Inspecting Informing Improving
Talking about medicines
The management of medicines in trusts
providing mental health services
Acute hospital portfolio review
2007 © Talking about medicines: The
management of medicines in trusts providing
mental health services
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Commission for Healthcare Audit and Inspection
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ISBN: 1-84562-128-X
Contents
Executive summary
Acknowledgement
Introduction
The use of medicines as a care option
Involving service users in their care
Care plans, consent and advance directives
Achieving concordance on medicines
Provision of information on medicines
Self-administration of medicines
Choosing and prescribing medicines
Prescribing guidelines
Monitoring the use of medicines
Electronic prescribing
Non-medical prescribing
Managing service users’ medicines
Teamworking and the role of pharmacy
Clinical pharmacy staff supporting inpatients
Clinical pharmacy staff supporting community teams
Working with GPs
Medication reviews
Quality of service users’ records
Supplying service users with medicines
Dispensing medicines
Supplying medicines to inpatients upon discharge
Supplying medicines to people in the community
Reducing waste
Effective governance
Responsibility for medicines management
Risk management and medicines
Drugs and therapeutics committees
Medicine-related incidents
Safe and secure handling of medicines
The cost of medicines
Ensuring the competency of staff
Pharmacy staffing
Service level agreements and delivery of services
Conclusions and recommendations – the way forward
References
Appendix A: Checklist of recommendations for trusts
Appendix B: Recommendations for national organisations
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Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
1
The Healthcare Commission
The Healthcare Commission exists to promote
improvements in the quality of healthcare and
public health in England. We are committed to
making a real difference to the provision of
healthcare and to promoting continuous
improvement for the benefit of patients and
the public. The Healthcare Commission’s full
name is the Commission for Healthcare Audit
and Inspection.
The Healthcare Commission was created
under the Health and Social Care (Community
Health and Standards) Act 2003. The
organisation has a range of new functions and
took over some responsibilities from other
Commissions. It:
We have a statutory duty to assess the
performance of healthcare organisations in
the NHS and award annual ratings of
performance, to coordinate inspections and
reviews of healthcare organisations carried
out by others, and register organisations
providing healthcare in the independent sector
on an annual basis.
We have created an entirely new approach to
assessing and reporting on the performance of
healthcare organisations. Our annual health
check will examine a much broader range of
factors than in the past, enabling us to report on
what really matters to patients and the public.
• replaces the Commission for Health
Improvement (CHI), which ceased to exist
on March 31st 2004
• takes over functions relating to
independent healthcare previously carried
out by the National Care Standards
Commission, which also ceased to exist on
March 31st 2004
• carries out the elements of the Audit
Commission’s work relating to the
efficiency, effectiveness and economy
of healthcare
2
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Executive summary
“Medicines management encompasses the
entire way that medicines are selected,
procured, delivered, prescribed, administered
and reviewed, to optimise the contribution
that medicines make to producing desired
outcomes of patient care”. (Audit Commission,
A spoonful of sugar, 2001)1.
In 2005, the Healthcare Commission carried
out a review of medicines management in 42
trusts (out of 83) that provided specialist
mental health services in England and Wales.
The trusts volunteered to take part in the
review, which used the same methodology as
that undertaken by acute and specialist trusts
in England as part of the acute hospital
portfolio. Where appropriate, the findings are
compared, as people being cared for by a
mental health trust should receive the same
standard of care with respect to medicines as
they would in an acute or specialist trust,
although delivered in a way that meets their
specific needs.
In the past, medicines management in mental
health trusts has been assessed in the same
way as in acute and specialist trusts, but there
are some important differences in the way that
mental health trusts provide services. Mental
health trusts tend to support people over
longer periods of time, providing their services
mostly through community settings (including
independent and supported accommodation)
but with some services for inpatients. They
cover a large geographical area with many
small units, whereas acute trusts tend to have
fewer sites and deliver more services from a
single location. Mental health trusts are also
much more likely to purchase aspects of
supplying, prescribing and managing
medicines from other providers. The findings
from the review of mental health trusts are
being reported separately to those for acute
trusts, so that discussion of the results can
properly reflect the care that mental health
trusts aim to provide.
Managing medicines safely, effectively and
efficiently is vital for delivering high quality,
value for money care that is focused on the
person using services. This study produced
a number of significant findings that point to
recommendations for trusts, and some of the
key findings are included in this summary.
Use of medicines as a care option
Surveys of people using mental health
services and audits undertaken as part of this
review have provided evidence of a very high
use of medicines in care plans (on average
92% of people who responded to the survey
of mental health services said that they had
taken medicines). Medicines play a significant
role in the care offered by mental health
trusts, therefore medicines management
must be a priority area for these trusts.
This review was not designed to explore the
appropriateness of the use of medicines in
great depth, but it is clear that more work is
required to develop performance measures
on the appropriate use of medicines. Trusts
should inform people on the possible different
approaches to using medicines whilst in their
care and allow them to be involved in
choosing the best approach for their care.
Involving people in their care
Audits at ward-level, carried out as part of
this review, suggest that medicines were a
clear factor influencing the admission for one
in every 33 people using services (twice as
high as the one in 69 ratio found in acute
trusts). More in-depth studies have shown
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Executive summary continued
that effective management of medicines
reduces lengths of stay and rates of re­
admission to hospital by 55 to 60%2.
Data gathered on medication reviews
highlighted issues with adherence to medicine
for 46% of inpatients. Failing to implement an
acceptable treatment plan can result in poor
outcomes for people using mental health
services as well as increased waste from
unused medicines. Joint working between
healthcare professionals, service users and
their carers is extremely important to ensure
that best outcomes are achieved and the role
of medicines is clearly defined in each
individual care plan.
The review showed that activity to establish
concordance with medicines is stronger in
mental health trusts than acute trusts. For
example, mental health trusts have developed
written information on medicines that is
focused on the patient, which other trusts
could learn from. There is still more to be
done in this high priority area (for example,
ensuring that people have access to a supply
of medicines after discharge and increased
opportunities for inpatients to manage their
own medicines where appropriate).
Choosing and prescribing medicines
Trusts should incorporate national guidance
into their guidelines to inform prescribers.
The Healthcare Commission’s improvement
review on community mental health involved
82 trusts and identified the proportion of
people with treatment-resistant schizophrenia
who were taking clozapine (an antipsychotic
drug used to treat this condition). The
evidence from this review suggests that
there may be variations in the level of
compliance with national guidance on
prescribing this medicine.
4
During a mental health crisis, the dosage of
medicines may need to be increased and it is
important that it is reduced once the crisis
ends. Failure to do this is one reason why
people are taking high doses of medicines for
unnecessarily long periods. An audit by the
Prescribing Observatory for Mental Health3
found that 36% of people were prescribed a
high dose (more than 100% of the maximum
recommended daily dose) of antipsychotic
medicines. This again suggests variable
compliance with national guidance and a need
to improve the overall quality of prescribing.
Electronic prescribing is included within the
NHS Connecting for Health programme and
has the potential to provide benefits in
efficiency and safety. Trusts need to engage
in this now to ensure that their implemented
system will support healthcare professionals.
They also need to ensure that prescribers
have suitable access to the results of patients’
tests to support safe prescribing.
Managing service users’ medicines
Trusts are responsible for the decisions made
by healthcare professionals about medicines,
as well as the storage, supply and day-to-day
safety of medicines for people using inpatient,
crisis resolution and home treatment services.
Pharmacy staff providing clinical services,
pharmacists and increasingly, technicians,
use their expertise to ensure that service
users achieve best outcomes from their
medicines and that the supply of medicines is
as efficient as possible. However, mental
health trusts have relatively weak investment
in clinical pharmacy services compared with
acute trusts. They reported that 24% of wards
did not receive any visits from pharmacy staff
(compared to 14% in acute trusts) and only
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
14% of wards received more than five hours of
visits by pharmacy staff in a week (compared
to 64% in acute trusts). Where clinical
pharmacy services do exist, the contribution
per patient on each visit was found to be
similar to that reported by acute trusts,
demonstrating the need for this service.
Mental health trusts have introduced a large
number of community teams that provide
support to people using their services. Many
of the healthcare professionals working in
these teams are involved in the management
of medicines and the trust is responsible for
their decisions about medicines, even when
requesting others to prescribe on their behalf.
Despite this, there is limited evidence of
pharmacy staff with detailed knowledge of
medicines being involved in these teams.
Knowledge of medicines within teams
providing services to inpatients and in the
community therefore needs to be strengthened
by the inclusion of appropriate pharmacy staff.
The review provided evidence of the benefits
of carrying out medication reviews, but there
are differences in how these are targeted and
undertaken. As trusts support service users
over long periods of time, it is important that
individual care plans include the dates and/or
changes in circumstances which are the
trigger for a medication review. A medication
review should involve a service user fully,
ensuring that their treatment complies with
the latest guidance and that medicines are
prescribed at safe doses, as well as checking
their physical health and general wellbeing.
People using mental health services often
receive care from a number of individuals
and organisations, including their GP,
community pharmacist and the mental health
service provider. Trusts reported difficulties
in implementing shared care agreements
with primary care providers. Shared care
agreements should make clear who is
responsible for different aspects of a person’s
care (a GP or trust staff), and should include
the prescribing and monitoring of medicines.
A recent audit by the Prescribing Observatory
for Mental Health3 found that only 11% of
records for people using the services of
assertive outreach teams documented that
appropriate physical health tests had been
carried out. These tests are extremely
important for people taking long-term
medicines for mental ill health. This is just
one element of shared care agreements that
needs to be in place to ensure effective
working across boundaries and seamless
pathways of care. Those who commission
services need to explore ways to encourage
GPs and trusts to work in partnership to
fulfil their responsibilities to people in their
care, including assessing and monitoring
physical health.
Supplying service users with medicines
Trusts should ensure that stocks of medicines
held in clinics or wards are managed and
audited appropriately and that if these
medicines are dispensed to people (rather
than administered), they are appropriately
labelled and the paperwork is in order. In
mental health trusts, medicines are often
required in smaller quantities, for example to
support short periods of home leave.
Automation to support dispensing is beginning
to be developed to meet the special needs of
mental health trusts, allowing single doses of
various medicines to be dispensed in separate
packs. Monitoring the success of automation
in trusts that have already implemented a
system will enable others to identify how it
could be of benefit to them.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Executive summary continued
Initiatives such as ‘dispensing for discharge’
and using patients’ own medicines are not
used as much in mental health trusts as they
are in acute trusts, although the financial
benefits from these initiatives are less in a
mental health trust. Effective management of
medicines on admission or discharge from
services can provide clinical benefits and
improve people’s experience of services, and
should therefore be addressed when
designing systems to dispense and supply
medicines. For example, trusts and GPs
should work with community pharmacists to
implement arrangements for repeat or
repeatable prescribing for those service
users who are stable.
Effective governance
When looking at medicines management in
acute and specialist trusts as part of the
2005/2006 annual health check, the trusts
that were able to deliver effective medicines
management across a range of indicators
displayed particularly important attributes.
These included strong leadership, embracing
new ways of working and deploying staff that
are knowledgeable and skilled in medicines
to work with patients. Trusts who do not have a
director responsible for medicines management
or do not have an approved strategy need to
address this as a first step to implementing
appropriate governance for medicines
management. Trusts should have a chief
pharmacist who has a status of a clinical
director (or equal position) and is accountable
through an executive board member. The
design of any new services should take into
consideration any requirements from the
pharmacy and the trust’s chief pharmacist
should be involved with any policy decisions
that have implications for medicines.
6
Mental health service providers care for a
significant proportion of people in the
community, often sharing responsibility with
GPs and other local services. Trusts need to
be clear on the extent of their accountability
for medicines for each area of their services.
Responsibilities can then be clearly defined for
staff working within the trust and with other
organisations through shared care
agreements. These responsibilities should be
documented for service users within their
individual care plans.
In this review, 34 mental health trusts
provided data on the costs of medicines, and
reported spending approximately £88m on
medicines in 2005/2006; this represented
about 16% of reported non-pay expenditure.
In order to control costs and reduce waste,
trusts should manage stocks and monitor
prescribing practices effectively. This could
be addressed by developing the roles of
pharmacy support staff.
When clinical pharmacy staff visited wards, it
resulted in one safety intervention to prevent
harm to the inpatient, for every 29 inpatients
seen, which is similar to that found in acute
trusts. Medicines are given because it is
believed that the benefits will outweigh any
associated risk, but trusts need appropriate
controls to ensure that these risks are
minimised. The involvement of clinical
pharmacy staff in caring for inpatients is a
service that provides such controls and safety
benefits, but there is scope for improvements
in trusts’ systems to further reduce risk.
Trusts’ have drugs and therapeutics
committees to oversee many of the policies,
processes and decisions relating to medicines.
Training in medicines should be part of the
remit of this committee, to help ensure that
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
the trust provides high quality training (that
is independent of any pharmaceutical
company) and that it has suitable checks in
place to ensure the competency of staff
working with medicines.
Pharmacy staffing
The review has shown that levels of staff in
pharmacies in mental health trusts are
noticeably lower than those found in acute
trusts. It also showed that the mix of staff
within the pharmacy differs from acute trusts,
as there are fewer pharmacy assistants and
pharmacy technicians. This suggests that
there is scope for developing services through
introducing new roles and new ways of
working, and by looking at their skill mix.
Service level agreements and
service delivery
A significant proportion of pharmacy services
for mental health trusts are delivered through
service level agreements (SLAs). Acute trusts
identified that 53% of SLAs with mental health
trusts were under-funded, and 35% of this
under funding was considered to be limiting
the service that they could deliver to a
standard below that experienced by their own
patients. However, there was no clear
relationship between some of the key service
outcome measures and the proportion of
services delivered by SLAs.
Next steps
Policies and processes should underpin good
practice in medicines management, so that
positive outcomes for people using mental
health services evolve from operating a well
designed ‘system’ rather than leaving it to
chance. As part of this study, trusts received
local reports that enabled them to measure
their performance against others. A checklist
of recommendations from the study is
grouped in this report under 10 focus areas,
each of which is described in terms of a
future vision. We recommend that trusts
review their strategy and leadership in
relation to medicines management using one
or both of these sources of information and
implement action plans to improve their
performance.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Acknowledgement
The Healthcare Commission would like to thank the advisory group and the large number of
individuals, regional and national groups who have contributed their time and expertise to help
us to interpret the results and draw conclusions from this review.
Advisory group members
Graham Parton
Celia Feetam
Russell Hill
Diana Kenworthy
Anne Spence
Gul Root
David Branford
Peter Pratt
Ian Maidment
Elaine Weston
Gill Harvey
Geraldine Strathdee
David Taylor
Neil Carr
Lynn Haygarth
Ron Pate
Graham Alexander
8
Avon and Wiltshire Mental Health Partnership NHS Trust
Birmingham and Solihull Mental Health NHS Trust
Central and North West London Mental Health NHS Trust
Department of Health
Department of Health
Department of Health
Derbyshire Mental Health Services NHS Trust
Doncaster and South Humber Healthcare NHS Trust and
Sheffield Care Trust
Kent and Medway NHS and Social Care Partnership Trust
Leeds Mental Health Teaching NHS Trust
National Prescribing Centre
Oxleas NHS Foundation Trust and Special Adviser, Healthcare
Commission Mental Health Strategy Team
South London and Maudsley NHS Foundation Trust
South Staffordshire Healthcare NHS Foundation Trust
South West Yorkshire Mental Health NHS Trust
West Midlands Strategic Health Authority
Worcestershire Mental Health Partnership NHS Trust
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Introduction
In 2005/2006, the Healthcare Commission
reviewed the topic of medicines management
as part of its acute hospital portfolio, which
was mandatory for all 173 acute and specialist
trusts in England. Trusts providing specialist
mental health services were also invited to
participate in this review in order to look at
the topic in mental health trusts. In total, 42
trusts took up this invitation (41 of the 82
English mental health trusts and the one
Welsh trust that separates the provision of
mental health services). A separate report
details the acute trust context and this report
considers mental health trusts. Comparisons
are made with acute trusts where this is
considered relevant.
