Download 62591_RPS_Mental_Health_Toolkit PINK ON SIDE:layout

Mental Health Toolkit
A toolkit to support the integration
of pharmacy into care pathways for
Mental Health in primary care
November 2010
© 2010 Royal Pharmaceutical Society of Great Britain
CONTENTS
1. Introduction
3
2. The Current Burden of Mental Illness in Great Britain
5
3. Mental Health Care Pathways – where does community or primary care
focused pharmaceutical care fit?
7
4. Pharmaceutical Care in Mental Health and Examples of Model Schemes
9
5. Considerations for Pharmacists in Mental Health:5.1 Promotion of Mental Health and Well-being
19
5.2 Communicating with People about Mental Health Issues
23
5.3 Improving Medication Adherence
25
5.4 Supporting People at Risk of Suicide
29
6. Mental Health Policy Drivers in Great Britain
6.1 England Mental Health Policy Drivers
32
6.2 Scotland Mental Health Policy Drivers
43
6.3 Wales Mental Health Policy Drivers
46
References
50
Visit our website for a list of Authors Acknowledgement and Consultation Panel
Participants/Stakeholders
2
1. Introduction
Mental health services are a key public health priority for governments and the National Health
Service (NHS) throughout Great Britain. Pharmacists, whether working in the community, GP
practices, hospitals or prisons already play a key role in supporting patients with mental health
problems. Pharmacists’ contribution to mental health services will grow as the NHS focuses
more on prevention as well as cure; exploiting pharmacy’s ready accessibility to people who
use the NHS and those who do not. Health departments now wish to see greater use made of
pharmacists’ accessibility and clinical skills in improving mental health.
Opportunities exist to improve the gateways for signposting, accessing and providing services
and information on health and health issues to the most vulnerable in our communities –
adolescents, older people, people with mental health problems, homeless people and
substance misusers. All of these are people who may have difficulty, for lifestyle reasons, in
accessing healthcare services and may also experience stigma when accessing services.
Pharmacists can make a significant contribution to the management of psychotropic drugs and
other medicines and can help support good patient adherence. They can also help to minimise
the stigma attached to mental illness by raising awareness of mental illnesses with the public
and improving patient and carer information. There are steps that can be taken to improve the
pharmaceutical care services for these patients, for example, monitoring side effects and
encouraging adherence. To help improve adherence the pharmacist could provide small
quantity dispensing with personal intervention (e.g. visits) to monitor the patient’s progress,
and provide individualised patient information with the appropriate use of prompts and
reminders. Different situations require different solutions – remembering to take medicines is a
common issue in dementia; however, not wanting to take medicines is particularly problematic
with psychosis where compliance aids are often not a solution.
Furthermore, there is a significant need in supporting older people with mental illness, for
example, in residential and nursing homes, in homes for dementia and other ‘outlying’ services
such as the long stay social care facilities. Pharmacists can provide training and support for
care home staff on medicines issues.
Considerations of non-adherence leading to stockpiling and risk of overdose are critical factors
in the care of some patients. The specialised knowledge pharmacists have should be used in
recommending appropriate prescription volumes to prescribers where this may be an issue.
There is widespread concern about the over-prescribing of antipsychotics in dementia.
Regular input from pharmacists can ensure appropriate prescribing of antipsychotics to this
patient group.
While there are a range of different resources available, there is currently no overarching
‘one-stop’ publication to guide pharmacy practitioners in this field.
3
The Royal Pharmaceutical Society of Great Britain (RPSGB) has therefore commissioned this
resource with the overarching aim to support the integration of pharmacy into care
pathways for mental health.
This is a toolkit to demonstrate how pharmacy can integrate into and contribute to the care
of patients with a mental illness as part of the wider healthcare team. This includes content
addressing specific policies within England, Scotland and Wales, and also practical crosssector examples and case studies.
It is accompanied by additional mental health guidance and useful resources that are
available on the website at http://www.rpharms.com/public-health-issues/mentalhealth.asp
Although this guide covers a spectrum of mental health specialties, it does not cover
specific issues regarding children under the age of 16.
4
2. The Current Burden of
Mental Illness in Great Britain
Throughout Great Britain and the rest of the world there is now a better recognition that
mental health must be taken more seriously and given a higher priority by government and
the health sector. Improving mental health in Great Britain represents one of the NHS’s key
health challenges in all three countries.
Evidence clearly demonstrates that providing effective treatment and support for affected
individuals benefits the patients themselves, their employers, (through reduced absenteeism
and higher productivity), their family members and friends, (through a lower ‘burden’ of care)
and for society and government (through reduced social costs).1
In the UK 1 in 4 adults experience at least one diagnosable mental health problem in
any one year, and one in six experiences this at any given time2.
Social deprivation, poverty, unemployment and social isolation have all been shown to
be associated with a higher prevalence of mental illness.5 Mental health issues are
common within the prison population, alongside substance misuse.
The economic and social costs of mental illness is estimated as £77.4 billion per
annum, when quality of life is considered alongside the costs of care and lost work6.
With an increasingly ageing population, the burden of mental illness on patients’
mortality, morbidity and costs to the NHS is set to increase dramatically7.
The breakdown below provides an overview of what treatment those who experience
mental health problems are likely to seek and get:
– around 300 people out of 1,000 will experience mental health problems every year
in Great Britain3
– 230 of these will visit a GP on average consuming 30% of GP consultation time4
– 102 of these will be diagnosed as having a mental health problem3
– 24 of these will be referred to a specialist psychiatric service3
– 6 will become inpatients in psychiatric hospitals3
Some key issues in mental health include –
•
Life expectancy - severe mental illness is associated with a 10-year reduction in life
expectancy due to physical health problems including cardiac disease, obesity,
diabetes, lack of physical exercise, poor diet and increased prevalence of smoking4.
Depression - the prevalence of major depression in people seen in primary care is
between 5% and 10% and two to three times as many people have depressive
symptoms but do not meet the criteria for major depression8.
Dementia The number of people with dementia in the UK is estimated to be 821,884,
representing 1.3% of the UK population. The financial costs of dementia to the UK is
over £23 billion a year9.
5
Bipolar affective disorder previously known as ‘manic depression’ is relatively common
with a lifetime risk of 1.3-1.6% and a lifetime risk of suicide of 10-20%. Approximately a
third of sufferers admit to at least one suicide attempt10.
Schizophrenia – approximately 1% of the UK11 population experience at least one
acute episode of schizophrenia at some time during their lives. People with
schizophrenia die on average 10 years earlier than the general population (compared
to the general population).10
The majority of premature deaths are due to coronary heart disease - the main risk
factors being smoking, obesity (leading to diabetes) and hypertension. These patients
are also at a 10% increased risk of developing alcohol and substance misuse
problems12.
Self harm - people with current mental health problems are 20 times more likely than
others to report having harmed themselves in the past13. The UK has one of the highest
rates of self harm in Europe, at 400 per 100,000 persons as a result of mental health
problems14.
Suicide - of the 6500 suicides each year in Britain, about 25% are committed by
people with mental illness15.
British men are three times more likely than British women to die by suicide and this is
the most common cause of death in men under the age of 3515.
Impact on carers - of the 7 million carers in Britain, one in five females and one in ten
males report mental illness16.
6
3. Mental Healthcare Pathways –
where does community or
primary care focused
pharmaceutical care fit?
Care Pathways (also termed: Clinical Pathways, Critical Pathways, Integrated Care Pathways,
Care Maps) are one of the main tools used throughout Great Britain to manage quality in
mental healthcare and aid standardisation of care processes within a healthcare setting.
Care pathways aim to improve the continuity and co-ordination of care across different
disciplines and sectors, and to provide detailed guidance and monitoring tools for each
stage in the management of a patient.
In the case of meeting the needs of patients with a mental illness in the secondary care
setting, the Department of Health’s publication in 2005 (England only); ‘New ways of
working for psychiatrists: Enhancing effective, person-centred services through new ways of
working in multidisciplinary and multi-agency context: Appendices’
(www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance
/DH_4122342) established and recognised the input of secondary care pharmacists in the
care pathway of these patients. The pathway and details of hospital pharmacists’ input into
patient care is detailed in Diagram 1 - Part ‘A’
There is however, a lack of inclusion of pharmacists working in primary care in the currently
developed pathway. The role of pharmacists working in primary care, or pharmacists
providing services to prisons, in the promotion of mental health and in the support of
people with a mental illness managed in the community could dovetail into the current care
pathway as shown in Part ‘B’ of Diagram 1. This illustrates an overview of the link between
input of pharmacists in primary care / prison pharmacists and those in secondary care
within the overall patient care pathway.
This toolkit offers guidance and a framework in modelling care pathways within mental
health to provide a holistic approach in delivering pharmaceutical care to patients with
mental illness in collaboration with other healthcare professionals.
7
Diagram 1: Pharmacist’s input in patient care pathways (mental health and illness)
within the primary and secondary care settings.
B
A
Pharmacist input into
patient care pathway
in primary care / prisons
Pharmacist input into
patient care pathway
in secondary care
Pharmacist roles explained
in detail under section 4,
tables 1-3
Pharmaceutical Care
in the community /
prisons
Admission to Hospital
Medication history taken
Multidisciplinary Team (MDT)
Regular review of medicine charts
CMHTs
Patients own medicines
assessed for suitability to use
Advice to medical staff re
selection of appropriate
medication for service users
Verbal and written counselling service
users re meds efficacy / side effects
1:1 or as a group Session
Assistnce with information to
service users re choice of
Medicines
Continued therapeutic monitoring of
medicines (blood samples if required)
Crisis
Resolution/
Home
treatment
teams
AOT
Undiagnosed
General Public
presenting with
mental health
problems Pharmacist
role includes signposting & referrals
GP
Current medication check with
GP/CPN
Medication Review on admission,
assessment of current medicines,
and appropriateness, interactions,
doses etc.
Baseline bloods for U&Es Liver
function tests if required
Medication review and advice for
further treatment
Dispensing of required Medicines
Continued monitoring for side effects
and physical parameters
Dispensing of medicines not kept
on stock on the ward
Supplementary & independent
prescribing
Assessment and advice for tretment
of minor ailments
GPs/ CMHTs &
Voluntary Agencies
1st Outpatients appointment
post Discharge
Dispense of medicines for
Outpatients
Pharmaceutical Care
in the community /
prisons
Advice to medical staff re
switching/stopping meds
Diagnosed patients
Medication review clinics
Pharmacist support roles
range from core to
specialist activities
Follow-up by MH/PCT pharmacist
re efficacy, symptom control, side
effects.
Written and verbal counselling re
meds – side effects etc.
AOT = Assertive Outreach Team
GP = General Practitioner
8
Continuing Secondary Care
A&E
Discharge
Prior to discharge
Copy of discharge letter to GP
with medicines & continued
monitoring re shared care
medicines
Self administration scheme set up to
aid concordance on discharge
Telephone Medicines Helpline
available
access to Pharmacist for
advice/meds information
Liaison with CPN/GP/community
pharmacy re discharge medicines
and continuing Monitoring
Advice/assistance regarding
compiance aids
Liaison with CPN, AOT etc.
Dispense medicines with PILs and
Telephone Helpline Card
Possible continued dispensing of
medicines from secondary care
Counselling re medicines for
discharge
CMHTs = Community Mental Health Team
A&E = Accident & Emergency
4. Pharmaceutical Care in
Mental Health and Examples
of Model Schemes
The role of the pharmacist in promoting mental health and supporting those people with
mental illness can be wide and varied, primarily depending on: the population needs, the
individual patient’s needs (eg, additional physical illness, particularly in the elderly), the
sector of care that the pharmacist works in, their interest in getting more involved in this
area and the level of expert knowledge and skills. The levels of mental health services that
can be provided by pharmacists in a primary care setting is demonstrated in the Mental
Health Pharmaceutical Care Matrix detailed below.
