The Royal Pharmaceutical Society has produced two new sets of practice guidance, one covering mental health and the other asthma and chronic obstructive pulmonary disease. They were launched at the British Pharmaceutical Conference on September 12 (see p403). Edited versions of their executive summaries are given below
One of the key issues identified in "Building the future", the Royal Pharmaceutical Society's strategy for the future of the profession, was the management of long-term conditions. This practice guidance on the care of people with asthma and chronic obstructive pulmonary disease (COPD) is one of a number of publications produced by the Society as part of this strategy to help pharmacists to continue to make a major contribution to health care.
The Society has prepared the guidance through its respiratory task force. Although its major focus is on primary care, the guidance includes sections relevant to the primary/secondary interface, and many of the principles will apply to pharmacists in other sectors of practice.
The ways in which pharmacists can deal with patients who are undiagnosed, newly diagnosed and with established conditions are explored. In addition, advice is provided on tackling the issues arising from the disease states.
This practice guidance is intended as a resource to help pharmacists in establishing themselves as an integral part of the health care team in the management of asthma and COPD, and to help to improve and develop current services to this group of patients.
The pharmacist
The underdiagnosis and misdiagnosis of adults with asthma and COPD continues to be a problem. Within these two disease states are two further patient populations: those with undiagnosed symptoms, and those taking ongoing medication for recognised disease. The management of both groups will be different, although many of the principles are the same, and it is important that pharmacists develop the necessary skills to manage these patients.
Pharmacists have a key role in improving patients' understanding of their condition and its management. Indeed, a recent survey carried out by the National Asthma and Respiratory Training Centre (NARTC) highlighted the recognition of poorly controlled patients and appropriate referral as a major strength of pharmacists. By being aware of symptoms of asthma and COPD, attentive to the signs of deterioration, alert to patients seeking non-prescription medicines inappropriately, and vigilant in dealing with prescriptions, pharmacists can be invaluable to the care of these groups of patients.
The patient
The undiagnosed patient Pharmacists are in a good position to identify patients with undiagnosed asthma or COPD. Questioning patients purchasing non-prescription medicines inappropriately or presenting with symptoms indicative of an undiagnosed condition means that pharmacists are able to refer patients who might not otherwise have consulted their GP about their symptoms.
The newly diagnosed patient Pharmacists can provide valuable support and advice to newly diagnosed patients. It is good practice to investigate local protocols to ensure consistency of information and to establish links with the local respiratory team in order to provide seamless care for patients. Encouraging patients to discuss what they have already been told about their condition can be worthwhile, providing a basis for continued, patient-focused management.
Prescriptions should be assessed, including checks for interactions, sensitivities, contraindications and the appropriateness of the dosage regimen. It is also useful to check with patients whether they have been shown how to use their inhalers or how to take their medication.
The patient with an established condition As with newly diagnosed patients, the information and counselling offered to patients with established conditions should remain appropriate to the individual and within the scope of local and national guidelines and protocols. Pharmacists can continually support the management of asthma and COPD. At each presentation of a prescription, the patient's progress can be checked, along with the continued appropriateness of the medication and the time elapsed since last having the medication dispensed. The patient's inhaler technique and any drug interactions (potential or actual) can be discussed. It may also be appropriate to discuss any side effects or problems with compliance that the patient may be experiencing, together with any action taken.
Pharmacists can advise patients on monitoring and interpreting peak flow measurements, discuss self-management plans, where appropriate, and counsel patients being changed to CFC-free inhalers.
There is also a role to play in advising patients on the use of nebulisers, even if the pharmacist is not directly involved in their supply. Pharmacists should investigate local procedures for the supply of nebulisers because some surgeries will lend them to patients and others will direct patients to purchase them via pharmacies. If a patient purchases a nebuliser, the pharmacist should give appropriate advice on its use.
Referring patients It is important that pharmacists are fully aware of the trigger points for the referral of patients with asthma and COPD. These trigger points should include worsening symptoms, any potential interactions with new or non-prescription medicines, poor compliance or any problems relating to the patient's prescription. Additionally, pharmacists should familiarise themselves with the recommended procedures should a patient present with acute asthma or COPD in the pharmacy.
Emergency supplies Inhalers and other devices used in the treatment of asthma and COPD, are frequently requested through the emergency supply route. Pharmacists should remain vigilant to patients who regularly make requests for an emergency supply and should take the opportunity to discuss the management of the patient's condition.
Integrated health care
Health care professionals Patients with asthma and COPD are cared for by a range of health professionals. It is important that pharmacists identify these professionals within their locality and work closely with them. Making contact and building relationships with other health professionals improves patient care and can be rewarding professionally.
Moving forward
As with all areas of practice, it is essential to recognise personal limitations and level of competence, particularly when considering changes to current practice. By assessing current levels of knowledge and skills and then examining areas for potential service development, pharmacists should identify what further training and/or facilities will be necessary to deliver that service competently. The Society's Code of Ethics provides further information on identifying and meeting training needs.
With all services provided, it is important to undertake periodical reviews. This not only provides important feedback and evidence of pharmacists' continued input, but can also provide evidence of quality, enabling risk assessment and risk management, particularly in the context of clinical governance. Up-to-date and accurate records should be maintained wherever appropriate.
There are various ways of undertaking review, both informally, by talking to other members of the respiratory team to seek their opinions about the service provided, and formally, using audit. The Society has audits available on asthma and related topics.