Managing medicines safely, effectively and
efficiently in a mental health trust is just as
vital to deliver high quality, value for money
care that is focused on the individual as it is
in an acute trust, but there are important
differences of emphasis. The following are
key areas of medicines management where
having sound practices in place helps trusts
to deliver effective care:
• Risks: medicines are given because it is
believed that the benefits will outweigh the
associated risk, but trusts need to have
appropriate controls in place to ensure that
these risks are minimised
• Costs: with the cost of medicines
representing about 16% of non-pay
expenditure, effective management of
medicines and monitoring of prescribing
practices is necessary to ensure that trusts
control costs effectively and reduce waste
• Quality: studies have shown that managing
peoples’ medicines effectively reduces
lengths of stay and rates of re-admission
to hospital4
• Staffing: using pharmacy staff enables
nurses and doctors to make better use of
their time, helping to comply with the
European Working Time Directive and
reducing the reliance on agency staff4,5
Before presenting the findings, it is important
to understand some of the differences
between the delivery of services in a mental
health trust compared with an acute or other
specialist trust:
• acute and specialist trusts have a mix of
patients, with most staying for relatively
short periods and their care passed back
to their GP, whereas mental health trusts
tend to support people over longer periods
of time, providing their service predominantly
through community settings but with some
services for inpatients
• mental health trusts cover a large
geographical area with many small units,
whereas acute trusts tend to have fewer
sites with more services being delivered at
a single location
• a small group of people using mental
health services have been formally
detained under the Mental Health Act and
are not in the trust’s care through their
own choice
• mental health trusts are much more
likely to purchase aspects of supplying,
prescribing and managing medicines from
other providers
• the staff of mental health trusts support
people by providing care in a range of
independent and supported accommodation
The review of medicines management was
designed primarily for acute trusts as part of
the acute hospital portfolio. Where a mental
health priority was not adequately explored
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Introduction continued
through the review, the priority is discussed
quoting findings of other studies, if relevant.
An advisory group, including members of
trusts who participated in our review and
those who chose not to participate, has
supported the drafting of this report.
This report focuses firstly on the delivery of
care to those using services, considering their
expectations, the importance of medicines in
care plans and the processes for choosing,
prescribing and supplying medicines. It then
moves on to consider issues concerning the
governance of medicines, pharmacy resources
and use of service level agreements to deliver
pharmacy services. The report is written
primarily as a resource for trusts, but
stakeholders, particularly those who
commission, should consider the importance
of the issues raised when developing local
agreements and purchasing new services.
Expectations of service users
Mental health trusts must understand
properly what they should be doing in the area
of medicines management before they can be
assured of the robustness of their medicines
management activities. There are nine
attributes that service users can normally
expect from a trust:
1. Appropriate sharing of information:
Wherever a person receives their care –
whether from a GP, community pharmacy,
community team or as an inpatient – the
healthcare professional should have
access to relevant patient records,
including care plans and advance
directives, to enable them to provide a
high standard of medicine-related care.
Information should be shared with those
using services in an open and transparent
10
way. Service users and carers should be
able to report adverse side effects of
medicines to trusts and, via the
confidential ‘yellow card’ reporting
scheme, to the Medicines and Healthcare
products Regulatory Agency (MHRA).
Trusts should facilitate this by providing
the yellow cards.
2. Information and education: Service users
and carers should be provided with written
and oral information that clearly explains
the condition being treated and why their
medicines are prescribed in a way that is
culturally appropriate and accessible.
Information should be available to those
cared for in the community as well as
inpatients. Healthcare professionals
should explain their role and what they
can provide in terms of support with
medicines. They should make time to talk
about medicines, helping people overcome
any fears they may have of their condition
or their treatment. As a minimum,
information should be provided on how
to take medicines, the most likely side
effects and essential monitoring tests.
Additional needs for information should
be identified and met directly or by
providing sources of further information.
Healthcare professionals should have
appropriate English language skills to
communicate effectively. Additional
arrangements should be made for those
with disabilities such as the deaf, the
blind and those with learning disabilities.
3. On-going care: Service users and carers
should be advised on how to get advice
and care if a problem occurs with their
medicines whilst under the care of a
mental health trust. People should be
directed to the best advice and not be
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
confused by excessive choice. Carers
and service users are often the first to
detect signs of deterioration in health;
appropriate open access clinics or free
phone support should be provided at this
time. Access to services and support
should also be planned for young people
who are away from home for the first
time. Primary care services, including
community pharmacists, should have
sufficient knowledge to support people
taking mental health medicines.
4. Care plans that include medicines: Care
plans should indicate people’s informed
choice of medicines, ongoing monitoring
requirements and a plan for reviewing
medicines. Trusts should consider using
other alternatives to medicines and to
helping people manage and live with a
condition without medicines if this is their
informed choice. Where possible, the
content of the care plan should be the
result of agreement between the service
user, their carer and healthcare
professionals, with service users taking
the lead in deciding their care. Where
appropriate, advance directives should be
made (stating patients’ preferred
treatment options when they are unable
to make decisions). These should cover
medicines, facilitating future choice and
the preferences of the service user. Where
medicines may impede thinking, decisions
on care should be explored before starting
the medicine if possible. Care plans should
be effective and workable and every effort
should be made to adhere to them. Service
users should be made aware that there is
an element of trial and error in optimising
medicines and they should be advised on
how they can help to ensure a good, timely
outcome within this process. Medicines
should be discussed in a non-intimidating
environment, not during large ward
rounds, so that people are given a proper
opportunity to consent and have adequate
privacy.
5. Medication review on admission:
Medicines should be reviewed as part of
an initial assessment by a trust and the
service user and their carer should be
asked if they have any concerns about
medicines.
6. On-going review of medicines: Medicines
should be managed and reviewed regularly
with service users by competent staff, to
ensure that they are on a safe and
optimum regime. Service users should be
given the opportunity to plan their own
service as much as is possible, identifying
who will be present at reviews, which may
include pharmacists. Medicines and
alternative methods of care should be
explained to allow service users to make
an informed choice. Unnecessary
medicines should be stopped, side effects
kept to an acceptable level and
unnecessary dependence or withdrawal
effects avoided, particularly if the benefits
of medicines or long-term effects are
unclear. Medicine-induced psychosis
should be detected and action taken to
address it at the earliest opportunity. GPs
and hospitals should design services that
help them to identify and contact people
who have not had appropriate tests or
have not been collecting their medicines
as expected.
7. Meeting physical health needs: People’s
physical health should be appropriately
and regularly monitored. Baseline tests
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Introduction continued
should be undertaken when a person is
stable and used as a comparator for long
term health checks. Ideally, a series of
baseline tests should be undertaken
before medicines are started where
clinically appropriate. If medicine for a
mental health condition is affecting health
adversely, then trusts should take
appropriate action – the preferred action
being to change medicines and reduce
side effects, rather than treat the side
effects with further medicines. People
who also receive treatment for physical
conditions should continue to have their
medicines managed appropriately
throughout their involvement with mental
health trusts.
8. Continuity in medicines: People who
bring their medicines into hospital in the
appropriate packaging should be able to
use them if they are still considered to be
suitable and pass quality checks.
9. Access to medicines: People should
receive their prescribed medicines, which
should be administered safely, at the
appropriate times. If medicines are to be
12
used without consent, the least invasive
form should be used and forced
administration of medicines should be
avoided unless it would result in a real
risk. If a person wishes to self-administer
they should either be encouraged to take
their own medicines or, if it is deemed
inappropriate, be advised on the reasons
why. Medicines should be available when
a person is ready to leave a ward – either
at discharge or for home leave. Those
based in the community should be able
to receive medicines at a convenient
location, with prescriptions managed by
their GP and local pharmacy if required.
Pharmacies should hold sufficient stocks
of medicines so that they will usually be
able to dispense any prescription in full.
Where a prescription is repeated, every
effort should be made to ensure
consistency in the supply of medicines,
both in dosage and packaging, with the
generic name taking precedence over the
brand on the packaging. Pharmacists
should have information on options other
than medicines that could improve a
particular condition.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
The use of medicines as a care option
The Healthcare Commission’s 2005 survey of
people using mental health services found
that, on average, 92% of people had taken
medicines for their condition in the last 12
months 6. Figure 1 shows a small number of
trusts with a marked decrease in their use of
medicines between 2004 and 2005. Mental
health trusts have been encouraged to
increase the provision of alternative therapies,
in particular ‘talking therapies’. However,
with relatively few trusts showing a decrease
in medicines prescribed, we cannot discount
that these changes may be due to differences
in how the survey was undertaken in
particular localities. It was beyond the scope
of the current review to explore the
appropriateness of therapy choice. Further
work is needed to understand how the use of
medicines is expected to change if appropriate
levels of alternative therapy options are
introduced, so that trusts can monitor their
performance. What the data clearly shows is
that medicines play a significant role in the
care offered by mental health trusts, therefore
medicines management should have the same
priority in a mental health trust as it does in
an acute trust.
Figure 1: Service users taking medicines
in the last 12 months
100%
80%
60%
40%
20%
0%
Trusts
2005
2004
Source: Healthcare Commission national survey of people
using mental health services 2005
In our review, trusts audited the experiences
of people on a sample of wards for inpatients.
People who need to spend time in hospitals
are often those with the most complex needs,
so it is not surprising that this data indicated
a higher percentage of people taking
medicines than in the Healthcare
Commission’s survey of people using mental
health services 6. Use of medicines was
found to be approximately 98 to 100% for all
types of ward except child and adolescent
mental health services (CAMHS), where the
average percentage of those taking
medicines was 84%.
From this ward-level audit, we know that
91% of people were taking two or more
medicines to treat physical and mental
health conditions (figure 2). Older people
represented a greater proportion of those
who were taking a high number of medicines,
which is unsurprising given that physical
health tends to deteriorate with age and may
account for some of the medicines.
The medicines prescribed to treat mental
health disorders, particularly atypical
antipsychotics, are believed to be associated
with the metabolic syndrome and influence
the development of diabetes and cardiac
disease. It is important that people’s physical
health needs are adequately addressed when
they receive care from a mental health trust.
Studies on wards for older people in mental
health trusts have shown some evidence of
an increased risk of errors when managing
medicine to treat physical health, perhaps
due to inadequacies in training7.
The number of medicines available to treat
particular mental health conditions varies
according to the condition. For example,
there are a number of medicines available
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
13
The use of medicines as a care option continued
Figure 2: Number of medicines taken by service users admitted to mental health wards
Service users
300
200
100
0
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21
Number of medicines
> = 65 years
20-64 years
< 20 years
Source: 2005/2006 medicines management review audit of clinical pharmacy services
to treat schizophrenia, but what distinguishes
them is their propensity to cause side effects,
rather than how effectively they treat the
condition. However, a single antipsychotic
medicine is recommended in the majority of
situations8. Where people are taking a
number of different medicines, it is important
that these are prescribed with full knowledge
of the potential for interactions.
There are different approaches to using
medicines. Treatment of the primary
diagnosis, for example schizophrenia, could
alleviate other symptoms such as depression,
which removes the need for any further
medicines. However, some prescribers
consider that a good outcome can only be
14
achieved by treating both the schizophrenia
and the depression, using more than one
class of medicine.
We recommend that trusts have adequate
expertise to ensure that appropriate
medicines are prescribed to inpatients with
physical illness, and that systems are in
place to provide results of tests from primary
care to support this activity. Trusts should
also check the appropriateness of people’s
medicines and look for potential interactions.
They should inform people on the possible
approaches to using medicines whilst in their
care and allow them to be involved in
choosing the best approach for their care.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Involving service users in their care
Healthcare professionals can only determine
whether medicines are being used
appropriately and are delivering the expected
benefit by talking to service users and their
carers. The Healthcare Commission’s 2005
survey of people using mental health
services showed that on average, 39% of
people felt they had a say in decisions about
their medicines, whilst 42% said they had
some involvement 6 . The audit of medication
reviews on a sample of wards, undertaken
as part of this review, found that doctors
carried out the majority of reviews and only
18% involved the service user fully.
Care plans, consent and advance
directives
People with severe mental illness should
have a personalised care plan that is
reviewed with them regularly and, where
appropriate, with their carer. The section
relating to medicines in this plan should
document their capacity to consent to, or
choose, medicines, their informed
preferences for particular medicines, the
requirements for monitoring medicines, and
the plan for reviewing medicines. It should
state clearly how they can get support if
they have concerns about their medicines.
It is important that all members of the
multidisciplinary team are involved in
developing the care plan, working with
service users and their care team, to ensure
that issues concerning medicines are
addressed adequately.
In order to use medicines as a treatment
option people must give their consent,
unless they are being treated under the
Mental Health Act. This is an ongoing
process that involves providing information,
discussion and decision-making. Consent
for an adult cannot be given by anyone else
and can only be made when a person is
competent to make the decision. Good
practice involves providing relevant written
information, obtaining written consent if the
treatment involves significant risk, providing
appropriate contacts for advice and advocacy,
giving adequate time to make a decision
and ensuring that people understand that
they can change their mind at any time.
Ideally, the prescriber should be the person
who asks for consent, as they understand the
treatment. Where a healthcare professional
cannot support a person’s choice they
should, if possible, transfer the care to a
different professional who would consider
their request to be reasonable. When asking
for consent, it should be clear that the
service user has been able to weigh up the
risks and benefits to come to their decision.
Advance directives identify actions that the
service user would like, including how they
want to be treated, at a time when they are
not able to clearly state their choice. Trusts
should be supporting service users to write
advance directives and an appropriate
member of pharmacy staff, ideally a
member of the multidisciplinary team,
should be prepared to provide advice in
relation to medicines. The directives should
cover medicines, making clear the preferred
options and those options that would not be
acceptable to the patient. Advance directives
must be adhered to in situations where an
adult temporarily or permanently lacks the
capacity to give consent and treatment is to
be given in their best interests.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Involving service users in their care continued
Good practice example 1
Hull and East Yorkshire Community Mental
Health Trust have a form to record advance
directives. Item 1 of the declaration reads
‘My wishes regarding medicines and
treatment are as follows’. Recognising that
it is often easier to comply with a person’s
wishes if the rationale behind them is
understood, the guidance on this item
advises people that it is helpful to write
down the reasons for their preferences.
Trusts need to ensure that forms to record
care plans and advance directives are
designed to capture appropriate information
on medicines. Trusts also need to check that
people are being offered a choice of medicines
(where there is a choice) and that this choice
is being routinely recorded in care plans and
advance directives.
Achieving concordance on medicines
For people to take their medicines safely, it
is important that they achieve a level of
agreement with healthcare professionals
on the appropriateness and acceptability of
medicines. However, issues can arise due to:
• the culture and values around medicines
being at odds with the needs of the person
using services
• problems with access to medicines, for
example, difficulties in collecting medicine
or opening the bottle
• people forgetting to take medicines
• concerns from service users or carers over
the side effects and risks from taking a
medicine which they consider outweighs
16
any benefits (based on correct or incorrect
understanding of the medicines)
• inadequate understanding on how a
medicine should be taken
• lack of appropriate information about both
the condition and its treatment
In the ward level audit undertaken by
pharmacists, it was found that 46% of people
who received a medication review were found
to have an issue with adherence to their
medicines. This compares to just 12% in acute
trusts, and shows why activity to support
achievement of concordance needs to be a
priority for a mental health trust.
The Healthcare Commission’s improvement
review on community mental health included
an audit carried out by the care co-ordinator
of the records of 100 service users. On average,
97% of people using depots (slow release
injectable medicines) were using these to
address adherence issues or by preference.
The performance of trusts ranged from 100%
(reported by 44 of the 79 trusts) through to
77%. This suggests that where measures are
put in place to improve adherence, they are
generally appropriate.
