Community psychiatric nurses in old age psychiatry play an integral role in the care of elderly patients in the community. In this article, Dr Eamonn Fottrell discusses how that role is adapting to suit the needs of the modern health service and how their job can be enhanced to bring old age psychiatrists and general practitioners into an ever closer working relationship.

Unless there is a profound change in the way health professionals work and relate to one another, there will be no major improvement in the NHS irrespective of the Government making more money available. An example of how this changing relationship is already evolving spontaneously is the manner in which Community Psychiatric Nurses (CPN) in old age psychiatry are adapting their roles to suit the needs as perceived by them, at the community coal face. This paper provides suggestions on how that role can be further enhanced with observations of relevance to general practitioners, consultants, nurses and the NHS in general. At the beginning it must be made clear that this is not about increasing the number of doctors or nurses or the building of new faculties or further expenditure to shore up the health service, essential as these are. This is something far more important Ð it concerns changing long entrenched attitudes and working practices of health care workers already in post and forming new working networks and breaking down old professional barriers. If we fail to change our working practices, then all other attempts at reorganization and improvement will fail and extra money will always be spent at efforts at managing the unmanageable.

If there is anything on which old-age psychiatrists agree, part from the need for more beds, it is that old age community psychiatric nurses are a most useful breed of people. Instinctively, after only a short period in the community, they begin to act as go-betweens, confidants, trouble-shooters, crisis managers, sorters out of assorted multi-coloured tablets, givers of depot medication, reporters on mental states, taxi drivers for out-patients and GPs surgeries, organisers of relative support groups and walking encyclopaedias on organizations and faculties in the local area for elderly and caring relative support.

It appears as if release from the confines of the wards embues them with manic drive, initiative is stimulated and new horizons and challenges open up for them in the community. Not only do they thrive on this commitment but their appetite grows by what it feeds on. How can their impact on elderly-care be even further enhanced while at the same time increasing their sense of achievement and job satisfaction? Arguable the increasing population of elderly people with their dependencies and degenerative illnesses, both mental and physical, will present the NHS with its major challenge in the first decade of the millennium. The example of how the functioning of a CPN has changed and could be even further enhanced, may stand as an example of what could be achieved in many other working relationships among professional NHS personnel in the community. There are three other areas, where fuller development of their role and enhancement of their overall job satisfaction can be achieved.

GP surgeries
The first change in the functioning of the CPN is aimed at providing even greater support to the GP surgery. Although many have a commitment here already, there is room for a more formal enhanced input. There could be two designated days for visiting the surgery weekly, when patients may be introduced and old patients reviewed. This visit could be synchronized when the GP with a special interest in the elderly (GPSI) in a primary care trust is holding surgery. This would be conducive not only to building up rapport with patients but also with GPs.

As approximately 90 per cent of psychiatric patients are already treated at the primary care level, this understanding between the CPN and the GPSI would further enhance this potential. This approach would also give the GPSI, near instant access to the skills of the multidisciplinary team of which the CPN is a member. In many cases (except acute psychiatric illness where urgent assessment and treatment is required, particularly acute psychosis) this would be preferable to the one off Ôhit and runÕ visit by the consultant on a domiciliary visit.

Elderly mental health patients prefer their illnesses to be sorted out at the primary care level, as the stigma associated with mental health difficulties may be particularly stressful for them. Also nurses so often have better empathy and achieve more rapport with patients then with doctors particularly consultants whom they find less approachable. Depending on the size of the practice, the commitment may have to increase either with more personnel involved and more frequent visiting. Community psychiatric nurses in this working environment are tremendous clinical trouble shooters.

All part of the same firm
This would result in more rapid assessment and management, with a decrease in the likelihood of hospitalization or indeed institutionalization1. Too frequently, there are not many alternatives for elderly patients seen late or in a crisis. As primary care groups evolve into primary care trusts with developed budgets it will be in the trustÕs power to directly employ CPNs and I believe that would be money very well spent.

As continuing care NHS and local authority bed numbers continue to decline and we become more dependent on community support and on the private health sector, the need for CPNs increases. The elderly psychiatric patient, especially if living alone, tends not to visit the surgery and the CPN is a great seeker-out of such patients. The GPSI should have no hesitation in seeking their help as they are all part of the same firm.

Residential and nursing homes
The second area where CPN may have an enhanced role is in their relationship with private elderly mentally infirm residential and nursing homes. Each nurse should be allocated one home and it should be their remit, in co-operation with the visiting medical officer (who should be the GPSI with special interest in elderly care), to help raise the general standard of care, particularly for patients with psychiatric histories or current mental health problems. The visiting medical officer must be a person committed to elderly health care and the job description of this officer is in urgent need of review2.

