Regional variations some examples

The catchment area system of service organization is generally used in areas where the services are planned and organized, which is in keeping with the WHO-WPA guidelines as it allows for the development of a range of services for a defined population. 'Catchment area' usually refers to a geographical area of about 200 ;000 people, although it can vary depending on the local population density and demographics. In the United Kingdom, 16 per cent of this number will be 65 and over, almost half of whom are over 75 years of age.

In the United States, where about 13 per cent of the population is over 65, a wide range of services is available. However, they are not organized according to the catchment-area system and tend to be fragmented, varying greatly in quantity, range, and quality, both between and within states. This is largely due to the free-enterprise nature of the United States health-care system, in which specialists may choose to work in a variety or combination of locations, including the public sector, state hospitals, community mental health clinics, the Veterans Administration (which now has an extensive network of geriatric services and a co-ordinated plan to meet the needs of ageing veterans(6)), and private practice. Physicians in the United States are reimbursed on a fee-for-service basis and there is no provision for reimbursement for indirect patient care, such as one may provide in one's role as team psychogeriatrician. In 1993, an American Psychiatric Association task force report highlighted a number of problems in the provision of mental health services to the elderly; they acknowledged gaps in the system and made specific recommendations to address these issues.(7> These recommendations included the establishment of an advisory committee to assist with service planning, the education of health-care workers, adjustment of reimbursement inequities for psychiatrists caring for the elderly, and the development of affordable and accessible community-based resources for mentally ill elderly people and their families. In addition, the task force recommended that Congress mandate that psychogeriatric programmes be made a priority within the Veterans Administration system, and that data be collected by psychiatrists working with the elderly and their families regarding the amount of time spent with elderly patients, their families, and other care providers.

In contrast, services in the United Kingdom are organized according to the catchment-area model, with almost every catchment area having its own old age psychiatry team and consultant psychogeriatrician. Although there is some regional variation in style and organization of services, there is more homogeneity throughout the country, which stems from the role of the Royal College in reviewing programmes and the way the National Health System is organized. (8) Good examples of comprehensive models of care, incorporating both geriatric medicine and psychiatry, include those at Crewe, which serves a rural population, and Nottingham, which is an urban area.(9) The Irish government developed a plan in 1984 for the provision of psychiatric services to the elderly. There are now five old age psychiatrists in the Irish Republic, serving catchment areas of between 17 ;000 and 27 ;000 elderly people, and using an interdisciplinary community-based model of care, as in the United Kingdom.

Australia also uses the catchment-area system nationwide. However, in 1992 it also developed, separately from its mental health system, a National Action Plan for Dementia Care, and organized the provision of services to dementia sufferers through a system of Aged Care Assessment Teams (ACATs).(l°) ACATs were set up in response to the increasing cost of long-term care, acting as gatekeepers to the long-term care system and assessing needs based on functional criteria. As such, they were part of a shift to the community care of the elderly. The federal government administers ACATs, and the states are responsible for mental health services. Initially, psychogeriatricians were not involved, but as it became clear that the population served by the teams exhibited considerable mental impairment, there has been increasing collaboration between the mental health system and the ACATs, although this varies across the country (B. Draper, personal communication, 1998).

The Canadian Government introduced legislation for the provision of mental health services to the elderly in 1988. (!1.) Health services are administered locally, and many communities had already recognized the need for co-ordination of effort and collaborated on developing systems of care with a community emphasis. Some good examples using the catchment-area model include the Baycrest Center for Geriatric Care (12> and the Sunnybrook Health Sciences Center(1:3 (this has a community-based dementia programme), both of which are urban and located in Toronto, and the Northern Alberta Regional Geriatric Program, (!5 based in Edmonton, Alberta, which serves an urban and rural population over an extensive geographical area.

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