Are we failing the frail? Lessons to learn from mental health transformation

hands on a walking stick

Older and frail people are experiencing the same set of challenges that spurred the birth of the mental health movement in the last century. Is it really deja vu and if so, what happens next? Three healthcare experts explain.

The Spring Budget response highlighted that one of society’s greatest challenges is how we best support older and frail people to remain self-caring and independent at home. Several of the challenges being experienced across the NHS and social care echo the drivers that led to the mental health movement in the last century, from which grew community psychiatry. 

Is now the time to learn from this movement and reframe how we see, report, care for and value frail older people?

The last 50 years witnessed four key phases of mental health reform:

  • Hospital closures: That society was detaining those with chronic and enduring mental illness in asylums became a matter of significant social injustice with the realisation of the consequence of institutionalisation. Hospitals were closed.

  • Minimised medication: Advances in psychopharmacology led to new medicines that could better treat symptoms. Excessive use of these medicines helped people become symptom free but often at the expense of their wider health. Side effects and obtunded affect rendered people incapable of engaging with society, work and the right to a full and enriching life. There was a shift to an approach characterised by the minimum amount of medication that helps people remain independent while not distressed by symptoms.

  • Investment: After the closure of asylums, little infrastructure existed to support people in the community. Fewer beds stimulated a need for cohesive and coherent community services. Following the National Service Framework for Mental Health (DH, 1999) crisis intervention, assertive outreach, early intervention in psychosis and continuing care and rehabilitation services were invested in. This supported a further revolution in mental health care and a consequent further reduction in inpatient beds.
  • Reframing the narrative: Poor mental health or an acute mental illness was seen by society and employers as an illness for life. The recovery movement reframed this by highlighting that recovery is about staying in control of lives despite experiencing a mental health problem. Care was refocused on not just treating or managing symptoms.
Older and frail people are experiencing the same set of challenges. Politicians, NHS decision-makers and wider society should look and learn from mental health reforms.

A risk-averse society is frequently admitting older and frail people at the convenience of services rather than investing in their continued independence at home. A UCLP survey of admissions aged 75 or over found that the decision to call an ambulance was mostly made by someone other than the patient. Upon arrival at an assessment unit older people are undressed and wait for long periods. Many are not dressed during their stay on wards. Hospitalisation can lead to loss of self-esteem and dignity.

After admission people see specialists, nurses or allied health professionals. Each will seek to optimise the treatment of their relevant expertise. Polypharmacy and side effects increase after admission. Patients can experience in-hospital clinical adverse events. We should learn from mental health prescribing about the minimum amount of medication a person needs to remain independent and able to remain mobile, alert, and return to home.

Discharge can result in older and frail people being dropped into disconnected and fragmented services. Overburdened GP practices no longer routinely provide home visiting and care coordination. Community staff may be the patient and carer's only regular contact. 

Access to community staff is variable. We must shift scarce resources from inpatient to community provision. If through sustainability and transformation plan implementation fewer beds are available, we must reset the paradigm in favour of better resourced community care.

Finally, there is a need to shift the debate towards recovery. Greater attention needs to be paid to pre-admission conditions and how a person can be supported to regain that. 

It’s time to transform how we treat older and frail people. Society and government need to reframe a growing problem into a solution. As a matter of social justice, we must optimise people’s opportunities to be active and engaged in their care, supported on their terms to be treated and remain in their own homes or care settings. 

We can learn from transformations in mental health care and design solutions that minimises risks of treatment and care, understanding the risks that independence may bring. A greater focus and respect for the dignified ways in which individuals recover is better than a response that focuses on flows and efficiency. This approach values citizens as contributors to society regardless of their age, and potentially offers some optimism to the human and financial challenges that the UK is currently facing. 

Active, engaged frail and older citizens can help us design solutions that work best for society and the vulnerable.

This post is a shortened version of a paper co-authored by:

Download the full-length paper.

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