Mohammed T. Abou-Saleh

THE PATTERN OF PSYCHOGERIATRIC SERVICES 663GUIDELINESThe first guidelines for provision of psychiatric services for oldpeople came in a Department of Health circular in 1972 9 . Thegovernment White Paper, Better Services for the Mentally Ill 10 ,in1975, suggested that services for old people should often beprovided by a psychiatrist with ‘‘a special interest’’ andincorporated guidelines for bed and day hospital provision forthe ‘‘elderly severely mentally infirm’’. Subsequently, the RoyalCollege of Psychiatrists produced guidelines intended to helpCollege representatives reviewing job descriptions for new orreplacement consultants. These were endorsed by the HealthAdvisory Service in its report, The Rising Tide 11 , and by the jointRoyal College of Physicians and Psychiatrists report, Care ofElderly People with Mental Illness 12 . The second joint report 13adopted a more multidisciplinary approach and described thedifferent types of mental illness in old age as well as appealing forequity and ‘‘national reference frameworks’’, which correspondedclosely to the concept of ‘‘National Service Frameworks’’introduced by the new government 14 . It cited ‘‘indicative servicelevels’’.REALITY AND GUIDELINESAlthough in the UK, old age psychiatry is now recognized as aspecialty by the Department of Health, we are still awaiting thecollection of routine statistics. Initial manpower statistics appearto be grossly inaccurate. The most comprehensive data availableare from the 1985 survey, updated by the 1996 survey, whichunfortunately did not achieve such wide coverage. There are alsonow agreed international standards for old age psychiatryservices 15 and an international survey has established that basiclevels of service exist in 12 countries worldwide 16 .SPECIALIST SERVICES OR NOT?In view of the documented rapid expansion of services over theyears, this question may seem superfluous. However, it waspossible as a result of the 1985 survey to compare services wherepsychogeriatricians work half-time or more in the specialty withthose where the consultant commitment to the elderly is less thanhalf-time 17 . Specialist services had generally higher staffing ratios(with the exception of non-consultant medical staff), a higherproportion of acute beds on general hospital sites and a greaterproportion of long-stay beds within the area served. These lasttwo could be regarded as surrogate indicators of quality of care.In addition, the specialist psychiatrists were more likely to lookafter all mental illness in old age—the recommended pattern ofservice—to engage in teaching and to show an interest in research.CONCLUSIONPsychogeriatrics has ‘‘come of age’’ in the UK. Provision,although geographically patchy and relatively under-resourced,still provides one model for future developments. This model,fostered in the National Health Service with its principles ofequality of access, payment from general taxation and centralplanning, survived the major changes of the 1990 ‘‘reforms’’ andshould thrive under the regime of equity and quality proposed bythe present UK government, always provided that old agepsychiatrists show adequate leadership and that governmentsfurnish adequate resources.REFERENCES1. Arie T. Morale and planning of psychogeriatric services. Br Med J1971; iii: 166–70.2. Arie T, Dunn T. A ‘‘do-it-yourself’’ psychiatric–geriatric joint patientunit. Lancet 1973; ii: 1313–16.3. Royal College of Psychiatrists, British Geriatric Society. Guidelinesfor collaboration between geriatric physicians and psychiatrists in thecare of the elderly. Bull R Coll Psychiat 1979; 11: 168–9.4. Kitwood T. Dementia Reconsidered: the Person Comes First.Buckingham: Open University Press, 1997.5. Koenig HG. Aging and God. Binghampton, NY: Howarth Pastoral,1994.6. Wattis JP. Geographical variations in the provision of psychiatricservices for old people. Age Ageing 1988; 17: 171–80.7. Wattis J, Macdonald A, Newton P. Old age psychiatry: a specialty intransition—results of the 1996 survey. Psychiat Bull 1999; 23: 331–5.8. Wattis J, Macdonald A, Newton R. Old age psychiatrists’ views oncontinuing inpatient care. Psychiat Bull 1998; 22: 621–4.9. Department of Health and Social Security. Services for Mental IllnessRelated to Old Age, HM(72)71. London: DHSS, 1972.10. Department of Health and Social Security. Better Services for theMentally Ill. London: DHSS, 1975.11. National Health Service. Rising Tide: Developing Services for MentalIllness in Old Age. Sutton, Surrey: NHS Health Advisory Service,1982.12. Care of Elderly People with Mental Illness: Specialist Services andMedical Training. London: Royal College of Physicians of Londonand the Royal College of Psychiatrists, 1989.13. Care of Older People with Mental Illness. CR69. London: The RoyalCollege of Psychiatrists and The Royal College of Physicians ofLondon, 1999.14. Department of Health. A First Class Service: Quality in the NewNHS. London: Department of Health, 1998.15. World Health Organization and World Psychiatric Association.Organization of Care in Psychiatry of the Elderly. Geneva: WHO,1997.16. Reifler BV, Cohen W. Practice of geriatric psychiatry and mentalhealth services for the elderly: results of an international survey. IntPsychogeriat 1998; 10: 351–7.17. Wattis JP. A comparison of specialised and non-specialisedpsychiatric services for old people. Int J Geriat Psychiat 1989; 4:59–62.