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The opening statement of the latest King’s Fund report (McCrone et al. 2008) unequivocally outlines the financial enormity of mental health care when it says, “Mental health is big business”.

Ten years ago mental health was designated a top NHS priority alongside cancer and heart disease and the government at that time made clear its intention to modernise mental health services. Mental health problems affect more than 8.65 million people in England (a number projected to increase by 14 per cent by 2026), and account for more NHS expenditure than any other health programme.

The report analyses the nature of the current provision of mental health care and the degree to which it is ‘fit for purpose’, and particularly how mental health services should respond to future demands over the next two decades to 2026. This was the driving force for the commissioning of the review, and is the successor to the report into the funding of social care ‘Securing Good Care for Older People: Taking a long-term view’ (Wanless, 2006). The primary aim of the report was to understand more clearly what future needs might be and to reflect on where investment, or disinvestment, could take place over the next twenty years. The report emphasises the fact that whilst studies involving projections have an inherent degree of uncertainty, this report underlines the importance of starting to plan ‘for it right now’.

With regard to the older population, the report looks at most mental health disorders across the full age range. Due to the expected large impact of dementia in future mental health service provision, this disorder has its own section. This article concentrates on dementia but other disorders – depression, anxiety, schizophrenia disorders and bipolar disorder in those aged 65 and over – are featured.

Big business
The direct costs of mental health in England are now around £22.5 million a year. This figure includes spending in health and social care and a variety of other agencies. The report comments that currently we are spending more than ever due to an ‘unprecedented expansion’ over recent years. In 2006/7 NHS organisations budgeted to spend £8.4 billion on mental health services (for all age groups) which accounts for 12.4 per cent of all NHS spending. Organic mental disorders accounted for 8.5 per cent of the total mental health spending but very little expenditure – 0.1 per cent – was on preventive interventions. Whilst there has been increased investment of more than £1.5 billion since 1999 the thrust has been towards specialist (e.g. assertive outreach, home treatment teams) secondary care services for people living in the community which in reality, cater almost exclusively for adults of working age and not the older population. The government’s 2007 Comprehensive Spending Review (CSR) suggests the NHS budget will be increased by 4 per cent per year in real terms for the next three years, enabling more investment in mental health services as a whole. The CSR also announced a smaller (1 per cent) increase in spending on adult social care and direct funding from the Department of Health for social care for older people, a significant proportion of which have mental health problems, and support services for carers will increase by £190 million to £1.5 billion by 2010.

The main challenge, of all the significant challenges noted, was the rise in dementia and the growing population of older people due to the success in extending the average lifespan. Dementia itself will drive the current spending from less than £15 billion in 2007 to almost £24 billion in 2026 – and considerably more if the real cost increases of employing staff at that time are taken into account.

National Service Frameworks for Mental Health (NSFMH, 1999) and Older People (NSFOP, 2001)
The NSFOP highlighted levels of depression and dementia among older people and set its own mental health standard, Standard 7: ‘Older people who have mental health problems have access to integrated mental health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support, for them and carers’. The ‘patchy’ implementation of this standard was noted in a report produced jointly by the Healthcare Commission, the Audit Commission and the Commission for Social Care Inspection (Commission for Healthcare Audit and Inspection, 2006). Some reports e.g. Sainsbury Centre for Mental Health (2003a; 2003b) have suggested that increased funds were not necessarily resulting in improved or expanded services. A Department of Health (2004) five-year review of the NSFMH demonstrated progress towards some of the targets but also acknowledged challenges in other areas and pointed to the diversion of money and existing inequities across the country. A more recent ten-year review by the Department of Health (2007) of mental health care reform emphasised the £1.5 billion increase in funding and staff numbers.

Projected demographic change in England for 2007 – 2026
The Government Actuary’s Department produces population projections for England by age and gender up to 2074. It estimates the current population of England is 50.80 million people and is projected to reach 58.68 million by 2026.

For the older age groups, those aged 75–84 and 85+ are increasing at a rate greater than those in other age groups. The gender distribution for most age groups is relatively even. Currently men account for only 31 per cent of all people aged 85 and above and 42 per cent of those aged 75–84. This difference is expected to narrow over the next 20 years due, in particular, to improved health in men. There is also a projected increase in the proportion of the population for black and minority ethnic groups in all age groups.

Dementia – prevalence and costs
The report notes that dementia stands out from all other mental health disorders in the report in two ways; firstly the number of people with dementia is expected to increase substantially over the next 20 years (prevalence rates for depression, anxiety and psychotic disorders are not expected to rise significantly), and secondly, the costs per person are higher than for all other conditions. By 2026 the total projected cost of dementia is £34.8 billion with a large proportion of this accounted for by informal care from family and friends.

The report provides key and up-to-date dementia statistics for the older population. In 2007 it was estimated that 582,827 people in England had dementia. This figure is projected to rise by 61 per cent to 937,636 by 2026. The estimated prevalence of dementia(s) in those aged 65 and over is 7.1 per cent; for those 65–69 it is 1.5 per cent for men and 1 per cent for women, and for those aged 95 and over it is 30 per cent for men and 34.4 per cent for women. The rates among those aged below 75 are higher for men, while rates in those aged 75 and over are higher for women. The rate is especially high for those aged 85 and in particular the number of centenarians with dementia rises dramatically from about 2018 onwards.

The total cost of dementia care in 2007 for England was estimated to be £14.8 billion (30 per cent of the total 2007 NHS budget of £48.6 billion) and is projected to rise by 135 per cent to £34.8 billion by 2026 which equates to nearly 40 per cent of the total (£88.45 billion) projected 2026 NHS budget (this large increase is due to the ageing population plus the increase in the real costs of care – the projected figures assumed dementia related service costs increase by 2 per cent ahead of inflation each year). The level of service costs, both currently and in future 2026 projections, for dementia far outweighs – indeed nearly double – that for all the other mental disorders combined.

