The national service framework (NSF) for mental health has now been published. This important document sets out standards of mental health care together with how those standards should be delivered and performance measured. Although the NSF applies to England, it is likely that similar documents will be published for other parts of the United Kingdom. One of the most striking aspects of the NSF is the almost complete absence of the word "pharmacy".
In this short paper, I will address the contents of the NSF that are relevant to pharmacy, consider what it could have said that might have been rather more useful to pharmacy and, finally, ponder on how such an omission could be avoided in the future.
The NSF focuses on the mental health needs of adults of working age (up to 65 years) who live in England. It aims to drive up quality and remove the wide variations in provision of services. It sets the standards and defines service models for promoting mental health and treating mental illness, puts in place underpinning programmes to support local delivery, and establishes milestones and performance indicators against which progress within time scales will be measured.
The NSF has been developed with advice from an external reference group. This group contains representatives from nearly all the professions involved in the delivery of care to people with mental health problems, but there is no pharmacist member. It would appear that the external reference group consulted widely, including, one would assume, the Royal Pharmaceutical Society.
Having read the NSF, one could be forgiven for imagining that medicines have little to do with mental health and that pharmacists have absolutely nothing to do with it. This is quite surprising when one considers that treatment with psychotropic medicines provides the most effective method of maintaining the well-being of many people with mental health problems. Also, there are pharmacists, whether in the hospital or community branches of pharmacy, who provide invaluable support and assistance to many such people.
Rather than complain about the lack of input by pharmacy to the NSF, it is probably more helpul to see what lessons or opportunities there are for pharmacists. Probably the most important lesson is around how services are to be organised. Forget the hospital/community divide; the important issue is how best to provide good pharmaceutical care to people with mental health problems. One of the measures of performance of local services will be the extent to which the prescribing of antidepressants, antipsychotics and benzodiazepines conforms to clinical guidelines. Who is to be responsible for the delivery of that local performance will vary from place to place, but I can see the request to audit performance arriving on the desks of many pharmacy advisers and senior hospital pharmacists? The NSF also implies the need for a well-trained and skilled workforce able to meet the challenges presented by people with mental health problems. How well equipped are we within pharmacy? How confident do pharmacists feel about assisting and advising patients about their medicines? Do hospitals have sufficient numbers of well-trained mental health specialist pharmacists to ensure that patients receive optimal therapy? Unfortunately, there is evidence that both hospital and community pharmacists have significant skill shortages when it comes to the drug treatment of mental illness.
One local milestone stipulated is that all service users should be assessed for and receive new atypical antipsychotics where indicated using clinical guidelines. If taken literally, this would involve a huge project just to identify all the people on antipsychotic drugs, let alone assessing whether they should be prescribed the new antipsychotics. The cost implications of such a change would be considerable.
Although these nuggets do provide a foothold for pharmacists, what might the NSF have included that would have been more useful? First, it could have recommended that all mental health trusts appoint a chief pharmacist with responsibilities for maintaining prescribing standards for the whole health community in the same way that the Duthie report makes them central to the procedures for the safe ordering, storage and administration of medicines.
Second, it could have advocated the co-ordination of pharmaceutical services to people with severe and enduring mental health needs by pharmacists specialising in mental health. These specialist pharmacists could purchase patient-focused additional services from either community or hospital pharmacists.
Third, it could have advocated linking patients to specially trained community pharmacists who are paid to maintain contact with those considered to be at risk in the community.
There is no shortage of ideas and there are even well-studied models. Unfortunately, none of them has appeared in the NSF.
The NSF is to be one of many. I am told that there will be an NSF for elderly people with mental health problems published in 2002. Others will soon be published in other health priority areas. Perhaps then it is time to look at how the contents of the NSFs may best be influenced in the future. After all, the Royal Pharmaceutical Society even has access to a specialist group (the UK Psychiatric Pharmacy Group), which was not asked to comment on this NSF. The Society has recently set up a task force for mental health but the NSF does not seem to be the focus of its work - perhaps it needs to be. If the excuse is that the Society is totally overloaded with requests to comment on an overwhelming array of documents (usually at very short notice), thought should be given to enabling members to know what documents are under consideration, how they might contribute, and what responses the Society has made. The Pharmaceutical Journal could highlight the requests and seek help from interested members or make use of a website on the internet.
The Register of Pharmaceutical Chemists must contain individuals with specialist knowledge of almost all aspects of medical and pharmaceutical care, and if they did not contribute when given the opportunity there would be no grounds for complaint. The challenge is to influence the contents of documents like the NSFs and to engage the membership of the profession in the process.
Dr Branford is director of pharmacy at the Southern Derbyshire mental health trust