Claire Hilton

The provision of mental health services in England for people over 65 years of age, 1970-78.

The twentieth century saw an increasing number of people living into old age, and consequently a higher prevalence of age-related chronic degenerative brain disorders. By 1971 the mental hospitals were almost half full with people over 65 years of age. Thus plans to close the mental hospitals meant that the development of community mental health services for older people was a necessity. Although there was a multi-disciplinary focus on the care of older people, the lead in service development was largely taken by psychiatrists, both individually and through the Group for the Psychiatry of Old Age at the Royal College of Psychiatrists.

Changes between the 1959 and 1983 Mental Health Acts (England & Wales), with particular reference to consent to treatment for electroconvulsive therapy

Consent to treatment was not mentioned in the Mental Health Act 1959, assuming that a detained patient could be treated against his/her will. However, consent was a cr ucial new feature in the 1983 Act.This paper traces and evaluates the issues, debates, people and organizations in England and Wales who advocated and enabled this important change to come about, using examples from the clinical practice of electroconvulsive therapy.

Psychogeriatrics in England in the 1950s: greater knowledge with little impact on provision of services.

In the 1950s, the population aged over 65 years continued to increase, and older people occupied mental hospital beds disproportionately. A few psychiatrists and geriatricians demonstrated what could be done to improve the wellbeing of mentally unwell older people, who were usually labelled as having irreversible ‘senile dementia’. Martin Roth demonstrated that ‘senile dementia’ comprised five different disorders, some of which were reversible. These findings challenged established teaching and were doubted by colleagues. Despite diagnostic improvements and therapeutic successes, clinical practice changed little. Official reports highlighted the needs, but government commitment to increase and improve services did not materialize.

Psychiatrists, mental health provision and ‘senile dementia’ in England, 1940s–1979

Until around 1979, ‘confused’ or mentally unwell people over 65 years of age tended to be labelled as having ‘senile dementia’. Senile dementia was usually regarded as a single, inevitably hopeless condition, despite gradually accumulating clinical and pathological evidence to the contrary. Specific psychiatric services for mental illness in older people began to emerge in the 1950s, but by 1969 there were fewer than 10 dedicated services nationally. During the 1970s, ‘old age psychiatrists’ established local services and campaigned nationally for them. By 1979, about 100 old age psychiatrists were leading multi-disciplinary teams in half the health districts in England. This paper explores the tortuous development of these new services, focusing on provision for people with dementia.

A witness seminar: the development of old age psychiatry in Britain, 1960-1989. Themes, lessons and highlights.

To create a record of the development of old age psychiatry in Britain, as seen through the eyes of some of the people who participated in building it, from the earliest days until it was officially recognised as a specialty by the Department of Health in 1989.

Investing in new services is key

David Cameron wants the UK to be a world leader in dementia1—he is clearly not aware that it used to be but has fallen behind over the past two decades.2 His funding boost for dementia research is welcome, but will not, at least in the short term, directly improve patient care. …

Diversity in older people's mental health services: black and minority ethnic groups or the universality of the rainbow?

Dimensions, concepts and definitions concerning minorities, cultural diversity and equality continue to evolve. In psychiatry, fulfilling diversity needs has often meant the provision of services for black and minority ethnic (BME) groups. However, this relates to only one of many facets of diversity. In line with recent government health service proposals and the Equality Act (2010), the Royal College of Psychiatrists’ Old Age Faculty has withdrawn its College Report (CR156; 2009) on services specifically for BME communities. How to achieve accessible and best quality services for a diverse population needs further consideration.