Trusts that took part in the medicines
management review reported on the extent
that they work to improve concordance,
indicating the frequency that a particular
initiative was used (figure 3). Overall, mental
health trusts were undertaking more activity
on concordance than acute trusts, reflecting
the greater significance of this issue to
improving outcomes for people in mental
health trusts. However, there was less activity
to address issues with gaining access to
prescribed medicines.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Figure 3: How trusts work to achieve concordance (percentage of trusts with response)
Self-harm issues addressed in care plan
Patient/carer trained in medicines management
Compliance aids provided
Patients’ issues explored and solutions to issues found
Patients’ issues identified and primary care informed
Specially targeted information provided for medicines with
known compliance issues
Appropriate packaging identified and supplied to older people
Education groups provided for medicines with known
compliance issues
Mobility issues identified and long term drug supply arranged
0%
10%
Source: 2005/2006 medicines management review trust questionnaire
One of the functions that clinical pharmacists
can undertake, if they have sufficient time, is to
educate people about their medicines. For
example, pharmacists have developed ‘lesson
plans’ which are used to support a series of
education programmes on medicines for
people on wards9. In the review it was found
that education was provided for just one in
every 38 people seen by pharmacy staff
during ward visits.
Good practice example 2
South West Dorset Primary Care Trust
has developed information on depression
and its treatment for service users and
their carers in prison environments.
This work highlighted the lack of training
and information on symptoms and
medicines for mental health conditions
within prisons. The PCT have an ongoing
programme to develop information leaflets
and training.
20% 30%
40% 50% 60%
Usually
70% 80% 90% 100%
Sometimes
Rarely/never
Provision of information on medicines
From the 2005 survey of users of mental health
services, an average of 63% identified that they
were informed of the purpose of their medicines.
This percentage is significantly lower than in
acute trusts, where the average was 86%.
Thirty seven per cent of people reported being
adequately informed on the side effects of their
medicines (compared to 49% in acute trusts).
One explanation of poor performance is that
people may not recognise information given at a
time when they have been unwell and cognitively
impaired. To address this, trusts need to check
regularly that service users and carers
understand the purpose of their medicines.
It is important that trusts make available written
information explaining people’s diagnoses, their
medicines and the testing required to check the
safety and effectiveness of their medicines.
Trusts should try to make information available
from support groups - for example, MIND have
developed information in a variety of forms
which can help people understand particular
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
17
Involving people in their care continued
conditions. To make information more
accessible than the information leaflets from
the manufacturer, the UK Psychiatric Pharmacy
Group developed a series of leaflets for trusts
to share with service users. Trusts have built
on these, developing their own information
leaflets for patients to meet local need. In the
review, trusts reported on the extra information
on medicines that they provided for people:
• 83% of trusts reported having an average of
19 leaflets providing additional information
on medicines (beyond the standard leaflet
from the manufacturer)
• 26% of trusts reported having an average of
nine leaflets which explained a condition and
the medicines used to treat it
• 26% of trusts reported having an average of
three leaflets providing additional information
on medicines application techniques
Although written information can be useful to
service users, they may need to speak to
someone in person if they are experiencing
difficulties with their medicines.
Good practice example 3
Norfolk and Waveney Mental Health Trust
have a resource written for care workers
and service users, which is made available
in community team and inpatient settings.
The booklet, entitled Your Medication - any
questions? provides answers to questions
such as:
• how does the medicine work?
• how long will the medicine take to work?
• what shall I do if I forget to take it?
• are there any foods or drinks that I
should avoid?
18
Figure 4: Wards with bedside lockers
for medicines
100%
80%
60%
40%
20%
0%
Trusts
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
Bedside lockers for medicines can enable
initiatives such as supporting inpatients to
bring their own medicines into hospital and
allowing them to look after their own medicines
in hospital. A less often quoted benefit is that
they also provide more privacy. If medicines are
held in a bedside locker, staff will automatically
administer them in an environment where
inpatients may feel more comfortable about
discussing their medicines. However, there is
limited evidence of bedside lockers being
installed in wards in mental health trusts
(figure 4).
It is important that hospital staff consider
how best to support people receiving
community-based care and those who have
been recently discharged, making them
aware of who they should contact if they have
problems with their medicines. A pharmacy
helpline can be useful.
Any pharmacy that dispenses medicines must
put their address on the label as a contact
point (a legal requirement) and many include
the pharmacy’s telephone number. Some
trusts go further, making it clear that the
hospital pharmacy is a source of advice for
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
further information on medicines. Thirty-one
per cent of trusts had a helpline for service
users. In 8% of trusts, the helpline is available
as a source of advice for the community
served by the trust and 9% of trusts reported
that their helpline was for recently discharged
people and local community pharmacists. In
11% of trusts, the helpline was available only
for people whose medicines were dispensed
by them, and 3% of trusts reported that the
helpline was for recently discharged
inpatients only. Trusts provided information
on the number of contacts handled by the
helpline in a week, which ranged from 0 to
60, with an average of five. The National
Information Centre for psychotropic medicines
is available for healthcare professionals and
other bodies and an associated service exists
for service users and carers. These services,
provided by the South London and Maudsley
NHS Foundation Trust respond to about 5,000
enquiries a year10.
We recommend that trusts make information
on medicines available to service users,
sharing and making appropriate use of the
material developed. Trusts should review with
other NHS organisations in their care
community how best to support people who
experience problems with their medicines
after discharge and ensure that they are
aware of who they should contact if such
problems arise.
Self-administration of medicines
There are advantages of allowing service
users, or in some cases their carers, to
administer their medicines whilst in hospital:
• it ensures that service users are able to
take their medicines at the right time,
which helps maintain their own and their
carers’ confidence in their ability to manage
their medicines
• it supports community care coordinators
and hospital staff planning for discharge
by ensuring that service users have
reached an adequate level of competence
in managing their medicines prior to
discharge
Self-administration does require significant
supervision and can be labour-intensive.
However, non-adherence to medicines is one
of the key reasons for admission to hospital
so there are clear incentives – both financial
and for service users – for making this
investment. Studies have shown that 55 to
60% of re-admissions to hospital are linked to
problems with adherence2. Ward level audits
undertaken as part of this review suggest that
medicines were a factor influencing the
admission for one in every 33 people, with
one trust reporting it as a factor in one in
three people.
To be able to offer self-administration, mental
health trusts need to ensure that there is no
unacceptable increase in risk from having
unsecured medicines. This can be addressed
through introducing bedside lockers for
medicines or by allowing people to collect
their medicines from a central storage area
where they can gain access to their medicines.
Trusts provided information on the availability
of self-administration for the five main ward
types. From this exercise, we know that selfadministration was offered on only 13% of
wards where self-administration was likely
to be possible. Self-administration is most
evident, unsurprisingly, on rehabilitation
wards (table 1). Ward level audits provided
evidence that 5% of people were partially self-
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Involving people in their care continued
Table 1: Evidence of self-administration on wards
Type of ward
Trusts with
ward type
Percentage of wards with self administration –
distribution of trust responses
0%
< 50%
> = 50%
100%
Rehabilitation
35
34
23
23
20
Older people
43
79
16
2
2
Acute inpatient
41
85
7
2
5
Psychiatric ICU
30
97
3
0
0
CAMHS
32
100
0
0
0
Source: 2005/2006 medicines management review audit of clinical pharmacy services
administrating on a rehabilitation ward.
The review identified little evidence of selfadministration in practice.
The Department of Health has set up funded
medicines management collaboratives, where
trusts learn about the PDSA (Plan Do Study Act)
technique and are able to try this on areas of
medicines management that need improvement.
The third wave collaborative included seven
mental health trusts - three of which identified
developing self-administration within the trust
as an objective. The medicines management
collaborative needs to share lessons learned on
the implementation of self-administration in
mental health trusts.
We recommend that trusts offer the
opportunity to self-administer to people who
are competent (or can reach competence) and
whose stay in hospital will involve sufficient
opportunity to self-administer their medicines.
Good practice example 4
Oxleas NHS Trust has a three-stage selfadministration policy. Stage one involves
the service user coming to a central place
and requesting their medicines. If this is
successful, stage two allows them to
receive their medicines but they must take
them when staff are present. Stage three
allows service users to take their
medicines without observation.
20
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Choosing and prescribing medicines
Prescribing guidelines
Clinical guidelines should help to ensure that
there is consistent good practice in diagnosis
and delivery of care. The National Institute of
Health and Clinical Excellence (NICE) provides
guidance, some of which relates to medicines,
for a range of clinical conditions that trusts
are advised to introduce and incorporate into
their own guidelines. The inclusion of
prescribing guidance within clinical guidelines
is one way for trusts to encourage best
practice in prescribing. Many trusts purchase
the Maudsley Prescribing Guidelines11, which
cover a range of issues and provide a
mechanism for supporting consistency of
approach across trusts. Stocks of medicines
in pharmacy departments should be aligned
with prescribing guidelines and, wherever
possible, competitive purchase prices
negotiated (this can be more difficult if
services are delivered through service level
agreements).
In our review, 74% of trusts reported that there
were at least some sub-specialities where
guidance based on diagnosis supported the
selection of medicines. Forty six per cent
reported that this was available in most subspecialties. Trusts need to ensure that their
current clinical guidelines provide sufficient
direction to ensure best practice in prescribing
and purchasing.
If guidance on prescribing has been developed
to achieve the best financial and clinical
outcomes within a trust, it is important that, if
there is no conflict with the service user’s
choice, prescribers comply with this guidance
where possible. How guidelines are published
is likely to affect the behaviour of the person
prescribing; paper-based publications have
the advantage of being portable, but are more
difficult to keep current. Software is available
for personal digital assistants (PDAs) and
some trusts have invested in this technology
as a way to provide guidance that is both
portable and easy to maintain. The
introduction of electronic prescribing offers
opportunities to build guidance into the
prescribing care pathways that will help and
encourage prescribers to follow their trust’s
guidelines. Twenty-three per cent of trusts
reported that they plan to link their trust’s
prescribing guidance into their electronic
prescribing system. The benefits achieved
through electronic prescribing will depend on
the availability of local customisation and the
resource to maintain it.
Commissioners and trusts have a responsibility
to ensure that treatment and care is based on
nationally agreed best practice where it exists.
Technology appraisals and clinical guidelines
from NICE provide guidance on the use of
medicines to treat a number of conditions.
When new guidance is issued, trusts develop
an implementation action plan. This can be
harder if the guidance involves changes in
working practices, with implications for
infrastructure and workforce, or the securing
of additional funding12. It is important that
difficulties in reaching agreements on funding
do not compromise the care offered.
Our review collected data on a sample of four
technology appraisals that were focused on
medicines, which showed that funding was
agreed with local commissioners for between
half to three quarters of trusts (table 2).
However, there are some communities
where agreement had not yet been reached.
The overall funding position appears weaker
than has been reported by acute trusts. The
adoption of recommended practice can start
without funding being fully agreed although
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
21
Choosing and prescribing medicines continued
Table 2: Implementation of relevant NICE technology appraisals
NICE technology appraisal
Percentage of
trusts with audit
in progress or
completed
(completed)
Alzheimer’s disease – donepezil,
rivastigmine and galantamine (No. 19)
(applicable at time of review)
Percentage of
trusts with some
service users
treated according
to guidance (all
service users)
Percentage of
trusts where
implementation
funding agreed
(% of funding
already in place
66% (33%)
94% (67%)
76% (76%)
Schizophrenia – atypical antipsychotics
(No. 43)
76% (59%)
100% (59%)
76% (76%)
Attention deficit hyperactivity disorder
(ADHD) – methylphenidate (No. 13)
30% (10%)
100% (57%)
57% (57%)
Bipolar disorder – new medicines (No. 66)
23% (9%)
97% (49%)
49% (49%)
Source: 2005/2006 medicines management review trust questionnaire
this is a financial risk for the trust and is not
an ideal situation. The sample data suggests
that progress is being made towards adoption
of recommended practice.
Trusts are expected to undertake audits in
relation to the technology appraisals. Initial
audits often only consider if advice has been
introduced and do not go as far as to
Figure 5: People with treatment resistent
schizophrenia taking clozapine
100%
50%
0%
Trusts
Source: Healthcare Commission community mental
health improvement review 2005/2006
22
consider omissions in people treated. NICE
provides suggested audit criteria to use
alongside the guidance on technology
appraisals, but as a minimum, trusts need
to check that people’s care is in line with the
guidance. Information for four medicinesfocused technology appraisals showed that
for two of these, over 50% of trusts have
audits in progress (table 2). The guidance
where most audit activity has occurred is
related to schizophrenia.
The Healthcare Commission’s improvement
review in community mental health 2005/2006
covered 82 trusts and identified the proportion
of people with treatment-resistant
schizophrenia who were taking clozapine
(figure 5). The evidence from this review
suggests that there may be variations in
compliance with national prescribing guidance.
We recommend that trusts review current
clinical guidelines to ensure that they provide
clear direction for best practice in prescribing
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
and that mental health trusts and PCTs ensure
that there are robust processes in place to
address the commissioning and
implementation of NICE guidance.
Monitoring the use of medicines
As part of this review, the Healthcare
Commission gained access to the IMS Health*
database, which contains information on
medicines purchased by a number of trusts.
Comparisons between trusts are affected by
differing policies on prescribing in the
community, for example, the extent that GPs
take over low-risk prescribing, and data for the
whole care community (hospital and community
pharmacy dispensing) would be required to
inform on prescribing practices. The data
provided by trusts to IMS Health may not
capture all their activity and may additionally
include activity for other organisations that
have a service level agreement with the trust.
However, there is sufficient data to explore the
potential for forming comparator indicators,
which could be used regularly to monitor
overall prescribing practices and further work
is required to develop comparators. The
Figure 6: Utilisation of clozapine as a
proportion of all antipsychotic drugs
40%
30%
20%
10%
0%
Trusts
Source: IMS Health data
*
review explored a series of comparative
indicators based on NICE technology
appraisals, which might inform on the pace
of implementation of guidance. Figure 6
provides an example of a comparator derived
from the guidance for treating schizophrenia,
based only on hospital data.
Audits at service user level provide a much
richer picture of the quality of prescribing. The
Prescribing Observatory for Mental Health
(POMH-UK) has initiated audits of prescribing.
The first involved 32 trusts and considered high
dose and combination antipsychotics on adult
acute and psychiatric intensive care wards.
Doses of medicines are often adjusted as part
of the process of finding a successful and
stable medicine regime. During a crisis, doses
of medicines may need to be increased and it is
important that they are reduced once the crisis
ends; failure to do this may be one reason why
people may be taking high doses of medicines
for unnecessarily long periods. The POMH-UK
audit found that 36% of people were prescribed
a high dose (more than 100% of the maximum
recommended daily dose according to the
nationally recognised limits) of antipsychotic
medicines. Trusts’ performance on this
indicator ranged from 17% to 71%3.
Guidance from NICE recommends that only one
antipsychotic should be administered at a time.
The POMH-UK audit found that 43% of people
audited were prescribed more than one
antipsychotic (values for each trust ranged
from 0 to 70%). Seventy per cent of those who
were prescribed more than one antipsychotic
were either switching medicines, had not
responded to mono-therapy or had experienced
disturbed behaviour, which are recognised
exceptions to the guidance. NICE also
recommended that first and second generation
IMS Health is a commercial company that obtains data on the supply of medicines from hospital pharmacy systems and
supplies anonymised data to the pharmaceutical industry.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Choosing and prescribing medicines continued
antipsychotics should not be used concurrently
unless for a short period when the person is
changing medicines. The POMH-UK audit found
that 31% of people were prescribed first and
second generation antipsychotics (trust values
ranged from 0 to 56%). Only 8% of these people
were switching medicines.
In the recent audit of 100 people in the
community mental health improvement
review, an average of 8.1% of those taking
Figure 7: People taking more than one
antipsychotic medicine who were not in the
process of changing medicines
40%
30%
20%
10%
0%
Trusts
Source: Healthcare Commission community mental health
improvement review 2005/2006
Figure 8: People taking atypical and typical
antipsychotic medicines concurrently
40%
30%
20%
10%
0%
Trusts
Source: Healthcare Commission community mental health
improvement review 2005/2006
24
antipsychotics were taking more than one,
and they were not in the process of having
their medicines changed (figure 7). On
average, 9.5% of people taking antipsychotics
were taking a typical and an atypical
antipsychotic medicine (figure 8). There is
clearly a need to review prescribing for people
being cared for in the community as well as
those in inpatient units and trusts need to be
clear about their responsibilities.
