Introduction
National Health Service (NHS) leaders repeatedly state that the demographic changes and needs of older people are new, with the mantra that now is the time to act. Psychiatrist Professor Sir Aubrey Lewis emphasised that in 1946. In 1960, the Ministry of Health described mental infirmity in old age as ‘urgent and complex’ and in 1966 Professor of Geriatrics James Williamson described dementia as ‘the greatest single factor’ for healthcare. The National Dementia Strategy in 2009 similarly stressed the urgency of providing services and David Cameron, in The Prime Minister’s Challenge on Dementia in 2012, said: ‘Dementia is one of the biggest challenges we face today’.
Before clinical interventions can be adopted, high quality evidence is required, preferably derived from randomised double blind controlled studies. That sort of study is often neither realistic nor appropriate for planning services. For those developments, it is important to understand past facilitators and hindrances, successes and failures. This is particularly important at times of economic constraint, to help ensure that pitfalls are avoided and that new services achieve the best outcomes.
Historical evidence needs to be incorporated into debate about future services. However, clinical leaders and health service planners like to perceive their ideas as original. If innovations are believed to be completely new, historical evidence is assumed not to exist. Often, evidence is ignored or seen as irrelevant to current dilemmas, responses I have encountered while participating in NHS planning meetings in 2013-14.
A survey of health service commissioners by ‘old age psychiatrists’ David Anderson et al (2013) concluded:
Governments and commissioners have shown a surprising failure to realise the significance of the ageing population, adopt best practice and make service development for older people a national priority.
Despite decades of rhetoric describing the urgency and enormity of the needs, resources are limited and high quality services are not universal. Reluctance to resource dedicated and enthusiastic services for older people, may be related to: society undervaluing older people; unwarranted negativity, including by policy makers and health service professionals, emphasising the impossibility of improving health in old age; the tendency to prioritise acute services over those for mental illness and chronic disorders; and a human instinct to distance ourselves from our own future frailty and inevitable death. However, without appropriate services, unnecessary suffering results for patients and people caring for them, and ultimately for us in the future.
The whole range of psychiatric disorders encountered in younger people can present in old age, a life phase usually understood within the post-war NHS to begin at 65. At any one time, in people over 65, 12% suffer from depressive illness, 3% anxiety disorders, 2% alcohol misuse and 0.5% schizophrenia. Delirium (‘acute confusion’) is found in 2% of over 65s in the community. Dementia occurs more frequently at older ages: in 1% of 65 year olds, 4% of 75 year olds and 16% of over 80s. These rates have remained fairly stable over time, but as more people live longer, the total number of people with dementia will increase. Examples of distressing behavioural symptoms of dementia include verbal abuse, aggression, disinhibition, incontinence, faecal smearing, wandering, difficulty in eating and restlessness. Such symptoms can often be alleviated with specialist intervention. In addition, in old age, unlike for younger people, physical and mental illnesses and physiological frailty frequently interact. This creates challenges for the NHS, as older people often require a range of overlapping health services rather than treatment for one specific condition.
Concepts of active intervention: 1930s-1940s
Until the 1930s, when physician Marjory Warren observed that older people previously considered incurable due to physical illness could be restored to health and discharged from hospital, providing them with active treatment and rehabilitation was rare. In the 1940s, there was new evidence that mental illnesses in older people could also be treated. For example, Willy Mayer-Gross, a leading psychiatrist in Britain, was impressed by improvements achieved by electro-convulsive therapy (antidepressant medication only became available in the 1950s) in older people with severe depression. Evidence began to accumulate that older people could benefit from treatments previously offered only to younger people, but expectations of a positive outcome were slow to emerge among professionals and public. Commitment by clinicians, government and NHS leaders to providing services for older people lagged behind the clinical evidence, and older people did not demand them.
Aubrey Lewis noted that social crises, rather than just illness, often precipitated hospital admission for older people, whereas younger people were admitted solely due to illness. This was reinforced with the observations of a physician, Joseph Sheldon, in 1947. He commented on the difficulties experienced by families caring long-term for dependent older people, especially if they were confused, describing the families as ‘working in a sweated industry’. He linked these stresses to higher demands for clinically unnecessary hospital admissions. This highlighted the need to provide appropriate support and interventions for patients and their families but did not result in provision of pro-active, treatment and rehabilitation focussed services.
