Interventions for severe mental illness

Interventions for severe mental illness

  • An earlier section of the mental health needs assessment covers the support offered to people with severe and enduring mental illness in Cambridgeshire and Peterborough.
  • Mental illness in older adults has historically been under-recognised and under treated; and is often under-funded (Stickland & Gentry, 2016).
  • Feedback from the SUN Network highlights older adults in Cambridgeshire and Peterborough with enduring or severe mental illness report feeling ‘left behind’ and unheard in services, and that they can ‘fall out’ of the mental health system after leaving working-age adult services.

Peterborough Exemplar (2019 – 2022)

  • Peterborough was chosen as the site of a two-year NHS England-funded pilot to transform the delivery of mental health support. The findings from this project have since been rolled out across the county. They aim to provide a sustainable, person-centred system of mental health care, which will deliver a better access to a broader range of care options, reduce demand for high-level interventions, give greater service efficiency, and improve patient experience and outcomes.
  • Older adults have not been able to benefit from all the services introduced as part of the Exemplar, as the Primary Care Mental Health Service (PCMHS), the Relational & Emotional Difficulties Service (REDS) and the Psychological Skills Service (PSS) do not support adults over the age of 65.

Primary care

Primary care works in partnership with secondary care community mental health provision to provide long-term support for people with enduring mental health conditions. The aspiration is that local people can access the right level of care, from the right place, at the right time.  As part of the Peterborough Exemplar, the Primary Care Mental Health Service (PCMHS) was introduced to provide specialist mental health interventions for anyone between age 17 and 65 in Cambridgeshire and Peterborough. Older adults are instead referred to Older People’s Mental Health services (OPMH).

Community mental health

Community mental health teams (CMHTs) support people living in the community who have complex or serious mental health problems. Patients are able to step down to primary care as their circumstances improve. Chapter 5 of this mental health needs assessment gives an overview of community mental health services in Cambridgeshire and Peterborough.

Overview

Older adults make up a smaller proportion of people referred into non-crisis mental health services in Cambridgeshire and Peterborough, compared to other adult age groups.

Figure 38: Referrals into non-crisis mental health services by age, Cambridgeshire and Peterborough ICB, October 2021 – September 2023

Referrals to older people’s mental health services have increased year on year since 2020.

Figure 39: Older adult services (OPAC) mental health referrals per week, CPFT, 2015 – 2023. Data source: CPFT analysis of the impact of the COVID-19 pandemic on mental health and community physical health services

There has also been an increase in the number of contacts with patients provided by specialist older adults’ mental health services post-pandemic, with an average of between 850 – 1150 weekly contacts pre-pandemic, to 1500 – 1850 weekly contacts since 2021. Similar trends are seen across children’s and adults’ mental health services.

Figure 40: Older adults services (OPAC) mental health contacts per week, CPFT, 2015 – 2023. Data source: CPFT analysis of the impact of the COVID-19 pandemic on mental health and community physical health services

Older People’s Mental Health (OMPH)

Older adults with more complex mental health needs (such as anxiety, depression, psychosis, bipolar disorder) and/or memory problems can be referred by their GP to the Older People’s Mental Health (OPMH) (CPFT, 2023). All new mental health referrals are initially referred to the OPMH triage service (excluding urgent/crisis referrals, which are triaged by crisis services. Around 550 people are referred to OPMH each month. There has been a recent increase in referrals, with over 600 referrals each month from May to October 2023.

Figure 41: Monthly referrals to the OPMH service, Cambridgeshire and Peterborough ICB, January 2021 – November 2023.

For a small proportion of these referrals (under 10 a month), the older adults team provides advice and guidance to the GP about the person referred, rather than directly assessing or supporting the patient.

Older People’s Stepped Care Therapies Service

The Older People’s Stepped Care Therapies Service (STC) provides psychological therapy, occupational and psychosocial therapies for older people in Cambridgeshire and Peterborough (CPFT, 2023). Staff also offer advice, consultation, supervision, training and support in areas of their therapeutic expertise to staff within mental health and integrated older people’s services, including inpatient units.

Between January 2021 to November 2023, around 55 people per month were referred into this service. The number of referrals per month has shown some increases in recent months.

