Mental health pharmacy changes

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Chapter: Hospital pharmacy : Mental health pharmacy

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 New Ways of Working programme

 

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.

 

The mental health pharmacy workforce survey

 

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 Healthcare Commission review of mental health pharmacy

 

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.

 

Other aspects of the New Ways of Working programme

 

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.

 

The UK Psychiatric Pharmacy Group and the College of Mental Health Pharmacy

 

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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