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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