Innovation and change in the 1950s and 1960s
During the 1950s a few psychiatrists and geriatricians were enthusiastic about actively treating mentally ill older people, although deeply rooted scepticism, in the profession and more widely, about their potential to improve, remained the predominant viewpoint. Society’s low expectations of wellbeing after retirement probably helped maintain the status quo.
In 1950 the Ministry of Health recommended that psychiatric assessment should be undertaken within geriatric departments, but this did not happen. Having made the proposal, there is little indication from medical journal reports and the National Archives that the Ministry seriously tried to implement it, or had clearly considered how to do so. In particular, there were insufficient and unequal numbers of geriatricians and interested psychiatrists, often located in different hospitals miles apart. Psychiatrists were expected to work in geriatric units without reciprocal plans for geriatricians to work in mental hospitals. Unrealistic intentions were unlikely to succeed.
Recommendations to increase spending on older people’s services, such as by the Guillebaud Report (Committee of Enquiry into the Cost of the National Health Service, Ministry of Health, 1956) were rejected. Other government reports in the 1950s and 1960s referred to a lack of evidence about what older people would require and the need to obtain further information before providing services. Those reports appeared to ignore or reject valid existing recommendations such as The Care and Treatment of the Elderly and Infirm by the British Medical Association (1947). Reasons for not utilising earlier recommendations were not stated, but it is a well recognsised pattern of response; Sir John Oldham, a clinical lead at the Department of Health, commented that the ‘culture of evidence’ may be ‘used effectively to delay implementation’ and therefore minimise spending (BMJ, 20th November 2013).
One scheme, led by geriatrician Lionel Cosin at Cowley Road Hospital, Oxford, provided active treatment and rehabilitation for older people with mental and physical disorders. It confirmed the findings from the 1940s. However, Cosin’s type of scheme remained unusual. The need for old age services more widely was acknowledged by the Ministry of Health, but little was done to actively address the deficit.
Around the mid-1950s, new approaches to treatment and more effective medication had the potential to improve the outlook for psychiatric illness in all age groups. The Royal Commission on mental illness in 1957 recommended mandatory provision of community services by local authorities, but this was not enforced. The Mental Health Act (1959), together with plans to close the psychiatric hospitals, provided opportunities for services to be based in the community and in district general hospitals. However, evidence in the 1970s indicated that the recommendations had been insufficiently adopted, a serious pitfall of non-mandatory strategies, especially for undervalued sectors of the community, such as older and mentally ill people.
The influential ‘anti-psychiatry’ movement in the 1960s took the view that psychiatric diagnoses were highly subjective and psychiatry was a coercive instrument of oppression. It drew attention to the need to modernise psychiatric services. The movement championed community and behavioural treatment for younger people. Benefits for older people resulted only indirectly. The movement’s objectives fitted with the tendency to marginalise older and prioritise younger people who were first to receive consideration in mental health policies and to be offered new medications, rehabilitation and discharge from mental hospitals. Concerning older people, the Department of Health and Social Security (DHSS, successor to the Ministry in 1968) continued to reject well-founded evidence from pilot schemes indicating clinical and social benefit, e.g. reducing long-term institutionalisation, and were hesitant to provide age-equitable interventions. England was not alone: there was little change in older people’s mental health provision in many countries despite recommendations from the World Health Organisation (WHO, 1959).
Provision of services for chronic illnesses, which occur most commonly in old age, changed little compared to the rapid development and provision of high-tech acute medicine and surgery which is often more highly valued by society. Low-tech rehabilitative or psycho-social interventions, or concepts which required a cultural shift of attitude by professionals, policy makers or society more broadly, were slow to be adopted. This included the result of studies by psychiatrists about mental illness in older people: Martin Roth, on accurate diagnostic classification, and Felix Post, on outcome of treatment. Their findings contradicted the doyen of psychiatry Emil Kraepelin (1856-1926) whose opinions remained influential; he had advised that almost all mental illness in old age was ‘senile dementia’ and therefore untreatable.
Public awareness of discrimination and the needs of vulnerable people increased in the 1960s. Individual autonomy and equality were more valued and there was more public discussion of issues previously often kept secret, such as mental illness and disability. Legislation was introduced concerning equality, on race relations, people with disabilities, sex discrimination and homosexuality. Newly coined terms ‘ageism’ and ‘gerontophobia’ reflected greater public awareness of age discrimination, but this was not paralleled by legal changes or significant improvement in services for mentally ill older people.