Mental Health Pharmaceutical Care Matrix
The Mental Health Pharmaceutical Care Matrix draws on the concept of ‘Levels of Care’. The
aim of the matrix is to enable pharmacists and/or commissioners to develop tiered ‘Levels
of Care’ models that are locally integrated and appropriate as per local patient/population
needs. It is likely that service providers (i.e. pharmacists) as well as local commissioners will
not be able to focus on all elements of mental health care at one time. It will therefore be
important to respond to the needs identified in healthcare needs assessment and the local
and workforce capabilities and to prioritise accordingly.
9
Figure 1: Mental Health Pharmaceutical Care Matrix
NEED
ROLE
LEVEL 1
LEVEL 2
LEVEL 3
Active health
promotion
Identify risk and
signpost
Assess
and treat
Education and
signposting
Adherence
coaching
Specialist
service
Supply + service
Extended
treatment
(prescribing)
See Table 3 page18 for more details
Supply
medication
+ supporting
information
PATIENT
BENEFITS
Inclusion in local
community
Ready access to
self care initiatives
Ready access to
specialist service
DEVELOPING THE
WORKFORCE
health
Core mental
health
Enhanced mental
health
competencies
PhwSI
Prescriber
ENVIRONMENT
Silo working +
signposting to
services
Integrated working
+ referral to
services
Leading service
redesign
PROMOTION OF
MENTAL HEALTH
AND WELL-BEING
See Table 1 page13 for more details
OPTIMISING
MEDICINES
INTERVENTIONS
See Table 2 page15 for more details
PROVIDING
TREATMENT
CAPABILITY
PhwSI= Pharmacist with Specialist Interest
The principles of this matrix are that the services:are additional to the core dispensing supply and core contractual services
are individual i.e. not ‘one model fits all’ – may move up different roles to different
levels and at different rates dependent on local need and capability
must address local needs
must be commercially sustainable
outline competencies and facilities needed to provide services
demonstrate continuity and quality as critical factors
10
The value of specifying levels of services
There are a number of important features that should apply to most of the service levels
outlined in this matrix. These will be crucial to ensuring quality of care. Failing to take them
into account may considerably reduce the potential benefit and outcome for people with
mental illness.
These features include that service levels are:
Developed in a co-ordinated way, taking full account of the responsibilities of other
agencies in providing comprehensive care.
Designed in response to the local needs assessment, ensuring the service can meet the
specific needs of the local population.
Take note of the principles of delivery for all long term conditions, embodied in the
service delivery.
Take into account the overarching principles of the mental health policy drivers.
Ensure and demonstrate that staff have the competencies needed to deliver the
functions.
Covered by written protocols and guidance that are adhered to and monitored.
Covered by locally agreed plans to deliver key outcomes such as timeliness, continuity
of care etc.
Providing a range of services to those people who are not able to access services in line
with the locally agreed model of care, e.g. residential homes, prisons, travellers,
housebound, those with long term complications and disabilities.
Locally audited.
Actively monitored with respect to uptake of the service, responding to non-attendees,
monitoring complaints and managing outcomes across the population of patients by
seeking out areas and individuals where further input would create improvements.
Developed and designed involving people with mental illness, service user
representatives and champions, and all clinicians, specialists and generalists,
depending on the level of care being provided.
The Levels of Pharmaceutical Mental Health Care and examples of roles and services under
each level are detailed below in tables 1-3.
The Mental Health Pharmaceutical Care Matrix sets out information under the following
categories (see Figure 1):
1. Heading – the name of this part of the service
2. Descriptor – a more detailed description of what this part of the service aims to
11
3. Service levels – tiered service levels under each service heading ranging from Level
1 (least specialist service) to level 3 (most specialised service). These service levels
are value-added services in addition to the core pharmacy services that are currently
in existence and being provided by pharmacists (an overview of such core services is
summarised under each service heading).
4. Suggested key patient benefits (or outcomes) – suggestions of outcomes that
providers might want to specify as part of the agreed contract. It is assumed that the
suggested key patient benefits (or outcomes) can also be used as evidence for
improvement.
5. Developing the workforce – key consideration for the workforce development
planning in readiness for each level of service provision
6. The environment – an indication of the degree of engagement with local agencies
and where the service provision takes place
12
4.1 – Table 1: PROMOTION OF MENTAL HEALTH AND WELL-BEING (See 5.1 on page 19 for further information)
DESCRIPTOR
ROLE
Promote mental health
and well-being
Service that actively seeks to increase awareness of mental health problems with the public and offers active intervention as well as helping to minimise the risk of stigma attached to mental illness.
LEVEL 1
Active Health Promotion
LEVEL 2
Healthy Lifestyle Interventions
LEVEL 3
Health Assessment
For general public and those presenting with a mental health problem
For people with mental illness and those with long term conditions that
predispose to mental health problems
For people with chronic mental illness
Promote good mental health and support of mental illness to public,
patients and their families and carers through provision of information and
support materials. Link with national awareness campaigns and local
community initiatives
Stress Management – brief and structured intervention
Encourage leisure activities which promote relaxation e.g. meditation, yoga, Tai
Chi etc. Also packages which promote development of key Life Skills e.g. Living
Life to the Full at www.livinglifetothefull.com
Monitor progress of interventions e.g. provide regular follow-up and support
for people engaged in healthy lifestyle interventions to encourage a change in
lifestyle behaviours that lasts
Physical health checks
Diabetes assessment
Weight management – Structured support and healthy eating advice
Vascular assessment
Alcohol assessment –brief and structured intervention
Dementia screening
Exercise engagement – promote activity
Suicide prevention – in liaison with multidisciplinary team - Advise on safety in
overdose and improved adherence e.g. once daily regimes
Targeted signposting of individuals experiencing recent life events (eg. divorce,
bereavement, childbirth)
Promote physical health
well-being
Targeted signposting of ‘at-risk’ groups: e.g. those experiencing concurrent
chronic illness, recent life events, previous mental illness, concomitant
medicines, interactions and iatrogenic psychiatric symptoms and or long-term
conditions that cause mental health problems, carers.
Raise awareness of need to monitor side effects of medicines e.g. weight gain,
extrapyramidal side effects, sexual dysfunction.
NHS Life Checks (England and Wales)
Specialist cessation treatment provision: specialist cessation services for
those with mental illness coordinate with psychiatric secondary care services
and NHS Stop Smoking Services to offer ongoing smoking cessation support as
part of a more joined up health promoting service
Linking to smoking cessation campaigns and promoting its benefits on
improving both physical and mental health. Recognise increased challenge for
those with affective disorders to quit – liaise with community mental health
teams (CMHTs) on anxiety management, relaxation techniques, coping strategies
NRT engagement in group in partnership with CMHT groups or individual
smoking cessation counselling
Nicotine Replacement Therapy
(NRT) available to all with counselling NB a change in smoking habits affects
clozapine levels (clozapine often managed in secondary care and therefore
need to check if patient is taking the medicine; also liaise with wider CMHT
which is supporting the patient to adjust dosage and avoid risk of toxicity.)
Tailored education campaigns aimed at service users, carers and health
professionals (both specialist mental health and primary care) about the
effects of smoking on mental health, as well as on physical health
Stigma reduction &
privacy & dignity
promotion
Outreach care to deliver patient / carer information and education and
support services for minority communities
Support on environmental issues causing mental illness in partnership with
community mental health teams /local councils (e.g. homeless)
PATIENT OUTCOMES
Inclusion in local community
Ready access to self-care initiatives
Ready access to specialist services
DEVELOPING THE
WORKFORCE
Provide training to staff on good communication and listening with people with
a MH condition e.g. awareness of values based approached to communication
Behavioural change /motivational interview
Staff trained to be able to provide brief advice and signpost to services and
information
Attend psychiatric pharmacy courses and events to upskill on mental health
management
Leading at service redesign. Provide mental health leadership across primary
care in bringing together multi-professional groups across the primary,
secondary and other care sectors and liaison and best-practice sharing with
specialist mental health pharmacists.
Promote smoking
cessation
(specifically in mental
health)
Targeted follow-up post cessation: monitor mental state (especially of those
with depression since depression can worsen in a minority)
Smoking cessation prescribing
Weight management prescribing
Training for all staff in mental health settings on brief interventions and /or
extensive training for medical and nursing staff
Improved self-esteem and integration into society; extending life expectancy.
Champion carer and voluntary groups.
Hosting outreach support services: use of pharmacy locations to provide
hosting activities in partnership with local support groups.
Training of staff as to need for inclusion in physical health clinics
Postgraduate training in mental health
ENVIRONMENT
13
Signposting to services as appropriate
Referral to services as appropriate and liaison with CMHT
Liaison with CMHT, GP & secondary care as appropriate
Examples of ‘model schemes’
SHEFFIELD PCT COMMUNITY PHARMACY MENTAL HEALTH CAMPAIGN
‘Looking after your Mental Health’
Background
Launched in February 2009, the community pharmacy campaign was coordinated by the PCT’s Health Improvement Manager and
supported by a project group. The PCT’s Pharmacy team representatives were responsible for assisting in engaging the community
pharmacies. Furthermore, the PCT’s Enhanced Public Health Programme (EPHP) representatives were responsible for engaging with
PCT colleagues to ensure all community pharmacies in the EPHP areas were provided with support, and particularly information on
where lifestyle interventions can be accessed.
CAMDEN PCT
Community pharmacy mental health self-help support to individuals with mental health problems
Background
This pilot project, implemented for nine months in 2007-8, was collaboratively developed by the London Development Centre (LDC),
Camden PCT and Primhe (Primary Care, Mental Health and Education).
The service aimed to enhance the support and information sharing activity already routinely offered by many pharmacists to their
clients but with a focus on, and information about, specific mental health issues (depression and anxiety and encompassed
information about self-harm and other difficulties that may also be present when an individual is suffering from depression or anxiety).
The Campaign aimed to address 3 key campaign messages:1. Do you know how to look after your own mental health?
2. Is mental health affecting your work or ability to work?
3. Do you know who to speak to if you think you may need help or support?
The intention was to build on this campaign with subsequent campaigns (e.g. anti stigma) targeting what people can do to reduce
their risk of developing mental health problems.
Overview of process
The basic campaign covered all pharmacies across the city, with additional resources targeted in the EPHP areas. All pharmacies were
provided with a briefing pack containing the rationale for the campaign and information on where to access approved patient
information via the internet and other sources. Pharmacies in EPHP areas were offered a basic training pack targeted at non-clinical
pharmacy staff, which included
• how to identify those at risk;
• signposting for assessment;
• interventions.
Overview of process
Eight community pharmacists took part in the service pilot and were required to attend a comprehensive one full-day preimplementation and one half-day 3-months post-implementation training. The training focused on depression and anxiety and
successful implementation of the service as well as best-practice sharing. The participants were issued with a training resource pack
at the outset of the service and a stock of all self-help materials for dissemination. Post-training support via telephone and email
contact and site visits (including re-stocking of leaflets and other materials) were provided to the participants.
Prior to service launch, a press campaign to alert the local population to the availability of new materials at selected pharmacies was
released by the Service Project team. This included the preparation and dissemination of a poster via the Camden Library monthly
mail out to such local services as the Healthy Living Centres, GP surgeries, local branches of Age Concern, Mind etc.
Local mental health services, social services and voluntary sector organisations were notified and engaged in the service process
before its launch re: arrangements for support of patients with depression/anxiety presenting to a pharmacist and requiring referral
on for specialist support or assessment.
