Features

How mental health trusts are making changes to medicines management

In January 2007, the Healthcare Commission published a report, “Talking about medicines” (PDF 1.2MB), which painted a picture of neglect of medicines management in mental health trusts (MHTs) in England and Wales.

For instance, one area of Kent and Medway NHS Partnership Trust has not had a specialist clinical pharmacist service for 20 years. However, there are glimmers of hope.

The report acknowledged that MHTs do more to support concordance than acute trusts and it cited a dozen examples of good practice in medicines management that are in place, for example, the specialist pharmacist medicines clinic provided by a community mental health team introduced by Central and North West London Mental Health Trust. A winner at this year’s Pharmaceutical care Awards (PJ, 7 July, p12), this clinic provides a much needed forum for patients to raise any concerns about their medicines.

Changes

It may also be worth noting that the audit on which the Healthcare Commission report is based was conducted in 2005. Although not denying that MHTs were not doing as well as they could, Graham Parton, chairman of the UK Psychiatric Pharmacy Group, told P&MM:“The snapshot then is not really how things are now. Things have moved on and there have been changes.”

For example, since the audit, Kent and Medway has developed an in-house, region-wide protocol for recording allergies to medicines. It has also looked at improving communication at care interfaces and GPs now fax medicines records to crisis teams.

In the north, use of an audit cycle by South West Yorkshire Mental Health NHS Trust has resulted in better prescribing practices through the implementation of pharmacy prescribing guidelines, and the most recent audit shows that 86 per cent of prescriptions for antipsychotics are for monotherapy — higher than reports from other areas.

The trust has also increased pharmacy cover in the Calderdale area from 23 pharmacist hours each week, to one full-time pharmacist and 24 technician hours per week. This has enabled areas where improvements could be made to be identified and dealt with. For example, the percentage of patients receiving a medication review within 24 hours of admission or the next working day is now regularly monitored and almost at 100 per cent, and the level of incident reporting (related to medicines) has increased.

“Introducing pharmacy cover has improved awareness of medicines management in ward areas. Increased incident reporting has led to improved education around medicines and the development of a medicines education training package for the trust,” said Lynn Haygarth, chief pharmacist at South West Yorkshire Mental Health NHS Trust.

Other examples from across England include the approval of a pharmacist post to work with early intervention teams (pre-empting a first episode of psychosis, before hospital admission) and the setting up of patient helplines.

All this can be described as speedy progress, considering that it is only fairly recently that many MHTs began directly employing pharmacists. For example, Mr Parton’s post as chief pharmacist of Avon and Wiltshire Mental Health Partnership NHS Trust is only three and a half years old.

He said: “We started with a low baseline in some aspects. Acute hospitals have had a pharmacist from the year dot. My trust started having a pharmacist three and a half years ago. Before that, the trust used pharmacists through service level agreements [SLAs], but who managed those SLAs? Who reviewed them?” Mr Parton predicts that as a result of reports like “Talking about medicines” more MHTs will employ their own medicines governance expert.

In Avon and Wiltshire, some medicines management initiatives are taking pharmacists out of the dispensary, enabling them to use their knowledge and expertise in direct involvement with service users and the multidisciplinary team. “Most professionals do not have the expertise that pharmacists, who are specialists in mental health, have through either years of experience or achieving a postgraduate qualification in mental health and psychiatric therapeutics. Clearly [pharmacists] are best equipped to advise on complex medicines issues for people with severe mental illness,” Mr Parton explained.

For example, in 2006, a post was created in Avon and Wiltshire which requires a pharmacist to spend nearly all his time within a forensic psychiatry unit where he can ensure that a prescription is right for a service user before it reaches pharmacy. “Intervention after a prescription is written is too late,” Mr Parton said.

For 18 months the trust has also had a pharmacist working with a crisis intervention team and home treatment team, which means working with psychologists, occupational therapists, psychiatrists, community psychiatric nurses and social workers. The pharmacist plays a consultative role on all issues to do with medication (eg, choice of medicine, choice of dose, timing, delivery, whether a compliance aid is needed, who will prescribe it and who will dispense it) and trains and educates staff.

“Traditionally, pharmacists were not included in these teams and mainly they are still not included. [Our pharmacist] is integrated with the team so, for example, if there was a meeting around a service user, he would be there to help develop a holistic treatment plan to include medication. [This initiative] is outstandingly effective. It fills gaps in terms of risk and governance that no one realised were there,” Mr Parton said. Having a pharmacist available has improved the other professions’ competence and knowledge around medicines, increased value for money and ensured that the best clinical decisions around medicines are being taken, he added.

However, such initiatives can be expensive. Mr Parton is working towards having a pharmacist member of every team but this does not mean one pharmacist per team — it is more economical to share a pharmacist’s time between teams and units. “We know we are not going to get massive additional resources [to improve medicines management] but we can make things better by changing the way in which we do things,” he said. “People are positive around the possibilities but there are worries around resources and the detailed planning of how we do it,” he added.

One example of how MHTs are changing the way in which they work concerns SLAs. SLAs, through which MHTs commission services (eg, ward visits, medicines information and dispensing) from acute trusts, are well-known for allowing poor performance. A solution would, therefore, be to examine critically services that are performing poorly and remodel them in novel ways.

New agreements could be clearer, building in key performance indicators and penalty clauses so MHTs get exactly what they want, Mr Parton explained. “We will be going out to tender shortly,” he said and envisages other MHTs taking a critical look at their current services. Humber Mental Health Teaching NHS Trust has already contracted to have its dispensing undertaken by Lloydspharmacy rather than an acute trust.

Leadership

Many MHTs have taken “Talking about medicines” to heart and are working to make a difference. “Following the report, we have identified areas of particular risk and are actively seeking investment in the clinical pharmacy service at board level,” Ian Maidment, senior pharmacist at Kent and Medway NHS Partnership Trust, told P&MM. “We have also developed business cases which will see major changes in the way clinical pharmacy services are delivered in several areas of the trust,” he added.

The report summarises 10 focus areas and calls for leadership from chief pharmacists on medicines management. “A lot of the focus areas are easy to envisage. What is missing, to some degree, is a sense of leadership and direction,” Mr Parton commented.

To Mr Parton, leadership means challenging status quos. It means having vision, communicating, facilitating and enabling. “A leader needs skills to argue his or her corner and has to be realistic, pragmatic and concise,” he said.

“Talking about medicines” adds to wider reports on mental health, including “Delivering the Government’s mental health policies: services, staffing and costs” (also published in January 2007), and programmes for new ways of working for mental health pharmacy. “We’ve got these reports coming through but [improvements need] effective engagement and communication, both up and down, from the chief pharmacists to the Department of Health and the Healthcare Commission.

There are a lot of initiatives happening but they are all in slight isolation. They need pulling together and co-ordinating,” Mr Parton said. “The report is another pressure for the trust. What I expect to happen is that, to some extent, some of the needs that we’ve identified will be met. But many won’t. It will be the progress of evolution rather than revolution,” he added.

However, trusts are trying to make improvements in a period of uncertainty as MHTs consider becoming foundation trusts. With organisational change, some trusts may not have the capacity to take all of their chief pharmacists’ recommendations on board.

Mr Parton’s vision is to see specialist pharmacists associated with every community team and inpatient unit, with a clear mandate to develop strong medicines governance and practice, to empower service users, to liaise across primary and secondary care and to have an effective and efficient way of providing medicines at the point of use. “It is do-able,” he said.