Written evidence submitted by Independent Age (FGP0282)

 

About Independent Age

Independent Age’s mission is to ensure that as we grow older, we all have the opportunity to live well with dignity, choice and purpose. Founded over 150 years ago, we are an established voice for people in later life, their families and carers. We offer free and impartial advice and information, as well as providing connection services to improve wellbeing and reduce loneliness. In addition, we use the knowledge and understanding gained from our frontline services to campaign on issues that affect older people.

 

We are responding to this inquiry as we have evidence and recommendations about the important role GPs play in supporting older people’s mental health.[i] This response focuses on people in later life (aged 65+) who experience common mental health conditions (e.g. depression and anxiety), bereavement, and poor mental wellbeing more generally.

 

For more information about this submission please contact public.affairs@independentage.org.

 

Summary

 

Recommendations:

  1. The government and NHS England (NHSE) should develop plans to give GPs the support they need to improve how they identify mental health problems in older people and offer them a choice of treatment, including signposting to talking therapy as an option.
  2. We support the Royal College of General Practitioners’ recommendation that the government and NHSE should develop plans and make available the resources required for GP consultations to be at least 15 minutes by 2030, or longer for those patients who require it.
  3. The government and NHSE should work with GPs, talking therapy providers and other health professionals, commissioners and the voluntary sector to develop a monitoring and evaluation plan for the implementation of the recently updated IAPT older people’s positive practice guide.[1]

 

Introductory comments

Many people in later life experience poor mental health for which they need support. Challenges include coping with a physical illness or long-term conditions, bereavement, caring responsibilities and chronic loneliness. In nationally representative polling conducted for Independent Age in 2020, 41% of respondents said since turning 65 they had experienced significant anxiety or low mood that impacted their life sometimes, frequently or all the time.[2] Analysis by City, University of London commissioned by Independent Age estimates that approximately 1 in 10 people aged 65+ in England have moderate or severe anxiety or depression.[3] However, mental health policy documents and debates sometimes overlook older people. For example, the government’s COVID-19 mental health and wellbeing recovery action plan[4] highlights a wide range of social groups but not older people.

 

We believe the future of general practice should retain and improve the ways GPs support older people’s mental health. GPs have a key role in identifying mental health problems. They can provide important direct support, such as through prescribing medication, and indirect support, such as referring patients to talking therapy services, bereavement counselling or community groups via social prescribing.

 

72% of people aged 65 and over who responded to an Independent Age 2020 Wellbeing in later life survey said their GP was the first professional they spoke to about their mental health.[5] Many people have told us about positive experiences with their GP with 80% of Independent Age survey respondents sharing that their GP listened well to them, while others said their GP was helpful, sympathetic and responsive. People also spoke about the value of their long-standing relationship with their GP.

 

However, only a third of people aged 65+ with symptoms of depression serious enough to warrant intervention discuss it with their GP, and only half of those get treatment, primarily medication.[6] There are a variety of reasons for this, but we believe more could be done to improve the number of people receiving mental health support as people aged 65+ consult their GP almost twice as often as other age groups (for all health issues).[7]

 

For context, some of our evidence was collected just before the pandemic in early 2020, and other testimony was taken while the pandemic was underway. Many of the challenges we highlight pre-date the pandemic but were exacerbated by it. We fully understand that the pandemic has introduced unexpected and huge new demands on GPs. We also understand the longer-term workforce challenges. Improvements are necessary but require significant resourcing to make them a reality.

 

Q1: What are the main barriers to accessing general practice and how can these be tackled?

Independent Age’s research for our Minds that matter report,[8] and our conversations directly with older people through the provision of our services, has identified the following barriers and challenges with general practice:

 

Getting appointments

Many people have trouble contacting their GP practice and making an appointment. This can be because they struggle to get through to speak to someone at the practice or there is a lack of availability.

 

I can’t ever get an appointment with the doctor, so just live my life in misery with no hope.”[ii]

 

The pandemic has posed severe challenges to GP capacity, but this problem pre-dates the pandemic. Findings from the 2019 GP Patient Survey show one in 10 (10%) people were dissatisfied with the appointment times available to them.

 

Barriers to high quality consultations

There are often barriers to having high quality consultations with a GP. Some people told us they felt their GP didn’t fully listen to them, take their concerns seriously or that they weren’t offered a range of support. Others felt rushed.

 

“I have had problems in the past with my GP whereby I felt they were too keen to medicate and get me out of the door.”

 

“My mental health needs are not being met… [The] only input now is a GP service where I never see the same doctor twice. Appointments are for 10 minutes, so I feel rushed and therefore do not disclose my mental health.”