Service funding and remuneration
Funded by Camden PCT. Delivered as part of the Essential services element of the Pharmacy Contract.
Facilitators were made available to deliver the training sessions in pharmacies, where appropriate. Pharmacies were required to
complete a short questionnaire ascertaining number of leaflets ordered and distributed; number of people signposted to GP practice
and/or other services. All GP practices received a letter and flyer informing them of the campaign, and provided with the same
information on how to access approved patient information.
Service funding and remuneration
Campaign funded by PCT. Delivered as part of the Essential services element of the Pharmacy Contract, therefore pharmacies not
remunerated for this specific campaign.
Contact for more information:
Steve Freedman
NHS Sheffield Deputy Head of Medicines Management
Tel: 0114 305 1134
E-mail: [email protected]
14
Contact for more information:
Neeshma Shah
Head of Medicines Management and Pharmacy
Camden PCT
Tel: 020 3317 2748
E-mail: [email protected]
4.2 – Table 2: OPTIMISING MEDICINES INTERVENTIONS
DESCRIPTOR
ROLE
Safety of medicine
treatments
Ensuring patients (and their carers and families where required) understand and take medicines as intended through periodic review of patients on medicines for mental illness and proactive approach to identify and support people at high-risk of
developing mental illness; with intervention by the pharmacist and referrals to other healthcare professionals where appropriate. Service delivered as an integral part of the patient care pathway for mental illness and in collaboration with the
healthcare team.
LEVEL 1
Proactive assessment and response to side-effect management and adverse
drug reactions (e.g. can be as an integral part of Medicines Use Reviews)
LEVEL 2
LEVEL 3
Targeting individuals to assess and manage therapy response, side-effects and
adverse drug reactions
Therapeutic blood monitoring of medication(s) and subsequent potential
required changes in patient medication and patient response management.
Identify all medication prescribed (including clozapine as it may be supplied by
secondary care),and purchased (including herbal and homeopathic remedies)
Medication reviews and near patient monitoring: Monitoring blood such as
glucose and lipid levels.
Appropriate patient targeting, with quality outcomes. Pharmaceutical care
assessment and advice on medicines and self care
Clinical medication reviews – Offers regular follow-up and support, specialist
pharmaceutical care and advice on medicines management and domiciliary
visits including removal of excess stores of medicines and communication of
adherence with prescribers
Identify if the person has a Care Programme Approach (CPA) record for their care
and name of Care Coordinator – if they agree.
Targeting could for example include:- patients on psychotropic medicine, high
risk groups [elderly, chronic illness, diabetes, Parkinson’s disease, dementia]
Provide input and information for CPA meetings
Prescribing role with appropriate training and liaison with
CMHT/GP/secondary care pharmacists
Training to undertake side effect assessments e.g. LUNSERs (Liverpool
University Neuroleptic Side Effect Rating Scale)
Supervision of consumption of psychotropic medication on community
pharmacy premises
Improving adherence with agreed clinical management or treatment plans
and adherence to agreed interventions and medical treatments
Adherence assessment with agreed management plans as part of patient care
pathway in discussion with the Mental Health Multidisciplinary Team.
Specialised pharmaceutical services to maintain independence and facilitate
rehabilitation, including provision of a range of aids to support self
administration
Address OTC purchases e.g. antacids and NSAIDs for people on lithium.
Medication review
Aiding adherence
Medicines Use Reviews
Ensure patients with mental health conditions have access to the service
Assess Adherence: Management of patients on repeat prescriptions in
community pharmacy and in partnership with community mental health
teams (CMHTs)
Proactive management of patients not collecting their repeat prescription on
time and feedback potential issues to CPA, where relevant
Aiding adherence, including:–
• Emergency supply of repeat medicines (in accordance to the emergency
supply legislation) for patients who have run out of medicines and request
emergency supplies at the pharmacy.
• Asking patients about any leftover medications at home and inviting them
to bring them in when collecting next prescription to determine nonadherence and hoarding
• Instalment dispensing
• Monitored dosage systems used as appropriate
Monitoring of Community Treatment Orders (CTOs) / For patients with
treatment orders for supervised therapy in pharmacies which would allow
treatment in the community rather than in mental health units or day care
facilities.
Promoting and prescribing of evidence-based treatments known to also
reduce risk of suicide and relapse
Patient actively involved in the choice of medication
Care Programme Approach liaise and communicate all relevant information
(with patient consent) as appropriate
Training and advice
Provision of training in safe use of medicines for voluntary sector and care
staff (especially in forensic and mental health hostels)
Provision of training in safe use of medicines for patient groups and patient
support organisations and training on psychopharmacology – understanding
mechanisms of action and interactions
Specialist pharmaceutical advice on mental health therapy for clinicians and
other healthcare professionals.
Providing services in special circumstances, e.g. medical input to
multidisciplinary primary care mental health teams, residential care, custodial
or Mental Health Act (section 12) settings
Therapeutic Interventions
Proactive assessment of patient’s understanding of their medicines, its
efficacy and perception of benefit in relation to symptoms
Proactive assessment of side effect experience for the patient and
appropriate advice and/or referral
Monitoring of recovery to ensure the prescribed medication is having desired
effect and referring as appropriate if signs and/or symptoms of relapse,
inefficacy or non-adherence resistance or deterioration of condition
Early intervention in psychosis services
Relapse management services /link to crisis resolution support services and
facilitation of medicines supplies to those returning home from secondary care
needing to reengage with their community.
PATIENT BENEFITS
Pro-active provision of advice and input; may prevent non-adherence due to
side effects etc
Regular review of pharmaceutical care issues; pro-active help and support of
medicine taking behaviours
Ready access to specialist care in terms of crisis/relapse or change of
underling condition or early identification of symptoms
DEVELOPING
WORKFORCE
Knowledge of clozapine to provide patient advice when required. Awareness of
treatment issues e.g. safety concerns, Mental Health Act, ‘red’ drugs (England
only). Appropriate training in communication skills.
Driver of change at operational level in managing and delivering of the
services
Providing strategic leadership, service redesign, direction, education and
clinical support
ENVIRONMENT
Signposting to GP/services as appropriate
Liaison with CMHT and GP
Bringing together multi-professional groups across the primary, secondary and
other care sectors
15
Examples of ‘model schemes’
SHEFFIELD MEDICINES INFORMATION EXCHANGE SCHEME
Management of patients on repeat prescriptions in community pharmacy and in partnership with CMHTs
Background
Launched in December 2008; designed to pilot a pathway for community pharmacy to alert the community mental health team
(CMHT) whereby a client has not collected their repeat medication (prescribed for mental health disorders) from community
pharmacy. Currently there is no formal mechanism by which the mental health team can be alerted if a client fails to collect their
medication from pharmacy. Whilst this collection is no guarantee of adherence it is an assurance of collection of medicines. By
exchanging information between the community pharmacy and the CMHT, the scheme aims to help manage risks which may arise if
the patient does not take their prescribed oral medicines regularly.
Designed collaboratively between NHS Sheffield and the Sheffield Health and Social Care Foundation Trust and in consultation with
the Local Pharmaceutical Committee (LPC).
Overview of process
Once the person is registered with the scheme, the pharmacy obtains repeat prescriptions from the GP at the appropriate intervals.
The person will collect the medicines from the pharmacy as agreed. If the medicines are not collected within the specified number of
days of the expected collection, then the pharmacy contacts the community mental health team by faxing the team using a
standardised form. Once the community mental health team is informed of non-collection, then they will act in accordance with a
specific care plan for that person. The care co-ordinator will liaise with the pharmacist about arrangements for next collection.
SOUTH TYNESIDE PCT
South Tyneside PCT-Supervision of consumption of Non-CD Drugs on Community Pharmacy Premises
Background
The scheme aims to:• ensure the safe and appropriate use of agreed non-CD drugs (benzodiazepines, naltrexone, disulfiram) supplied by instalment
• ensure the patient for whom the drug is prescribed is the patient who receives it and takes it
• reduce the risk of “leakage” or “spillage” of drugs liable to misuse into the community
Pharmacists accredited by South Tyneside PCT to operate the scheme.
Overview of process
The patient is introduced to the pharmacy by a member of the DAT. A contract will be agreed between the patient and the pharmacy
covering aspects such as when to attend, missed doses cannot be dispensed, weekend arrangements, the agreement that relevant
information will be shared with the general medical practitioner (GMP) and community psychiatric nurse (CPN) and confidentiality.
Prescriptions (and any accompanying forms for daily dispensing and supervision) will be brought to the pharmacy by member of the
drug and alcohol team.
The initial instalment of any non-CD drug is supplied to the patient accompanied with a patient information leaflet. GMP and CPN are
informed if the patient obtains injecting equipment from the participating pharmacy.
Service funding and remuneration
Locally agreed, funded and paid for by NHS Sheffield. Pharmacy contractors remunerated for an initial set up fee, followed by a service
fee per registered client per month.
Service funding and remuneration
Funded by South Tyneside PCT. Pharmacy contractors remunerated per supervision upon provision of claim form and a photocopy of
original prescription.
Contact for more information:
Chris Hall
Senior Pharmacist
Sheffield Health and Social Care Trust
Tel: 0114 2718632
E-mail: [email protected]
Contact for more information:
Kathryn Featherstone
LPC Secretary, Sunderland LPC
Strategic Development Officer, Sunderland LPC
Support Officer, Gateshead and South Tyneside LPC
Tel: 0191 385 7127
E-mail: [email protected]
16
Examples of ‘model schemes’
EAST RIDING OF YORKSHIRE PRIMARY CARE TRUST
LOCAL ENHANCED SERVICE: MEDICINES MANAGEMENT SUPPORT OF VULNERABLE ADULTS
Background
The service enables participating community pharmacies to help support vulnerable people, who require more support than one-off
adjustments, as covered under the Disability Discrimination Act 1995 criteria. The service does not specifically target mental health
illness, however, it includes vulnerable people who may have mental illness.
The service aims to:• support independent living;
• help people manage their medicines safely and appropriately and reduce wastage;
• improve patient adherence with therapy and providing advice and support, including referral to the PCT Medicines
Management Team or GP for further referral to other health and social care professionals where appropriate.
Overview of process
The enhanced service is commissioned from community pharmacies providing the full range of Essential Services as defined by the
Pharmacy Contract. The PCT agrees the patient eligibility criteria for the service, assessment of patient’s support needs and the referral
mechanisms. Participating pharmacies are contacted by the PCT Medicines Management Assessment team for professional discussion
to establish the patient’s need prior to completing the Patient File and Action Plan. Using the ‘Open Action Planning’ process the role
of the PCT Medicines management Team and the community pharmacist is established in the patient care management. The
community pharmacist is required to evaluate and address the patient’s medicines management needs using pre-requisite
requirements. A framework is utilised to capture service data for purposes of sharing relevant information with other healthcare
professionals, auditing and pharmacist remuneration.
Service funding and remuneration
Funded by East Riding of Yorkshire PCT. Pharmacists are remunerated according to three levels of service provision depending on
individual patient needs:• Level 1 – Review and monitoring
• Level 2 – Moderate support (with review and monitoring)
• Level 3 – Higher level support (with review and monitoring)
Contact for more information:
Cath Boury
Newland Community Pharmacy Ltd.
E-mail: [email protected]
17
4.3 – Table 3: PROVIDING TREATMENT
DESCRIPTOR
ROLE
SUPPORTING AND
ADVISING ON
TREATMENT
Ensure patients and their carers and families, where appropriate, have access to timely healthcare services appropriate to their needs.