Fit for purpose? Dementia and the healthcare professions

The massive impact of the dementia lobby is evident worldwide and most certainly in the UK. Dementia is seen to be everywhere. It contributes to the difficulties of people living in the community, in care homes and in hospitals. Its characteristics of variability, 24 h presence, and combinations of dependency and hazardous behaviour, make it the number one threat to the peace of mind of patients, their families, clinicians and managers; people experience adversity and money can be misspent. A huge amount is being done to improve dementia care across the spectrum of lay and professional education and action [1]. Dementia is not the only mental disorder encountered in late life: the three most common mental disorders affecting older people when they are in hospital are dementia, depression and delirium. These may occur separately or concurrently and each of them is associated with poorer outcome in terms of survival, continuing disability and return to the community. Among older people admitted to a general hospital, out of 330 people, 220 will have a mental disorder: 102 will have dementia, 96 depression and 66 delirium [2]. This means that appropriate care of at least two-thirds of older patients requires that general hospital professionals of all disciplines are competent in the recognition and management of these conditions. Geriatricians should feel equipped to play their part in this by their educational, clinical and training experiences. In this issue of the journal Mayne et al. [3] report findings from a survey of geriatricians who are identified as ‘Dementia Champions’. They are a mixed bunch. Their range of clinical activity varies and their experiences of dementia, which have prepared them for their role, span reading, self-study, involvement in research, clinical attachments and structured training. They ask that trainees in future have more and better dementia training, with more structure and less variability between centres. Their comments indicate that there is experience, education and encouragement to be found, but that trainees have to make an effort to make up the best programme to suit their ambitions. Some may feel there is nothing wrong in that, others may prefer a more coordinated approach.

An intermediate care unit for older people with both physical and psychiatric disorders: naturalistic outcome study.

BACKGROUND An intermediate care unit opened in 2008 aiming to relieve pressure on beds in the local general hospital. Its goal was to provide rehabilitation for people recovering from physical illness who had coexisting psychiatric symptoms, including from delirium, but for whom assessment suggested that discharge home might be achieved. As an experimental unit, it warranted evaluation. We aimed to identify clinical factors associated with higher rates of discharge of the patients to their own homes. METHODS A naturalistic retrospective exploratory cohort study of 100 consecutive admissions to the intermediate care unit. A backward logistic regression analysis was performed. RESULTS Discharge home was associated with better scores on the Barthel Index of Activities of Daily Living at the time of discharge, a shorter duration of stay, and a psychiatric diagnosis other than delirium. CONCLUSIONS At the time of pre-admission assessment, clinical factors which were likely to predict discharge home were unclear, suggesting a need for further studies to determine who might best benefit from this sort of intermediate care placement.

Coming of age: Reflections on old age psychiatry as a specialty in the National Health Service, 1989-2010

Mental illness in old age is one of the most important healthcare issues of our times: if dementia were a country, it would be the world’s 18th largest economy (Alzheimer’s Disease International, 2010). In 1989, the UK Department of Health formally recognized old age psychiatry as a specialty in its own right, and by 2010 it had come of age. This anniversary was commemorated with a special edition of Old Age Psychiatrist, the newsletter of the Royal College of Psychiatrists, Faculty of Old Age Psychiatry (2011). To produce this, we called for “Janus” articles drawing on past experiences and giving thought to the future. Thirty-seven authors, ranging from students to retired colleagues, responded. Most contributors were UK-based but five worked elsewhere and provided an international perspective. The majority were psychiatrists who had devoted many years to the specialty, but their thoughts were set in context by representatives from other disciplines closely aligned to specialist healthcare services for mentally ill older people. By 1989 a great deal had already been achieved to create better services for older people in the UK. Old age psychiatry developed within a social psychiatry model, which drew on the best practices of psychiatry in association with geriatric medicine and social care. Mental hospitals were closing, units in general hospitals became the norm, and recruitment grew despite the Cinderella status of the specialty (Hilton et al., 2010). Specialty status was aimed to make it possible for best practice to become available equably throughout the UK by facilitating service development, monitoring services, and enabling recruitment and adequate training of staff. Contributors to Old Age Psychiatrist reflected on the widespread international interests, adoption, and interpretation of the UK model. The newsletter was stamped with the enthusiasm and devotion of contributors. They have become involved in, or seen at close hand, the flourishing of a specialty which is relevant to the world’s demographic and epidemiological needs, now and for the foreseeable future. There was much pride and satisfaction that despite social, economic, political, and professional challenges, something good has evolved, through innovation, dedication, and creativity, which will benefit future generations. But confidence was muted with recent frustration; influence and control is so often falling into the hands of policy-makers and managers who have not had the benefit of direct learning in the realities of this exacting and complex area of human need.