Significant media attention was paid to scandals of inhumane practices in NHS hospitals for older and mentally handicapped people in the 1960s. This raised awareness of inadequate provision for these groups of people. The most publicised scandal was at Ely Hospital, Cardiff, although similar occurrences elsewhere were reported, by witnesses, to Barbara Robb and published in her book Sans Everything. Formal inquiries upheld complaints of inhumane treatment by staff such as hitting patients, hosing them down in the yard, removing personal possessions such as spectacles and hearing aids, and sitting elderly frail patients on commodes in view of other people. The Report of the Committee of Inquiry into Allegations of Ill-treatment of Patients and other Irregularities at the Ely Hospital, Cardiff (DHSS, 1969) attributed bad practice to systemic deficits including understaffing, lack of training, poor management and leadership, and staff lacking in sympathy. The findings of the inquiries resonate today. Ely closely parallels the Winterbourne View scandal (2012) of abusive care in a hospital for people with learning difficulties, with similar causes identified in both. Sans Everything parallels the BBC ‘Panorama’ documentary Behind Closed Doors: Elderly Care Exposed (30th April 2014) which revealed neglect and staff shouting, threatening, and ignoring residents. Repetition of abuse in institutions suggests that high quality NHS and local authority commissioned care for vulnerable mentally unwell people is still not automatic, and raises questions of the effectiveness of previous government responses.
Establishing dedicated services nationally
By 1969, there were only a handful of hospitals in England which had a dynamically led, constructive and creative approach to treating mentally unwell older people. After the scandal inquiries, the DHSS appeared keen to engage with clinicians to improve these services.
Psychiatrist Tom Arie established an old age mental health service at Goodmayes Hospital, Ilford, in 1969, which impressed the Chief Medical Officer, Sir George Godber. Godber was keen to involve Arie, and other psychiatrists interested in older people, in planning new services. Around the same time, Richard Crossman, Secretary of State for Health and Social Services (1968-70) established the Hospital Advisory Service, a peer-led inspectorate which aimed to improve standards.
In 1972 WHO reiterated the need for comprehensive, proactive mental health services for older people, based on understanding the epidemiology, origin, prevention, development and treatment of all psychiatric disorders which affected them. In line with these recommendations and in conjunction with the new ‘old age psychiatrists’, in 1972, the DHSS published Services for Mental Illness Related to Old Age for England and Wales. It was a non-mandatory blueprint for future services. Implementation was slow and uneven, but services developed fastest where there was fervent local leadership by consultant psychiatrists dedicated to working with older people. Features of pioneering ‘psychiatry of old age’ (POA) services included: holistic, proactive and optimistic expectations of treatment; assessment, diagnosis and treatment in patients’ own homes; support for their families; collaboration with social services, geriatricians and other agencies; admission to hospital for acute interventions and long-stay care only when a domiciliary approach was unsuccessful; a low hierarchical team structure valuing the contributions of all staff; adequate staff training; and consultants advocating for older mentally ill people at all levels of NHS administration. In 1973, a nucleus of old age psychiatrists who were creating services and finding the work intellectually and emotionally satisfying established a national body, a ‘special interest group’, for POA at the Royal College of Psychiatrists. This group aimed to further the development of services.
The success of POA schemes in the 1970s was demonstrated by declining death rates on in-patient wards, improved discharge-home rates, closure of long-stay wards and an infectious spread of enthusiasm from staff working in dynamic departments. Specialist low-cost, low-tech treatments contributed to enabling mentally ill older people to be supported at home and to avoid hospital admission. This has implications for practice today: total costs might be reduced by providing more POA services in order to reduce patients’ future demands on hospital services and institutional long-stay care. Supporting and enhancing patients’ and carers’ skills for managing dementia and providing adequate treatment and support for people with depression, might, for example, reduce crises and therefore also demands on emergency services.
With concerns about the sluggish introduction of comprehensive old age services, in 1979, the National Association for Mental Health (then known as MIND), urged the government to make ‘early assessment and intervention’ services for dementia mandatory. That did not happen. Unsurprisingly, based on experience of earlier optional strategies for undervalued sectors of the community, implementation was slow. Lessons from previous non-mandatory goal setting seem not to have been learned: optional recommendations were implicit, for example, in the 2009 National Dementia Strategy:
[T]he pace of implementation will inevitably vary, depending on local circumstances and the level and development of services within each NHS and local authority area. … There is no expectation therefore that all areas will necessarily be able to implement the Strategy within five years.
Predictably, in 2012, according to Unlocking Dementia by the All-Party Parliamentary Group on Dementia, levels of service provision remained uneven.