LEVEL 1
Minor Ailment Scheme
(diagnosis and advice on minor ailments, and medication supply)
Supply of clozapine in partnership with specialist mental
healthcare providers
LEVEL 2
LEVEL 3
Limited Treatment:
Extended Treatments:
• Supporting pre and peri-natal mental health and post partum advice and
signposting
• Supplementary or independent prescriber
under supervision of /liaison with secondary care
• Supervised consumption of psychotropic medication
• Managing more complex therapy for people with mental health conditions
and those with significant co-morbidities, for example:
Provision of written and/or individualised information
• Smoking cessation – accredited 1:1 plus NRT
NB. – Provision of supportive advice to patients on off-label medicine e.g.
valproates for mood disorders – patient information leaflet refers to licensed
use ie epilepsy which can be confusing for the patient and needs to be
explained to them
• Weight management – structured support and PGD
¡ specialist lithium or clozapine clinics
• Sleep hygiene clinics - structured support without provision of medicines
and PGD
¡ depot antipsychotic medication clinics
¡ ‘medically unexplained symptoms’
• Alcohol use – assessment and support and referral
¡ treatment-resistant symptoms
¡ long-term medical conditions
¡ pre- and peri-natal mental health and advise risk post partum
¡ older people’s mental health
¡ eating disorders
¡ prison health care
• Medication history preparation and subsequent choice of medication
DOMICILIARY SUPPORT
Provision of medication supply in most appropriate form and time for
patient and general pharmaceutical advice
Proactive engagement as part of a structured service provision programme.
E.g.
• Medication reviews
• Adherence assessment
• Training of staff / carers and healthcare professionals
Leading in initiating and developing the way medicines are used by the
multidisciplinary healthcare team and the patient, in liaison with secondary
care expertise Assertive Outreach Team /Crisis Response Team
Leading in initiating and developing the way medicines are used by the
residential facility
RESIDENTIAL SUPPORT
PATIENT BENEFITS
Ready access to treatment and support for minor ailments. Less time to
being assessed
Access to specialist advice in specific areas of need
Access to specialist services which may form part of continuing care needs and
support for individuals with a chronic mental illness
DEVELOPING THE
WORKFORCE
Appropriate training in communication skills and minor ailments
Appropriate training in clinics being offered
Providing strategic leadership, service redesign, education and clinical support
for pharmacy
ENVIRONMENT
Education of staff to support patients with mental health issues, suitable
premises and equipment
Appropriate clinical premises and equipment. Confidential record keeping and
documentation. Share of information (with consent) as appropriate
Bringing together multiprofessional groups across the primary, secondary and
other care sectors
18
5. Considerations for Pharmacists
in Mental Health
5.1 Promotion of Mental Health and Well-being:
considerations (See Figure 1 page 10 for Pharmaceutical
Care Matrix)
Background
What is good mental health?
“Mental health influences how we think and feel, about ourselves and others and how we
interpret events. It affects our capacity to learn, to communicate and to form and sustain
relationships. It also influences our ability to cope with change, transition and life events –
having a baby, going to prison, and experiencing bereavement. Mental health may be
central to all health and well-being, because how we think and feel has a strong impact on
physical health”1
Who is at a greater risk of mental ill health?
Up to 50% of people with a chronic medical illness (e.g. diabetes, chronic obstructive
pulmonary disease or cardiovascular disease) develop a clinically significant
depression; negatively impacting the outcome of their physical illness.
Individuals with a continued exposure to poverty, social exclusion, inequality or
discrimination can develop mental ill health with a resultant negative effect on their
physical health.
Mental health promotion can:
improve physical health and well-being
prevent/reduce the risk of some mental health problems
assist recovery from mental health problems
improve mental health services and the quality of life for people experiencing mental
health problems
strengthen the capacity of communities to support social inclusion, tolerance and
participation and reduce vulnerability to socio-economic stressors
increase the ‘mental health literacy’ of individuals, organisations and communities
improve health at work, increasing productivity and reducing sickness absence
19
Issues
Stigma and Mental Health
Everyone has mental health needs. If needs are not met and individuals feel excluded, different
or unsafe, mental well-being may deteriorate and a mental health problem may develop.
Other findings demonstrate that not only does the community at large maintain a stigma
about people with a mental illness but that workers within the mental health profession may
also enforce this negative attitude.
Ethnic minorities are: much more likely to:
much less likely to:
receive a diagnosis of schizophrenia
– be offered psychosocial treatments
be detained under the Mental Health Act
experience social exclusion and discrimination
• commit suicide
Consideration of an individual’s cultural and religious beliefs in relation to the presentation
of their mental health illness symptoms is important.
People with a chronic mental health problem are
more likely to be long-term unemployed and/or
rely on state benefits due to the associated stigma of mental illness and discrimination
by prospective employers
Recommendations and Potential Solutions
Look after your mind
Evidence2 suggests that there are simple steps people can take to protect and maintain
their mental well-being. Pharmacists as healthcare providers and as well as being employers
can help by making the public (and their staff) more aware of these healthy choices:-
Tips for staying happy:
1. Keep physically active
7. Care for others
2. Eat well
8. Get involved, make a contribution
3. Drink in moderation
9. Learn a new skill
4. Value yourself and others
10. Do something creative
5. Talk about your feelings
11. Take a break
6. Keep in touch with friends and family
12. Ask for help
Useful Patient information leaflet : How to look after your mental health
20
Pharmacist Roles in Mental Health Promotion (See Table 1 page 13 for further details)
Pharmacists have the opportunity to provide services in the following levels:General:
Ensure no interactions with prescribed/OTC medication including herbal remedies
Ensure appropriate information about medication and/or condition available
Raise public awareness of good mental health in the local community
Link in with National or International Mental Health Week and provide leaflets on diet,
exercise, stress management, alcohol use (see health awareness events link
http://www.infolinkcheshire.nhs.uk/default.aspx?pg=bbea5179-1028-4d43-9a60d5093fdfb1bf )
Support and advise carers on medicines and administration of medicines
Level 1 Services:
Signpost people at risk (those with concurrent chronic illness, the unemployed, those
experiencing recent life event/s e.g. bereavement, work-related stress; previous
episode of depression, carers); especially when responding to symptoms and refer
as appropriate.
Identify new patients (i.e. new prescriptions and ensure understanding of mental health
problem, treatment and available support including information on adverse effects,
treatment outcomes, concordance and support groups)
Identify pharmaceutical issues (interactions; OTC medication; alcohol, smoking, caffeine)
Link with CMHTs / MHO’s as appropriate
Level 2 Services:
Drop-in advisory sessions such as:→ Weight management
→ Use of alcohol
→ Smoking cessation
→ Diet and exercise
Liaise with other members of the community mental and general health team and carers
to improve the quality of pharmaceutical care for people with a mental health problem.
Level 3 Services: Specialist Mental Health Level; Pharmacists role in effective care for
those with chronic mental illness
Ensure evidence-based approach to minimising symptoms and side effects
Treatment optimisation
•
Physical health monitoring
Treatment response monitoring
Active patient follow-up
21
Prescribing
Role in suicide prevention in liaison with multidisciplinary team:
→ recognise signs of relapse and refer as appropriate
→ promote evidence-based treatments such as lithium for bipolar affective disorder
and clozapine (initiated in secondary/hospital care) for schizophrenia which
reduces mortality of people with severe and chronic illness.
Liaise with CMHT, GP and secondary care as appropriate
Useful resources
DH 2007. Choosing Health Through Pharmacy. Section 3.2 “How pharmacy can help
reduce inequalities in health”
Stigma: The Royal College of Psychiatrists ‘Changing Minds Campaign’ aimed to address
the role that psychiatrists and other health professionals play in the maintenance of
stigma associated with providing healthcare services to people with a mental illness.
See Me campaign: Scotland’s national campaign to end stigma around mental ill-health
Pharmacy Guidance on Smoking and Mental Health (Feb 2010).
Smoking calculator:
Depression self-assessment
DH Carer website:
Patient information leaflets
Range of Patient information leaflets available on Mental Health Foundation website:
Review articles
Models of MH promotion (NHS Evidence - Mental Health 2004)
Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for
smoking cessation. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.:
CD003698.
Best practice examples:
Health promotion- Scotland:
1.
2.
22
Making it happen: a guide to delivering mental health promotion (DH 2001)
Making it possible: Improving Mental Health and Well-being in England (CSIP 2005)
5. 2 Communicating with People about Mental Health
Issues: considerations
Communication is a complex process where what is ‘heard’ is influenced not only verbal
content (about 7%); but by tonality and volume (38%); and body language (55%). It is very
much a two-way process and we also need to be aware of the person’s response to us and
the information that we are trying to give.
Miscommunication forms the greatest reason for dissatisfaction with a patient and health
care provider consultation resulting in an evident move towards a patient-centred
communication process, where the patient is involved in the decision-making processes and
subsequently more likely to follow the treatment plans.
Key principles
of effective communication
Listening entails making eye
contact; the use of non-verbal
feedback such as smiles, nods or
interested body language. The use
of verbal sounds (‘yes’ ‘oh’ etc)
also help.
Briefly summarising the
conversation ensures understanding
by checking your understating of
their problem
Frequent checking of
understanding is advised and also
the recognition that people cannot
remember large chunks of
information.
It is often best to give smaller
chunks of information repeatedly
until you are sure understanding is
gained, rather than a large chunk
at once.
Slow, clear and articulated
speech - specific and personalised
to the person
23
A step-wise communication
approach with mutually agreed
achievable targets has been shown
to be more effective in the long run.
For example, leaving information
leaflets/booklets with the person to
review at leisure and review jointly
later is a beneficial approach.
General principles
Communication processes can be
impaired by other factors which can be
overcome by ensuring:- :
reading or sight glasses are on and
clean during review of written
information (if worn)
hearing aids have a working battery
and are switched on (if worn)
false teeth are being worn properly
(if worn)
you are facing the person and that
you maintain eye contact and
speak slowly, and with a moderate
volume and tone.
Communicating with Patients with Dementia: hints and tips
Importantly patients with dementia are still able to communicate and will probably enjoy
the opportunity to do so; however retaining the information is probably difficult and unlikely
to be sustained beyond 5-10 minutes.
Communicating with Patients with Dementia: hints and tips
ALWAYS provide written back-up of information. (NB impaired memory is a part
of normal ageing and written supporting information is also needed).
supporting information may be necessary from relatives or caregiver(s) if
accurate and reliable information is needed
capitalise on the preserved memory systems:Communicate in a quiet area (turn down radios or televisions)
Simplify your sentences
Slow your speech rate (but not too slow)
Limit the number of participants in the conversation
Vary the pitch and tone of your voice
Use a pleasant, accepting tone
Talk about the here and now, not the abstract
Simplify your vocabulary
Ensure that what you say is understood
Ask yes, or no not multi-choice questions
Summarise if the patient forgets
Use direct language where ever possible
Avoid teasing and sarcasm
Speak clearly and audibly
Communicating with a Person who is Agitated; hints and tips
Evidence suggests that two-thirds of all violence against (inpatient) healthcare professionals
is preceded by a verbal direction given to a patient with increasing agitation or aggression
with less than appropriate delivery e.g. given in a raised voice or with anger or impolitely.
De-escalation of aggression includes verbal interventions to try to bring calm to the situation.
Sometimes, decreasing the noise or activity level in the immediate area can help.
24
Communicating with a Person who is Agitated; hints and tips
Remain calm, becoming aware of what the person is saying and doing, and
maintain respect for the person not the behaviour
Make them feel safe
Share your observations non-judgmentally and listen to what is being said
Identify what is causing the issue and/or feeling
Assist the person with developing more productive avenues to express feeling
You may need to take them to a quiet part of the pharmacy or to a consultation
area; if appropriate notify colleagues if you are going to do this alone
Keep the doors open so they feel able to leave and not feel trapped
Ascertain if there is anyone they would like you to contact or they would like to
make contact with themselves (Some patients may be managed by a Care
Programme Approach, which outlines this information and gives contact
numbers of relevant healthcare professionals).
