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Services for frail older people are patchy and disjointed according to a report by district auditors Fred Andrews, Paul Burdon and Kevin Huggins Cooper.

All agencies involved in the provision of older people's mental health and rehabilitation services are undergoing a degree of self-scrutiny. The national service frameworks and NHS Plan set numerous challenging targets, often demanding a fundamental reorganisation of how agencies work - particularly how they work together.

During the past two years, the Audit Commission's district audit, which audits local authority and NHS spending, has reviewed the provision of mental health and rehabilitation services for older people by the NHS and local authorities. The views of more than 8,000 people in England and Wales were gathered, mainly through surveys.

These reviews foreshadowed the publication of the NSF and while not mirroring the framework, they provide useful data about how close bodies are to meeting the targets and where the most concerted effort is needed.

The recurring picture is one of committed professionals struggling to provide services and support to older people. However, provision consistently falls short of that outlined in the NHS Plan and NSF. Through local action plans, auditors are helping agencies identify areas of weakness and priorities to tackle. Some of the key concerns are outlined here.

GPs and other primary care staff play a key role in supporting older people with mental health problems - they are usually the starting point for support and care. But GPs are not always alert to early signs of memory problems, confusion or depression when older people consult them for any health problem. Without a GP referral, people are unlikely to receive specialist services early on.

It is obvious when a frail older person needs help for physical problems. Having identified a problem it is then important to assess a person's needs, but many GPs said they did not have access to a comprehensive geriatric assessment.

Most professionals are struggling with the national service framework requirement for a single assessment process. We found assessments were often sequential and particular to a single discipline rather than being truly multi-disciplinary. Users and carers are often assessed by a number of professionals, which can be confusing and delay the provision of essential services.

Older people with mental health problems need access to a comprehensive range of services: support in their own homes, day care and outpatient clinics, respite care, nursing and residential care and hospital beds. But we found service provision was uneven and unrelated to population needs. There are significant gaps and availability may depend simply on where people live. Only 34 per cent of GPs felt there were satisfactory specialised services in their area for older people with dementia while 40 per cent felt services were adequate for depression sufferers.

The rehabilitation services audit revealed that GPs felt ill-informed about the range of services available. New services drawing together health and social services are springing up to plug gaps, such as community rehabilitation and step-down beds. These can help provide a cohesive service but GPs wanted one source of information on the services available.

Rehabilitation is most effective if users are involved in deciding their own priorities. In our stroke services user survey we asked patients: "When you saw therapists how often did they ask you what you wanted to work hardest on?" About a quarter of patients said that therapists hardly ever or never asked them this - in some trusts it was much worse. Forty one per cent of stroke sufferers said it was not explained to them what a stroke was.

Users and carers often say they need clear written information to help them understand a diagnosis and what is likely to happen. In the mental health audit we found comprehensive information for carers, in appropriate languages, was available in only 24 per cent of areas. Many agencies acknowledge that information provision is patchy and unco-ordinated, securing resources for this can be difficult.

If agencies are to develop patient-centred services, they must put users and carers at the heart of planning and obtain their views on a systematic basis. Yet we found that only 44 per cent of carers of older people with dementia knew how to complain or express views about the help they get.

The national picture is one of fragmented and variable service provision. Agencies often do not work well together and do not provide seamless care. National policy emphasises the importance of health and local government bodies working with voluntary organisations and support groups to commission services jointly. However, we identified a number of common issues including a lack of joint commissioning, little mapping of service provision, no explicit targets or monitoring mechanisms and no evaluation of outcomes. Consequently, service providers often work in isolation. Auditors will track how service providers address these issues in the coming year and offer ongoing support.

To help focus wider attention on the critical factors in meeting NHS Plan and national service framework targets, a district audit bulletin will be published in the spring. An Audit Commission report due out at the end of this month, Forget Me Not 2002, draws on the findings specifically in mental health.

The problems faced by service providers are often complex and reorienting their approach to meet NHS targets will not be an easy or overnight job. However, an overriding message is that services can often be improved quickly and significantly by viewing them from the user's and carer's perspective.

Fred Andrews, Paul Burdon and Kevin Huggins Cooper are senior specialists in performance audit at district audit.

Websites

For more about the Audit Commission's district audit go to www.district-audit.gov.uk  

"Initial diagnosis of my mother's condition was extremely difficult to obtain. It was only through my insistence that referral to a specialist and social services assessment was eventually obtained." Carer

"It took two years of fighting from me before an assessment was made of my husband" Carer of older person with dementia

"The system is straining to cope with the present workload. This problem would be made much worse if we were actively looking for signs of the two illnesses" GP

"We had to fight and ask for everything we got both in the stroke unit and rehab ward - there are not enough therapists. The speech therapy department agreed to come to the house but soon had to stop. No physiotherapist follow-up was even offered, even after a fall and a broken hip. A stair lift was suggested after the stroke, but only followed up after the condition worsened and still took seven months to materialise." Carer

"The occupational therapist who visited me was very helpful. She listened to what I wanted to do and arranged visits so that I could try and get back to some of my usual activities. She chased up my aids and gave me hope that things could improve." Stroke patient

"We feel that there is not enough communication and information regarding my relative's condition such as to what exactly is wrong with her and how her condition will deteriorate." Carer