Count me in even if I am old!
Authors: A. Shah, K. McKenzie
Journal: Journal of the Royal Society of Medicine (2007)

The findings of the 2006 ‘Count Me In’ one-day census of all mental health and learning disability inpatients in England and Wales were recently published by the Healthcare Commission.1 Twenty-one percent of inpatients were from black and minority ethnic (BME) groups, although they account only for 9% of the general population. Admission rates to mental health units, for all the age groups combined, were lower than average in the white British, Indian and Chinese groups, but three or more times higher in the black African, black Caribbean, and white and black Caribbean mixed groups. Moreover, individuals from the latter three BME groups in hospital were between 19% and 39% more likely to be admitted under the Mental Health Act 1983. Rates of referral from general practitioners and community mental health teams were lower and from the criminal justice system higher than average for black African, black Caribbean and other black groups. Patients from the black Caribbean group had the longest duration of admission. Black Caribbean, white and black Caribbean mixed and other black groups were also two to three times more likely to be admitted to learning disability units. There are likely to be a number of reasons for the disparities, including institutional racism.2

Although a third (10,334) of the 32,023 mental health inpatients surveyed were over the age of 65 years, separate analyses were not conducted for this group. This was surprising because the BME population aged 65 years and over has been rapidly increasing over the last two decades,3 presenting new challenges for geriatric psychiatry services. Dementia and depression are the two most prevalent mental illnesses in old age and their prevalence in BME groups is either similar to or higher than that in the indigenous white British group.4,5 However, socio-cultural and cross-cultural aspects of service delivery are poorly researched. There are questions about different pathways to care and secondary care service use. BME elders, in general, are well aware of services provided by primary care and have high registration and consultations rates in general practice.6,7 Despite this, the prevalence of BME elders within old age psychiatry services is generally considered to be very low.7,8 It is unclear whether the high admission rates published in the ‘Count Me In’ census apply to all age groups and whether they are relevant to older people.

There is a risk that policy makers, service commissioners, service providers and individual clinicians may erroneously assume that BME elders may be subject to the disparities reported in the ‘Count Me In’ census. If all age groups are treated the same, national, regional and local interventions to correct assumed disparities could worsen the existing inequity in access to old age psychiatry services for BME elders. The combination of being old, belonging to a BME group and having a mental illness is well recognized to disadvantage an individual in society.8 Assumptions about the specific applicability of the findings ascertained from the analysis of all the age groups combined to BME elders may enhance this further.

One of the three building blocks of Delivering Race Equality in Mental Health Care (DRE), the Department of Health's plan to improve mental health services in England, is the intelligent use of high-quality information to drive the development of appropriate and responsive services.9 The aim of DRE is to move away from the current ‘one size fits all’ approach to developing psychiatric services;9 this is not only relevant to different BME groups, but to different age groups. There is, therefore, a specific need to analyse the data from the ‘Count Me In’ census for those over the age of 65 years. Given that this census is of all inpatients in mental health and learning disability units and with large numbers, such analysis should unequivocally clarify whether the findings from the analysis of all the age groups combined apply to the elderly. Should it confirm reports from the literature of reduced access to old age psychiatry services for BME elders,7-9 strategies required to correct this are likely to be very different from those suggested for younger age groups.2

Standard one of the National Service Framework for Older People advocates rooting out age-related discrimination in health and social care.10 Specific analysis of 10,334 elderly inpatients for the variable discussed above, as well as others measured in the ‘Count Me In’ census, has the potential to further stimulate a debate and generate activities to achieve this ambition for a highly disadvantaged group of patients.

Unless and until the needs of the elderly, particularly those from BME groups, are considered separately from the needs of younger age groups, the elderly will continue to experience discrimination related to age, ethnicity and mental illness. Not only should the elderly be counted in, but the information ascertained should be used to develop equitable services.