Useful Resources:
For brief advice versus brief interventions see :
http://www.pharmacymeetspublichealth.org/pdf/10389%20BA%20vers%20BI%20doca.pdf
O’Connell. Improving compliance and communication in psychiatric care. Hosp Pharm.
2003;10:225-228
http://www.pharmj.com/pdf/hp/200305/hp_200305_psychiatriccare.pdf
Oliver James. Improved communication skills for working with people with dementia in
‘Contented Dementia’. Published by Vermilion an imprint of Ebury Publishing in 2008.
5.3 Improving Medication Adherence: considerations
Issues
People with chronic mental health conditions have an increased rate of relapse if
adherence is poor. The vast majority of these people are cared for in primary care. It is
therefore important that people with chronic mental health conditions are identified and
followed up at regular intervals.
25
Patient Education about Medication
Understanding the needs of the individual (and family or carers) for knowledge and
information about their condition and its treatment is of paramount importance. Often,
individuals’ concerns are very different from those of healthcare professionals. It is
important that these concerns are identified in order to establish a good therapeutic
relationship; the cornerstone of which is trust.
Be clear when medicines are given Off-Label , as the patient information leaflet will cover
information around its licensed use which can be confusing for the patient and needs to be
explained to them, for example, valproate used for mood disorders and clonazepam used
in anxiety will both contain information on epilepsy in the patient information leaflets.
Common patient concerns about their medication
Are there any foods or drinks that I should avoid?
Will they affect my other medications?
If I am taking the oral contraceptive pill, will this be affected?
Will I need a blood test?
Can I drive while I am taking this medication?
The most frequently asked questions
What is this medication used for?
How does it work?
How should I take it?
When should I take this medication?
How long will it take to work?
For how long will I need to keep taking it?
Are they addictive?
Can I stop taking them suddenly?
What sort of side effects may occur?
What should I do if I forget to take a dose?
Will they make me drowsy?
Will they cause me to put on weight?
Will they affect my sex life?
Can I drink alcohol while taking this medicine?
26
General measures to improve adherence
1. Simplify the medication regimen
Tailor the dosage times to the individual’s lifestyle e.g. if the label says ‘Take one
every morning’ and the person does not get up until midday, it is unlikely the
medication will be taken. Agree times that are appropriate.
Educate the person in terms that they understand
Ask the person what information is most important for them e.g. side effects and
what to do about them, repeat prescriptions, payment issues
Dispense the medication with labels that can be read and with clear instructions
Provide written backup information
Provide the individual with a medicine reminder card if needed.
2. Ensure Medicines Are Taken Correctly
Stand or sit upright
Keep head forward and down
Place capsule/tablet in front centre of tongue
Take a sip of water
•
Swallow while keeping head forward and down
Wash down with 100ml of water (half a glass)
Follow label instruction for timing of dose with respect to food, if appropriate.
Other considerations: Covert Administration of Medicines
Covert medication is sometimes necessary and justified, but should never be given to
people who are capable of deciding about their medical treatment. Giving medication by
deception is potentially an assault. Legally patients must give consent to treatment and
even if a patient is deemed to be unable to give consent, no one else can consent to
treatment on that patient’s behalf (although in practice the wishes of the family or carer or
friends are usually taken into account as well as the best interests of the patient). However,
under the Mental Capacity Act a decision to treat covertly can be made with appropriate
consultation and documentation if shown to be in the best interest of the individual and
regularly reviewed. Pharmacists are reminded that covert administration of medicines must
only be undertaken in accordance with a locally written policy and where relevant
pharmacists must advise on suitable formulations for giving covertly e.g. liquid or crushing.
It is best practice that there should be a multidisciplinary meeting about what medicines
the patient should be prescribed. Where possible a patient advocate should be appointed
to ensure that the best interests of the patient are maintained. Patients needing rapid
tranquilisation (that is sedation when in a high state of excitability, as in acute psychosis)
are only so treated when the patient becomes a danger to themselves or to others. It is best
practice to ‘talk the patient down’ as administering medicines without consent (even if
27
capacity is temporarily absent) may be detrimental to the future once the patient regains
insight. Detained patients are subject to Consent to Treatment Legislation Mental Health Act
Section 58 – emergency treatment which has not been previously consented can be given
under Section 62.
Useful Resources:
RPSGB Law and Ethics Bulletin: Covert administration of medicines. Pharmaceutical
Journal 2003:270:32 (Jan 4)
The Royal College of Psychiatrists publication on covert administration:
The Mental Welfare Commission for Scotland - The legal and practical guidance on
covert medication
The UKCC statement on covert administration:
NICE Clinical Guideline, Medicines Adherence: quick reference guide for pharmacists
Medicines Partnership. A question of choice; compliance in medicine taking. October
2003.
O’Connell. Improving compliance and communication in psychiatric care. Hosp Pharm.
2003;10:225-228
Patient Support Resources
Patients Choice:
United Kingdom Pharmacy in Psychiatry Group (UKPPG):
Stephen Bazire. ‘Drugs used in the treatment of mental health disorders: Frequently
Asked Questions’ 4th edition 2004.Published Fivepin.
Stephen Bazire et al. ‘Medication Education Support Pack’ or “MedEd”.
NPC, NIMHE, DH (March 2005) Improving mental health services by extending the role
of nurses in prescribing and supplying medicines. Good Practice Guide.. (useful
resources for developing a medicine education session for people with mental health
problems, their carers and/or staff):
28
5.4 Supporting People at Risk of Suicide: considerations
Suicide Risk in Metal Illness
The risk of suicide is increased in most mental illnesses including: depression, schizophrenia
and bipolar affective disorder; especially if the sufferer is under the age of 25 and/or is
male. The majority of people who attempt or succeed at a suicide contact a healthcare
professional perhaps one or two weeks before their attempt. Developing positive
relationships with people with a mental health disorder can be beneficial to the person’s
well-being and perhaps reduce the risk of a suicide attempt.
Depression – Around 15% of people with depression will eventually commit suicide. Young
and recently widowed men are at an increased risk of attempted suicide. Assessment of the
risk of suicide is, therefore, extremely important. It is a myth that questioning patients about
suicidal ideas or thoughts may provoke suicide attempts. Most people do not want to die
they just see it as the only way out. Listening to people and offering support and/or
signposting can make a real difference.
Schizophrenia is associated with a significant suicide risk. The lifetime risk of people with
schizophrenia committing suicide has been estimated at 10%.
Bipolar affective disorder is associated with a significant mortality rate that is two or three
times greater than in the general population. Between 10% and 20% of bipolar sufferers
commit suicide, mainly during a depressive episode. Almost a third of patients admit to at
least one suicide attempt. Long-term lithium prophylaxis has been shown to reduce the rate
of suicide.
Reducing Suicide Risk: Pharmacists Role
Anybody expressing strong suicide ideas or wishes should be referred as an emergency to
specialist psychiatric services; ensure you know how to do this. These services may include
Crisis Resolution or Assertive Outreach Teams or access via the local Accident and
Emergency department.
Pharmacists can:
recognise signs of mental illness relapse and refer as appropriate
recognise signs of mental distress when responding to symptoms and refer as appropriate
promote evidence-based treatments such as lithium for bipolar affective disorder and
clozapine for schizophrenia (in secondary care) which reduce mortality of people with
severe and chronic illness.
support people in the community with mental illness by providing education on their
treatment and
signposting to appropriate support agencies (these may be charitable or belong to the
National Health Service)
provide limited supplies of prescribed medication to reduce impulsive acts
be aware of the risks of OTC medicines for vulnerable groups
29
Recognising Suicide Risk
The SAD Personas Scale was developed by Patterson et al in 1983 to help to identify people
at risk of suicide and then guide clinical management. The ‘SAD Personas’ name is an
acronym for the 10 questions that need to be asked to assess suicide risk:
Sex (for males score 1 point)
Age (aged 18 to 25 score 1 point)
Depression (if present score 1 point)
Previous attempt (if present score 1 point)
Ethanol abuse (if present score 1 point)
Rational thought loss (if present score 1 point)
Social supports lacking (lives alone) (if present score 1 point)
Organised plan (if present score 1 point)
No spouse (or partner) (if present score 1 point)
Access to lethal means (if present score 1 point)
Sickness (if present score 1 point)
Higher scores are associated with a higher risk of suicide.
This is only guidance and one area, which this does not include, is if the patient is psychotic
and hearing a voice, which is telling them to kill themselves. The person may have a low
score on this scale but actually complete a suicide attempt.
The teen advice line suggests a number of behaviours that are associated indicators of
suicide risk: Referral to the GP or Child and Adolescent Mental Health Services (CAMHS) is
recommended as a priority.
Useful Resources
Mind’s Suicide rates, risks and prevention strategies information leaflets:
Department of Health (2002) National Suicide Prevention Strategy for England.
London:Department of Health.
Mental Health Foundation statistics:
Anyone concerned about a friend or relative who may be feeling suicidal recommended
Mind’s booklet How to help someone who is suicidal
Anyone who is experiencing suicidal feelings recommended Mind’s booklet How to cope with
suicidal feelings
30
Samaritans help and advice. Helpline tel: 08457 90 90 90
Help is at hand: a resource for people bereaved by suicide and other sudden, traumatic
death (2008 edition). Department of Health.
31
6. Mental Health Policy Drivers
in Great Britain
In Great Britain, mental health is a core part of the health and social care service
development agenda. Mental health remains a priority area in the NHS across England,
Scotland and Wales, and changes in the way services are now provided emphasise the
importance of primary care as a key setting for the identification and treatment of patients
with mental health problems.
The core of the policy drivers identify and advocate the need for collaboration across
multidisciplinary healthcare teams and organisations, management of the market and
improved procurement capabilities to ensure patients receive real choice, equity of service
and quality improvements.
Information on health policy drivers for each country is detailed below.
6.1 England Mental Health Policy Drivers
The major focus on commissioning, long-term conditions and on a shift towards quality and
safety driven by initiatives such as World Class Commissioning and the Darzi Review provide
opportunities to further improve how medicines are used in treating people with mental
health problems.
In addition, more pharmacy specific initiatives such as the Pharmacy in England White
Paper, National Patient Safety Agency (NPSA) Alerts and involvement in improving the safe
use of medicines in general, could enable the pharmacy profession to take a more
prominent place on the agenda of those responsible for commissioning and delivering
services. An overview of polices relating to mental health in England is outlined below.
The National Service Framework for Mental Health (NSFMH)
In 1999, the NSFMH laid out a series of seven minimum standards (see below) in five areas
for mental health services to address the mental health needs of working age adults up to
65; to be delivered over a ten-year period. It sets out national standards; national service
models; local action and national underpinning programmes for implementation; and a
series of national milestones to assure progress.
Standard 1
Standard 2 &3
Standard 4 & 5
Standard 6
Standard 7
32
Mental health promotion and discrimination/exclusion
Primary care access to services
Services for people with severe mental illness
Services for carers
Actions necessary to reduce suicides
The NSF five-year review
In addition to reviewing the progress of the NSFMH towards targets over the first five years, this
publication, released in 2004, also acknowledged challenges in other areas and pointed to the
diversion of money (away from mental health services) and existing inequities across the
country. The document set some new priorities for the next five years; such as ethnic minorities,
care of long-term mental disorders and workforce redesign. This report also put mental health
services in context of overall developments in health and social services.
