The Pharmaceutical Journal
Vol 268 No 7182 p92
26 January 2002

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Towards the mental health super trust — evaluating the options for pharmacy

By Dave Branford and Peter Pratt

The National Health Service has recently undergone a bewildering series of changes. These include: the development of primary care trusts; the merger of acute hospital trusts into larger acute hospital trusts; the abolition of community trusts; the merger of mental health trusts into larger mental health Trusts, and soon to be merged again with social services; the transfer of the care of people with learning disabilities to local authorities; and the abolition of district and regional health authorities and their replacement by strategic health authorities. The emerging picture in mental health is the formation of large new mental health (or mental health and social services) trusts. The new combined trusts will typically serve a population of one to two million people, will provide services to a multitude of PCTs and will, in some cases, cross strategic health authority boundaries. Whether or not such trusts will include learning disabilities remains unclear. In many areas the model currently in favour is for local authorities to become their lead agencies.

For much of the 20th century, services to people with mental health problems or learning disabilities were provided through institutional care. Large institutions, called asylums, provided care for as many as 3,000 people in isolated, largely self-sufficient communities. With the advent, in the 1950s, of "new" medicines to treat mental illnesses and a change in the public view of the merits of institutional care, the policy of community care developed. A part of this development included the now discredited notion of acute mental health services within district general hospital sites.

Despite the evolution of community care, the NHS hospital provision for people with mental health problems or learning disabilities remained largely separate from other types of acute medical care. Even in those few areas where mental health care was integrated with general medical care, the mental health aspects were never compatible and generally separated from acute care with the formation of NHS trusts. The most common NHS organisational unit eventually became either a stand-alone mental health trust or combined mental health and community trust.

The development of pharmaceutical services for people with mental health problems or learning disabilities has similarly undergone many changes. From the 1950s many institutions employed specialist pharmacists to oversee the supply of medicines to the "inmates". In the next 50 years the role of the pharmacist in psychiatric hospitals changed dramatically with the development of clinical pharmacy. Many pharmacy departments developed a dual role as "technical" suppliers of medicines and therapeutic clinicians. With the closure of large institutions, a number of new models of pharmaceutical provision emerged. Although other variations exist, these can be grouped broadly into the following:

• District general hospital provision of all aspects of the pharmaceutical service under a service level agreement (SLA)
• DGH pharmacy provision of supplies under an SLA with specialist pharmaceutical clinical expertise directly employed by the mental health trust
• DGH provision to those mental health facilities in the DGH campus and provision by other hospital pharmacies to the remainder (several SLAs)
• Provision to all mental health facilities from within the mental health trust's own pharmacy service
• Provision of medicines from a local community pharmacy (under an SLA) with pharmaceutical clinical expertise directly provided by the mental health trust
• Local community pharmacy provision of total service (under an SLA)

With the current development of many new large mental health trust, it is time to reflect on how successful these models have been, both for the mental health trusts as "organisations" and for the clinical care of patients within those trusts.

The most common provider of services to the existing mental health trusts is the DGH or acute hospital trust. Clearly this model of provision has failed for most mental health trusts. This is not necessarily a reflection of poor or inadequate general hospital pharmacy services. It is, however, recognition of the simple fact that the pharmaceutical needs of people with mental health problems just cannot be met from within a pharmacy department geared to deliver the needs of acutely medically ill patients.

A second model involves separation of the technical supply of medicines (under an SLA) from the clinical and ward based activity. The staff that work in the pharmacy (usually the DGH) then work for an organisation different from those which provide the clinical services (usually employed by the mental health trust).

Pharmacists who complain that they cannot visit wards or units because of the technical demands of the dispensary see such a system as Nirvana. But whether the person is more or less able to be an effective clinical pharmacist separated in this way is currently unresearched. Another problem may be the potential isolation and consequential lack of clinical supervision, particularly where the mental health pharmacist may be working single-handedly. Whether this model gives mental health trusts any real control over the supply of the medicines, even within an SLA, could be questioned. The ideal solution is for these new organisations to develop their own pharmacy services under the leadership and direction of a specialist mental health chief pharmacist. Clearly providing both a comprehensive clinical and technical pharmacy services across an organisation that covers a large geographical area may not be immediately realisable — or viable — without a substantial additional investment. However this should not detract from the overall aim of aligning pharmacy services firmly within the heart of these new trusts. Where it is possible to develop technical pharmacy supply services in true collaboration with acute trusts or local community pharmacies this should be considered But where there is no prospect of collaboration, new pharmacy services must be developed.

Whether or not the new large mental health trusts are organised so that best drug treatment will be achieved will depend on their pharmaceutical leadership.

The rate of change is rapid. New organisations are already emerging. The issues for mental health are complex. Our fear is that many of the new chief executives or other key players will not have considered the best organisational configuration of pharmacy provision within their modern mental health services.

Our own profession has, as yet, made no mention of pharmaceutical leadership in mental health. If our aim is to "get medicines right" in mental health, there must be a clear and unequivocal statement from our own profession that the pharmacy services within the new mental health organisations must be developed and led by competent and specialist mental health chief pharmacists.

Mr Branford is director of pharmacy at Southern Derbyshire Community and Mental Health Services Trust. Mr Pratt is chief pharmacist at Community Health NHS Sheffield