Changes under the Conservative government, 1979-1989
During the late 1970s and 1980s, engrained stereotypes about older unwell people perpetuated among influential senior health service and DHSS staff, and little regard was paid to evidence of benefit from psychiatric interventions. The DHSS and influential clinicians at the Royal College of Psychiatrists remained unconvinced that the work could be rewarding and offered little encouragement to establish the specialty. Most psychiatrists lacked interest, and in psychiatric departments without dedicated old age leadership, older people were reported to be almost inevitably neglected among the competing demands of work with younger people.
Demeaning ageist attitudes persisted. In the 1980s reports indicated that some staff working with confused older people used terms such as ‘dement’ and ‘babies’ and patients were labelled as ‘social problems’. Staff were stigmatised along with their patients. Nurses enthusiastic about their POA work at the Bethlem-Maudsley Hospital, South London, were described as ‘shit shovellers’ by colleagues who worked with younger people. However, derogatory labelling could be regarded by enthusiasts as a spur to action. Some pioneers used military metaphors about establishing new services – guerrilla activity and conquering new territories. Within health services, negative attitudes and expectations could be overcome by enthusiastic teaching and positive early career experiences of working in high quality departments, with implications for improving standards in many part of the NHS.
In 1980, the Black Report, Inequalities in Health, highlighted the links between old age, poverty and health and that older people had had a ‘poor deal’ from services. There was little evidence of attempts to remedy this situation; the Conservative government comprehensively ignored Black’s recommendations. The DHSS stated in the White Paper Growing Older (1981):
To enable people to enjoy secure, dignified and fulfilled lives in their later years is a large and ambitious objective. It will never be possible to achieve it for everyone, but there is no doubt that society can do more for its elderly members, just as elderly people can do more for themselves and for society.
High expectations of older people to contribute to society were welcome and realistic. However, with the DHSS’s emphasis on the role of families and society in the care of dependent older people, it was difficult to understand how policies for managing their chronic illnesses were equitable with those for acute illness or for unwell younger people. This focus was similar to the current government’s (2010-present) concepts of ‘The Big Society’ and creating ‘dementia friendly’ communities. These are good for people with little impairment and no disruptive symptoms, but hardly touch the needs of those with difficult-to-manage dementia and other mental illnesses where specialist treatment is required. Skilled health services are essential to achieve the latter, working alongside families and other agencies to achieve best outcomes.
Growing Older also stated that the needs of increasing numbers of older people could not be met wholly, or even predominantly, by public authorities and finance. Government objectives to reduce expenditure and statements about the impossibility of providing POA services were unlikely to promote dispassionate financial analysis of the real costs and benefits of providing these services. Optimistic evidence, since 1980, when James Fries described the ‘rectangular curve’ of longevity, indicating that older people maintained good health for many years followed by a rapid decline and death in late old age, was not incorporated into official economic analyses. Official reports, such as the Royal Commission on the NHS (1979), dwelt on the expense and the needs of older people and ‘the immense burden these demands would impose’ rather than balancing their comments with the contributions of older people to society such as through paid and voluntary work, spending money and providing social care. A compelling recent financial analysis by the Royal Voluntary Service, Gold Age Pensioners, (2011) highlighted that people over 65 made a net contribution of £40 billion to the UK economy in 2010. For NHS resources, historical and recent analyses have not separated the low costs of the ‘healthy’ years in old age from costs in terminal illness, expensive at any age. Dying young is the alternative to dying old: the value of often numerous productive additional years remains ignored.
An unexpected course of events led to significant developments in the early 1980s. Following The Rising Tide report (NHS, 1982) on POA services, the Government promised £6 million (equivalent to approximately £20 million in 2013) – a modest sum for a major national initiative – specifically to promote these services. This incentive spurred many local social and health service teams to devise schemes and apply for funding. Most failed to get it, but, having spent time and effort on their applications, implemented their proposals anyway. Numerous applications reflected gaps in services which were obvious to local teams, confirming inadequate levels of relevant health and social service provision by the authorities. The outcome also reinforced the notion of central government that money could be found within existing services and reinvested, rather than additional resources being needed, risking making future under-funding more likely.