 

The Royal College of General Practitioners (RCGP) has been calling for longer appointments, saying by 2030 face-to-face GP consultations will be at least 15 minutes, with longer ones for those patients who need it.[9] We support this recommendation and believe it would enable better interventions to support older people’s mental health.

 

Another barrier to high quality support is unhelpful attitudes among a minority of GPs. An academic review of studies examining how healthcare professionals manage older people with depression found that some held assumptions about older people’s attitudes to depression.[10] The most pervasive of these was that older people themselves normalise depression as part of ageing, isolation and decline. A minority of people Independent Age surveyed as part of our research reported negative encounters with their GP who expressed assumptions or even ageism in their attitude.

 

“I was assessed for NHS treatment – therapy – and the doctor who saw me asked if I felt it was worth my while looking for treatment, now that I was on the run down to the end of my life!”

 

The academic review also found that some healthcare professionals dismissed talking therapies as a solution, due to assumptions that older people would not be interested in them as a treatment (especially if offered online). It also showed that GPs can sometimes prioritise patients’ physical health issues over mental health issues, explicitly or implicitly. 

 

Lack of continuity of care is also a barrier, which we discuss below under Q1c.

 

Q1a. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

Given the frustrations that Independent Age staff often hear from people struggling to get through to GP practices on the phone, we welcome the aim to improve access for patients, including improvements around telephone systems and triage. Improvements to call waiting times and queuing would also be hugely welcome.

 

Regarding the balance of face-to-face versus remote appointments, policymakers should avoid generalisations about older people’s preferences and abilities. While many older people prefer face-to-face appointments, many others prefer telephone or online appointments, which are convenient for people with mobility problems or disabilities that make it difficult for them to travel to GP surgeries.

 

"Just getting to the doctors for me is not easy because I’ve got to use the walker, then I’ve got to wait for the bus, and then the bus is only running every two hours because of the lockdown restrictions, and then you’ve got 20 minutes at the doctors before the bus goes back in the other direction. If I don’t get it then I’ve got to wait two hours for the next bus, or walk... So that doesn’t help. And when you’re in a lot of pain you get very upset. It makes you wonder what the point is.[11]

 

The key is to provide choice to people of all ages to choose what works for them.

 

Q1c. What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

A lack of continuity of care is a barrier for older people to seek support and share information about their mental health and wellbeing. People in later life have shared with Independent Age that seeing the same GP allowed trust to develop, which resulted in their GP being better able to recognise changes in mood and identify emerging problems.

 

“I have been very lucky to be able to see the same doctor for over 30 years. He knows me very well and is able to spot any depression I may have.”

 

“I received good support, especially from my GP. I was seriously feeling suicidal and he rang every week that I didn’t see him, to ask how I was doing. He told me he was seriously worried about me because he had never seen me like that.”

 

This was amplified by others who didn’t receive continuity of care.

 

“It would have been so much better to have one GP who could consistently keep a holistic approach.”

 

This echoes findings from the 2021 GP Patient Survey, which found that 58% of people aged 65+ said they have a GP they prefer to see.[12] Of this group, 11% said they see their preferred GP never or almost never, and 40% said some of the time.

 

Q4: What part should general practice play in the prevention agenda?

GPs can be well-placed to intervene early to prevent the escalation of mental health problems in patients, by being aware of life events that can trigger such problems, including bereavement, diagnosis of physical illness, and caring responsibilities.

 

Prevention in the context of bereavement

Bereavement in complicated or traumatic circumstances, for example, can lead to prolonged grief disorder, a condition in which the normal emotions of grief are more intense, more disabling and continue for much longer than would normally be expected.

 

However, as shown by Independent Age’s report Grief encounters: Experiences of bereavement support in later life,[13] many bereaved older people miss out on information and support at this crucial time. In recent polling done for Independent Age, only 20% of people aged over 65 who had been bereaved in the past five years were given information about emotional support after the bereavement.[14]

 

In the course of Independent Age’s qualitative research on bereavement we have heard about the challenges people face:

 

“[The GP] obviously knew I'd been bereaved because obviously the hospital told him. They knew we lived together, so even an email to say, 'Look, the support is available should you need it,' would've been handy. But they just don't.”

 

“I did ask the doctor about [support] but nothing happened so, as I say, I’m quite independent-minded, so I’ll just muddle along.”