Conclusion
Multidisciplinary working is essential to help deliver the best care to patients with asthma and COPD. This practice guidance encourages pharmacists to become fully integrated into the health care team, using their expertise and skills to enhance the level of care for this group of patients.
Mental health is one of the Government's three "supercharged" priorities (alongside cancer and coronary heart disease) as identified in the Government White Paper "Saving lives: our healthier nation".
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All pharmacists will be involved, to a greater or lesser extent, in providing services to people with mental health problems |
The guidance will also be useful for those interested in understanding more about the role of pharmacists in the current mental health policy context. For example:
Implementing the NSF
The vast majority of people with mental health problems live in the community, with most accessing services through primary care. It is estimated that as much as 90 per cent of mental health care is provided in primary care settings. Pharmacists are therefore key partners with other primary care providers, mental health service users and carers in the delivery of effective mental health care.
The NSF sets its seven standards in five areas and the role of pharmacists in each of these areas is highlighted:
Mental health promotion: standard one Community pharmacists have a key role to play in health promotion, being able to engage effectively with vulnerable groups known to be at risk of developing mental health problems, eg, women suffering from post-natal depression. Possible activities for pharmacists are:
Primary care and access to services: standards two and three Community pharmacists Community pharmacists already play an important role in the provision of services to people with mental health problems and, for many, there is scope to develop their services further. Outlined below are some of the areas in which community pharmacists might become involved:
There is also a role for community pharmacists, particularly those interested in developing their role in the area of mental health, to work with members of the community mental health team (CMHT), focusing on areas such as care planning and continuing professional development.
Pharmacists in secondary care There is considerable scope for pharmacists to develop services in secondary care settings. The developing role of specialist mental health pharmacists is particularly important. Service developments could include:
Pharmacists involved in commissioning and advising on services Pharmacists involved in commissioning, monitoring and advising on services can help ensure the provision of pharmaceutical services to support the safe, effective use of medicines in mental health. Areas for further consideration include:
Effective care for those with severe mental illness: standards four and five Since medicines are an important component of follow-up care, several areas need to be integrated in relation to the care of people with severe and enduring mental health problems:
Caring for carers: standard six It is estimated that the number of relatives, friends and professionals acting as carers for people suffering from schizophrenia alone could number over 400,000. Pharmacists frequently deal with carers, possibly more so than with mental health service users. Social services departments have a duty to assess the needs of all carers, including carers of people with mental health problems, and have responsibility for implementing this standard under the Carers Act 1999.
Community pharmacists can play a continued and enhanced role by providing information about medicines (eg, benefits and side effects), by dealing with compliance issues) and by contacting the local SSD or referring a carer to the local SSD to have their caring needs assessed, eg, respite or domiciliary care. Additionally, pharmacy academic practice units and schools of pharmacy could work with local SSDs, education and training consortia for health care workers and colleagues in other sectors to assess the educational and training needs of carers relating to the use of medicines and to develop courses to meet those needs.
Prevention of suicide: standard seven This standard relates to national targets for reducing suicide rates. The NSF suggests that this will be achieved by the combination of standards one to six. However, some drugs have been clearly shown to reduce the likelihood of suicide in those who are at high risk of overdosing on medicines. Specialist mental health pharmacists clearly have a role in keeping abreast of this evidence and disseminating it to primary care professionals, community mental health teams and other service providers.
Moving forward
All pharmacists working within patient care settings will be involved to a greater or lesser extent in the provision of services to people with mental health problems. This guidance provides some suggestions for those pharmacists wishing to play a more active role.
Improved communication will be a critical success factor for all involved in mental health care provision and should be a key target for pharmacists. This involves communication with service users, carers, other pharmacists and members of the CMHT. Good communication hinges on confidence and confidence will increase with experience and competence. The guidance concludes by focusing on three main areas:
Checklist A checklist is provided, which highlights the importance of a collaborative approach, which involves networking with pharmacists and other practitioners locally and, where appropriate, nationally.
Practice examples and guidelines The Society's mental health task force has collated details of recent projects involving pharmacists. These are examples of what has already been done in this area and are intended to help pharmacists identify areas in which they may wish to develop services. The information is contained in the appendices of the report.
Training and education needs There is a significant training agenda for all professionals in the delivery of mental health services. For pharmacists wishing to become more involved in this area, there is a need to identify relevant and appropriate training needs. For example, advances in psychiatric therapeutics have taken place over the past 10 years, bringing a need for pharmacists to update their knowledge of current and developing drug therapy. It is useful to have knowledge of the alternative and psychological therapies available to patients and to recognise their place alongside medication. In addition, an appreciation of the role of other members of the multidisciplinary team also facilitates a broader appreciation of the many problems frequently encountered in the management of acute and chronic mental health problems. The guidance identifies a number of agencies that are already providing relevant post-qualification training.
Conclusion
Multidisciplinary working is the only way to help deliver the objectives of pharmaceutical care in the context of mental health care. The guidance issued by the Society offers advice across major sectors of pharmacy practice. Improvements in co-ordination and focused effort on the development and provision of services could have a significant impact on improving pharmaceutical care for many patients with mental health needs, with benefits also for their families and carers.
Copies of the guidelines can be downloaded from the Society's website as PDF files (www.rpsgb.org.uk/pdfs/asthmaguid.pdf and www.rpsgb.org.uk/pdfs/mhealthguid.pdf). Copies may also be obtained from Ms Angela Canning, Royal Pharmaceutical Society, 1 Lambeth High Street, London SE1 7JN (tel 0207 735 9141 ext 270; fax 0207 582 3401; e-mail acanning@rpsgb.org.uk) |