Costs of healthcare increased in all Western countries, but compared to other countries, the NHS was efficient. Greater than the effects of demographic changes on increasing costs were growing expectations and demands for good health at all ages, staff salaries rising above inflation and the expense of high-tech investigations and treatments. However, with prevailing beliefs about excessive use of resources by older people coupled with stereotypes of old age and mental illness, it seemed unlikely that priority would be given to specialist POA services, whatever the evidence for them. Nevertheless, in 1986, 70% of the population of England had access to some specialist POA provision. This success was mainly driven by psychiatrists working with older people and their families in conjunction with other health and social services staff in the localities. Policy decisions ‘from above’ had less influence and rarely provided ring-fenced funding.
Conclusions
Today POA services are found country-wide. However, the specialty continues to suffer from decades of under-funding coupled with a new generation of resource constraints. In my clinical practice and historical research, stereotypic pessimistic views persist concerning improving wellbeing for mentally unwell older people, including by older people themselves. Ageism continues in the allocation of resources. Mainstream media emphasises the costs of caring for older people, without balancing this with the contributions they make to society. They scapegoat older people for the difficulties of the NHS. For example, Gerard O’Donovan wrote in the Daily Telegraph (17 April 2014):
‘The facts are sobering. There are more pensioners than children living in Britain today. Two in every three hospital patients are aged over 65.’ It would be far sadder if ‘Two in every three hospital patients’ were under 65. Previously unheeded messages about demographic changes, the health and social challenges of dementia and the need to provide age-appropriate services are reiterated in current policies. Cameron’s promotion of the ‘Big Society’ and the ‘dementia challenge’ resemble the Conservative government in the 1980s urging families and communities to support elderly mentally ill people, with little recognition of the difficulties this entails or of evidence, such as from Pat Thane (Happy Families? 2011), that families have consistently provided that support to the best of their ability.Urging social responsibility complements, but does not provide, necessary specialist services.
The link between inadequate community POA resources and demand for hospital beds was made in the 1940s, with major implications for cost. No evidence has emerged to disprove this, yet specialist services still struggle for resources. Consistently, humanely principled ideas have not been accompanied by financial commitment to provide high quality services. Permissive directives without ring-fenced resources have not encouraged prioritisation. High quality services led by dedicated clinicians were achieved in spite of, rather than because of, government support.
The Equalities Act (2010) should have improved the situation as public services ‘must not discriminate against a person requiring the service’ by not providing it. However, like all legislation, the Act is open to interpretation; some health authorities have concluded that specialist POA services are inherently discriminatory and should be abandoned in favour of ‘ageless’ services. This does not reflect the real differences in healthcare needs of older people, or the historical evidence that outcomes improved when specific age-appropriate services were created.
Enthusiastic, dedicated staff work in many POA services providing high quality, effective clinical interventions, working alongside, and supporting, families and communities. However, they continue to struggle with limited resources and low levels of staffing. More needs to be done, to strengthen services. There might be some shift towards valuing healthy older people, but it seems not to be matched by commitment from the state to providing high quality services for those who are unwell. Government rhetoric about parity of esteem for mental and physical illness does not fit with their recent objective to make savings of 1.5% for physical illness services and 1.8% for mental illness services (Sue Bailey, http://www.rcpsych.ac.uk/discoverpsychiatry/thepresidentsblog.aspx, 8th May 2014). Chronically under-resourced services for older people are likely to suffer most. The cost-cutting objective appears short sighted in the light of evidence that services have the potential to achieve savings in the wider health and social care economy by alleviating suffering and distress, minimising health and social care crises and avoiding unnecessary demands on acute hospital services. The rhetoric of universal fully comprehensive effective specialist POA services seems even further from reality.
Acknowledgements
Tom Arie, Benjamin Hilton and Pat Thane offered constructive criticism on drafts of this paper.
Anderson D, Connelly P, Meier R, McCracken C, ‘Mental health service discrimination against older people’, The Psychiatrist, 2013; 37: 98-103
DHSS, Services for Mental Illness Related to Old Age, HM (72)71 (HMSO, 1972)
DHSS, Inequalities in Health: Report of a research working group (Black Report) (DHSS, 1980) in Inequalities in Health: the Black Report, ed. Peter Townsend, Nick Davidson (Harmondsworth: Penguin Books, 1992)
DHSS, Growing Older, Cmnd. 8173 (London: HMSO, 1981)
Oldham, John, ‘Reform reform: An essay by John Oldham’, BMJ 2013;347:f6716
Robb, Barbara, Sans Everything: A Case to Answer (London: Nelson, 1967)
World Health Organisation, Psychogeriatrics (Geneva: WHO, 1972)
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