We recommend that trusts and PCTs audit their
prescribing and should consider participating
in the POMH-UK audit programme. The
Department of Health should consider an
intiative to improve the quality of prescribing
of antipsychotics, for example, using a model
similar to that used to improve the quality of
antimicrobial prescribing in acute trusts (this
work led to cost savings and improved care for
patients).
Consideration should be given to developing a
wider set of comparator indicators to monitor
prescribing for care communities regularly,
feeding any requirements for data to support
this activity into the NHS Connecting for
Health secondary user service requirement.
Electronic prescribing
Most, if not all, GP surgeries are able to
produce prescriptions electronically, where
the GP selects the medicines needed and then
prints out a prescription. As well as making
the process of writing prescriptions more
efficient, electronic prescribing reduces
problems at dispensing, helping to ensure that
prescriptions are legible and complete. Time
spent dealing with inaccurate prescriptions is
poor use of a pharmacy’s resources and can
lead to people experiencing significant delays.
Just 6% of mental health trusts reported
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
having electronic prescribing for outpatients
with an average of 7.5% of prescribing
undertaken electronically. Three per cent of
trusts reported having electronic prescribing
for inpatients with an average of 15% of
prescribing undertaken electronically.
The national programme for IT from NHS
Connecting for Health, whose centrepiece is
the electronic patient record, contains
provision for electronic prescribing to be
delivered as part of the strategic solutions.
There is an additional level of complexity for
mental heath trusts, because in order to get
the full benefit, electronic prescribing systems
need to link into pharmacy departments, which
will be complex where pharmacy services are
delivered through a number of service level
agreements with acute trusts.
Our review found that 6% of mental health
trusts intend to implement ahead of the
national programme; 47% of trusts reported
that they would implement with the national
programme, whilst 47% did not expect to
implement until after the national programme.
Trusts who have already started, or who would
like to start adopting electronic prescribing are
concerned with the pace of progress of the
national programme. They are concerned that
the industry will deliver systems that will not
support current working practices and could
increase risks for patients. The NHS
Connecting for Health team are keen to see
more trusts engaging with the process to help
ensure that the systems developed will meet
clinical needs. It is important for trusts and the
Connecting for Health team to work closely to
identify the changes needed to ensure that
working practices and culture are developed
ready for its introduction. Connecting for
Health will need to ensure that implementation
by trusts is supported by appropriate safety
management practices to minimise the risk,
both during and after the installation.
We therefore recommend that trusts identify
and communicate their requirements for
electronic prescribing systems and review
timescales and local actions required to
ensure that benefits can be realised at the
earliest opportunity. The Government should
ensure that electronic prescribing is available
at the earliest opportunity as part of the
National Programme for IT. NHS Connecting
for Health should consider working with a
small number of trusts who want to be early
adopters of electronic prescribing, which
could help to speed up the time to the first
implementation and allow learning to be built
into solutions before they are shared across
the NHS.
Non-medical prescribing
Doctors undertake the majority of prescribing,
but recent changes have extended prescribing
responsibilities to other professional groups.
Non-medical prescribing is an evolving service
development, and suitably qualified nurses,
pharmacists and other healthcare professionals
are now able to prescribe subject to their
professional registration and local agreement.
Non-medical prescribing has been introduced
to improve access to services for patients and
to improve the efficiency of services. The
benefits from non-medical prescribers can
vary by service area, but to develop a service
based on non-medical prescribing, there must
be sufficient trained practitioners to be able to
guarantee the service.
Of the 35 mental health trusts that responded
to this part of the review, 26 reported that they
have nurse prescribers and six trusts had
pharmacist prescribers. In total, trusts
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
25
Choosing and prescribing medicines continued
reported 187 nurse prescribers, 170 who are
supplementary prescribers* and 30 who are
extended formulary nurse prescribers**. Of the
187 nurse prescribers, 81 (43%) reported that
they prescribed at least once a week. Trusts
reported nine pharmacist supplementary
prescribers, none of whom are prescribing. To
maintain competence, non-medical prescribers
need to be given the opportunity to use their
skills regularly once they are trained. The
significant percentage of staff who are not
regularly prescribing is a concern both from the
potential loss of competence and the failure to
benefit from the investment in training.
Of the 27 trusts with non-medical prescribers,
70% of trusts had a policy to select staff
eligible to receive training for prescribers,
78% of trusts had a process for registering
staff prescribing responsibilities, 67% of trust
policies covered support and training to non­
medical prescribers and 52% of trust policies
addressed competency checking for non­
medical prescribing staff. The introduction of
non-medical prescribers has opened up
opportunities for trusts. However, as with all
changes, it is important that the introduction
is managed with suitable processes to
adequately control risks.
We recommend that trusts maximise the
benefits from independent and supplementary
prescribing by determining where it can be best
utilised to meet clinical and operational need.
*
Supplementary prescribing is a voluntary prescribing partnership between the independent prescriber (doctor) and
supplementary prescriber to implement an agreed patient specific clinical management plan with the patient’s agreement.
Suitably qualified nurses, midwives, radiographers, physiotherapists, chiropadists and pharmacists can be supplementary
prescribers.
**
Until May 2006, nurses who obtained an Extended Formulary Nurse Prescribers qualification were able to prescribe for
a restricted list of medical conditions. The list initially covered 80 medical conditions and 180 prescription only medicines.
Since May 2006, suitably qualified pharmacists and nurses have been able to become Independent Prescribers allowing
them to prescribe all licensed medicines.
26
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Managing service users’ medicines
Team working and the role of the
pharmacy
People who use mental health services are
cared for by a multi-disciplinary team that
includes psychiatrists, nurses and other
health professionals. It is important that this
team also includes pharmacists, to ensure
that there is sufficient knowledge of
medicines to ensure best outcomes from
their use. Where a person is taking medicines
for both mental and physical health, the
pharmacist’s knowledge can be extremely
beneficial, as expertise on medicines for
physical health may be limited within a
mental health trust.
The Diploma in Psychiatric Pharmacy
provides pharmacists with more specialist
knowledge to support both prescribers and
people taking medicines for mental health.
In the review, 77% of the mental health trusts
reported having pharmacists with specialist
mental health qualifications. Thirty-two per
cent of acute trusts also reported having
staff with this qualification. These acute trust
staff are likely to be providing services
through a service level agreement to mental
health trusts.
Figure 9: Staff who were clear on expected
contribution of pharmacy staff
An effective team of healthcare professionals
understands each other’s roles and
contributions. A survey of non-pharmacy staff
provided a view on how well these staff
understood the contribution of pharmacy staff
(figure 9) and how well they felt pharmacy
staff understood other hospital staff (figure 10).
The survey showed that there were gaps in
understanding, particularly of how pharmacy
staff could contribute when on wards.
We recommend that, with support of the
trust board, pharmacy staff look to improve
their profile, ensuring that other hospital
staff and service users are aware of how
they can contribute to care. Pharmacists
should be permanent members of multi­
disciplinary teams.
Clinical pharmacy staff supporting
inpatients
Clinical pharmacy staff, pharmacists and
increasingly, technicians, use their expertise
to ensure that people achieve best outcomes
from their medicines and that the supply of
medicines is as efficient as possible.
Activities that clinical pharmacy staff can
undertake include:
Figure 10: Percentage of staff who thought
pharmacy staff understood their role
100%
100%
50%
50%
0%
0%
Trusts
Source: 2005/2006 medicines management review staff
survey on the pharmacy service
Trusts
Source: 2005/2006 medicines management review staff
survey on the pharmacy service
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Manage service users’ medicines continued
• regular review of medicine charts to check
for accuracy, completeness, adherence to
guidelines and prescribing problems
(interactions, therapeutic duplications,
appropriateness of medicine and dosage)
• ensuring that appropriate monitoring,
including physical health, occurs
• checking with service users and staff for
adverse reactions
• taking or reviewing medicine histories for
new service users
• undertaking fuller medication reviews (see
later section) and recommending changes
to medicines where appropriate
• being part of multi-disciplinary team
meetings and contributing to the
development of individual treatment plans at
the point of prescribing
• managing the supply of medicines to ensure
that there are sufficient stocks on wards
which are appropriately managed, ensuring
appropriate transportation of medicines to
remote sites, quality assuring patients’ own
medicines and appropriate planning for
discharge
• talking to service users and carers about
their medicines and advocating on their
behalf
• liasing with primary care colleagues on
follow up with medicines to ensure that care
is not compromised by organisational
boundaries
• advising and training both medical and
nursing colleagues on pharmaceutical care
issues
• acting as a second opinion with reference
to the Mental Health Act
Good practice example 5
Leeds Mental Health Trust introduced a
pharmacy-led service to monitor medicines
following concerns over the limited
monitoring of blood that was being
undertaken for inpatients.The service
started with pharmacists checking notes
and referring service users for tests and the
pharmacy technicians taking the blood
samples when necessary. The long term
plan is to train pharmacy technicians to
check notes and ask the pharmacist to
endorse any referrals for tests.
Table 3: Support from pharmacy staff to wards (hours of visits per week)
Ward type
Percentage
of wards
with 30+
hours
Percentage
Percentage
of wards with of wards with
10-30 hours 5-10 hours
Percentage
Percentage
of wards with of wards with
less than 2
2-5 hours
hours
Percentage
of wards
with no
visits
Psychiatric ICU (PICU)
0
5
8
47
34
6
Adult acute
1
11
17
47
10
14
Older people
0
2
10
38
31
19
Rehabilitation
0
1
5
28
38
28
CAMHS
0
0
3
20
23
53
Source: 2005/2006 medicines management review audit of clinical pharmacy services
28
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
The time typically spent on wards by pharmacy
staff is shown in table 3 for the most common
types of ward. There is wide variation in levels of
service. Mental health trusts reported that 24%
of wards had no visits from pharmacy staff,
compared to 14% of wards in acute trusts.
Mental health trusts reported 14% of wards
having more than five hours of pharmacy staff
visits in a week (compared with 64% in acute
trusts) and just 4% receiving over 10 hours
(compared to 34% in acute trusts). Mental
health inpatients clearly receive a lower level
of support from clinical pharmacy staff on
wards than patients in acute care.
During this review, trusts reported on the
processes and outcomes from ward visits made
by clinical pharmacy staff (table 4). Forty six per
cent of the outcomes for service users involved
ensuring an adequate supply of medicines.
Thirty-nine per cent of contributions by staff
contributed to therapy, a large proportion of
Table 4: Types of contribution made by
pharmacy staff on wards
Supplying inpatients
37%
Discussing therapy
12%
Changing dose
11%
Changing choice of therapy
9%
Supplying for discharge
9%
Monitoring change
7%
Identifying allergies
6%
Educating patients
4%
Identifying adverse drug reactions
3%
Writing prescriptions
2%
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
Figure 11: Contributions of staff against time spent with service user
Contributions per service user
3
2.5
2
1.5
1
0.5
0
0
5
15
10
20
30
25
Time per service user (mins)
Acute adult
Rehabilitation
Forensic
Older people
CAMHS
Source: 2005/2006 medicines management review audit of clinical pharmacy services
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Manage service users’ medicines continued
which were accepted as being necessary. The
interventions that led to a change in either the
choice of therapy, the dose or monitoring are just
over twice as high as those contributions that did
not lead to change (labelled as therapy
discussions). This demonstrates the importance
of ward visits by pharmacy staff to the care of
service users.
As only a limited number of clinical pharmacy
staff are available in most trusts, it is important
that they are deployed to achieve the greatest
benefit. Plotting the average time spent per
service user seen against the contributions made
by pharmacy staff per service user by ward type
shows that in most cases, the time spent on a
ward visit per service user was low and
contributions made were correspondingly low
(figure 11). As the time spent with people
increased, the levels of contributions did appear
to rise, though not in all cases. For acute adult,
older people and CAMHS wards, 75% of the
observations show less than seven to eight
minutes on a ward per service user seen per visit
(not all this time will be spent directly with the
service user) and 95% of the observations show
10 to 11 minutes or less per service user seen.
For forensic and rehabilitation wards, these times
rise to nine to 10 minutes and 12 to 13 minutes
respectively.
The average number of contributions not
related to the supply of medicines per service
user seen on a visit is shown in table 5, with
Table 5: Evidence from ward level clinical pharmacy audits
Service area
Contributions
per service
user
Minutes
per service
user
Average
beds per
ward
Weekly
visits per
service
user place
(bed)
Average
time per
week
(hours)
Target
time
per
ward
(hours)
Target
WTE
for the
ward
General medical
(Acute trust)
0.35
6.2
27
6.0
16
General surgical
(Acute trust)
0.39
5.9
27
5.5
15
Acute adult
0.30
6.3
21
2.9
7
16
0.4
PICU
0.42
5.7
11
2.7
3
8
0.2
Older people
0.26
6.0
19
2.5
5
14
0.4
Forensic
0.22
8.2
19
2.0
5
15
0.4
Rehabilitation
0.52
7.2
14
1.6
3
11
0.3
CAMHS
0.62
7.5
14
1.0
2
11
0.3
Learning
Disabilities
0.40
6.0
12
0.8
1
8
0.2
Source: 2005/2006 medicines management review audit of clinical pharmacy services
Note: The target time is determined as 9.5 minutes per service user in forensic and rehabilitation and 7.5 minutes elsewhere (from
analysis of ward distribution above). Visits on six days a week are assumed for each service except forensic, rehabilitation and
learning disabilities where visits are set to 5 days a week. Whole time equivalents (WTE) are derived based on a 37 hour week
30
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
values for general surgical and medical wards
in acute trusts shown for comparison. This
data suggests that the average time spent
per service user on a visit and contributions
per service user are similar to those found in
general medical and general surgical wards
in acute trusts. However, wards in mental
health trusts tend to have fewer beds and
less frequent visits by pharmacy staff per bed.
To be able to provide an effective clinical
pharmacy service, pharmacy staff undertake
some activity away from service users,
including administrative work associated with
clinical care through to continual professional
development. Analysis of data from acute trusts
shows variation in the proportion of clinical
pharmacy time spent near patients, however,
the median value suggests that 75% of clinical
time is spent near patients. Assuming the
target time in table 5 is 75% of required clinical
pharmacy time, the whole time equivalents
shown for mental health trusts would increase
by a third of their value (i.e. acute adult, PICU
and rehabilitation wards would require 0.6, 0.3
and 0.4 whole time equivalents respectively).
The Sainsbury Centre for Mental Health has
published a report showing the resources
required for a ‘good mental health service’
for adults13. This initial report did not cover
the contribution of pharmacists, but the update
following an open consultation will address
pharmacy requirements. The consultation has
identified the following requirement:
• rehabilitation wards require 0.4 WTE (0.3
pharmacists and 0.1 technicians) for 10
service users
• acute adult inpatient wards require 0.5 WTE
(0.25 pharmacists and 0.25 technicians) for a
ward with 20 beds
• PICU require 0.4 WTE (0.3 pharmacists and
0.1 technicians) for 8 PICU, 10 low secure,
14 medium and long term secure beds
The data collected in this review supports the
assumptions developed during the Sainsbury
Centre’s consultation with the exception of the
resources required to support a psychiatric
intensive care unit. The data suggests that
resourcing per bed for these units is more in
line with that of an acute adult ward.
Good practice example 6
Cheshire and Wirral Partnership Trust have
developed their system for care notes to
record interventions by pharmacists in
order to measure how they are helping to
provide clinically effective care and
optimising the use of medicines.
We recommend that trusts consider
increasing the support time offered by clinical
pharmacy staff for inpatients towards the
target time identified from this review,
evaluating the service, and providing
appropriate training to ensure that the
benefits are realised.
Clinical pharmacy staff supporting
community teams
The modernisation of mental health services
has led to a move away from inpatient services
to community-based services, with a minority
of service users admitted into hospital settings.