As the NSFMH comes to an end of its lifespan in 2009, New Horizons for Mental Health is
the national vision for better mental health and well-being in England from 2010. Its agenda
sets out to improve mental health and well-being of the population through a framework
and improve the quality and accessibility of services for people with poor mental health and
mental illness. Key merging themes include prevention of mental health problems and
promotion of public mental health, stigma minimisation, early intervention, personalised
care, multi-agency commissioning and collaboration, innovation, value for money and
strengthening transition between services. An article on the contribution the pharmacy
profession can make to public health describes the “New horizons” strategy. (Shah C;
Aslanpour, Z. A new year, new horizons and a new agenda for public mental health.
Pharmaceutical Journal 2010:284:77-78 (Jan 23) ).
“Confident Communities, Brighter Futures. A framework for developing well-being”
(2010) outlines how to take forward the first aim of New Horizons – to improve the mental
health and well-being of the population. The report sets out the evidence for different
approaches to mental health improvement.
The National Service Framework for Older People (2001)
highlighted levels of depression and dementia among older people, and set its own
mental health standard, Standard 7: ‘Older people who have mental health problems
should have access to integrated mental health services, provided by the NHS and
councils to ensure effective diagnosis, treatment and support, for them and their carers’.
Our NHS, Our Future - High Quality Care for All
This report led by Lord Darzi (June 2008) sets a new foundation for a health service that
empowers staff and gives patients choice. It ensures that healthcare will be personalised
and fair, include the most effective treatments within a safe system, and help patients to
stay healthy. It sets out an opportunity to make mental health a priority for the NHS at
all levels with emphasis on prevention and promotion work around mental health.
Initiatives introduced such as care plans (Care Programme Approach) for those with long term
conditions, such as mental health, poses an opportunity for integrating pharmacy services into
the care pathways for mental health. This report further supports the potential role pharmacists
can play in meeting and optimising the care of people with mental health issues.
33
Implementing care closer to home - providing convenient quality care for patients: A
National Framework for Pharmacists with Special Interests
This initiative will enable the development of pharmacy services that require specialised
competencies. It is likely that this will apply to fairly small numbers of pharmacists /
services but these could be of extremely high value as they may be targeted at low
volumes of patients with high need around medicines management for mental health
Care Closer to Home
World Class Commissioning
World class commissioning builds on the Commissioning a Patient-led NHS (2005)
which defined the shift to a focus on commissioning through structure and process –
moving the emphasis from spending on services to investing in health and well-being
outcomes. The Department of Health advocates that Primary Care Trusts (PCTs) build on
this by adding vision and content and developing a consensus on the characteristics of
world class commissioning. Delivery of world-class commissioning will take place within
a commissioning assurance system. There are four key elements to the programme; a
vision for world class commissioning, a set of world class commissioning competencies,
an assurance system and a support and development framework.
To enable this, a set of competencies have been developed to support the process and are
important factors to be met when commissioning for Pharmacy-led services.
The Pharmaceutical Needs Assessments (PNAs) as part of world class commissioning:
guidance for primary care trusts published in January 2009, is a key tool for identifying
what is needed at local level to support the commissioning intentions for pharmaceutical
services and other services that could be delivered by community pharmacies and other
providers. It is aimed at directors of commissioning and pharmacy leads in PCTs and will be
of interest to providers of pharmaceutical services.
Practice based Commissioning: Practical implementation
Practice based commissioning: practical implementation (November 2006)
recommends that community pharmacy should be involved in the local population
needs assessments that underpin service redesign. Community pharmacy has a
significant role to play in engaging in Practice Based Commissioning (PBC) and PCTs will
want to play a facilitative role in nurturing collaborative approaches between practice
based commissioners and other key professions, such as community pharmacy.
Pharmacists could be well placed to develop business cases to PBC groups where they
are able to demonstrate impact on usage of antidepressants and antipsychotic
medicines. There may be an opportunity to develop interventions aimed at improving
adherence to medication, especially if they can be shown to have an impact on
prescribing costs and reduced wastage as well as quality.
34
Payment by results (PBR) – progress
A commitment was made in Lord Darzi’s Next Stage Review – High Quality Care for All – that
mental health currencies would be available for use in 2010/11. This will allow contracting
and payment for mental health in a consistent way, facilitating benchmarking and
comparison. National currencies allow the introduction of a national tariff in future.
As yet, mental health is not included in PBR. Subsequently, interventions in reducing
hospital costs are not yet the driver they might be in other therapy areas.
Pharmacy in England building on strengths – delivering the future (“Pharmacy in
England White Paper”)
This paper published in April 2008, sets out a vision for improved quality and effectiveness
of pharmaceutical services, and a wider contribution to public health. Whilst acknowledging
good overall provision and much good practice amongst providers, it revealed several areas
of real concern about medicines usage across the country. For example; 50% of patients
don’t take medicines as intended and 4% to 5% of all hospital admissions are due to
medicines-related problems. [For further information see the RPSGB briefing paper:
The vision directs pharmacists to focus on:promoting health and self care – such that community pharmacies become recognised
as “healthy living” centres promoting health and well-being to maintain good physical
and mental health, with the support of educational resources and signposting to
appropriate healthcare professionals and organisations.
making a shift from dispensing to clinical services - delivering clinical services to
people in the community – especially for those in the most deprived areas – through
services, such as treating minor ailments and offering more support for people with
long term conditions (eg, mental health) with routine checkups and monitoring,
available on a drop-in basis.
supporting patients with long term conditions (LTCs) - offer more support to people in
the early stages of taking a new course of medicines to treat a LTC, (such as
depression/schizophrenia) and develop a more structured follow-up advice and support.
[For more information see RPSGB: Long-term conditions: integrating community
pharmacy (Executive summary)
development of the pharmacy profession – developing consultant pharmacists;
working mainly in hospitals but with the potential to extend into primary care – who
have expertise in specialties such as mental health.
development of pharmacy support staff - the Government commissioned work from
the National Institute for Mental Health in England on expanding the role of pharmacy
technicians. This forms part of a range of initiatives on medicines management in
mental health trusts, including an organisational self-assessment toolkit, guidance on
service level agreements and leadership development
35
The Pharmacy In England White Paper highlights the health challenges specific to mental
health and how pharmacy can contribute, a summary of which is detailed below:-
Mental Health challenge
Long term impact if
not addressed
How pharmacy can contribute
Likely benefits and
Outcomes
A large number of people
have mental health
problems. For example, the
2001 Psychiatric Morbidity
Survey published by the
Office for National Statistics
suggested that one in six
adults were assessed as
having a neurotic disorder.
Services users and carers
will not receive the support
they need to benefit from
medicines.
Awareness and promotion
of good mental health
Better quality of life for
people with better
adherence to their
medicines
According to the World
Health Organisation, by
2020 depression is expected
to be the second most
common cause of disability
worldwide.
It is the third most common
reason for consultation in
general practice, and
occupies about a third of
GPs’ time.
People with a severe mental
health problem or learning
disability have markedly
poorer health outcomes
than the rest of the
population – e.g. on average
people with schizophrenia
die 10 years earlier.
Simple mechanisms to
help people understand
and take their medicines
as intended
Liaison with GPs and
community health teams
Instalment dispensing and
supervised administration
Training for patients and
carers about medicines
Involvement in evidence
based alternatives to
medicines, e.g.
information
about/provision of
computerised cognitive
behavioural therapy and
general information about
talking therapies
Information about local
support networks, mental
health helplines, etc.
Involvement in outreach to
minority communities
Identification of people
who may show signs of
depression and referring
them on appropriately
Senior leadership on
medicines issues and
governance in mental
health trusts and ensuring
that appropriate service
level agreements are in
place with provider
organisations
36
People with mental
health problems are
better able to understand
and manage their own
condition
Readily available support
in the community and/or
closer to home
Improved access to drug
therapy monitoring
Carers more supported in
dealing with people
taking medicines
Medicines policy issues
in health systems that
care for people with
mental health problems
are discussed and
resolved at a senior level
For community pharmacy to take on these additional clinical roles as envisaged in the
White Paper, pharmacists and their representative bodies will need to understand and fully
engage with local commissioning processes and understand the local mental health plans,
needs and priorities in optimising the care of people with mental health at a local level.
General Medical Services Contract (GMS) and Quality and Outcomes Framework (QOF)
With the introduction of the GMS contract from April 2004, QOF have been the core funding
stream, which sets out a range of national standards based on the best available research
evidence, with targets to reach and a set number of reward points for reaching each
standard. There are obvious opportunities for community pharmacist to be commissioned
to contribute similarly to patients care through the QOF and help practices to achieve GMS
quality indicators. The indicators relevant to this guide are:
Dementia
Depression
Mental Health
Commissioning Pharmacy Services in Mental Health
in England
In order to obtain support from local commissioners those aiming to develop mental
health pharmacy services will need to understand the key drivers within commissioning
organisations, e.g. Primary Care Trusts (PCTs), and to demonstrate in their proposals how
they aim to support the delivery of these key objectives.
The main framework in place in England to assess PCT’s commissioning capability is World
Class Commissioning.
PCTs are scored against eleven competencies and are required to produce evidence in
each of these to demonstrate they have met the required standards.
Working with and developing pharmacists and their services can help PCTs to provide
crucial evidence to put forward in their assessments under World Class Commissioning.
The eleven World Class Competencies are as follows:
37
World Class Competencies
1. Locally lead the NHS
2. Work with community partners
3. Engage with public and patients
4. Collaborate with clinicians
5. Manage knowledge and assess needs
6. Prioritise investment
7. Stimulate the market
8. Promote improvement and innovation
9. Secure procurement skills
10. Manage the local health system
11. Make sound financial investments
Each of these competencies has sub-components that the PCT must demonstrate
capability against.
When business cases or proposals to develop pharmacy services are submitted to
commissioners, it would be highly advisable to identify which of these competencies and
sub components could be met as a result of approving such services.
Examples of Competencies and sub-components relevant to pharmacy mental health
service development:
World Class
Commissioning Competency
Sub-component
(PCTs need to demonstrate achievement)
How competency could
be demonstrated
Work with community
partners
Uses the skills and knowledge of partners,
including clinicians, to inform
commissioning intentions in all areas
of activity
Engagement of pharmacists and Local
Pharmaceutical Committees (LPCs) and
inclusion of pharmacy services in local
care pathways for mental health
Engage with public
and patients
Routinely ensures that patients and the
public can share their experiences of
health and care services and uses this to
inform commissioning
Patient feedback surveys on pharmacy
services and identification of needs for
people with mental illness
38
World Class
Commissioning Competency
Collaborate with clinicians
Manage knowledge
and assess needs
Sub-component
(PCTs need to demonstrate achievement)
How competency could
be demonstrated
Works in partnership with clinicians along
care pathways to facilitate and harness
front-line innovation and drive continuous
quality improvement
PCT works as an active partner with
pharmacists to develop and integrate
pharmacy mental health services into
wider care provision
Evidence of regular and active dialogue
with local clinicians, seeking their data
and information needs, supporting
engagement that turns information into
knowledge and action
PCT provides relevant information to
ensure service developments are in line
with local needs e.g. provision of
prescribing data to guide service
development
Robust ongoing Joint Strategic Needs
Assessment demonstrating a full
working understanding of the current
and future local population’s health and
well-being needs
PCT develops and incorporates the
pharmaceutical needs assessment in its
wider commissioning plans
A comprehensive map of local service
provision
PCT develops pharmacy services to match
identified needs, especially where
inequalities are identified
Mapping and identification of areas
of greatest need and relatively poorest
health and well-being access and
outcomes
Prioritise investment
Identifies and commissions against key
priority outcomes, taking into account
patient experiences, local needs and
preferences, risk assessments, national
priorities and other guidance, e.g. NICE
Develops short-, medium- and long-term
commissioning strategies enabling local
service design, innovation and
development
Uses financial resources in a planned and
sustainable manner and invests for the
future, including through innovative
service design and delivery
39
PCT commissions innovative pharmacy
services for mental health to ensure
optimal use of its investment in
medicines and aligned to local health
needs
World Class
Commissioning Competency
Stimulate the market
Sub-component
(PCTs need to demonstrate achievement)
How competency could
be demonstrated
Promotes services that encourage early
intervention, to avoid unnecessary
unplanned admissions
PCT promotes the development and
commissioning of mental health
pharmacy services at the heart of the
community to support mental health
wellbeing and improve medicines use
leading to improved outcomes
Stimulates provider development matched
to the requirements and experiences e.g.,
timely and convenient access to services
that are closer to home.
