Most of the UK mental health teams for older people only accept referrals from general practitioners (GPs) or other medical specialties. Referrals directly from social services are generally not accepted.
Reaching people with mental health problems early is an aim across services and age groups (Rethink, Reference Rethink2002, Reference Rethink2004). Social care staff have contact with large numbers of older people early on and are well placed to identify mental health problems and facilitate early recognition and management (Reference Manthorpe, Iliffe and EdenManthorpe et al, 2004).
There is currently little information in the UK on the social worker's ability to recognise mental health problems in later life. Moriarty's (Reference Moriarty2002) systematic review found just one study reporting on recognition rates of dementia. Cohen & Fisher (Reference Cohen and Fisher1987) found that social workers correctly identified approximately 65% of cases of dementia among people on their case-loads. More recently, Challis et al (Reference Challis, Clarkson and Williamson2004) found that care managers were not aware of cognitive impairment at the time of their client's referral in 36% of their cases.
Method
The area of Broxtowe in Nottingham has a population of 19 177 people aged 65 and over (Office for National Statistics, 2001). Approximately 80% of all patients referred to the Broxtowe community mental health team (CMHT) for older people by their GPs receive a diagnosis of dementia with the remaining having a functional illness. The team started accepting direct referrals from social services in April 2003.
All referrals from social services to the CMHT during a 2-year period from May 2003 were identified. The referral letters were reviewed for details of the patient's mental health problems including reason for referral and assessment of cognition. Furthermore, it was also noted if the referral fulfilled the team's existing referral criteria (Box 1) and if the referral was accepted or rejected. The case notes were then reviewed to identify whether there was a diagnosis of mental illness.
With the establishment of the open referral system from social services there were initial apprehensions within the team, particularly regarding the potential increase in referrals and workload. The total number of referrals in the 12-month period following the start of the open referral system was compared with the number of referrals in the preceding year.
Box 1. Team's existing referral criteria
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• Patients of all ages with memory impairment as evidenced by a score of 25 or less on Mini-Mental State Examination.
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• Patients of 65 years or older who suffer from a functional psychiatric illness, which cannot be managed by primary care services.
Results
There were 55 direct referrals from social services to the team. Referral letters were missing for 9 referrals and in 5 instances, case notes could not be found. In one case the referral was out of the area. Hence, the number of referrals evaluated was 40.
Of the 40 referrals, 38 (95%) were deemed suitable for the specialist services and were accepted. The referral letters had details of the patient's mental health problems and gave the reasons for referral to the CMHT for 36 patients (90%). None of the referrals with memory problems had an assessment of cognition. Of the 38 referrals accepted by the team, only 6 (15%) fulfilled the team's existing referral criteria and these referrals were of patients with functional illnesses. On assessment, 36 (90%) of the referrals were found to be suffering from a mental illness (Table 1).
Table 1. Diagnosis
| Diagnosis | n=36 |
|---|---|
| Alzheimer's dementia | 15 |
| Vascular dementia | 11 |
| Depression | 5 |
| Schizophrenia | 2 |
| Lewy body dementia | 1 |
| Alcohol-related memory problems | 1 |
| Unspecified dementia | 1 |
There was no increase in the overall number of referrals when compared with the preceding year, before the open referral system from social services was introduced. There were 450 referrals in the year following the start of the open referral system compared with 476 referrals in the preceding year.
Discussion
Social services often have contact with a large number of older people and it was felt that accepting direct referrals would help identify older people with mental health problems early in their illness, thereby giving opportunity for early intervention.
The results of the study showed that the majority of the referral letters had details of the patient's mental health problems and the reasons for the referral to the specialist services, thereby reducing the chances of inappropriate referrals. The majority of the referrals were accepted despite not fulfilling the team's existing referral criteria indicating that the teams existing referral criteria are inadequate and in need of revision. Manthorpe & Iliffe (Reference Manthorpe and Iliffe2005) revealed that social workers are familiar with possible signs of early dementia and tend to be aware of the problems that might indicate the need for referral for assessment.
The results also showed that none of the referrals with memory problems had an assessment of cognition. Cognitive screening tests may not be relevant, due to fair access to care services criteria (Department of Health, 2003), when dealing with people with a significant level of vulnerability. However, there are advantages in using a quick and easy to use standardised screening test like the Mini-Mental State Examination (Reference Folstein, Folstein and McHughFolstein et al, 1975) and Six-Item Cognitive Impairment Test (6-CIT) (Reference Brooke and BullockBrooke & Bullock, 1999) for the less obviously vulnerable, who might be at an early stage of a dementia.
The majority of the accepted referrals after assessment were found to be suffering from a mental illness indicating that social services are appropriately identifying and referring older people with mental illness. The open referral system did not lead to an overall increase in referrals, suggesting that patients referred by social services would have been referred by their GPs, but perhaps at a later stage.
Constant changes in social work practice have increased the nature and scope of the social worker's role in the National Health Service. They play an integral role in the planning, organisation, staffing, and coordination of health services for older people and are in a unique position to detect mental illness early and make efficient use of an open referral system for the benefit of our patients.
Declaration of interest
None.
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