Figure 42: Referral trend for Stepped Care Therapy, Cambridgeshire and Peterborough ICB, January 2021 – November 2023. Data source: CPFT

In mid-March 2024, there were 305 people waiting to access Stepped Care Therapies. This was an almost 25% increase in the waiting list over the previous 12 months.

Figure 43: Total waiting list for Stepped Care Therapy by week ending, 17th March 2023 – 17th March 2024. Data source: CPFT

Living Well with Psychosis

Many older people with psychosis are supported with the wider Stepped Care Therapies service. The Living Well with Psychosis team offers recovery-based psychiatric rehabilitation for people aged 65+ with long term psychosis (CPFT, 2023). This service works with patients to develop person-centred goals to enhance access to meaningful occupations, promote community and peer engagement, improve confidence, skills and motivation and increase hope and quality of life. It comprises of occupational therapists located in Peterborough, Cambridge, Huntington and Fenland.

Personality disorder services

In Cambridgeshire and Peterborough, the Personality Disorder Community Service and the Relational & Emotional Difficulties Service offer two separate pathways to help people manage emotional dysregulation, to control unhelpful coping behaviours and improve their ability to sustain meaningful relationship. This service is not currently commissioned to support older adults. Instead, older adults are supported within older people’s mental health services (OPMH). Although OPMH teams can receive guidance from PDCS, there is an inequality in the treatment of personality disorder based on age. People aged 65+ do not receive the full range support of provided by PDCS, such as group support sessions and a wider range of treatment options.

Crisis and acute mental health

The mental health charity Mind has defined a mental health crisis as when some is in a ‘mental or emotional state where they need urgent help’ (Mind, 2011). Older adults experiencing mental health crisis may present differently to younger adults and requires a different response, particularly older adults living alone (Raffertys, 2013). Urgent, emergency and acute mental health care is provided by a range of teams and services in Cambridgeshire and Peterborough, which are outlined in chapter five of this mental health needs assessment.

Overview

The majority of referrals to crisis services are from younger adults. There are smaller number of referrals to crisis services from older adults, with a declining number of people aged 80 and above.

Figure 44: Number of referrals to crisis services by age group, Cambridgeshire and Peterborough ICS, October 2021 –September 2023.

During the year between December 2022 and November 2023, 69% of referrals to community crisis services for older adults were routine referrals, and 28% were urgent or serious referrals. The proportion of urgent or serious referrals was the second highest in Cambridgeshire and Peterborough amongst other areas in the East of England.

Figure 45: Referrals to community crisis services by clinical response priority, older adults, Cambridgeshire and Peterborough ICS, December 2022 – November 2023. Data source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

The majority of referrals to community crisis services are for ‘single point of access service’ (65%). This provides a single entry point for referrals to secondary mental health services and support in a mental health crisis. The Mental Health Single Point of Access team screen all referrals and signpost people to a service which can best meet their needs.

Figure 46: The community crisis services older adults were people referred to, Cambridgeshire and Peterborough ICS, December 2022 – November 2023. Data source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

Accident and emergency

National research shows that older people with mental health needs are more likely to wait longer in emergency departments, compared to those who do not have mental health needs (Goode et al., 2021). Whilst there is limited qualitive research on this topic, one small study shows that attending Accident and Emergency can be a distressing experience for older people with mental health needs and their partners and carers (Goode et al., 2023):

  • Older people with mental health needs can find it very difficult to wait in a noisy and crowded Emergency Department, with one person reporting that ‘it had a serious mental effect on me personally’.
  • Older people and carers reported finding this busy environment confusing and lacking in privacy.
  • Stigma around mental health prevented people from disclosing their diagnoses.

From December 2022 to November 2023, around 1.6% of Accident and Emergency attendances amongst older adults in Cambridgeshire and Peterborough were for the primary reason of ‘mental health’, including self-harm.

Figure 47: Proportion of mental health attendances out of total older adult attendances in A&E, Cambridgeshire and Peterborough ICB, December 2022 – November 2023. Source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

Around 0.3% of Accident and Emergency attendances amongst older adults in Cambridgeshire and Peterborough are for the primary reason of self-harm.