This change meets the needs of people who
prefer home-based treatment and can improve
the speed of recovery. Supporting people
through effective mental health community
services should help to avoid admissions to
hospital and prevent re-admission following
discharge from an inpatient unit. Healthcare
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
31
Manage service users’ medicines continued
professionals working in community teams
prescribe, administer and deliver medicines,
develop agreement on use of medicines, provide
psychological education and review physical
health. They may also advise general
practitioners prescribing medicine for mental
health conditions. Ensuring adequate medicines
management for community-based services
presents challenges for mental health trusts
that are different to those faced by acute trusts.
The National Service Framework for Mental
Health14 supported the development of new
community teams including assertive outreach,
early intervention psychosis and crisis home
treatment teams to support the more generic
community mental health teams. As services
have evolved, there is a plethora of different
community teams with different names and
slightly different remits.
Where community teams are using medicines,
trusts need to ensure that there is appropriate
governance of this activity. If people are being
prescribed medicines through a community
team, then pharmacy staff within the team
should help to ensure good practice in using
medicines, through activities such as:
• supporting early medication reviews for
new service users (particularly those under
the care of a crisis resolution team) and
medication reviews for existing service
users at appropriate intervals
• promoting and facilitating good
concordance by providing information on
medicines and education for carers and
service users; clinical pharmacists and
technicians can educate service users on
a one-to-one basis
• ensuring that the team has access to
culturally acceptable and accessible
32
information leaflets for any medicines
supplied regularly
• making appropriate interventions following
a review of prescriptions and at multi­
disciplinary team meetings, to prevent
predictable interactions between medicines
or adverse reactions and to encourage
evidence-based practice
• providing regular education (starting at
induction) and support on medicines
management to other healthcare
professionals in the team, including the
provision of an information service on
medicines for clinicians
• managing the stock of medicines that is
held in the team base for use by team
members and supporting the introduction
of new ways of working to improve the
efficiency of the supply of medicines
• providing regular reports on the use of
medicines and expenditure
• supporting audits of the use of medicines,
prescribing guidelines and compliance with
local policies and procedures
Home treatment and crisis resolution teams
can be viewed as ‘wards in the community’.
People receiving these services represented
27% of those experiencing either home
treatment or inpatient care (trusts’ positions
ranged from 0% through to 60%) in
2004/2005. The experiences of people
supported by home treatment teams in
relation to medicines are likely to be similar
to those in a mental health adult acute
inpatient unit. All trusts have the same
responsibility for ensuring the safety of
medicines for people receiving home
treatment as for those in an acute adult
inpatient unit. In addition to the pharmacy
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
services listed above, pharmacy staff should
participate in the processes that develop and
monitor treatment plans of individuals. The
trust’s pharmacy can also supply diagnostic
materials and dispense medicines for
individuals, support discharge planning and
dispose of any unused medicines safely.
The consultation by the Sainsbury Centre
identified the need for 0.8 pharmacy whole
time equivalents to support crisis resolution
teams of 30 service users, in line with the
support expected for an adult inpatient unit.
In our review, two trusts provided information
for a week on the activities of the clinical
pharmacy staff for their home treatment team.
There was on average one pharmacy
contribution for every five service users seen
and, on average, five minutes were spent per
service user every three weeks. These two
teams received less than an hour’s pharmacy
support a week, which is well short of the
observed support given to adult acute
inpatient wards and probably explains the low
rate of contributions.
Good practice example 7
The crisis resolution team in East Kent
Partnership employ 0.5 whole time
equivalent pharmacists to support service
users with specific medicines needs who
are referred to them by other team
members. They undertake medication
reviews, prepare treatment plans, counsel
on compliance and side effects, provide
information to carers, monitor responses
to treatments, provide training and support
for team members and carry out clinical
audits.
A survey of the pharmacy workforce of 38
trusts9 identified that 28 trusts had crisis
intervention teams (of which five had some
support from pharmacists) and 19 trusts had
home treatment teams (of which seven had
support from pharmacists). The evidence
collected in the workforce survey
demonstrates that few trusts have support
from clinical pharmacy staff within crisis
resolution or home treatment teams and our
review has shown that for two teams where
support is provided it is far from adequate a worrying conclusion.
The assertive outreach team works with
service users who are often difficult to
engage and can have difficulty accessing
local services. Staff in mental health trusts
need to work with providers of primary care
services, GPs and community pharmacists,
to promote social inclusion and a normal
way of life for these service users. If they
prefer to receive medicine directly from the
mental health trust or if there is difficulty in
securing service from primary care,
medicines may also need to be supplied
through the mental health trust. The
pharmacy workforce survey identified that 31
trusts had assertive outreach teams and of
these, two had support from pharmacists.
Early intervention teams work with service
users who are usually young people, to
support them after a first psychotic episode.
The team helps them to understand and
learn to manage their conditions and ensure
that, as far as possible, support is provided
to give sufficient stability in other aspects of
their lives. The pharmacy workforce survey
identified that of the 20 trusts with early
intervention teams, just one had support
from a pharmacist. Pharmacy staff can also
support the early intervention team by:
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
33
Manage service users’ medicines continued
• developing care guidelines and pathways
for medicines and information for young
people
• addressing issues of concern to young
people including side effects of weight
gain and sexual dysfunction
• supporting smoking cessation, as nicotine
interacts with psychiatric medicines, and
providing education on the dangerous
interaction between prescribed medicines
and illicit drugs and binge drinking
The Sainsbury Centre consultation13
identified the need for 0.8 whole time
equivalent pharmacy staff (0.5 pharmacists
and 0.3 technicians) to support an early
intervention team working with 135 service
users or an assertive outreach team
working with 90 service users. It was
beyond the scope of our review to collect
evidence that can inform on the appropriate
level of support for these teams. The
structure of pharmacy support within teams
that provide long term care to service users
differs from that provided within a crisis
resolution team. Typically, medicines are
supplied through community pharmacies,
therefore removing the need for the trust to
dispense medicines, but there may be a need
to supplement community pharmacy advice
given on mental health medicines. As a
result, interactions with service users are
likely to be less frequent and so the trust
cannot be responsible for the daily
monitoring of the safety of medicines.
Service users’ medicines should, however,
be managed through a plan for regular
medication reviews.
Generic community mental health teams
can support people using medicines over a
34
significant time period, for example people
with depression. The Sainsbury Centre
consultation identified the need for 0.94
WTE pharmacy staff (0.5 pharmacists and
0.44 technicians) to support a community
mental health team supporting up to 350
service users. Eight of the 36 trusts taking
part in our review reported some clinical
pharmacy support to community mental
health teams. Of these, one trust was
providing over 10 hours support a week,
one was providing five to 10 hours and the
remainder provided five hours or less. One
trust audited the contributions of pharmacy
staff to a community mental health team
and an average of 13 minutes was spent per
service user with a contribution made for
one in every seven people seen. With 13
service users seen on each visit on two
visits per week, this equated to 5.5 hours
clinical pharmacy support per week. The
pharmacy workforce survey identified a
worse situation, where 28 trusts had adult
community mental health teams of which
only two had a pharmacist attached.
Good practice example 8
Central and North West London Mental
Health Trust have introduced a specialist
pharmacist medicines clinic within a
community mental health team setting.
The clinic provides a forum for
counselling and advice. People can raise
any concerns about their medicines and
receive advice on the use of medicines.
The pharmacy workforce survey 9 showed
that there are many titles for teams (table 6).
People who would receive clinical pharmacy
services as inpatients should also clearly
receive appropriate support in the community.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Table 6: Other types of teams providing services
Trusts with team
Teams with pharmacist
attached
Older people community teams
29
3
Learning disability community team
15
0
Forensic community team
18
1
Substance misuse community team
27
3
CAMHS community team
19
0
Rehabilitation and recovery
1
0
Working age dementia
1
0
Therapeutic community outreach
1
0
Diversion at arrest
1
0
Deaf services
1
0
Eating disorders
1
0
Mother and baby
1
0
Personality disorders
1
0
Source: Pharmacy workforce survey 9
The survey showed that pharmacy support
is also being provided to some substance
misuse teams.
In summary, for those teams where service
users are not receiving intensive treatment,
but the trust retains responsibility for aspects
of prescribing, there should be appropriate
clinical pharmacy time to support trusts’
prescribers and to ensure that each service
user receives appropriate medication reviews,
monitoring of their medicines and access to
advice on their medicines. Community services
have similarities to GP models of care and
mental health trusts need to consider the
benefit of introducing enhancements to
services developed in primary care. For
example, working with community, pharmacists
to deliver ‘medication use reviews’ or primary
care pharmacists who work through GP
surgeries may be one way to provide more
access to medication reviews.
We recommend that support from clinical
pharmacy staff be provided in crisis resolution
and home treatment teams, bringing pharmacy
support levels in line with corresponding
inpatient units. Trusts should consider
providing clinical pharmacy support of at least
one day a week to all community teams where
the team regularly manages service users’
medicines. Trusts should consider
collaborating with PCTs and community
pharmacists to use the ‘medication use review’
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
35
Manage service users’ medicines continued
scheme, with appropriate training, to help
ensure that people receiving community-based
care who are taking medicine have had a review
within the last year.
Figure 12: Patients on wards with high
quality GP information
These recommendations do not advise the
best way to deliver services and there is
clearly a real need to develop and test different
clinical pharmacy support service models in
community teams. The National Institute for
Mental Health in England (NIMHE) should
consider developing a tool for evaluating the
contribution of pharmacy staff to community
teams and inpatient wards and, if possible,
provide funding to evaluate pilots of the
proposed models.
100%
Working with GPs
It is important that appropriate information
on the physical and mental health of service
users is shared between the GP and mental
health trust. Often people using mental health
services are admitted as an ‘emergency’, which
can make obtaining important information
more difficult. Where the person is already
known to the mental health service, the risk of
inadequate information on admission can be
reduced. In ward-based audits undertaken as
part of the review, trusts identified people who
had a complete medicine history from their GP
and also those who had more comprehensive
information, for example recent test results.
Eighty-one per cent of trusts reported that
less than half of inpatients had a complete
medicine history (figure 12).
Being discharged from hospital is a key risk
period for service users and it is important
that all those involved in their care have the
information needed to support them. GPs
need appropriate information if they are to
36
80%
60%
40%
20%
0%
Trusts
complete
comprehensive
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
take responsibility for a person’s care.
Through the survey of PCTs completed as
part of this review, 12% of returns indicated
that GPs usually receive discharge notes in
time to be fully informed before they see
service users, 58% indicated this sometimes
occurred, while 31% reported that GPs often
have not received discharge notes in time.
There was a range of responses about the
quality of information with the majority stating
that they received adequate information on
medicines but the situation was slightly worse
in terms of providing information on the
diagnosis (table 7). Although there is room for
improvement, this is better than was reported
for acute trusts, where at best 30% of
respondents identified an aspect of the
discharge information as adequate.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Table 7: GPs’ views on information at discharge
Excellent
Adequate
Slightly
inadequate
Inadequate
Information on medication prescribed
and ongoing care
0%
54%
19%
27%
Information on diagnosis and reason
for medications
0%
38%
38%
23%
12%
42%
27%
19%
Shared care information
Source: 2005/2006 medicines management review trust questionnaire
Shared care is the term used to describe the
situation where both primary care (GP
practices) and secondary care (hospitals) will
be involved in managing a person’s medicines.
Shared care allows a person to receive ongoing
care from a convenient location. Shared care
guidelines should make clear who is
responsible for different aspects of a person’s
care. A well-designed guideline will cover the
monitoring requirements (for example blood
tests required for lithium and antipsychotic
medicines) and what should trigger a referral
back to the initiating hospital. Trusts who had
shared care in place reported that on average
46% of these covered monitoring and triggers.
Clearly there is scope for improving the clarity
of some shared care agreements. If shared
care is not well implemented, care may not be
properly followed up, for example routine tests
associated with a medicine may not occur.
Access to laboratory results can be poor in
mental health trusts, as there is no
infrastructure linking them to the reporting
systems of diagnostic services in acute trusts.
If a mental health trust is to maintain
prescribing responsibilities it is important that
there is timely access to any test results.
Trusts and PCTs reported for eight treatment
areas, where there are some shared care
agreements, on their views on the area’s
suitability for shared care and the extent that
shared care exists (table 8). There is
consistency between the views of both PCTs
and trusts. The proportion of communities with
agreements in place is well below that where
the treatment area is suitable for agreement,
and where there are agreements these are
often not well utilised. Service users clearly
experience differences in how their medicines
are and can be managed across organisational
boundaries.
Good practice example 9
Worcester Mental Health Partnership NHS
Trust has developed a care pathway for
transferring the prescribing and general
healthcare of stable service users from
secondary to primary care. This represcribing model represents a significant
cultural shift and there is evidence of high
levels of satisfaction and no evidence of
relapses. There is a close relationship with
GPs and community pharmacists.
We recommend that trusts and GPs
implement processes for sharing information
on service users and working practices, so
that people experience consistent care
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
37
Manage service users’ medicines continued
Table 8: Availability of shared care for treatment areas
Trusts with
shared care
in place
Trusts
considering
suitable for
shared care
CNS stimulants/
ADHD
84%
100%
Substance misuse
35%
Bi-polar disorder
PCTs with
shared care
in place
PCTs
considering
suitable for
shared care
75%
92%
100%
70%
90%
78%
32%
92%
67%
54%
100%
69%
64%
100%
75%
Anti-psychotic
54%
97%
65%
40%
96%
70%
Dementia
69%
97%
85%
80%
88%
90%
9%
100%
100%
27%
100%
80%
12.5%
100%
no data
33%
83%
100%
Monoamineoxidase
(depression)
Anti-arrhythmic
Trusts
identifying
agreements
usually used
PCTs identifying
agreements
usually used
Source: 2005/2006 medicines management review trust questionnaire and PCT survey
wherever they go. To reduce the
inconsistencies across the country on how
service users are able to access care, a
nationally agreed list of medicines suitable
for shared care should be produced, and
health communities should put in place
shared care agreements for this agreed list
of medicines. Service users should become
overt partners in shared care agreements
and be informed on who is responsible and
what to expect from their care. A suitable
mechanism should be introduced for sharing
model shared care agreements to assist
development. Consideration should be given
to using the qualities and outcomes
framework (QOF) to encourage GPs to
engage in shared care, and, in particular,
to assess and monitor the medicines
management aspects of the physical health
of service users.
38
Medication reviews
Trusts need to build a medicine history for
individuals as soon after admission as possible,
both to identify any issues and to ensure
continuity. The Department of Health’s
medicines management framework states that
a medication history should be taken within 24
hours of admission to hospital15. Figure 13
shows that trusts taking part in our review
showed a mixed performance against this
standard. It is recognised that there may be
difficulties in building a medication history if
a person is very unwell at the time of
admission, but every attempt should be made
to meet this target.
Although the term ‘medication review’ is
widely used in the NHS, there is no clear
definition as to its meaning outside primary
care. The word ‘review’ implies going beyond
recording a medicines history. The percentage
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
of people who were identified as having a
review in this sense shows large variation
(figure 14). Service users and, where
appropriate, their carers should be involved in
any review and staff should take the opportunity
to develop concordance as part of the review.
Figure 13: Service users with medicines
history within 24 hours of admission
100%
80%
However, on average, just 18% of medication
reviews involved them.
Trusts’ pharmacists, working as part of the
multi-disciplinary team, can be involved in
identifying prescribing options for people with
more complex needs who are not benefiting
from their current medicines. When an
individual’s records have built up over a long
time there can be considerable work involved
in doing this. The unified record should have
improved access to information but individual
feedback suggests the sheer volume of
information in some people’s records makes
it hard to identify relevant information.
60%
40%
20%
0%
Trusts
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
Figure 14: Service users with comprehensive
medication review
100%
80%
not involving service user
involving service user
60%
40%
20%
0%
Trusts
Source: 2005/2006 medicines management review audit
of clinical services
During the review, trusts reported on the
outcomes of medication reviews. In acute
trusts, there is a clear relationship between
the number of medicines being taken and the
probability of the review identifying a medicine
or adherence issue. In mental health trusts,
the benefits of a medication review do not
appear to change with the number of
medicines being taken (figure 15).