This would be a very effective combination of personnel, meeting at regular intervals in the home to review the mental state of the residents, with particular emphasis on current medication. The CPN liaising with the old age psychiatrist and the multidisciplinary team is in a favoured position to mobilize more specialist in-put as needed. This would surely be the sensible way forward, which would result in a drawing together of the network of care and capture the diverse strands and be a major factor in raising moral and quality of care in these homes.

Private sector
The great majority of elderly mentally infirm needing institutional care, are currently in the private sector3. Although many of these homes are registered in the elderly infirm category, they are frequently deficient in the number of staff with psychiatric training on duty at any one time. The home also has waiting lists and there may be no alternative placements available locally. The end result is that private homes are tempted to pick from the waiting list the less challenging clients.

The more challenging may then be referred for on-going NHS continuing care (Band 1) even though they could be very well managed in an adequately resourced Elderly Mentally Infirm (EMI) nursing home. This puts increased pressure on the consultantÕs beds and the old age psychiatrist service. The ongoing input of the CPN into these homes will not only lighten this load but help to ensure that in the first instance the home is not too discretionary in patient selection and more empowered to hold onto those already there, who develop challenging behaviour. We still have a responsibility for these patients in private care homes, much as we may wish to relinquish it due to other commitments, they may call on our services, and they do not cease to be NHS responsibility once they enter private care.

Doctors would be well advised to encourage and support this role for CPNs. A mutually beneficial bond between the NHS and the private sector would have been established. If we are to run a responsible old age psychiatric service then we must go on making overtures to the private sector and develop a symbiotic relationship. This is more important now than ever before, as we have little options for alterative beds. This practical approach at clinical level would be far more productive than the endless abstract sterile discussions and argument on the respective roles of the public and private sectors in health care. The experience gained could inform the on-going debate and this is a role, which CPNs would welcome as they would take pride in contributing to upgrading the level of care.

Career frameworks
Thirdly, not only should the role of the CPN in the community evolve but also the career structure. A nurse consultant grade in elderly mental health community psychiatry should be widely established and would be in line with the spirit of the NHS plan4 and the Department of Health National Service Framework for Older People5. The need to establish a clinical career framework in which experienced nurses in the areas of patient care should be encouraged to develop skills in teaching, research and leadership, while remaining active in patient care is great. The shift in NHS focus to primary care makes this role all the more relevant. Community psychiatric nurses could aspire to the nursing consultant grade in their own speciality as they gained experience and skills. The training and development should always be closely linked to acquiring skills in assessment and management of old age psychiatric patients in community settings. They would become autonomous practitioners within the context of a comprehensive local age old psychiatric service and take the lead role in training and development of other CPNs while showing leadership in liaison and innovative networking.

They would have developed special skills in prescribing psychotropic medication and monitoring their effects. This would be a natural extension of their current activities of monitoring the contents of dosset boxes, administering depot medication, observing for therapeutic responses and side-effects and reporting to the teams. In addition, they should be spokespersons for their speciality both nationally and locally.

Any tendency over time, to remove totally from hands-on patient care, such high profile nurses and place them full time behind desks (as occurred in a different context in the past) should be robustly resisted. Such a move would be completely against the principles and practices of the community psychiatric nursing. Financial recompense should reflect the importance of the role. Consultants must show a willingness to relinquish some of their power over patient management, analogous in some aspects to how they gradually adopted the multidisciplinary approach to patient care in the sixties and seventies but this time with perhaps a little more willingness and grace.

If our response to the ever changing demands of the increasing population of old people with degenerative physical and mental illness is to be meaningful in a rapidly changing sociodemograhic setting then we must continue to scruntise our professional job-descriptions to see if they continue to be best value for money. Strict professional demarcation lines between the caring professions must blur at the edges and nowhere more than in the practice of old age psychiatry which has psychiatric, physical, social, familial, community and institutional dimensions.

Conclusion
Perhaps the best time to start this blurring is at the training level. For a period, medical and nursing students could share aspects of training and get greater insight into the social dimension of care. Let the needs of our patients as best we can perceive them in our working situation, determine the type of our training as it appears to be doing with CPNs. Community psychiatric nurses are catalysts who are triggering action which is bringing old age psychiatrists, and general practitioners with a special interest in the elderly into an ever closer working relationship with them, from which patients are benefiting. There are lessons here also for developing closer contact with the private sector and better working relationships in general in the wider NHS of the future.

References
2. Fottell E. Visiting MO: Time for a new job description. Geriatric Medicine 2001; 12: 20-22

3. Wattis J, MacDonald A, Newton P. Old age psychiatry Ð a speciality in transition. Psychiatric Bulletin 1999; 23: 331-5

4. Department of Health, The NHS Plan. A plan for investment. HMSO 2000; London

5. Department of Health. The National Service Framework for Older People. HMSO, 2001; London

Eamonn Fottrell is a retired Consultant Old-Age Psychiatrist

return to main menu