric services in the UK arediscussed in the previous chapter. The evolution of psychogeriatricservices has been guided by professional knowledge andopinion, by the politics of the health and social services, byfinancial constraints and, occasionally, by public opinion.From the inception of the NHS, which effectively antedatedthe beginning of provision of specialist psychogeriatric servicesuntil the 1990s, there was a consensus about how developmentsin services should occur in response to changingdemography and epidemiology as well as advances in medicalknowledge.This consensus was threatened in the UK by the impositionof the ideology of ‘‘market forces’’. Much long-stay hospitalaccommodation was effectively ‘‘privatized’’ by decisions tosupport patients in private nursing and residential homes fromstate funds and to close down as many long-stay NHS beds aspossible. The ideology of market forces was briefly applied tolocal authority provision of community care. Since April 1991,psychiatric patients with social needs have been subject to a ‘‘careplanningprocedure’’ in which all parties, including social services,have to agree. In April 1993 the full implementation of theCommunity Care Act made local social services departmentsresponsible for purchasing continuing nursing and residentialhome care, largely from the private sector and with a limitedbudget.In the late 1990s, a government came to power that did notshare the vision of market forces as the best way to regulate theNHS. This government emphasized equity and quality andreturned to a modified vision of the NHS as a centrally regulatednationalized service industry. It is not certain that the oppositionshares this vision, and so there is a danger of the NHS remaining a‘‘political football’’. For the time being, though, despite thedistractions provided by problems in under-resourced psychiatricservices for working-age adults, it seems likely that the conditionsin the NHS will again be more favourable to the growth of old agepsychiatry services, which are essentially a collaborative ratherthan a competitive enterprise.THEORETICAL BASIS FOR PSYCHOGERIATRICSERVICESThe pioneers of specialist psychiatric services for old peoplewere motivated by the increasing need for psychiatric servicesfor the age group, consequent upon increased life expectancy,the growing knowledge base about psychiatric disordersamongst old people, and the success of geriatric medicine.The special needs of older people were not always recognizedby the generic services. Diagnostic problems included thedifferential diagnosis of dementia, the association of apparentcognitive impairment with some cases of depressive illness, andthe non-specific presentation of disease in old people. Themultiple pathology suffered by old people led to a need for newpatterns of multidisciplinary working and for close liaison withphysicians in geriatric medicine and social services 1–3 . As in theearly days of geriatric medicine, assessment and treatment inthe community were emphasized not only because of ‘‘blockedbeds’’ but also because a more realistic picture of the patient’shealth problems usually emerged. More recently, advances inpsychosocial care 4 , interest in the spiritual needs of old people 5and the advent of new classes of antidepressant, antipsychoticand antidementia drugs (discussed elsewhere in this volume),have all had their impact on the organization and delivery ofpsychiatric services.CARE OR TREATMENT—PRIMARY ORSECONDARY?One of the key theoretical issues for the future development ofcommunity services is likely to be the distinction between careand treatment. ‘‘Care’’ is a word with many connotations.Some are positive but, in the medical world at least, some arenegative. For example, ‘‘care’’ is seen as what is provided whenthere is no possibility of effective treatment, as in the‘‘prescription’’ of ‘‘tender loving care’’ for the terminally illperson. ‘‘Care’’ tends to be relegated to untrained (although notnecessarily unskilled) workers employed by Social Services,whereas ‘‘treatment’’ is the province of highly trained personnelemployed by the Health Service. The move to ‘‘Care in theCommunity’’ may serve to reclassify older mentally ill people asnot needing medical treatment, and this will have to be resistedvigorously.This situation is further complicated by the tendency of somehealth planners to equate primary care with low cost andcommunity care, and secondary care with high cost and hospitalcare. Old age psychiatry services straddle the hospital–communitydivide and provide essentially secondary services, largely in acommunity setting. The new term, ‘‘intermediate care’’, describeswell some of these community services, but some who use the termbelieve that community psychiatric nursing services should be partof ‘‘primary care’’, when in fact they work most effectively as partof secondary community care.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd