The Pharmaceutical Journal
Vol 269 No 7228 p842
14 December 2002

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Is there a role for community pharmacists in community psychiatry?

By Dave Branford

In a short letter to The Pharmaceutical Journal, Nasr and Guirguis (PJ, 9 November, p676) expressed concern that, although community mental health services had developed strong links with many community initiatives and organisations, they have not done so with community pharmacy. They thought it was about time that community pharmacy identified means of developing such links.

The fact that such a development has not occurred generally in community pharmacy is worthy of analysis. After all, there have been many projects and initiatives to explore such potential links and here we are, many years after the move towards community care, with little or no substantial development. Why?

At first such a seemingly simple question might appear to have simple answers depending on which branch of pharmacy you work for. Some may say that it is all a question of funding; if people are not prepared to pay for a service they are unlikely to receive it. Others may say it is a lack of expertise; community pharmacists do not have the skills that are required. Others may say it is a lack of leadership from the Royal Pharmaceutical Society and so it goes on.

It is also difficult to be objective because practice is so varied throughout the United Kingdom. My analysis may appear offensive to some and not reflect local experience for others. Some areas have strong secondary care pharmacy leadership in mental health and others have primary care trust-led initiatives; yet others are working in a vacuum.

What could be concluded from the various studies and projects? Overall they failed to demonstrate a clear role for community pharmacy and few areas where the community pharmacy clearly provided a health gain to people with mental health problems. There were two notable exceptions — the Liverpool and Derby projects, both of which received great plaudits from the pharmaceutical communities, but only one of which is now managing to achieve substantial funding to carry the initiative into mainstream pharmacy practice.

As an aside it is worth looking at why these two projects were successful. First, each was led by a charismatic and dynamic leader who trained, managed and co-ordinated the time and work of the community pharmacists. Secondly, the community pharmacists were enthusiasts, were specially trained and, more importantly, they did not necessarily provide the service from their own pharmacies or to their own patients. One could ask the question whether or not these tasks could have been undertaken by specialist mental health pharmacists or PCT pharmacists as effectively but, of course, such an approach would never be funded because it is counter to the current ideologies.

What these studies do show is that community pharmacists provide a pool of labour, well able to take on additional part-time jobs that make use of their knowledge about medicines, provided that they can be released from their pharmacies. What perhaps needs greater work is how community pharmacists might benefit community psychiatry as a part of their everyday work. The studies suggest that providing information and reassurance and supporting adherence to medicine taking are valuable contributions. The National Service Framework for Mental Health sees the front line services, eg, general practitioners' surgeries (and this would equally apply to community pharmacies), as providing general public health support to people with mental health problems.

The next issue to consider what the business of community psychiatry is. Such a simple question is again incredibly difficult to answer, because the models will be so different around the UK. There is such a proliferation of teams that it is difficult even for the specialists to keep track of their individual roles. We now have crisis intervention teams, first illness teams, assertive outreach teams, learning disabilities teams, rehabilitation teams and mental health elderly teams to mention but a few. My overview is that they are specialist services mostly funded by mental health services. These will be part of a large mental health trust or a PCT with a large specialist mental health service. In other words, they are secondary care outreach services and will relate to the management structures in secondary care or the PCT. Perhaps the reason that community pharmacy has not developed a relationship with community psychiatry is because specialist mental health pharmacy services have not been allowed to develop them. The funding has remained within health authorities and now PCTs. So perhaps the reason why this link has not developed is that it lacks facilitation. How can a community pharmacist have links with so many different teams all with different remits when the contact person may be one of a number of nurses, social workers, psychologists or more often unqualified workers? How can the community pharmacist participate in reviews when they can occur in any one of 10 locations and last all morning just for one patient? If the community pharmacist had one person to relate to and that person was a fellow pharmacist then we might be in business. This of course is not how it has developed. There has been the assumption that as the institutions closed the community pharmacist would meet the medication needs and the need for secondary care pharmacists would wither away. Unfortunately, the supply of medicines moved to primary care but the management of the medicines did not. Secondary care specialist pharmacy departments did wither away and in many parts of the country disappeared completely and now many places have nobody to manage the medicines

So if I had the chance what would I do? As a chief pharmacist of a specialist mental health trust I would develop the community pharmacist as my eyes, ears and source of local information to enhance the specialist psychiatric pharmacist's role in the community teams and outpatients departments. I would pay the community pharmacists to provide alerts for particular patients if they failed to collect their medicines and to channel problems and queries about the medicines to specialist pharmacists involved in the reviews. The community pharmacist could then be trained and paid to undertake a variety of patient-centred tasks that really would lead to an enhanced and rewarding role of great benefit to patients.