The Alzheimer’s Society (2007) report the annual cost of dementia care is on average £25,472 per dementia case. The report calculated the distribution of service costs for dementia: residential care accounts for the largest proportion of costs (41 per cent) with informal costs being 36 per cent, social services costs 15 per cent and NHS costs being relatively small at 8 per cent.

Whilst there was a lack of robust data, but given that disease-modifying drugs are available and there is much research into dementia, using scenario modeling techniques, the report examined the impact of reducing the prevalence rates for dementia for those aged 65–74 and 65–84. The report suggests that current situation costs could be reduced by around £2.4 billion if the prevalence among 65–84 year olds was reduced by 30 per cent, and £0.8 billion if reduced by 10 per cent. By 2026 a 30 per cent reduction in prevalence for 65–84 year olds could result in substantial cost savings of up to £5.2 billion. Again such projected savings for dementia hugely outweigh projections for other mental disorders in the report (measured only in millions, and not billions of pounds as for dementia).

The future cost of mental healthcare
The report concludes that mental health problems in England result in substantial costs in terms of service requirements, informal care and lost employment. Whilst the prevalence of specific mental disorders are likely to remain broadly stable over the next 20 years, the costs are projected to increase substantially due to the estimated 300,000 increase in the number of people with dementia (36 per cent of the increase in costs) and the assumption of a real pay and price increase of 2 per cent per annum (64 per cent of the increase in costs).

The report considers who may benefit from improved mental healthcare. For the older population it suggests that if the NHS invests significant resources in reducing the prevalence of dementia, then the local authorities would predictably take the bulk of the benefit in reduced pressure on residential and social care support services.

The report is relatively upbeat that prevalence rates for most mental disorders has been broadly stable in recent years and are to remain so for the next 20 years. Despite this, the report clearly advocates that the thrust of future efforts really should be focused on how to reduce prevalence rates (as noted above only 0.1 per cent of the current NHS budget is directed towards preventative interventions). It envisages that the area of dementia has the most potential for this, particularly if newer and improved dementia-slowing drugs continue to be developed. This would allow people to live more independently for longer with little informal or formal support and would have a substantial impact on costs. Such a drive for the establishment of effective mental health promotion and prevention strategies accords with the views of the World Health Organisation (Saxena et al., 2006) and the Prime Minister’s call for a ‘new drive for a more preventive health service’ and an NHS ‘focused on prevention as much as cure’ (Brown, 2008). Similarly the report opined that we need to find ways of encouraging government to think more about how effective investment in one area can produce real savings in another.

One of the report’s main recommendations pertains to the major cost impact of dementia, which underlies much of the estimated increase in mental health costs by 2026. It suggests, again reviving one of the main (possibly under implemented) themes of the NSFOP in that healthcare professionals, and in particular GPs and primary care staff should make it a priority to establish better systems of early detection and treatment of dementia, and pharmaceutical companies should maintain their efforts to develop cost-effective treatments that will help people remain independent for as long as possible.

The report concludes that the lesson to learn is that without the right level and type of investment we will ‘all pay the price – not just in wasted resources but also in wasted lives’; and hopes the report can be a driver to the future nature and shape of mental health support in which dementia is a primary area for investment and development. This report comes at an opportune moment whereby the massive NHS and social care impact that dementia undoubtedly already has, and will have in the future, is finally (albeit well overdue) being accepted and addressed by the National Dementia Strategy, currently being developed for introduction later this year. Hopefully such large-scale reviews can dovetail with each other to produce the investment and development old age mental health care, and in particular, dementia care has needed for too long. Hopefully such development comes within a relatively quick timeframe and with appropriate funding otherwise there is an inevitable crisis in old age care looming in the next couple of decades.

Martin Curtice

References

Alzheimer’s Society (2007). Dementia UK. London: Alzheimer’s Society.

Brown G (2008). The future of our NHS: personal and preventative. Speech at King’s College, London, 7 January2008. Available at:www.kcl.ac.uk/media/speeches

Commission for Healthcare Audit and Inspection (2006). Living Well in Later Life. Available at: www.healthcarecommission.org.uk/_db/_documents/Living_well_in_later_life_full_report.pdf.

Department of Health (1999). National Service Framework for Mental Health: Modern standards and service models. London: The Stationery Office.

Department of Health (2001). National Service Framework for Older People. DH website. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4003066.

Department of Health (2004). The National Service Framework for Mental Health – Five Years On. London: Department of Health.

Department of Health (2007). ‘Mental Health Ten Years On: Progress on Mental Health Care Reform’. DH website. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074241.

McCrone P, Dhanasiri S, Patel A, Knapp M & Lawton-Smith S (2008) Paying the Price: The cost of mental health care in England to 2026. London: King’s Fund.

Sainsbury Centre for Mental Health (2003a). Money for Mental Health: A review of public spending on mental health care. London: Sainsbury Centre for Mental Health.

Sainsbury Centre for Mental Health (2003b). ‘The economic and social costs of mental illness’. Available at: www.scmh.org.uk/80256FBD004F3555/vWeb/flKHAL6XCJ3V/$file/ costs_of_mental_illness_policy_paper_3.pdf.

Saxena S, Jane-Llopis E & Hosman C (2006). ‘Prevention of mental and behavioural disorders: implications for policy and practice’. World Psychiatry, vol 5, pp 5–15.

Wanless D (2006). Securing Good Care for Older People: Taking a long-term view. London: King’s Fund. Available at: www.kingsfund.org.uk/publications/kings_fund_publications/securing_good.html.

BGS Newsletter, Aug 2008
Issue 17 ISSN 1748-6343 17