Hospital Pharmacist
2007;14:74
March 2007

“Talking about medicines” — agreeing on the way forward

By Ian Maidment, BPharm, MRPharmS, Denise A. Taylor, MSc, MRPharmS and David Branford, PhD, MRPharmS

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Although “Talking about medicines”, the recent report from the Healthcare Commission on medicines management in trusts providing mental health services, (Hospital Pharmacist 2007;14:37) might appear to impact solely on mental health trusts (MHTs), it also raises a variety of issues that affect other areas of the pharmacy profession.¹

The report challenges entrenched views within pharmacy and MHTs about the need for specialist mental health pharmacy services, the scope of these services and the role of medicines in mental health. It also reflects the journey that the Healthcare Commission took from assuming that the medicines standards reflecting good practice in acute trusts would be the same for MHTs, to identifying that in many aspects they are completely different.

The challenge

First, we need to understand the structure and function of MHTs. Many are currently undergoing mergers, but will eventually become large organisations serving populations of one to two million people, spanning the catchment areas of a number of acute trusts and primary care trusts. Their focus is on service users with severe and enduring mental illness with whom they will remain engaged for long periods of time. Although these service users may be admitted to acute wards from time to time, mental health policy currently focuses on managing and treating them in the community.

MHTs have developed a large array of community-based teams with responsibility for medicines management, but they generally lack the support of a commissioned and dedicated pharmacy service. Moreover, the traditional model for resource allocation to secondary care pharmacy services, namely bed numbers, does not cover community teams.

In the past medicines management has not been a high priority for MHTs. The commissioning of new services has been based on the National Service Framework for mental health, which largely omitted pharmacy. Furthermore, many MHTs devolved or contracted out medicines management to an acute trust or to primary care.

The extent of under-investment in mental health pharmacy has been highlighted in recent surveys by the New Ways of Working Mental Health Pharmacy subgroup, which concluded that the pharmacy workforce is too small to provide effective medicines related services for most MHTs.²

So where does this leave acute trusts? Many are providing unsatisfactory levels of services to a rapidly reducing number of mental health wards for which they receive a low level of funding.

Understandably, acute trusts are not prepared to invest in MHT services for which they are not paid, and MHTs are reluctant to invest because an acute trust may not be an appropriate organisation to deliver community-based services. Nevertheless, acute trusts should provide appropriate services, particularly as aspects of the acute trust model of pharmacy services, such as one-stop dispensing, robotics, and ward pharmacy services may not be suitable for MHTs.

The future

Mental health clinical pharmacy services must be aligned with the increasingly community-based service. As complex treatments move into the community this role may be outside the clinical capabilities of many community and primary care pharmacists.³ Secondary care services need to be redesigned so that specialists are engaged in community services; the responsibility of secondary care does not end at the hospital gate. New ways of working, linking different care sectors, should be seen as a priority for service development and be based upon delivering collaborative medicines management services with a patient focus rather than a sector focus.

Higher education institutions and MHTs should focus on developing training packages to enable community and primary care pharmacy staff to provide enhanced medicines management. Specialists may be able to provide appropriate support and supervision. Developments could include enhanced pharmacist medication reviews and mental health prescribing initiatives.

So what needs to happen now? Initially, MHTs should review their current pharmacy services. The recently published Sainsbury report should be able to provide some guidance on staffing levels.⁴ However, there will be barriers to overcome. In some MHTs developing robust services will take years, and now is not an easy time to obtain additional resources. The time of centrally driven initiatives has passed, and local commissioners will only fund new services identified as imperative. Successful ventures will need to develop a collaborative approach.

Patients with mental health problems deserve the same level of medicines management as anyone else. The Healthcare Commission report highlights that this may not be occurring. Chief pharmacists in PCTs, acute trusts and MHTs must work together with commissioners to agree on a way forward to improve medicines management for these patients.

Reference

1. Healthcare Commission. Talking about medicines – a report on the management of medicines in trusts providing mental health services. The Healthcare Commission; London:2007.

2. Branford D, Parton G, Taylor DA, Sutton J. Summary and key findings of the report on the mental health and learning disabilities secondary care pharmacy workforce survey. National Institute for Mental Health in England;University of Bath:2006.

3. Phokeo V, Sproule B, Raman-Wilms L. Community pharmacists’ attitudes toward and professional interactions with users of psychiatric medication. Psychiatric Services 2004; 55:1434-6.

4. Boardman J, Parsonage M. Delivering the Government’s mental health policies – services, staffing and costs. The Sainsbury Centre for Mental Health;London:2007.