Figure 48: Proportion of self-harm attendances out of total older adult attendances in A&E, Cambridgeshire and Peterborough ICB, December 2022 – November 2023. Source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

Waiting times in Accident and Emergency

Waiting times for older adults attending Accident and Emergency for the primary reason of ‘mental health’ have increased in Cambridgeshire and Peterborough since 2021.

Figure 49: Proportion of older adult mental health attendances spending over 6 hours and over 12 hours in Accident and Emergency, Cambridgeshire and Peterborough ICB, 2021 – 2023. Data source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

The proportion of older adults waiting over 6 hours and over 12 hours after attending Accident and Emergency for mental health is the highest in Cambridgeshire and Peterborough out of the East of England.

Figure 50: % of older adult MH attendance spending over 6 and 12 hours in A&E, East of England, December 2022 – November 2023. Data source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

First response service

The First Response Service (FRS) provides support for people in Cambridgeshire and Peterborough experiencing a mental health crisis and is available 24/7. Support offered can include telephone support, a face-to-face assessment and referrals to other CPFT services. A detailed analysis of FRS service use from August 2021 and March 2023 found that the greatest rates of referrals come from people in their late teens to early thirties.

Figure 51: Age distribution of referral rates (per 1,000) to FRS, August 2021 – December 2022

Crisis response and home treatment teams

There are three types of crisis response and home treatment teams which can be accessed by older adults in Cambridgeshire and Peterborough:

  • Crisis Resolution and Home Treatment Team (CRHTT)
  • Older Peoples Crisis Resolution and Home Treatment Team (CRHTT-OP), which includes the Dementia Intensive Support Team (DIST)

The Crisis Resolution and Home Treatment Team (CRHTT) is a 24/7 service that provides intensive support to people experiencing mental health crisis. They offer intensive home treatment rather than hospital admission if this is safe and feasible. They also work to facilitate early discharge from hospital where possible and appropriate (1). An analysis of referrals to this service over June 2021 to August 2023 showed a low rate of referrals for people over 65, with very small rates of older people accessing this service.

Figure 52: Age distribution of referral rates (per 1,000) to CRHTT, June 2021 – August 2023.

Older Peoples Crisis Resolution & Home Treatment Team (CRHTT-OP) provides assessment and short-term intensive treatment (up to 6 weeks) for older people experiencing a major mental health concern that may otherwise require a period of hospital admission (CPFT, 2023). The Dementia Intensive Support Team (DIST) sits within this. It offers a specialist short-term holistic support (up to 2 weeks) for people experiencing severe behaviours and psychological symptoms of dementia (CPFT, 2023).

  • An evaluation found that the DIST prevented admission hospital (across psychiatric and general hospitals) in 50% of people referred to the North team and 70% to the South over a 2-month period (Royal College of Psychiatrists, 2019c).
  • Feedback from carers suggests that there is currently a gap in service for provision for people with dementia who require less intensive support. People who do not meet the threshold for DIST may end up being referred to community mental health services or the older adults’ crisis team, however these services are not designed to provide specialist dementia support.

From January 2021 to November 2023, around 100 people were referred to CRHTT-OP each month. There was a significantly higher rate of referrals in the first half of 2021, and period of lower referrals in the start of 2023.

Figure 53: Referrals to the Older People’s Crisis Response and Home Treatment Team, January 2021 – November 2023. Data source: CPFT

Joint Emergency Team

The Joint Emergency Team (JET) provides an urgent response that supports older adults and people with long-term conditions in their home environment when they become unwell and need urgent care, but do not need to go to hospital immediately. This team can support patients with emergency care, pharmacy and therapy (occupational therapy and physiotherapy), and works closely with patients’ GP.

There were between 500 to 800 referrals to JET each month in 2017 and 2018.

Figure 54: Referrals to JET over 4 week period, February 2016 – March 2018. Data source: CPFT evaluation of JET

An evaluation of this service estimated that the use of JET prevented 3,626 hospital admissions between April 2017 and March 2018. It highlighted that close working between the CRHTT-OP and JET had been particularly successful in caring for older patients with dementia, frailty and delirium. This evaluation also found that 88% of patients said they were ‘likely’ or ‘very likely’ to recommend the JET team to friends or family.