The percentage of medication reviews that lead
to change is significantly higher in mental
health trusts than was seen for acute trusts.
The average percentage of patients having a
medication review is similar for both acute
trusts (94%) and mental health trusts (90%).
Acute trusts undertook comprehensive
medication reviews for 53.5% of patients, whilst
mental health trusts reported 40.2%. Given the
similarity in the proportion of people receiving
reviews, differences in outcome may be the
result of higher numbers of those using mental
health services having issues with their
medicines, rather than by differences in
targeting people for reviews.
The audit data clearly shows that spending time
reviewing service users’ medicines can lead to
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
39
Manage service users’ medicines continued
Figure 15: Medication reviews leading to change
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
Medicine change and adherence
5
6
7
Medicine change
8
9
10
Adherence issue identified
Source: 2005/2006 medicines management review audit of clinical pharmacy services
changes that should be to their benefit. There
is, however, a need to provide better clarity on
the term ‘medication review’ in the mental
health setting. Given the long term relationship
built up between mental health trusts and
service users, medicines treatment plans need
to be reviewed at regular intervals and at points
of key risk to ensure that the medicines are
safe and the benefits are being realised. Ideally,
medication reviews will be undertaken within
the context of multidisciplinary working. Ideas
developed during our review on the types of
‘medication review’ are:
• a routine medication review (or medication
summary), the first of which takes place
within 24 hours of admission for inpatients,
confirms the current use of medicines,
identifies recent changes to medicines and
40
allergies to medicines and reviews available
physical health test results. Advance
directives will be considered and service
users will clarify how they have been taking
their medicines and will be given the
opportunity to discuss any issues with
medicines and the possibilities for selfadministration (for inpatients). The need
for a more comprehensive medication
review will be identified, for example, if there
is a suspicion that the admission is related
to medicines.
• comprehensive medication reviews are
generally undertaken when there is a
concern about potential interaction of
medicines, a failure to achieve a good
outcome, complexity of regimen or a request
for a review from the service user. These
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
reviews, generally undertaken by a
pharmacist or doctor and involving the
service user, can involve obtaining a full
medicine history, the range of medicines
tried (including ‘over the counter’ and
herbal medicines), the dosages used, the
effectiveness of controlling the mental
health symptoms and side effects, (as well
as acceptability to the service user),
considering wider clinical information (for
example, test results) and an assessment
of the effect of complicating factors such
as alcohol, tobacco or illicit drug use. The
service user’s physical health (which will
include bio-chemistry monitoring) and ability
to take part in everyday activity will be taken
into account. The review should take into
account any advance directives and
adherence issues and provide appropriate
education to service users and their carers.
At the end of any medication review, the
appropriateness of the treatment plan and
advance directive should be checked and
updated as necessary and the reviewer should
be confident that the treatment complies with
the latest guidance, the medicine is at a safe
dose and that they are assured about physical
health and wellbeing.
Once trusts have clarified the purpose and
scope of medication reviews, they can identify
which staff are already trained to undertake
this activity, as well as any gaps in the skills
needed or resource issues. Trusts need to
decide the appropriate level of involvement
by the GP in this process. Skills for Health,
the UK Sector Skill Council for Health, is
undertaking work to identify the range of
functions that relate to medication reviews,
as part of its project on national occupational
standards in pharmacy.
POMH-UK is carrying out an audit to screen
for metabolic side effects of antipsychotics
for people under the care of assertive
outreach teams. They have found that only
11% of people (from a sample of 1,966) had
documented results for the four tests that
should be undertaken each year. Results of
blood glucose tests were available for 28%
of people, blood pressure results for 26%,
lipids for 22% and body mass index
monitoring results for 17% of people.
Monitoring of physical health is clearly weak
for the audited teams.
We recommend that the National Prescribing
Centre publish definitions and guidance on
the different types of ‘medication reviews’,
linking in with the work of Skills for Health,
which is identifying the competencies
required to undertake a medication review.
Trusts should have a policy on how they will
review the medicines of service users in
their care which covers the training and
competency requirements for undertaking
reviews and the triggers for undertaking a
comprehensive review.
Quality of service users’ records
The medicines that people take are recorded
in their notes. Each inpatient has a drug chart
to record medicines prescribed and
administration history. Trusts have tended to
develop their own drug charts, which means
that any professionals moving between trusts
will often need to alter their working
practices. Recognising this issue and the
resources involved in producing such charts,
South East Coast Strategic Health Authority
have agreed a health authority-wide drug
chart within mental health which should be
implemented by the end of 2006.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
41
Manage service users’ medicines continued
Figure 16: Service users whose medicines
changes were clear for their hospital stay
100%
80%
60%
40%
20%
0%
Trusts
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
As part of the audit undertaken in this review,
pharmacy staff identified whether they could
detect a clear and understandable history of
changes to medicines from notes. The service
user’s record is an important component of
effective team working, as different
professionals will not necessarily be working
on a ward at the same time. The assessment
demonstrated weaknesses in the way that
information is recorded (figure 16).
There is evidence that mental health units
record medicines to treat physical health
poorly, and that primary care establishments
record mental health medicines less well than
physical medicines16. The recent community
mental health review audit of 100 service
users’ records identified that on average, 96%
of care records documented responses to
medicines and side effects, with responses
from trusts ranging from 100% (11 of the 60
trusts) through to 60%. This data suggests
that there is generally good practice.
42
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Supplying service users with medicines
Dispensing medicines
Acute trusts are gradually automating their
dispensaries and stores. Much of the
technology installed is designed to handle
original packs but in mental health trusts,
medicines are often required in smaller
quantities. For example, when people have
short periods of home leave, they need small
amounts of labelled medicines at the
appropriate time to obtain maximum benefit
from their leave or if there is a risk of selfharm, medicines must be dispensed
appropriately to reduce this risk.
Supplying small volumes of medicines
regularly creates an additional workload and
will influence the method used to improve
dispensing processes. In some trusts with low
levels of pharmacy staff, such supplies are
made up by nursing staff, either as a primary
dispensing activity which is against guidance
from both trusts and the Nursing and Midwifery
Council, or as a secondary dispensing activity
which may be indemnified by some trusts only
after suitable training and if accreditation has
been undertaken by individual nurses.
Many mental health trusts have service level
agreements with acute trusts for their
dispensing services. Trusts reported on levels
of automation in their dispensaries (table 9).
This data probably reflects the benefit to
mental health trusts from the investment that
acute trusts have made. In total, 68% of mental
health trust sites were identified as being
unsuitable for automation. However, a new
generation of automation may prove more
suitable for meeting the needs of mental health
trusts. These supply small numbers of
individual solid oral dosage forms in plastic
sachets, which are labelled appropriately.
Norfolk and Waveney Mental Health
Partnership NHS Trust are the first mental
health trust in the country to have
commissioned this technology and lessons
from this may benefit other trusts.
Generally, medicines are dispensed for an
individual person and services should be in
place to support this. However, there are
occasions when services can be improved
through the provision of pre-packs. These
are medicines that are fully labelled with
administration instructions, requiring only
the patient’s name and the date to be hand
written into the label. Pre-packs enable
people to obtain their medicines at the point
that they are prescribed without waiting for
the pharmacy. This can be beneficial, for
example, during an out-of-hours crisis. Prepacks provide a more acceptable solution to
providing emergency medicines than ‘brown
Table 9: Extent of automated pharmacy dispensaries and stores (2005)
Dispensing sites
Joint stores and
dispensaries site
Stores
Total
In place
1 (4%)
4 (11%)
1 (4%)
Planned
3 (13%)
6 (17%)
5 (21%)
14 (17%)
Needs business case
1 (4%)
3 (9%)
2 (8%)
6 (7%)
18 (78%)
22 (63%)
16 (67%)
56 (68%)
Not appropriate
6 (7%)
Source: 2005/2006 medicines management review trust questionnaire
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
43
Supplying service users with medicines continued
envelopes’ (small stocks of medicines
inappropriately used to support service
users in a crisis) as medicines supplied to
service users should be stored appropriately
and should be provided with the legally
required information. On average, trusts
estimated that 0.4% of outpatient prescribing
is supplied via pre-packs, this is significantly
lower than the 26% estimated in acute trusts.
A limited number of pre-packs, which involve
re-packaging, can be produced legally in a
pharmacy dispensary, whereas larger
volumes need to be supplied from licensed
manufacturing units or direct from the
pharmaceutical industry. Some pharmaceutical
companies are starting to provide packs with
pre-printed labels. Trusts have reported that
the capacity to produce pre-packs is a
constraint on service and availability can be
a particular problem where pharmacies’
dispensing services are being delivered via a
service level agreement.
We recommend that the NHS Purchasing and
Supply Agency work with trusts to identify areas
where pre-packs could be of significant benefit
and work with the pharmaceutical industry to
make available a wider selection of pre-packs,
ensuring that trusts are aware of the pre-packs
that are available. Trusts should ensure that
dispensing systems can support the provision
of small amounts of medicines for home leave
or for service users whose care plan involves
collecting medicine regularly.
Supplying medicines to inpatients
upon discharge
Our survey of the pharmacy service conducted
as part of the review shows a mixed
performance in terms of delays experienced
by people when receiving their medicines
44
Figure 17: Staff reporting service users’
discharges delayed due to pharmacy
60%
50%
40%
30%
20%
10%
0%
Trusts
Source: 2005/2006 medicines management review staff
survey on the pharmacy service
upon discharge (figure 17). Staff in some
trusts reported no regular delays, whilst in
others up to 55% of staff reported that
discharges are often delayed beyond the
expected time.
One initiative in acute trusts that can reduce
delays is ‘dispensing for discharge’. This
involves prescribing sufficient medicines
when first dispensing, in a pack labelled with
the patient’s details and directions on how to
take the medicine, that they can take home
with them on discharge. Mental health service
users tend to stay in hospital significantly
longer than acute trust patients and it is
likely that some would need to be dispensed
for discharge numerous times before they
are finally ready for discharge. Changes to
medicines can occur during a stay in hospital,
making it wasteful to dispense for discharge
too early. Looking at the data by ward type
(table 10) shows very low use of dispensing
for discharge. Acute trust ward types all had
significantly higher rates, with many showing
rates above 60%.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Table 10: Dispensing for discharge
Ward type
Audited wards
Service users dispensed for discharge
average (standard deviation)
CAMHS
11
6.5% (12.7%)
Acute inpatient
56
2.7% (7.7%)
Older people
45
18.7% (36.2%)
Rehabilitation
24
12.2% (29.6%)
Psychiatric ICU
19
1.3% (5.7%)
Source: 2005/2006 medicines management review audit of clinical pharmacy services
Dispensing for discharge may play a role
towards the end of a person’s stay in
hospital when they have regular periods of
home leave, but other initiatives may prove
equally beneficial. The pharmacy workforce
survey reported that 16 out of 30 trusts had
mini-dispensaries on the ward where medicines
can be labelled legally prior to an immediate
discharge. This saves time as discharge
medicines do not have to be ordered from the
central dispensary and, if local procedures are
in place, a suitably qualified nurse or doctor
can issue medicines for weekend leave.
We recommend that trusts ensure that they
have systems in place to enable service
users on home leave or those who have
been discharged to have timely access to
their medicines.
Supplying medicines to people in
the community
On average, 24% of prescribing is undertaken
using hospital prescriptions, which can only
be dispensed in the hospital pharmacy.
Prescribing using hospital FP10 prescriptions
(prescriptions like those issued by a GP)
accounts for about 47% of prescribing (standard
deviation of 28%) which is higher than the
15% found in acute trusts. Hospital FP10
prescriptions can be taken to either the issuing
hospital pharmacy or a community pharmacy.
However, hospital FP10 prescriptions can
reduce trusts’ ability to manage prescribing
behaviour, which may have implications for
budget control if there is inappropriate
prescribing in high volumes or of high cost
medicines, although this risk can be managed
by pre-printing part of the prescriptions.
Trusts have been encouraged only to
prescribe for outpatients if a condition is
acute or if specialist medicines are required17.
Risks to patients are minimised when
medicines are prescribed by only one person
(the GP), who has a complete record of their
history. Barriers such as increased costs for
primary care, poor communication and
increased workload on GPs are not sufficient
reasons to hinder this practice. GPs may need
to address aspects of their working practices
that can cause concerns, to encourage these
people to use primary care services, for
example, preventing long waits in crowded
waiting rooms. Trusts estimated that, on
average, 28% of outpatient prescribing is
passed back to primary care, but there are
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
45
Supplying service users with medicines continued
considerable differences in practice (standard
deviation is 28%). Community pharmacists
can manage repeat prescriptions, and trusts
and GPs should consider if they can work
more with community pharmacists to
implement repeat or repeatable prescribing
arrangements for stable service users.
Encouraging patients to bring their own
medicines to use in hospital is promoted
because people prefer the continuity of using
their own medicines. A lesser mentioned but
important benefit of this is that it can prove
invaluable in building a medicine summary at
admission (including medicines for physical
health, ‘over the counter’ and herbal
medicines). Encouraging people to bring in
their own medicines should help to remove old
and unwanted medicines from peoples’ homes
and reduces the risk of duplicate supplies being
taken at the same time. The above reasons
promote quality of care, and highlight the need
to encourage the use of patients’ own
medicines in mental health trusts. Trusts need
to make service users aware that they should
bring their medicines to hospital and should
have processes to handle them.
Reducing waste
Significant cost savings can be made in acute
trusts by encouraging people to bring in their
medicines and by using these medicines after
they have been checked. This review showed an
average cost of medicines (measured per patient
day) in a mental health trust as £13 compared
with £30 in an acute trust. As the number of
people admitted per bed is lower (as lengths of
stay are longer), the cost savings of using
patients’ medicines is lower. In addition, some
people may not bring in their medicines because
of their state of mind, so the cost benefit of using
patients’ own medicines may be less for mental
health trusts. The main cost involved in using
patients’ own medicines is the time required to
check that the medicines are fit for purpose.
The review identified that the type of ward
where patients’ own medicines were most likely
to be used was for older people but even here,
they are unlikely to be used (table 11). For
audited wards using patients’ own medicines,
one CAMHS ward used 100% of patients’ own
medicines, 13 wards for older people used, on
Table 11: Use of patients’ own medicines by ward type
Type of ward
Trusts with
ward type
Percentage of wards using patients’ own medicines
– distribution of trusts responses
0%
< 50%
> = 50%
100%
CAMHS
19
79
0
5
16
Acute inpatient
35
69
11
9
11
Older people
35
54
17
17
11
Rehabilitation
32
56
13
25
6
Other ward
18
78
22
0
0
Physciatric ICU
26
81
4
12
4
Source: 2005/2006 medicines management review audit of clinical pharmacy services
46
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
average, 33% of patients’ own medicines, one
rehabilitation ward used 50% of patients’ own
medicines and 10 acute inpatient wards used
an average of 18% of patients’ own medicines.
Using patients’ own medicines is not the only
activity that can eliminate waste. Mental
health trusts have also seen cost savings
from improved re-use and management of
medicines prepared for periods of leave. For
example, Derby Mental Health Services NHS
Trust have found that medicines prepared to
support home leave are not always used and
that although bringing these medicines back
into stock is time consuming, it generates
cost savings.
We recommend that trusts consider developing
the roles of pharmacy technicians to include
the efficient management of medicines stock
and patients’ own medicines, and to monitor
the benefits of those roles, including any
reduction in the medicines budget.
Good practice example 10
Following a study that identified a potential
annual saving of £100,000 if all suitable
medicines unused by the home treatment
and assertive outreach teams are returned
to stock for reuse, Birmingham and
Solihull Mental Health Trust have
introduced a new technician post to
supervise this work.
South Birmingham Learning Disabilities
Service developed a role for a pharmacy
technician to provide medicines
management support to care homes. This
development was initiated to address
concerns over the quantities of medicines
ordered and the level of returns. The
technician provides additional support for
service users with complicated medicines
regimes and ‘as required’ medicines and
helps with actions to reduce general
overstocking and wastage.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
47
Effective governance
Responsibility for medicines
management
Decisions, policies and processes underpin
good practice in medicines management.