 

While not everyone who is bereaved needs formal support, the lack of consistency in signposting support and information is a problem, and GPs are well-positioned to do this. One person gave a positive example of their GP reaching out to them after a bereavement:

 

“And I'm fortunate my GP rang me up, out of the blue, just to see how I was because he obviously dealt with [my wife] too.”

 

We welcome the efforts that are already underway to help GPs identify and support the needs of their bereaved patients – in particular the recently published toolkit developed by RCGP in partnership with Cruse to help GP practice teams provide consistent and compassionate support for all grieving patients.[15]

 

Prevention in the context of the pandemic

Bereavement is also an example of an issue that has likely increased mental health problems during the pandemic, as we set out in a new report.[16] Independent Age estimates that up to 318,000 people aged 65 and over in England and Wales were bereaved of their partner during the COVID-19 restrictions/lockdown period between March 2020 and May 2021 – an increase of 14% on the average for the previous five years. This is likely to lead to an escalation of need in the coming years resulting from the pandemic. Recent analysis by the Centre for Mental Health backs this up, suggesting there will be an increase in the number of people with prolonged grief disorder, as well as other mental health conditions such as depression and anxiety.[17]

 

Independent Age’s survey of older people in summer 2021 found that half (48%) of respondents agreed ‘My mental health has got much/a bit worse’ as a result of the pandemic. One in ten (11%) said they feel they need formal support for their mental wellbeing, such as from a GP or therapist.[18] In this context, it is vital that older people with worsening mental health are able to access their GP and are signposted to a choice of support where appropriate.

 

Recommendations

  1. The government and NHS England (NHSE) should develop plans to give GPs the support they need to improve how they identify mental health problems in older people and offer them a choice of treatment, including signposting to talking therapy as an option.
  2. We support the Royal College of General Practitioners’ recommendation that the government and NHSE should develop plans and make available the resources required for GP consultations to be at least 15 minutes by 2030, or longer for those patients who require it.
  3. The government and NHSE should work with GPs, talking therapy providers and other health professionals, commissioners and the voluntary sector to develop a monitoring and evaluation plan for the implementation of the recently updated IAPT older people’s positive practice guide.[19]

 

 

 

 

 

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[i] See our 2020 report Minds that matter: Understanding mental health in later life.

[ii] All verbatim quotes are from people in later life who spoke to Independent Age during research, including interviews and surveys. We have kept all respondents anonymous.


[1] Older Adults Positive Practice Guide (babcp.com)

[2] UK online poll of 2,316 people. Conducted by Opinium, Independent Age, July 2020

[3] “In Focus: Experiences of older age in England.” Independent Age, 16 Apr. 2020, www.independentage.org/in-focus 

[4] Policy paper overview: COVID-19 mental health and wellbeing recovery action plan - GOV.UK (www.gov.uk)

[5] Mental_health_report_FINAL.pdf (amazonaws.com)

[6] “Older People, Positive Practice Guide.” Department of Health, Jan. 2009, https://www.uea. ac.uk/documents/20142/603973/ norwich-medical-schooliapt-older-peoplepositive-practice-guide. pdf/5bad5a56-50b7-fb59-5d29- df610722efef?t=1576366647178

[7] “Health survey for England 2005, Mental health and wellbeing, The health of older people.” Edited by Rachel Craig and Jennifer Mindell, volume 4, The Information Centre, 2007, https://files.digital. nhs.uk/publicationimport/ pub01xxx/pub01184/heal-survheal-old-peo-eng-2005-repv4.pdf

[8] Mental_health_report_FINAL.pdf (amazonaws.com)

[9] 15-minute minimum consultations, continuity of care through 'micro-teams', and an end to isolated working: this is the future of general practice (rcgp.org.uk)

[10] Frost, Rachael, et al. “Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies.” British Journal of General Practice, vol. 69, no. 680, Mar. 2019, pp. 171–81, https://bjgp.org/ content/69/680/e171

[11] The Mental Health Experiences of Older People During the Pandemic | Independent Age

[12] GP Patient Survey (gp-patient.co.uk)

[13] Full_Report_0.pdf (amazonaws.com)

[14] Independent Age, ‘Experiences of seeking and accessing bereavement support’ (online survey, 4,107 respondents, conducted by YouGov, 12–13 August 2021) 

[15] https://www.cruse.org.uk/about/blog/grief-toolkit/ 

[16] The Mental Health Experiences of Older People During the Pandemic | Independent Age

[17] Covid-19 and the nation's mental health: May 2021 | Centre for Mental Health

[18] Independent Age online survey of 3,117 people aged 65+, conducted June-July 2021.

[19] Older Adults Positive Practice Guide (babcp.com)

 

Dec 2021