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Challenges
Although there are a wide range of mainstream and specialist services for older people with mental health problems and their carers, provision tends to be uneven, access variable and integration (Integration means that the health and social care elements of a package of care have no apparent 'joins' to service users and carers and that agencies arranging services work toghether.) far from universal.
Some areas in the UK still do not have CMHTs for older people for example and of those that do a number do not have a full complement of professions represented. Respite care can be very difficult to access, and day hospital care and Admiral Nurses are only available in some areas. Quality varies widely.
Social care provision for people with functional mental disorders (Functional means 'not simply due to structural abnormalities of the brain'. Functional mental disorders result from a complex interaction of biological, social and psychological factors. They are very different from organic mental illnesses such as dementia which is caused by an identifiable brain malfunction) as opposed to dementia is under-developed. Depression is routinely overlooked, among both those with dementia and those without.
One of the major organisational challenges is to coordinate the development and funding of services in ways that are effective, cost effective and fair. Although guidance is now available for taking this forward, particularly for people with dementia (e.g. NICE/SCIE, 2006), persistent geographical and organisational differences remain.
Different finance arrangements and agency responsibilities, eligibility for services and systems for assessment of need are a considerable source of concern for users, carers and those working with, and for, them.
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Financing Arrangements
Financing care services is a complex issue. Over the last ten years responsibility for ‘who pays’ has shifted away from the state and towards the individual user and their family.
National Health Services are free at the point of delivery. Some local authority (Social Services Departments) social care services are charged for, e.g. home care, day care. Councils vary in the extent of charging.
There is substantial tension, and local differences, about where dementia services should sit in relation to the boundary between NHS services and social care. In some areas NHS nursing care subsumes personal care for people with dementia and is free to users; in others this service is provided by social services and is charged for. This creates unevenness between localities and countries.
In Scotland all long-term care is free to the user; in the rest of the UK it is means-tested i.e. you are charged according to how well off you are.
There are a number of new funding developments that shift the monies allocated to pay for care to the individual user. The most well known are ‘Direct payments’ and, more recently, ‘individual budgets’ (Dementia UK, 2007).
(Direct payments are cash payments made in lieu of social service provisions, to individuals who have been assessed as needing services.)
(An Individual Budget is designed to provide individuals who currently receive services greater choice and control over their support arrangements. It is being piloted at present with a view to rolling it out more widely.)
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Quality Assurance
Raising standards in care homes – and in services more widely has been a key policy concern for some years. In 2000 ‘The Care Standards Act’ set up the Commission for Social Care Inspection (CSCI) which established a new system of national minimum standards for all residential and nursing homes and domiciliary services (Department of Health, 2000). Its primary function is to promote improvements in social care for vulnerable adults. It provides a comprehensive overview of social care in England, inspects services and monitors standards.
In 2008 CSCI will merge with its counterpart in health to form a single commission for health and social care services.
The 2000 Act also established a General Social Care Council to regulate the training and conduct of social care staff. Recruitment and retention of care home staff remains a big challenge especially in times of full employment since other sectors, e.g. retail, pay higher wages.
Of interest also is the recent Department of Health (DH) and the Department for Education and Skills (DfES) review of the Social Care workforce – Options for Excellence – which sets out a vision for the social care workforce.