Ensuring that people get the best outcomes
from their medicines and that they are
supplied safely and economically requires good
practice within the trust and effective liaison
with other organisations.
The Department of Health’s medicines
management framework recommends that
trusts have an executive director accountable
for medicines management and that the chief
pharmacist has access to the chief executive15.
With the large number of healthcare
professionals involved, improvement in
medicines management across a trust requires
leadership and a clear strategy. Sixty-nine per
cent of trusts in our review had a medicines
management strategy (29% had executive
approval and progress regularly reported, 26%
had executive approval, and 14% did not have
executive approval). Thirty-one per cent of
trusts stated that the strategy was ‘work in
progress’. We recommend that trusts should
have a medicines management strategy that is
monitored and updated regularly.
Three trusts in the study (9%) reported having
no director responsible for medicines
management, in 14% of trusts the position
was filled by the chief pharmacist, in 57% of
trusts the manager of the chief pharmacist
fulfilled the role, and the position was filled by
someone outside the main pharmacy
reporting chain in 20% of trusts.
In 90% of trusts with a chief pharmacist, there
was no more than one reportee between the
chief pharmacist and chief executive. Four
trusts reported that they did not have a chief
Figure 18: Pharmacy involvement in trust level initiatives (percentage of trusts with response)
NICE implementation
NSF implementation
Clincal policy
Risk register
0%
20%
40%
60%
Highly involved
Sometimes involved
Contributes on specific issues
Minimal/no involvement
80%
100%
Source: 2005 medicines management review trust questionnaire
48
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
pharmacist, which is a concern. With a high
proportion of mental health services obtaining
their pharmacy services through service level
agreements, the number of in-house trained
pharmacists can often be small in mental
health trusts. It is important that some
knowledge of pharmacy exists within the trust
to manage the service level agreements and
to provide appropriate input into key trust
activities, for example development of the
medicines management strategy and clinical
policies.
Pharmacy staff should be contributing to the
overall management and policy development
within the trust. Our review showed that the
pharmacy was represented on the executive
team in 15% of trusts, on the trust’s clinical
governance committee in 55% of trusts, on
the risk management committee in 53% of
trusts and on the research and development
committee in 45% of trusts. The review
explored the engagement of pharmacy staff in
a number of key initiatives. There are high
levels of involvement in most initiatives in
about 30 to 40% of trusts (figure 18).
The Department of Health has introduced the
role of consultant pharmacist18. These posts
are structured to provide expert practice,
research, evaluation and service development,
education, mentoring and overview of practice
and professional leadership. Introduction of
these posts will clearly support continuous
improvement in medicines management.
We recommend that trusts have a chief
pharmacist with status equivalent to that of
an acute trust clinical director and who is
accountable for delivery through an executive
board member of the mental health trust.
The chief pharmacist should be actively
involved in clinical and operational policy
development and pharmacy staff should be
key stakeholders in trust initiatives with a
medicines-related content.
Risk management and medicines
Medicines have a number of known side effects
and there is a chance that patients will
experience an adverse reaction. The confidential
yellow card reporting scheme from the
Medicines and Healthcare products Regulatory
Agency (MHRA) collects data on adverse
reactions. This scheme has recently been
extended so that patients can report directly and
trusts should make the cards available. Due to
the confidential nature of reporting, it was not
possible to obtain data on local reporting as part
of this review, so no conclusions can be made
on this aspect of trusts’ safety culture.
Medicines that are prescribed can fall into three
categories:
• a licensed medicine being used for its
licensed indication (in the UK the MHRA
manages the licensing process); the majority
of medicines prescribed by GPs are
medicines being used for their licensed
indication
• a medicine which has a licence but is not
being used for a licensed indication,
commonly referred to as ‘off-label’
prescribing
• a medicine which is unlicensed; reasons for
a medicine being unlicensed include
insufficient commercial interest in marketing
the medicine in the UK, the medicine still
being on clinical trial (this prescribing is
regulated by the MHRA) or the medicine may
be waiting for approval from the MHRA
Hospitals treat more unusual conditions than
those handled in general practice, which by
necessity leads them to use more unlicensed
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
49
Effective governance continued
and off-label prescribing. Much of this
prescribing has been developed over years
and across trusts, and historical evidence can
afford trusts a level of confidence in their
prescribing. In the review we asked trusts if
they had an appropriately documented risk
management process for each unlicensed
medicine. This process not only makes the
level of risk clear to trust managers but
should also ensure that all those asked to
treat service users are aware of the risk and
the controls that need to be in place when
prescribing an unlicensed medicine. A
robust formal risk assessment process was
in place at 40% of trusts.
We recommend that trusts produce
prescribing guidance which records any
unlicensed medicines and clearly states any
agreed controls required to maintain an
acceptable level of risk. Both the supply side
risks (for example, quality of medicine,
information provided with medicines,
security of supply) and the potential risk to
those taking the medicines (for example
effectiveness of treatment) should be
explored. Trusts should ensure that suitable
information explaining off-label and
unlicensed medicines is shared with people
who are prescribed these medicines and
that the requirement for a consent process
is considered for those with highest risk.
Trusts should encourage the use of licensed
medicines to ensure that off-label and
unlicensed medicines are used when they
are the only clinically acceptable options.
Drugs and therapeutics committees
Trusts should have a committee responsible
for making decisions on how medicines are
used within the trust19 and the review found
that all trusts had such a committee. The
committee tackles issues such as the
managed entry to the trust of new medicines
and new formulations of existing medicines.
This committee may also consider the
financial case for a medicine, considering for
example, if the benefits of a more expensive
Figure 19: Percentage trusts identifying situation as initiator for drug review
Drugs relatively old in their class
PCT or Health Board requests to review drug
Non-formulary prescribing
Drugs with expenditure higher than budgeted
Formulary drugs licensed for new indications
Drugs which incur high spend
Newly licensed drugs
0%
20%
40%
60%
80%
100%
Source: 2005/2006 medicines management review trust questionnaire
50
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
medicine outweigh the additional cost
pressures from its use, though some trusts
prefer to keep finance and clinical decisionmaking distinct. If these two decision-making
groups are distinct, it is important that there
is sufficient clinical expertise on the
committee that takes the decision on the
financial case for the medicine.
Evidence provided on the events that can
initiate a review of medicines by the
committee suggest that there is scope for
trusts to widen the committee’s role to
consider the continued use of medicines that
are old compared to similar medicines in the
same class (figure 19).
It is important that the committee has an
awareness of wider medicines-related issues
as these could inform its decisions. Trusts
reported on which medicines-related issues
are the business of the drugs and
therapeutics committee or one of its sub­
committees. Of the listed activities, training
staff to manage medicines is the activity
least likely to be considered by the committee
(figure 20).
If a trust is relatively slow at taking
decisions on new medicines, people may fail
to benefit in a timely way from new advances
in treatment, and slow decisions may also
lead to divergent practices within the trust.
However, waiting to use a treatment can also
protect people, as treatment risks are
relatively unknown. Trusts were asked to
provide the date on which they decided
whether or not to use a newly-licensed
medicine for a given list of medicines (figure
21). The shortest average time observed
between a medicine being licensed and it
Figure 20: Medicines related activities covered by committee
Staff groups medicines training
Medicines risk management analysis
Implementation and training for new drugs
Medication error rates and incidents
Drugs spend against budget
Medication alerts
Financial effectiveness of drugs
Trust treatment guidelines
Trust medicines policy
Independent evaluation of drugs
0%
20%
40%
60%
80%
100%
Source: 2005/2006 medicines management review trust questionnaire
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
51
Effective governance continued
Figure 21: Average time to decision on
medicine from date of first license
500
450
400
285
committee attendees, primary care trust
representatives represent 13%, community
pharmacists represent 1% and GPs
represent 4%. Forty-six per cent of trusts
reported that service users attended the
committee and trusts have provided examples
of forums where they work with service users.
350
days
300
228
290
250
200
167
150
100
50
0
Duloxetine Aripipazole Atomoxetine Pregabalin
Average
Plus 1 standard deviation
Less 1 standard deviation
Source: 2005 medicines management review trust
questionnaire
being accepted for use was five months.
Trusts need to gather information to inform
decision makers, which requires significant
effort from staff, usually from a formulary
pharmacist. Some medicines have a
considerable variation in decision time, which
may be linked to the importance and need for
the medicine within a particular trust.
Service users can reasonably expect effective
working between primary and secondary
care in most aspects of medicines
management. Representation on the trust’s
drugs and therapeutics committee provides
one view on stakeholder engagement. On
average, service users represent 4% of
52
Medicine-related incidents
Incidents related to medicines reported by
trusts vary in the extent that they caused
harm to people. An effective safety culture
will generally show high reporting but the
majority of incidents reported will be
evaluated as low risk. Reported incidents
collected as part of this review have been
turned into a rate by dividing by a trust’s
activity measure (the number of inpatient
bed days plus the number of first outpatient
attendees). The average number of incidents
reported is 0.044 per 100 bed days/attendees.
Acute trusts reported an average of 0.09
incidents per 100 bed days/attendees.
Figure 22: Safety interventions per 100
service users seen
30
25
20
15
10
5
0
Trusts
Source: 2005/2006 medicines management review audit
of clinical pharmacy services
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
As part of this review, clinical pharmacy staff
reported on the number of interventions made
that were required to protect the safety of the
service user (figure 22). There is a level of
subjectivity in this classification, which could
explain some of the variance between trusts.
Mental health trusts reported an average of 3.5
safety interventions per 100 service users seen.
This is a similar rate to the 3.9 average found
for acute trusts. There is clearly a large gap
between safety interventions (those considered
necessary to prevent harm) identified through
clinical pharmacy staff and the events that feed
through into the safety reporting system.
Much of the activity relating to medicines is
susceptible to human error. Automation can
offer opportunities to engineer risks out of the
system to some extent. Working practices have
developed which build in safety barriers, such
as setting protocols which staff are trained to
follow or ensuring that a second staff member
checks high risk activity. There is an ongoing
challenge for trusts to ensure that new ways of
working are not weakening safety barriers. For
example, in pharmacies, an independent check
is made to ensure that each service user has
the right medicine; if wards and clinics use prepacks an independent check would be required
before these are passed to service users to
reach similar levels of safety. Our review
explored the effectiveness of lessons learned by
looking at the safety barriers that trusts had in
place for some known risk areas.
Most trusts use an independent check when
using high-risk medicines (medicines which, if
used incorrectly, could cause serious harm).
The review explored the use of independent
checks for injectable medicines. All trusts
reported that their policy required an
independent check on administration and 58%
of these reported that this usually happened.
The results showed that independent checks
are less likely to be made on prescribing, where
60% of trusts stated this was required (60% of
these reported that it usually took place).
Ninety-four per cent of trusts reported that an
independent check should occur when
injectables are dispensed and 97% of these
Table 12: Methods used to highlight knowledge of service users’ allergies
Percentage
of trusts
using method
Percentage of
trusts usually
using method
Different colour patient bands for different allergies
0%
0%
Reminder on patient allergy status that will print on medicine label
3%
0%
Notice on medicine labels which reminds dispenser to check
patient allergy status
0%
0%
Recording of patient allergies on drug chart
94%
80%
Active recording of patients' non allergy status on drugs charts
71%
51%
Refusing to dispense unless allergy status is clearly recorded
on drug chart
46%
9%
Other
20%
17%
Source: 2005/2006 medicines management review trust questionnaire
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Effective governance continued
trusts stated that this usually happened.
Timely review of prescribing by clinical
pharmacy staff is one way to provide an
independent check on prescribing activity.
When staff levels are reviewed, it is important
to maintain safety by retaining independent
checks for high-risk activities.
An identified cause of incidents is the
prescribing or administration of medicines to
service users with known allergies20. There are
a number of ways to reduce this risk (table 12).
Ninety-four per cent of trusts reported that
they write known allergies on drug charts and
71% will positively affirm if patients do not have
an allergy. A number of trusts identified safety
barriers that were only used ‘sometimes’. The
divergence between the availability of a safety
barrier and its use shows the importance of
building up a series of different barriers to
prevent errors. Electronic prescribing will
provide new opportunities to reduce errors if
the system is linked to an electronic patient
record where allergies are recorded. Twenty
six per cent of trusts plan to implement
electronic prescribing alongside an electronic
patient record.
Safety of medicines can be improved by more
contact between pharmacy staff and service
users and through ensuring that processes are
designed for safety. For example, guidance
from NICE indicates that rapid tranquillisation
may be necessary on occasions, but trusts
need to ensure that staff are trained to
administer an appropriate level of medicines
safely and to monitor physical health after
administration of rapid tranquillisation. Clearly,
pharmacists’ expertise should inform rapid
tranquillisation policies, training and practices.
We recommend that trusts implement
systems to regularly record the safety
54
interventions made by pharmacists and use
this information to identify potential
improvements. Trusts should ensure that
they have adequate mechanisms to report
safety issues, particularly in the community.
Trusts should also review their performance
on learning lessons from issues explored in
the review and look to increase the safety
barriers where they have shown to be weak
compared to other trusts.
Safe and secure handling of medicines
Trusts are responsible for the safe and secure
handling of all medicines. Mental health trusts
tend to be based on a number of sites and each
of these sites can have their own medicines
store. There should be suitable governance over
the management of these stores and regular
audits by pharmacy staff. Our review looked in
detail at one aspect of the safe and secure
handling of medicines: the management of
controlled drugs.
There has been considerable focus on
controlled drugs and trusts are now
introducing changes to meet new legislation.
The review looked at the systems in place prior
to the latest additions to the legislation to
ensure that controlled drugs were being
managed appropriately.
The review showed that 97% of destructions
of pharmacy stock, a legal requirement, were
being appropriately witnessed and that 94%
of trusts demonstrated good practice, with all
or nearly all destructions of controlled drugs
returned to pharmacies by patients being
witnessed.
Custom and practice is for audits of pharmacycontrolled drugs to take place every three
months, both for pharmacies and other hospital
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Figure 23: Average number of controlled
drugs audits per year
14
Figure 24: Average annual growth in trust
medicines spend
30%
12
10
Pharmacy
20%
Wards, depts
10%
8
0%
6
2002/2003
4
-10%
2
-20%
0
Trusts
Source: 2005/2006 medicines management review trust
questionnaire
stores21. The independent audit should ensure
that all drugs are accounted for and that usage
appears appropriate. Figure 23 shows that 30%
of trusts reported that pharmacy audits take
place at least every three months (25% recorded
an audit frequency of more than once a month).
For other controlled drug storage areas, wards
and departments, only 19% reported audits
occurring every three months (6% recorded an
audit frequency of more than once a month).
The data suggests mixed practice and follow up
conversations have shown that a number of
trusts consider that the reconciliation of each
drug after use constitutes an audit. Just 35%
of trusts reported compliance with their audit
policy for pharmacies and 19% were compliant
with their policy for auditing other clinical areas
(wards and departments). Twenty per cent of
trust pharmacies and 22% of other trust clinical
areas had either not been independently audited
in a year or had no policy of regular auditing.
Trusts should review their controlled drugs
policy to determine how it complies with the
2003/2004
2004/2005
2005/2006
Source: 2005/2006 medicines management review trust
questionnaire
perceived audit custom and practice. Their risk
management committees should review their
controlled drug audit policy and ensure that
the policy and associated resourcing are
reviewed to reach a position where they can
meet audit policy and get sufficient assurance
that controlled drugs are being managed
appropriately and in accordance with
appropriate regulations. Trusts should ensure
that stocks of medicines held in clinics or wards
are appropriately managed and audited and
that if these stocks are used for dispensing
medicines (rather than administering), they are
appropriately labelled and paperwork is in order.
The cost of medicines
The 34 trusts providing information on the
cost of medicines in this review estimated
that they would spend just over £88 million
on medicines in 2005/2006, a decrease on
the previous year (figure 24). Pharmacies in
mental health trusts have been able to realise
the cost saving from being able to purchase
clozapine as a generic medicine.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
55
Effective governance continued
cost growth (figure 25), part of which can be
explained by differences in case mix. It is
however important that trusts work to
ensure that the medicines bill is not higher
than necessary due to challengeable
prescribing practices.