Liaison psychiatry services

Liaison psychiatry provides psychiatric assessment and treatment to patients who experience mental illness whilst in general hospital wards (such as Emergency Departments and inpatient wards) or when the patient is admitted to a medical ward as a consequence of their mental illness (1). This is a consultation service which covers all wards in collaboration with the acute hospital treating team. National studies show that these services improve quality of care, reduce the length of time people stay in hospital and reduce the risk of adverse events linked to mental health (100).

Referrals to liaison psychiatry for older adults in Cambridgeshire and Peterborough are predominantly from Accident and Emergency (45%).

Figure 55: Referrals to Liaison Psychiatry for older adults by source, Cambridgeshire and Peterborough ICB, December 2022 – November 2023. Data source: Urgent and Emergency Mental Health Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform. Note: For Cambridgeshire and Peterborough ICB, a higher proportion of referrals from ‘other’ is seen due to coding issues from one of the acute providers.

The provision of liaison psychiatry services for older adults in Accident and Emergency varies across Cambridgeshire and Peterborough:

  • In Peterborough City Hospital, the liaison team supports older people 24/7 and has on-call support as needed.
  • In Hinchingbrooke Hospital, there is no liaison service for older people outside 9am – 5pm Monday to Friday.
  • In Cambridge University Hospitals (Addenbrooke’s), there is no liaison service for older people outside 9am – 5pm Monday to Friday, instead this relies on on-call provision.

The trends in referrals to older people’s liaison psychiatry for all three local hospitals (Addenbrooke’s, Hinchingbrooke and Peterborough) have remained relatively stable since 2021.

Mental Health Act

The Mental Health Act is a law that allows people to be sectioned (detained in hospital) if they have a mental health condition and need treatment, and certain conditions are met. There are different types of sections, which have different rules about how long people can be detained (103).

In Cambridgeshire and Peterborough there was 250 episodes of the Mental Health Act amongst older adults in the 2023 financial year.

Figure 56: New episodes (light blue) and active episodes (dark blue) of the Mental Health Act in older adults, Cambridgeshire and Peterborough ICB, financial year 2020 – 2024

Types of detention

In Cambridgeshire and Peterborough, in the 12-month period ending in June 2023, 23% of people detained under the Mental Health Act were age 65+, This is the highest proportion for any age group. The ages of people detained varied substantially by the type of section, with 31% of all people detained under ‘other short-term orders’ were over 65 years old.

Figure 57: People detained under the Mental Health Act by age group, Cambridgeshire and Peterborough, May 2022 – June 2023. Data source: MHA Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform

Repeat detentions

The proportion of repeat detentions under the Mental Health Act declined in 2022 and 2023, compared to 2021.

Figure 58: Proportion of repeat detentions (within 6 months of being detained) amongst older adults, Cambridgeshire and Peterborough ICB, April 2020 – June 2023. Image source: MHA Dashboard – Mental Health, Learning Disability and Autism Resource Hub – FutureNHS Collaboration Platform. Note that these graphs only show until June 2023, not the full 2023/24 financial year. 

Inpatients

Acute inpatient services provide treatment when a person’s mental health condition cannot be managed in the community, and where specialist care is required in a safe and therapeutic setting (1). Inpatient admissions should be purposeful, integrated with other services, open and transparent, and as local and short as possible (68). NHS guidance on acute inpatient mental health care highlights that older adults and people with dementia are ‘particularly vulnerable to delirium, falls, poor nutrition and functional decline while in hospital’, which can contribute to increased length of stay as well as poor mental wellbeing.

CPFT has four acute admission wards which support the assessment and treatment of older people, although younger people may also be admitted on a needs-led basis. The wards are located in:

  • Fulborn Hospital in Cambridge: Denbigh ward is a 14-bed specialist dementia unit; and Willow is an 18-bed acute assessment ward, providing assessment and treatment for older adults with functional mental health conditions requiring hospital treatment;
  • The Cavell Centre in Peterborough: Maple 1 is an 8-bed assessment and treatment ward for patients who have a primary diagnosis of dementia and behaviours that challenge; and Maple 2 is a 14-bed assessment and treatment ward for patients who have a functional mental health need.

Note that older adult mental health inpatient services do not follow the 333 model.

