In the third article in his series on old age psychiatry, Dr Eamonn Fottrell discusses the core elements of a successful old age psychiatric service. He believes that unless these ingredients are present, the service will tend to flounder. The matrix of care should include a committed elderly mental health team of psychiatrists, enhanced provision for respite care and also an outreach community-orientated multidisciplinary team geared towards greater carer support and involvement.

There are eight essential ingredients of an old age psychiatric service and if one of these ingredients is missing then the ramifications may be widespread, with negative interactions on all other components. If all the ingredients are present they will complement and facilitate one another symbiotically so that the end product will be greater than the sum of the individual components. So what are the essential ingredients of a comprehensive old age psychiatric service as I perceive them? They are listed below:

1. Committed psychiatric team A committed psychiatric team dedicated to care of the old age patient is of paramount importance. This team will be led by a consultant who has shown an interest in old people during training and will have spent at least two years training in an old age post during the specialist training years. If the consultant has taken the post because it offered an opportunity to achieve consultancy status, but otherwise has not a genuine interest in old people, then this lack of interest will be evident over time to the other members of the team Ð the specialist registrar and senior house officers (SHOs) and paramedical teams. The consultant will show little interest and no enthusiasm for developing services.
2. A multidisciplinary team The second ingredient is a multidisciplinary team, comprised of community psychiatric nurses (CPNs) and allocated liaison social workers with a special interest in the elderly, who will also be a source of information on facilities available and benefit entitlements and how to access them. The team would be incomplete without dedicated occupational therapists and a specialist old age clinical psychologist. The numbers from these individual professionals will vary directly with the population of the catchment area and its geographic compactness. A characteristic of this team is that it will be far more than an outreach community team. Smaller and perhaps less well-endowed hospital teams will work closely with them prior to admissions and discharges.
3. Community psychiatric nurses Special role CPNs will have a specialist advisory and go-between role. They should become semi-autonomous practitioners and one or more should be allocated to large general practitioner (GP) groups. In the first instance GPs could make referrals to the CPN unless there were obvious reasons (such as acute psychosis) for seeking immediate medical advice. They are quite capable of identifying who needs onward referral for further investigation and assessment by the psychiatrist. Over time CPNs have become highly skilled community workers, who know the local facilities far better than the junior medical personnel rotating in training schemes. CPNs have become adept at identifying tablets amongst the myriad of medication, which old people receive, and also in noting therapeutic results and side effects. They get to know patients far better than the consultant, who very often only sees the patient infrequently at outpatients or worse still, on a one off hit and run domiciliary visit. Patients also find nurses far more approachable and confide in them better. Comprehensive old age psychiatric departments should encourage primary care trusts to use budgets to directly employ such special role CPNs. They would relate within these trusts to the GPs with a special interest in elderly care who should also now function as the visiting medical officers to the local residential and nursing homes. They would run regular combined visits to the homes and this would not only raise the standard of care but would facilitate the homes in widening the spectrum of patients to whom they could offer a service. The NHS must co-operate better with private care for mutual benefit and better care for our elderly psychiatric patients. This expanded role for the CPN is crucial for a comprehensive old age psychiatric service.
4. Respite care Enhanced access to respite care is also essential. Caring relatives, particularly elderly spouses, probably represent the greatest number of unpaid or poorly paid workers (with little or no time off) in health care of the elderly. Ten beds should be made available, with a few more or less depending on population size for this purpose. They should be identified within the general purpose NHS elderly mental health nursing home. An arbitrary period of six to eight weeks annually should be made available to all, which can be taken at the discretion of the carer in one, two or three week periods. Staff will be skilled in identifying those who need NHS respite from those needing social respite. This would be a very flexible allocation and the period available would increase with the need. Other components of respite include attendance at a day hospital or day centre and relative support groups. The life of the carer can be one of loneliness and a feeling of isolation, coping with an ongoing problem with no end in sight. Membership of a relative support group gives them opportunities to share problems, receive useful information, develop supportive relationships with other carers and is a social outlet. It can be the function of any member of the multidisciplinary team to facilitate this.
5. Acute old age psychiatric unit A ten-bed acute old age psychiatric unit to assess and treat acute psychosis and demented patients with severe challenging behavioural disorders could be provided at the local general hospital, although such units have considerable drawbacks, some beds are essential. This unit should not be used to admit and assess non-challenging demented patients on the basis that a reversible cause for the problem might be found. Unfortunately, personal experience with these units suggests that rarely are treatable reversible causes found. These patients may be investigated from home as admission to hospital frequently exacerbates behavioural problems. Once admitted it is frequently difficult to discharge them as support facilitates are difficult to re-establish.
6. A multi functional NHS old age psychiatric nursing home A multi-functional NHS old age psychiatric nursing home is absolutely essential to a comprehensive service. In a thirty bedded unit ten beds could be allocated for NHS continuing care. The numbers to be used flexibly as need at a particular time dictates. There must be active weekly rounds in these units by the consultant and his team between on going assessment and throughput. Before being allocated a continuing care NHS bed this group should be allowed up to maximum cut off point of six months assessment before a decision is made as to whether they need ongoing NHS care because of what appears an intractable behavioural problem. Frequently over that period of time many patients improve and can be transferred to settings of less dependency, such as residential or nursing homes, more suited to their needs. Life sentences with no hope of reprieve for old age psychiatric patients should be a thing of the past in the age of intermediate care and ongoing assessment. Patients change, circumstances change and so should we. The need for on-going old age psychiatric care in the NHS is indeed far less than we thought as we closed the old mental hospitals, and will get even less as community care become more comprehensive.
7. Information There is a need for continual updating and circularizing of information on the facilities available for old age psychiatric patients and their carers in the catchment area. Usually there is far more available than people know and that includes not only carers but doctors, consultants and social workers. 8. Rapport between NHS and social service teams Close rapport with the elderly team in the local social services office is very important. The teams should meet regularly to discuss mutual pressure points and how they may co-ordinate their services. The tendency to sit in isolated groups and discuss the shortcomings of one another should be discouraged. Personnel in both services are well intentioned, under resourced and scapegoated for criticism.