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 0-470-84641-0123Community Care: the BackgroundColin GodberMoorgreen Hospital, Southampton, UKThe specialty of old age psychiatry in Britain grew out of thefailure of orthodox, institutionally-based psychiatry to meet theneeds of the growing number of elderly people with dementia. Itssuccess stemmed from its proactive community-based approach,an emphasis on the support of family and other carers and thedemonstration of the positive outcomes obtainable through betterrecognition and energetic treatment of much of the functionalillness of old age 1 . Crucial to that approach and the effectivenessof the elderly mental health service itself has been the developmentof partnerships across health and social services, support toinformal carers and the increasing range of care staff workingdirectly with patients. Just as it has led the rest of psychiatry inassertive outreach, it has often taken over from the increasinglyhospital-centred geriatric medicine as a catalyst and advocate forcommunity care for older people. This chapter will look at someof the components and contributors to that care, as well as someof the wider organizational and political factors that haveinfluenced it.PRIMARY HEALTH CAREGeneral practice has always been the cornerstone of the NationalHealth Service (NHS) in Britain, providing continuity ofindividual and family care and acting as gatekeeper to secondarycare. Aggregation into group practices paved the way to theestablishment of the primary healthcare team (PHCT), with itscore membership of general practitioner (GP), practice nurse,district nurse and health visitor, and later a looser attachment orsessional input from community mental health nurses (CMHNs),podiatrists, physiotherapists, counsellors and specialists fromsecondary care. The PHCT provides the bulk of domiciliaryhealth care and surveillance of those at risk and the main day-todaylink with social services, housing and other local agenciessupporting disabled people in their homes.With the aim of strengthening the locality and primary carefocus of the NHS, the incoming Labour government 2 hasaggregated groups of PHCTs covering ‘‘natural’’ localities of50–150 000 population into primary care groups (PCGs). Healthcarebudgets for these localities have been devolved to PCGs, whoare responsible for increasing the equity and quality of primarycare within local populations, for assessing their health needs andfor commissioning secondary care services. There is also theoption/expectation that PCGs will progress to fuller autonomy asprimary care trusts (PCTs). These will be empowered to take overthe management, for instance, of community hospitals andappropriate secondary care services and will be expected todevelop closer partnerships with local social services. It is likely,therefore, that PCTs will take on a much more comprehensive rolein the provision of community care within the Health Service.Parallel legislation 3,4 will also facilitate partnership with localauthority services by enabling them to pool and ring-fencebudgets to promote joint services, long advocated by proponentsof community care.INFORMAL CARERSBy far the largest contribution to domiciliary care, particularly forthose with dementia, is of course that of family members andfriends. The main carer is usually a spouse or partner, althoughcare by daughters, sons and daughters-in-law remains substantial,despite greater geographical mobility, changing employmentpatterns and the steadily falling ratio of middle-aged to elderlypeople. Input from neighbours can also be vital and some areashave well-developed community networks. The House of CommonsSocial Services Select Committee 5 estimated the‘‘replacement cost’’ of informal carers for the disabled in Britain(over three-quarters of a million ‘‘on their feet’’ for more than 50 hweek) as well above the total expenditure on all statutory care.The government recently acknowledged the importance of carersand the load they carry and announced a strategy to ensure thattheir needs will be properly assessed and that they become eligiblefor extra financial support 6 .BACK-UP FROM GERIATRIC PSYCHIATRYPartnership with family carers is fundamental to the practice ofold age psychiatry, especially in the context of dementia. Initialassessment should include the extent of informal care, the healthand attitude of the carers and the prospects for sustaining suchcare in the future, given adequate help. Carers need the support ofa key worker with a good knowledge of the ‘‘system’’ who canhelp them access appropriate services and allowances and thepractical and psychological value of carer support groups.Important aspects of that key working are its continuity, attentionto the health and morale of the carers and prompt arrangement offurther assessment, intervention and respite when the need arises.For those with psychiatric illness, and particularly dementia,the key worker will usually be the CMHN, working closely withcolleagues in primary health care and social services teams.CMHNs also have an important support and educational role,with the increasing number of untrained voluntary and paidcarers working with patients in their homes, day centres andresidential care. They will also draw on the range of skills andPrinciples 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