Promote improvement
and innovation
Shares research, clinical and service best
practice linked to clear specifications
that drive innovation and improvement
Communicates with clinicians and
providers to challenge established
practice and drive services that are both
convenient and effective
PCT works with pharmacists to develop
evidence based services to improve
understanding of mental illness and
improve adherence to medication
Translates research and knowledge into
specific clinical and service
reconfiguration, improving access, quality
and outcomes
Make sound
financial investments
Analyses costs, such as prescribing, and
identifies areas for improvement
Works effectively with all service providers
by providing financial support and
information to achieve the most clinically
effective and cost-effective approaches
PCT commissions pharmacy services
aimed at providing proactive support to
maximise positive outcomes from
medicines use e.g. pharmacy support
programmes for antidepressant usage
In addition to World Class Commissioning, service proposals should also refer to other NHS
policies and priorities identified in the section on ‘Mental Health Policy Drivers in Great
Britain’ in this document.
In particular, PCTs will be looking to commission services from pharmacists that will improve
the safety and cost-effectiveness of medicines usage and those that would lead to reduced
admissions / uptake of secondary care services and those supporting the delivery of care
closer to home.
The recent Department of Health Publication: World Class Commissioning: Improving
Pharmaceutical Services (April 2009)
www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_097408 is a useful resource
that can be applied to meet the needs of England.
40
Additional useful publications: England
Please see links below, listed in chronological order of most recent publication date:A Future Vision for Mental Health (The Future Vision Coalition, July 2009)
This report sets out a new vision for the future of mental health and well-being in England.
Based on four principles, it outlines the priorities that the Future Vision Coalition believes
should underpin mental health policy for the next decade. The Future Vision Coalition is
comprised of mental health providers, charities and professional bodies, and is committed
to a new model of mental health care.
Mental health: New Ways of Working for Everyone. (DH 2007)
This Progress Report completes a trilogy of publications on ‘New Ways of Working’ showing
how it is now being applied across the whole of the mental health workforce.
Improving Mental Health Services for Black and Minority Ethnic Communities in
England (DH 2007)
In the report key objectives and recommendations for change to improve the overall mental
health of black and minority ethnic people living in England are set out.
Breaking down barriers - the clinical case for change. (DH 2007)
This report explains why further work is required to improve community care and break
down the barriers that can prevent people with mental health problems from rebuilding
their lives.
Our Health, Our Care, Our Say: A New Direction for Community Services (DH 2006)
Specific ways in which mental health and emotional well-being will be supported are
described in detail (in Chapter 2).
The Future of Mental Health: A Vision for 2015 (The Sainsbury Centre for Mental
Health, 2006)
The paper includes proposals for mental wellbeing to be promoted in all schools, and
working environments to be well-being workplaces.
41
A New Deal for Welfare: Empowering People to Work (Green Paper, Department for
Work and Pensions 2006)
Outlines plans for investment in personal trainers for people claiming incapacity benefits
due to mental health problems, and in condition management programmes in Pathways to
Work areas.
Reaching out: An action plan on social exclusion (HM Government 2006)
Sets out the actions being taken across government to improve the life chances of those
who suffer, or may suffer in the future, from disadvantage, including measures to encourage
employment for those suffering from severe mental health problems.
Making it Possible: Improving Mental Health and Well-being in England (DH 2005)
Examples of good practice and sets a framework for action; contains information such as
making the case: the benefits and effectiveness of promoting good mental health,
prioritisation, delivery and evaluation.
Everybody's Business: Integrated Mental Health Services for Older Adults (DH 2005)
Service Guide: summary fact sheets are provided for service commissioners, providers,
professionals, and users and carers.
Defining a Good Mental Health Service (The Sainsbury Centre for Mental Health 2005)
The report focuses on what the staffing and service configuration would look like for a total
population within a 250,000 catchment area and, where possible, these estimates are
compared to existing levels.
Delivering Race Equality in Mental Health Care (DH 2005)
An action plan for achieving equality and tackling discrimination in mental health services in
England for all people of Black and minority ethnic status, including those of Irish or
Mediterranean origin and east European migrants.
Action on Mental Health - A Guide to Promoting Social Inclusion (Social Exclusion
Unit) 2004
There are 12 individual fact sheets covering a range of topics from families to discrimination
to employment. They include case studies and best practice drawn from across the country
and full lists of sources and contacts for extra support and advice.
42
From here to equality: A strategic plan to tackle stigma and discrimination on mental
health grounds (NIMHE) 2004-2009 (DH 2004)
sets out a framework for a sustained programme to give people their rights, working in
partnership across government.
NSF for Children, Young People and Maternity Services: The mental health and
psychological wellbeing of children and young people. (DH 2004)
National suicide prevention strategy for England (DH 2002)
Sets out a suicide prevention strategy for England. It is intended to be an evolving strategy
which will develop in light of progress made and emerging evidence.
A resource centre for NHS policy relating to the mental health care needs of older
people is available at:
6.2 Scotland Mental Health Policy Drivers
In Scotland, Government policy on mental health integrates mental health improvement (i.e.
promotion and prevention) and treatment (i.e. implementation of mental health legislation
and mental health services) within the Scottish Government Health Department, under the
auspices of the Mental Health Division.
Strategic direction for mental health improvement or public mental health has evolved from
a number of policy areas including: mental health, public health, social justice and social
inclusion, education, enterprise and life long learning and arts, sports and culture.
Wider public health policy in Scotland has increasingly identified mental health as an
integral part of the wider agenda for health improvement.
In 2000 a framework for further improvements in health and health services was
established and included a commitment to a national anti-stigma campaign, the promotion
of positive mental health and a national framework to reduce suicides in Scotland: Our
National Health: a plan for action, a plan for change, Scottish Executive
Further emphasis on the importance of continuing efforts in these areas was given in 2003
Partnership for Care: Scotland's Health White Paper, Scottish Executive included a
commitment to establishing a 3 year action plan for the National Programme between
2003-2006 (Improving Health in Scotland: The Challenge, Scottish Executive, 2003
43
Since the above mental health policies and frameworks, the key drivers to enable strategic
advancements and implementation in mental health, have been through the following
developments:NHS Quality Improvement Scotland (NHS QIS)
NHS QIS was established as a Special Health Board by the Scottish Executive in 2003, in
order to act as the lead organisation in improving the quality of healthcare delivered by
NHSScotland.
NHS QIS' leads the use of knowledge to promote improvement in the quality of healthcare
for the people of Scotland and performs three key functions:
providing advice and guidance on effective clinical practice, including setting standards
driving and supporting implementation of improvements in quality
assessing the performance of the NHS, reporting and publishing the findings
In addition, NHS QIS has central responsibility for patient safety and clinical governance
across Scotland.
Delivering for Mental Health
Published in December 2006 by the Scottish Executive, it sets out the mental health delivery
plan with targets and commitments including better prevention, more local care and improved
support to help aid recovery for the development of mental health services in Scotland.
Mental Health Integrated Care Pathway (ICP) Programme
This is in working progress (2008/2009 Q1) and aims to develop an accreditation system
that allows NHS QIS to assess the quality and effectiveness of mental health Integrated
Care Pathways that have been developed by each NHS board.
Mental Health Strategy 2009-2011
In 2005, the NHS QIS Mental Health Strategic Work Programme 2005-2008, Improving the
Quality of Mental Health Services in Scotland was published
NHS QIS is now working on the new strategy for 2009-2011 which will be released later this
year and is based on the NHS Quality Improvement Scotland
2008/09 – 2010/11 Delivery Plan highlighting key Mental Health Objectives for Scotland.
44
Mental Health Collaborative
Established in 2008, the Mental Health Collaborative is a 3-year programme, developed by
the Scottish Government and hosted in collaboration with NHS Greater Glasgow & Clyde.
The main aim of the Collaborative is to work together with NHS boards to support staff and
share information in order to improve mental health services. The 3-year programme has
also identified crossovers with the Mental Health Integrated Care Pathway (ICP) Programme
and it is in working progress, providing opportunities for pharmacists to provide integrated
pharmacy-led mental health services in mental health care pathways.
The services focus on improvements in the following areas in accordance with the aims of
the Collaborative and Scottish Government HEAT targets
reduce the annual increase in prescription of antidepressants
reduce the number of readmissions to psychiatric wards
achieve agreed improvements in the early diagnosis of patients with dementia by
March 2011
improve the quality of healthcare experienced
Right Medicine: A Strategy for Pharmaceutical Care in Scotland
The role of pharmacists in improving the public’s health and tackling health inequalities, as
in the case of mental health, have been recognised in a number of government papers. The
Right Medicine: A Strategy for Pharmaceutical Care in Scotland (published by the Scottish
Executive in February 2002) outlined a commitment to work with the pharmacy profession
to improve the public’s health, provide better access to care, deliver better quality services
for patients, users and carers, and develop the pharmacy profession. With reference to
mental health, the paper advocated that making better use of pharmacists’ expertise in
planning and delivering services was required in priority areas such as mental health.
Furthermore, pharmacists were highlighted as a valued profession for inclusion in the
pharmaceutical care planning process for some patients in the monitoring of Community
Treatment Orders (CTOs).
Better Health, Better Care: Action Plan
Better Health, Better Care: Action Plan (published in December 2007) is the national
strategy for health and wellbeing and sets out a new vision for the NHS in Scotland. The
community pharmacy contract builds on the principles outlined in Better Health, Better
Care by improving access to NHS services and promoting collaborative working between
community pharmacists and GPs to improve patient care. In this paper a further
commitment is made to extend the use of the Community Pharmacy Public Health
Service to improve access to support and advice in deprived areas.
45
Scottish Community Pharmacy Contract
The Scottish Community Care Pharmacy Contract was changed in 2006 and includes
provision for a electronic Chronic Medication Service (eCMS) , The eCMS allows patients
with long-term conditions to register with a community pharmacy of their choice for the
provision of pharmaceutical care as part of a shared agreement between the patient,
community pharmacist and General Practitioner. It introduces a more systematic way of
working and formalises the role of community pharmacists in the management of individual
patients with long term conditions in order to assist in improving the patient’s
understanding of their medicines and optimising the clinical benefits from their therapy.
6.3 Wales Mental Health Policy Drivers
Welsh Assembly Government Policy
The Mental Health agenda is currently a focus for Welsh Assembly policy initiatives, based
around key themes of:
Children and Young People
Communities
Health and Social Care Settings
Mental Health Literacy
Older People
Parenting and Early Years
Workplace and Employment
In late 2009 the Welsh Assembly Government reorganised the NHS in Wales to 7 Local
Health Boards (LHB). The Welsh Assembly Government has taken the opportunity to show its
commitment to Mental Health services by giving the vice chairman of the 7 LHB a specific
brief to oversee the LHBs performance in the planning, delivery and evaluation of primary
care, community health and mental health services ensuring a balanced care model to meet
the needs of the LHBs population.