How many people are admitted?

There have been similar numbers of people admitted to acute older adult mental health care in recent years, although an increasing proportion of admissions have been referred from crisis home resolution teams. From December 2021 to November 2023, all admissions were people previously known to mental health services.

Table 14: Number of admissions to acute older adult mental health care, Cambridgeshire and Peterborough ICB, December 2019 – November 2023. Data source: Workbook: Acute Mental Health Dashboard

Admission rates per 100,000 of the older adult population in Cambridgeshire and Peterborough (149 per 100,000) were statistically similar to the East of England average from December 2022 – November 2023.

Figure 59: Rate of admissions admissions to acute older adult mental health care per 100,000 of the older adult population, December 2022 – November 2023. Data source: Workbook: Acute Mental Health Dashboard

How many beds are occupied?

There was a notable drop in the average number of occupied bed days for older adults with functional mental health needs in 2020 and 2021, which is likely as a result of the COVID-19 pandemic. By 2022, the average number of occupied bed days returned to pre-pandemic levels.

Figure 60: Average occupied bed days per week for older adult (OPAC) functional mental health services, CPFT, 2015 – 2023. Data source: CPFT analysis of the impact of the COVID-19 pandemic on mental health and community physical health services

Similarly, there was a notable drop in the average number of occupied bed days for older adults with dementia in 2020 and 2021, which is likely as a result of the COVID-19 pandemic. This returned to pre-pandemic levels in 2022.

Figure 61: Occupied bed days per week for older adults dementia services(OPAC), CPFT, 2015 – 2023. Data source: CPFT analysis of the impact of the COVID-19 pandemic on mental health and community physical health services

Length of stay

GIRFT highlights that the ‘flow’ of individuals between different services and levels of care is a key part of ensuring people have access to the right mental healthcare at the right time (Davidson, 2021).

From December 2022 to November 2023, the mean length of stay in acute older adult mental health care was 73 days in Cambridgeshire and Peterborough. This was the lowest length of stay in the East of England.

Figure 62: Mean length of stay for discharged hospital spells in acute older mental health care, East of England, December 2022 – November 2023. Data source: Workbook: Acute Mental Health Dashboard (england.nhs.uk)

From December 2022 to November 2023, in Cambridgeshire and Peterborough almost a half (48%) of hospital spells in acute older adult mental health wards lasted over 60 days, and 30% lasted over 90 days. This is lower than regional averages.

Figure 63: Proportion of discharged hospital spells over 60 days and 90 days in acute older mental health care, East of England, December 2022 – November 2023. Data source: Workbook: Acute Mental Health Dashboard (england.nhs.uk)

Discharge

  • There is a range of research into transitions out of general hospitals for older adults, which shows that older people are at an increased risk for health and care problems in the first 30 days post-discharge. As many as 1 in 5 older adults experience an adverse event over this time period, the majority of which are preventable (Jones et al., 2021).
  • National research also shows that delayed transfers of care (DTOCs, when people are ready to leave hospital but are unable to do so) for older people can be reduced by increases in care home and home care provision, greater information flow and communication through the care system, and early planning for hospital discharge (Jones et al., 2021).

Voluntary and community sector 

There is a range of voluntary and community sector organisations in Cambridgeshire and Peterborough which offer support for people with severe mental illness. The age of people accessing these services is not always recorded, which means we cannot always understand how many older adults access these services.

CPSL Mind

CPSL Mind (Cambridgeshire, Peterborough and South Lincolnshire Mind) provides a range of support services and activities that promote good mental wellbeing through the Good Life service. This includes 5 types of peer support groups, which offer opportunities to people to connect and form supportive bonds with others who have had similar experiences.

Lifecraft

Lifecraft run a range of services, which are developed and run by people with lived experience of mental health issues (Lifecraft, 2023). Any adults living in Cambridgeshire and Peterborough who have, or have had, lived experience of mental illness or mental health issues can become a member of Lifecraft. In 2022/23, 9% of Lifecraft members were older adults. The most common age group accessing services was 45- to 54-year-olds.

Figure 64: Age breakdown of Lifecraft membership, 2022/23

Additional resources

References

Full list of references is included at the end of this chapter.

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