By the 1970s the landscape of mental health services was dominated by institutional care.
Mental health pharmacy changes
By the 1970s the
landscape of mental health services was dominated by institutional care. A
report undertaken in the late 1970s showed that most mental health pharmacy
departments were situated within institutions and much of the workload was
associated with providing ward stock to in excess of 1000 beds. The pattern of
LD institutions being supplied for by the same mental health pharmacy was
common, as was the model of one mental health pharmacy supplying another nearby
institution. Such pharmacies were usually poorly staffed (usually just one
pharmacist) with high vacancy of posts.
The Noel Hall report
for pharmacy recommended that hospital pharma-ceutical services be organised on
an area basis and for many mental health pharmacies this provided for the first
time a managerial link to the rest of hospital pharmacy. However, whilst this
managerial change did at first bring great benefits in the reduction of
isolation, it resulted in the priorities for the now area pharmaceutical
service becoming acute hospital pharmacy rather than focused on mental health
and LD. As the model for mental health services changed to that of fewer beds, moving
acute wards to district general hospital settings and developing community
services, from a hospital phar-macy viewpoint where only bed numbers mattered
this was an opportunity to cut and redeploy the available staff.
Throughout the 1980s
and much of the 1990s there were few new medi-cines in mental health and
compared to other medical specialties it remained an area of low cost. In an
environment of staff shortages of hospital pharma-cists, poor understanding of
mental health within an acute hospital environ-ment and a continued thrust
towards community care, the specialty struggled to survive. Periodic surveys of
staffing indicated poor levels of service, pro-vided by staff of low grades,
very poor knowledge within hospital pharmacy of mental health and limited
development of mental health clinical pharmacy. Finally, with the trend for
contracting out it became common for services to mental health hospitals to be
put out to tender and to be provided by others, usually via a service level
agreement.
By the 1990s the
significance of medicines in mental health care and the attitude towards mental
health pharmacy began to change. The reintroduc-tion of the antipsychotic drug
clozapine (now requiring pharmacy oversight of the necessary monitoring) and other
new medicines, as described earlier, focused attention on the escalating costs
and demands for pharmacy services. The development of clinical pharmacy
training specifically in mental health by the UK Psychiatric Pharmacy Group
(UKPPG) and the development, in England, of specialist MHTs all contributed to
an awareness of the need to develop specialist mental health pharmacy services.
These historical factors in general determine the nature and size of the
pharmacy service now available to any MHT.
During the 2000s
this focus on mental health pharmacy services led to a number of initiatives,
the most significant of which are described below.
The Spread Programme
demonstrated a wide range of potential impacts on patient care and treatment in
mental health that can be achieved by the various grades of pharmacy staff.
Fundamental findings
were:
·
Schemes that resulted in better access to pharmacy staff for
wards/ community teams resulted in improved medicines management.
·
Any project that placed a pharmacy staff member as a member
of the clinical/ward/community team was likely to improve relationships,
improve medicines management and lead to better outcomes for service users.
In addition to the
Spread programme, a wide range of initiatives were undertaken to improve
medicines management in MHTs. The New Ways of Working initiative included a
specific programme for pharmacy, with docu-ments developed to support frontline
teams.
In 2005 help was
enlisted of Bath University and the UKPPG to undertake a mental health pharmacy
workforce survey. The results showed that MHT pharmacy services vary
significantly in size, that most are dependent on other providers for their
pharmacy service (only 17% did not use another trust to provide pharmacy
services) and that the number of pharmacists employed did not appear to have
any rationale, with some very large MHTs employing only one or two per million
population served and others employing 15–20.
The management of
medicines in general hospitals had been a subject of growing interest to the
Audit Commission with its publication of the docu-ment A Spoonful of Sugar –
Medicines Management in NHS Hospitals. Much of the learning from the workforce
survey highlighted to the Healthcare Commission (now replaced by the Care
Quality Commission) the extent to which medicines management and pharmacy had
been neglected in mental health care and contributed to its 2007 report Let’s
Talk About Medicines. The document made 46 recommendations relating to how MHTs
can maximise the benefits from medicines across 11 broad areas. It placed
leadership by a chief pharmacist as a central role.
Following publication
of the Healthcare Commission document, the
Department of Health
commissioned a number of follow-up projects to assist MHTs to develop their
management of medicines.
In 1970, a
psychiatric pharmacists association was established. The primary achievements
of the association were to carry out a survey of pharmacy in psychiatric
hospitals and to establish an annual psychiatric conference. Although the
association replaced an informal group of psychiatric pharma-cists, it became
the organising committee for the annual conference, then later formed the
Psychiatric Pharmacy Group, evolving still later into the UKPPG.
In 1989 clozapine
was marketed by Sandoz (now Novartis), with a revolu-tionary pharmacy-managed
monitoring scheme. As a part of the agreement Sandoz agreed to fund three or
four training courses per year for 100 mental health pharmacists. This training
framework proved pivotal in helping to revolutionise the practice of
psychiatric pharmacy in the UK.
In March 1993 a
joint postgraduate clinical diploma course in mental health was established
with De Montfort University and the UKPPG and this then led to the programme of
postgraduate courses in mental health phar-macy, now with Aston University.
These educational programmes, together with leadership from the UKPPG, changed
the landscape for mental health pharmacy, taking it from a clinical backwater
to one of the most progressive specialties. In 1999 the UKPPG established the
College of Mental Health Pharmacy, one of the first specialties to develop an
accreditation scheme for its members.
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