One Wales – A progressive agenda for the government of Wales – June 2007. Is the
agreement between the Labour and Plaid Cymru Groups in the Assembly and sets out the
programme for government over the assembly term. The key mental health policy statement
is to:
place a new priority on providing for mental health, including child and adolescent
mental health services
seek legislative competence in relation to mental health.
46
In Oct 2007 Jonathan Morgan Conservative AM called for a Mental Health Legislative
Competence Orders (LCO), the principle of the LCO1 has been accepted by the Assembly and
welcomed by minister. The LCO is currently awaiting Whitehall approval.
A LCO if granted will transfer specific legislative competence from Parliament to the
Assembly. This will allow the Assembly to make its own legislation known as ‘Assembly
Measures;’ these have similar effect to an Act of Parliament.
The draft principles of LCO: Extending patients rights to assessment, treatment and
independent advocacy
1. Designed for Life
1.1. Mental Health Services will be remodelled over the three years to meet any new
legislative requirements, the Adults of Working Age Mental Health National Service Framework
and the Mental Capacity Bill. This will include action on workforce reconfiguration, provision
of low secure beds, risk management skills, substance misuse, psychological therapies, eating
disorder services, perinatal mental health services, comprehensive rehabilitation facilities,
court diversion schemes, a liaison psychiatry service, day activity services, work entry
programmes and strengthened primary care. There will be significant capital investment in
modernising mental health services over the next three years.
1.2 Chronic Disease Management Services will be remodelled over the three years to
develop a new care programme approach within an integrated chronic disease framework.
This will draw upon work on arthritis and musculoskeletal disease, pain, respiratory disease,
epilepsy, stroke, diabetes, coronary disease, mental health and renal disease, and
intermediate care and community equipment initiatives. The result will include care pathways
for the management of major chronic diseases. This will be aimed at early assessment;
accurate and timely diagnosis; an appropriate level of specialist service provision by a
multidisciplinary team; self-management training schemes; active multidisciplinary
rehabilitation programmes to reduce patient re-admission and development of tele-health
facilities to support extended care pathways. Networks will lead clinical audit of the pathways
for cardiac and renal disease.
1.2.2. A profile of long term and chronic conditions in Wales (WAG, 2006)
includes mental disability but does not include mental health (depression/anxiety or
nervousness Its argument for not including these conditions was that mental health is now
being addressed by the NSF
2. NSF for Older People in Wales (2006)
Mental health problems are common in older people and can severely affect the quality of
life of individuals and their families. Mental health conditions more common in old age are
depression and dementia
47
An LCO can be proposed by the Assembly Government, an Assembly committee, or an Assembly
Member. Once approved by the Assembly, the LCO is sent to the Secretary of State to be laid
before both Houses of Parliament and, if approved, made by Her Majesty in Council.
1
Depression is often triggered by unexpected or uncontrollable life changes, but factors such
as physical fitness, positive coping behaviours and social networks can protect against this
NICE CG on Depression recommends screening tools for those at high risk of depression to
enable early intervention (the National Public Health Service suggests a correlation between
mental health and deprivation)
Dementia cannot be prevented other than through the avoidance of certain known causative
factors such as alcohol misuse, poor diet and vitamin deficiencies. Maintaining a mentally,
socially and physically active lifestyle and continuing life-long learning may reduce the risk of
developing dementia. Older persons with a high burden of vascular risk factors are at an
increased risk of developing dementia, suggesting treatment for such vascular conditions
might reduce such risk.
3. Strategy for Older People in Wales – recommendation 52
Action: There should be a robust implementation of mental health standards of the NSF for
older People in Wales, and a separate mental Health Promotion Plan for Wales.
4. Adult Mental Health Services- Raising the Standard
The revised Adult Mental Health NSF and Action Plan for Wales - Oct 2005
Standards are set for 8 key activities
Social inclusion, health promotion and tackling stigma - standard 1
Service user and carer empowerment - standard 2
Promotion of opportunities for a normal pattern of daily life - standard 3
Providing equitable and accessible services - standard 4
Commissioning effective, comprehensive and responsive services - standard 5
Delivering effective, comprehensive and responsive services - standard 6
Effective client assessment and care pathways - standard 7
Ensuring a well staffed, skilled and supported workforce - standard 8
Key Points
Action 36 of this document requires primary care teams, Community Mental Health Teams
(CMHTs) and Local Health Boards (LHBs) to develop medicine management systems for
those people where medication is part of the care plan. As many people with a chronic
mental illness need complex medication regimens, this is to form part of the services
provided by community pharmacists to support individuals with self management.
Additionally LHBs need to establish an appropriate level of pharmacy advice to ensure a
smooth transition for the pharmaceutical needs of people with mental illnesses from
secondary care through to community pharmacy.
48
5. Stronger in Partnership 2 – launched October 2008
The Welsh Assembly Government’s revised good practice guidance on mental health service
user and carer involvement.
This document is a guide to involving mental health service users and their carers in all
aspects of designing, planning, delivery and evaluation of mental health services in Wales. It
updates the original ‘Stronger in Partnership’ document published in Sept 2004
The policy guidance endorses and accepts that additional emphasis needs to be given to
ensuring effective and meaningful involvement of users, carers and the voluntary sector in the
initial strategic planning of services.
6. Service Framework to meet the needs of people with co-occurring Substance
Misuse and Mental Health Problems.
Despite the availability of effective treatments, most individuals who have mental health and
substance use problems are not receiving effective treatment. Poor medication adherence;
possible interaction between medication and other substances; and the need for
pharmacotherapy for substance misuse are highlighted.
7. Cross Party Group on Pharmacy in the National Assembly for Wales Report of the
Inaugural Meeting. Feb 2010.
At the inaugural meeting of the Welsh cross-party pharmacy group, members discussed the role
of pharmacy in providing mental health care in the community and in prisons. Medicines are a
key component of mental health care and pharmacists have the expertise required to improve
adherence to medication and bridge the gaps between services in different healthcare settings,
the report says. However, the services pharmacists can provide in supporting mental health
appear to lack recognition and integration into models of care.
49
9. References
1. Department of Health (2008). Roadmap for Commissioners for the Procurement of
Mental Health Services in England: Mental Health Policy, Background and Context.
London: Department of Health.
2. Office for National Statistics (2001). Psychiatric morbidity among adults living in private
households, 2000. London: TSO
3. Goldberg D, Huxley P (1992). Common mental disorders: a bio-social model. London:
Routledge.
4. RETHINK: 2006/07 GMS Contract.
5. Department of Health (2009). New Horizons: towards a shared vision for mental health
– consultation. London: Department of Health
6. The Sainsbury Centre for Mental Health (2003). The economic and social costs of
mental illness. London: The Sainsbury Centre for Mental Health.
7. King’s Fund (2008). Paying the Price: The cost of mental health care in England to 2026.
London: King’s Fund.
8. Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry
1992; 14: 237–247.
9. Health Economics Research Centre, University of Oxford and the Alzheimer’s Research
Trust (2010). Dementia 2010. Cambridge: Alzheimer’s Research Trust.
10. Müller-Oerlinghausen B, Berghöfer A, Bauer M. Lancet. 2002 Jan 19; 359(9302): 241-7.
11. Clinical Knowledge Summaries: www.cks.nhs.uk – schizophrenia guidance
12. Connolly M, Kelly C. Lifestyle and physical health in schizophrenia. Advances in
Psychiatric Treatment (2005), vol. 11, 125–132.
13. National Collaborating Centre For Mental Health (2004). Self-Harm. London: NICE.
14. Horrocks JA, House, AO. Self-poisoning and self-injury in adults. Clinical Medicine 2002;
2(6): 509-512
15. Department of Health (2001). Safety First. Five-Year report of the National Confidential
Inquiry into Suicide and Homicide by People with Mental Illness. 2001.
16. Office for National Statistics/Department of Health (2002). Mental Health of Carers.
London: TSO.
50
Authors
Lead Author and Editor
Ziba Rajaei-Dehkordi MRPharmS
Consultant
Soar Beyond Ltd.
Co-Authors
Denise Ann Taylor MRPharmS
Author of Practice Guidances and in the Mental Health Toolkit the 'Considerations
for Pharmacists in Mental Health' as well as contributions to the Pharmaceutical
Care Matrices.
Senior Teaching Fellow in Clinical pharmacy, Programme Lead for Pharmacist
Prescribing, Department of Pharmacy and Pharmacology, University of Bath
Shailen Rao MRPharmS
Consultant
Soar Beyond Ltd.
RPS Project Management
Team
Rachel Norton
Information Pharmacist
Heidi Wright
Head of Practice
Meghna Joshi
Senior Professional Support Pharmacist
Acknowledgements
The Royal Pharmaceutical Society would like to thank the Authors, the RPS Project
Management Team and each individual in the Consultation Panel for their valued time, input
and advice, in particular Liz Kelly (Senior Pharmacist, Ailsa Hospital, Ayr) and her
colleagues (Mental Health Pharmacists, Ailsa Hospital, Ayr) below for their dedicated input:•
Margaret Bingham
•
Donna Dunlop
•
Karen Fraser
•
Joan Hoek
•
Karen Liddell
•
Sukhdeep Narwan
•
Joanne Rafferty
Thanks are also extended to the members of the RPS/NTA Substance Misuse Working
Group for their comments.
Consultation Panel
(In alphabetical order)
Gillian Arr-Jones
Chief Pharmacist
Operations, National Inspection and Assessment
Care Quality Commission
Christine Braddick
Integrated Care Pharmacist (Mental Health)
Royal Edinburgh Hospital
Cath Boury
Community Pharmacist
Newland Community Pharmacy Limited
Dr. David Branford
Chief Pharmacist
Kingsway Hospital
Derbyshire Mental Health Services NHS Trust
Aileen Bryson
Principal Policy Advisor
RPS Scotland
Sue Carter
Secretary
Primary Care Pharmacist’s Association
And
Head of medicines management, West Sussex PCT
Dr Christopher Cutts
Director
Centre for Pharmacy Postgraduate Education
Wendy Davies
Principal Pharmacist
Whitchurch hospital
Katherine Delargy
Advanced Clinical Pharmacist (Community Focus)
St Clement's Hospital
Kathryn Featherstone
LPC Secretary, Sunderland LPC
Steve Freedman
Deputy head of Medicines Management
NHS Sheffield
Carole Green
Pharmacist Advisor
RPS Legal and Ethical Advisory Service
David Green
Associate Director, Community Health Services
East & South East England Specialist Pharmacy Services
Colchester Hospital University NHS Foundation Trust
Chris Hall
Senior Pharmacist
Sheffield Health and Social Care Trust
Trudi Hilton
Chief Pharmacist
West London Mental Health Trust
Michael Holden
Chief Officer
Hampshire and Isle of Wight LPC
Liz Kelly
Senior Pharmacist
Ailsa Hospital, Ayr
Vanessa Lawrence
Locality Lead Pharmacist
Hampshire Partnership NHS Trust
Bridget O'Connell
Head of Information
Mind
Jocelyn Parkes
Principal Policy Advisor
RPS Wales
Barbara Parsons
Head of Pharmacy Practice
Pharmaceutical Services Negotiating Committee
Neeshma Shah
Head of Medicines Management and Pharmacy, Camden
PCT
Community pharmacist, Copes Pharmacy
Member of the National Pharmacy Association Board
Ash Soni
Benjamin Sporton
Andrew Walker
Information and Policy Analyst, RPS
Pharmacy Services Manager
Dykebar Hospital
Judith Woolley
Associate Director of Pharmacy
North Essex Partnership NGS Foundation Trust
Ian Wright
Clinical Pharmacy Manager
NHS Fife