Figure 25: Change in medicines spend ­
2005/2006
40%
30%
20%
10%
0%
-10%
-20%
-30%
-40%
-50%
-60%
Trust
Source: 2005/2006 medicines management review trust
questionnaire
Given that costs of medicines typically
represent 3% of a trust’s overall budget and
16% of its non-staff budget, it is important
that there is ongoing active management to
ensure that costs remain within budget.
Trusts have experienced differing rates of
Fourteen per cent of trusts reported that
medicines budgets were managed at
trust/hospital level, 29% at directorate, 26%
at specialty and 29% at ward or consultant
level. Fifty-three per cent of trusts reported
that budget holders received monthly reports
on their medicines expenditure, 21% received
quarterly reports, 24% received them when
requested and 3% did not receive them. The
survey of non-pharmacy staff suggested that
on average 43% of trust staff considered that
they received adequate medicines expenditure
reports (20% considered they were timely and
adequate). Twenty-seven per cent of PCTs
considered trusts’ medicines expenditure
reports as adequate (12% considered they
were timely and adequate).
Figure 26: Extent medicines business case is informed by information source
PBR tariffs
All
Some
Limited
Disease incidence
Service changes
Horizon scanning information
NICE guidance
Previous historic spend
0%
20%
40%
80%
60%
Percentage of trusts with response
100%
Source: 2005/2006 medicines management review trust questionnaire
56
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
To have effective budget management, it is
important that the budget is based on good
information. Trusts produce business cases
for their medicines budget and 11% of trusts
reported that their business case was highly
influential, 49% considered it had some
influence, 26% reported limited influence and
14% reported no influence.
service than for a new consultant post or
clinic. Forty per cent of trusts reported that
the pharmacy department would be fully
involved in planning a new service (9% had
no involvement), 31% were fully involved in
planning for a new clinic (14% had no
involvement), no trusts were fully involved in
planning for a new consultant and 83% had
no involvement at all.
Trusts advised on the sources of information
used to build their business case (figure 26).
Previous spend is the most influential source.
Supply side sources, NICE guidance, service
changes and horizon scanning (gaining
knowledge of which medicines will be
available and when) are viewed as more
useful than demand side sources, payment
by results (PBR) tariffs and disease incidence
models.
We recommend that trusts allocate budgets
down to a level where they can influence
prescribers’ behaviour and that data on
expenditure on medicines is shared with
budget holders, ideally once a month, so that
they can identify any unexpected cost issues
and take appropriate and timely action. Trusts
should review the content of existing
medicines reports with their stakeholders
and agree jointly how it could be improved to
meet commissioning needs. Trusts should
include a pharmacy and cost impact
statement in the business cases for any
service changes.
Trusts need to plan for the implications for
medicines management from known service
changes. The review showed that the
pharmacy department was more likely to be
consulted on these implications for a new
Figure 27: Competency re-assessment processes in place
100%
100%
Prescribing
Nurses
Pharmacists
Doctors
Technicians
Locum doctors
80%
80%
Dispensing
60%
60%
Administration
Agency nurses
40%
40%
Agency pharmacy staff
20%
20%
0%
0%
Trusts
Trusts
Source: 2005/2006 medicines management review trust questionnaire
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
57
Effective governance continued
Ensuring the competency of staff
It is important for staff who work with
medicines to have appropriate knowledge and
training. Trusts need to be aware of the
training that new staff have already received,
and ensure that their own internal training
fills in any gaps, for example, using the
hospital’s drug chart and local medicines
policies. Trusts need to assure themselves
on the independence and quality of training
that staff receive.
Good practice example 11
The induction programme at Oxleas NHS
Trust includes a medicines management
component, which covers guidelines and
information on medicines, good prescribing
practice, and the trust’s administration and
medicines policy. A questionnaire has been
used to assess the impact of the ongoing
induction sessions.
A trust’s responsibility to staff and those
using services involves providing appropriate
training as well as ensuring that staff working
with people are competent in various aspects
of managing medicines. Checking competence
58
systematically is a challenge, given the
frequency of staff changes, the high number
of staff involved and the regular use of agency
staff. In the review, trusts were asked whether
they had any re-assessment process for
medicines-related competency for each
staff group and medicines activity. Trusts’
responses indicated that there is some re­
assessment activity taking place (figure 27).
Pharmacy technicians and nurses are the
group most likely to receive competency
checking and doctors are the least likely
group. Processes to re-assess competency
are stronger for trusts’ own staff than for
agency staff.
We recommend that the National Prescribing
Centre leads a national exercise to develop
tools to test the medicines-related
competencies of staff in identified high-risk
areas. These tools should be suitable for
assessing all professional groups involved in
prescribing and handling medicines. Existing
best practice should be sought at the start of
this work. Trusts should identify the areas of
medicines (including concordance) that are
not adequately covered on training courses
for each of the professional staff groups and
put in place actions to address deficiencies.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Pharmacy staffing
In the review we derived an estimate for the
clinical pharmacy staff available per occupied
bed day (including home treatment places).
This estimate assumed that all the available
clinical pharmacy time was spent with
inpatients or service users receiving home
treatment. The robustness of this measure is
affected by the level of service delivered
through service level agreements (SLAs), as a
number of assumptions have had to be made
to derive staffing levels for SLA services*.
The estimates suggest that three quarters of
mental health trusts have clinical pharmacy
staff time per occupied bed day which is
below the acute trust review median trust
value (figure 28). Given that no account has
been taken of the staff time required to
support the majority of community teams,
the gap with acute trust resourcing is wider
than this picture presents. There is no clear
relationship between resourcing and the
proportion of services delivered in-house.
The review identified that the proportion of
pharmacy staff who are assistants and
technicians is significantly lower in mental
health trusts (12% and 34% respectively)
than in acute trusts (23% and 39%). There
are a number of possible explanations:
• Many trusts obtain their dispensing
services under SLAs from acute trusts and
this is the area of pharmacy service where
there is most scope for developing the
roles of assistants and technicians.
However, when clinical pharmacy staffing
is considered, 25% of acute trust
pharmacy staff are technicians compared
to 12% in mental health trusts so this
cannot fully explain the difference.
• New ways of working are slower to be
adopted in mental health trusts and there
is scope for further staff mix and role
developments through competency-based
training and assessments of support staff.
• The scope for role development is greater
the bigger the size of the pharmacy team,
but some mental health pharmacy teams
are too small to be able to achieve the skill
mix that acute trusts can achieve.
0.5
100
0.4
80
0.3
60
0.2
40
0.1
20
0
percentage
hours
Figure 28: Clinical pharmacy time (hours) per occupied bed day
0
Mental health trusts
Acute trust median
% pharmacy activity delivered in house
Source: 2005/2006 medicines management review trust set up form and questionnaire
*
SLA clinical pharmacy time per occupied bed day has been derived based on provider trust estimates of SLA activity
levels compared to their own trust activity and assumes SLA resources are allocated consistently across all of a provider
trust’s agreements.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
59
Pharmacy staffing continued
Figure 29: Percentage trusts where technicians recorded activity during review audit
Inpatient supply
Mental health
TTO supply
Acute
Therapy discussions
Suggest change in therapy choice
Suggest change in dose
Suggest change in monitoring
Drug charts reviewed
Adverse drug reaction identified
Allergy identified
Medication reviews
Patients educated
0%
10%
20%
30%
40%
50%
Source: 2005/2006 medicines management review audit of clinical pharmacy services
There is some evidence of technicians taking on
clinical pharmacy work. Our review showed that
technicians working on wards are supporting
the supply of medicines and providing education
for service users (figure 29).
We recommend that consideration be given
to developing special training for technicians
working in mental health to support the
introduction of new roles.
Good practice example 12
In South West London and St George’s
Trust, a senior pharmacy technician is
responsible for keeping records for
individual service users, supplying repeat
prescriptions for service users’ medicines
and checking and re-using patients’ own
medicines. From structured interviews it
was identified that this role has been well
received by nurses and has reduced the
workload involved in ordering medicines.
The new ordering process has reduced the
number of missed doses, allowed improved
planning of pharmacy work and generated
medicines cost savings.
60
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Service level agreements and delivery of services
Current medicines management arrangements
are influenced by the history of trusts. In April
2001, health services in England were reshaped,
leading to the formation of specialist mental
health trusts and primary care trusts providing
mental health services. Prior to this
development, the provision of mental health
services was managed alongside physical
healthcare and many of the facilities owned by
mental health trusts are co-located with acute
trusts. This has implications for medicines
management. Pharmacy services at the time of
the re-organisations tended to remain in acute
trusts. Mental health providers often found the
most cost effective access to a pharmacy
service for them was through setting up a
service level agreement (SLA) with the co­
located acute trust.
Only 17% of the trusts taking part in the review
had their own pharmacy services covering all
trusts’ activities. Twenty seven per cent of
trusts had one SLA and 27% had two SLAs.
There are 29% of trusts whose services are
provided through three or more SLAs (13% had
three, 10% had four, 3% had five and 3% had
six). Clearly, the development and management
of effective SLAs is essential for effective
medicines management in mental health trusts.
SLA arrangements can be based on geography
or on service area. Some trusts have chosen to
develop in-house clinical pharmacy services
whilst purchasing their supply and dispensing
services using an SLA. This helps them ensure
that the pharmacy staff working in clinical areas
are accountable to the trust and have specialist
skills in mental health. Another approach has
been to include a clause in the SLA that the
clinical pharmacy staff will be accountable to
the mental health trust’s chief pharmacist.
Acute trusts were asked to volunteer their
assessment of the funding they received and
the service they were able to provide. They
identified 53% of agreements with mental
health trusts as being under-funded and 35%
of this under-funding was considered to be
limiting the service acute trusts could deliver
to a standard below that experienced by their
own patients.
In testing the philosophy that an acute trust
should provide the same standard of service to
people served via an SLA as it does to its own
patients, people in eight of the 33 trusts who
receive services via SLA receive the same
standard of services as those in the providing
trust (figure 30).
Figure 30: Relative pharmacy time spent on SLAs compared to time spent on own patients
(1 = same service)
2
1.5
1
0.5
0
Trusts with service provided via SLA
Source: 2005/2006 medicines management review trust set up form and questionnaire
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
61
Service level agreements and delivery of services continued
The data collection could not distinguish which
part of the service was delivered via SLA
(clinical or dispensing), which is a limitation of
this analysis. However, there are no clear
correlations between service outcome and the
proportion of the service delivered via SLA.
Where mental health trusts consider the
services delivered via SLAs to be inadequate,
this needs to be addressed with service
providers and commissioners and they should
either strengthen the SLA, with additional
funding if necessary, or secure alternative
service provision. In-house pharmacy provision,
particularly of the clinical pharmacy service, is a
preferred option chosen by a number of trusts.
62
Some mental health trusts are satisfied with
their SLA services and have provider trusts
who are committed to providing a high quality
service to mental health service users. Some
are very concerned that acute trusts will decide
to opt out of providing pharmacy services to
mental health trusts, once they achieve
foundation trust status. It is extremely
important during the next few years that
pharmacy provision for mental health services
is not weakened by changes in service.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Conclusions and recommendations
- the way forward
The review has assessed trusts’ performance on
a range of issues that are encompassed by the
term ‘medicines management’. It has provided
a mixed picture on the strength of medicines
management governance. Nearly a third of
trusts reported that their medicines
management strategy was still ‘work in
progress’ and there are trusts without a director
responsible for medicines management and
trusts without a chief pharmacist to provide
expertise. Services for inpatients from the
clinical pharmacy looked relatively weak when
compared with acute trusts but where services
do exist, levels of contribution, including safety
interventions, are similar. Support provided to
community teams was found to be even weaker
and there is a need to identify models of service
to include pharmacy support in each of the
teams that work with medicines. Given the long
term relationships that service users have with
teams, these models should consider the
content and frequency of medication reviews.
The review identified that implications for the
pharmacy should be given more consideration
when planning for new services.
Medicines are used as a treatment option in the
majority of treatment plans and service users
often take a number of different medicines.
Information obtained from POMH-UK suggests
that there are problems with the prescribing of
antipsychotics for a significant number of
people. The recent community mental health
service improvement review also found a wide
variation in the proportion of service users with
treatment-resistant schizophrenia who were
taking clozapine. This all suggests variable
compliance with national guidance and a need
to improve the overall quality of prescribing.
The review obtained evidence from medication
reviews that a significant proportion of people
are not adhering to their medicines. Mental
health trusts have undertaken more work on
concordance than acute trusts, for example,
development of information for people.
Improving adherence is clearly a priority area
for trusts providing mental health services.
There was limited evidence of inpatients being
allowed to manage their own medicines, yet
problems with medicines could be identified
and addressed before discharge if people are
allowed to manage their own medicines whilst
in hospital.
With a high proportion of people cared for in
the community, it is important that there is
effective working with other organisations. The
review identified weaknesses in obtaining and
sharing information with GPs and poor use of
shared care agreements.
The review identified a need to improve the
supply of medicines on discharge in some
trusts. Pharmacies in mental health trusts
need to be able to dispense small amounts of
medicines often at short notice. New technology
is only just being developed to meet this need.
Initiatives such as dispensing for discharge and
using patients’ own medicines are less utilised
in mental health trusts than in acute trusts,
however, financial benefits from these initiatives
are smaller than in acute trusts. Inadequate
support from clinical pharmacy staff will also
be a barrier to implementation.
The mix of staff within the pharmacy differs
from acute trusts, with assistants and
technicians forming a smaller proportion of
the workforce. This suggests that there is
scope for developing services through
introducing new roles. As with acute trusts,
assessment of the competency of staff working
with medicines is relatively weak. There is also
a need for drugs and therapeutics committees
to take responsibility for ensuring the quality
of training for staff.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
63
Conclusions and recommendations – the way forward continued
A significant proportion of pharmacy services
are delivered through SLAs. The review
identified that the services received through
SLAs are often inferior to those provided to
acute trusts’ own patients and that funding was
often an issue. Outcome measures showed no
clear relationship to the proportion of services
delivered by SLAs.
Trusts need to review their medicines
management strategy following this review and
ensure sufficient leadership and governance
for all medicines management activities
undertaken. There should be appropriate
engagement from all professional groups to
deliver improvement across the spectrum of
activities that relate to medicines management.
Leadership for medicines management will be
required from the chief pharmacist.
The recommendations from this review for
trusts are represented in appendix A arranged
under 10 focus areas (figure 31), each of which
is described in terms of a future vision. Some
of this vision is achievable now, and other
areas rely on new technology that trusts
should be planning to introduce. Whether
pharmacy services are delivered in-house or
via SLAs, trusts should aim to deliver the same
standards of care.
Figure 31: Ten focus areas for medicines management
10. Supplying and
managing medicines
in the trust
1. Involving people
in decisions and
management of
their medicines
9. Accurately
recording and
reporting on use
of medicines
2. Ensuring
appropriate and
effective use of
medicines in
peoples care
Medicines
Management
Strategy and
Leadership
8. Ensuring staff are
competent to work with
medicines
7. Choosing and
prescribing medicines
6. Governing
use of medicines
64
3. Efficiently and effectively
providing and
administering medicines
4. Promoting multi­
disciplinary team working
to provide seamless care
5. Coordinating
care with other
service providers
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Ten focus areas for a vision for medicines management
1. Involving people in decisions and
management of their medicines
Time should be spent with service users and
their carers explaining medicines and
allowing them to raise issues. Concordance
should be achieved on how medicines will be
used within a person’s care package to
achieve the best outcome. Care plans and
advance directives should be developed that
cover the role of medicines, ongoing
monitoring requirements and the person’s
preferences for medicines. Where
appropriate, people should manage their
own medicines whilst in hospital. They
should have access to a range of appropriate
information which they can discuss with a
knowledgeable healthcare professional.
Medicines should be managed with
appropriate privacy and sensitivity to
individual needs. Care pathways, drawn up
with service users and their carers should
explain how their care is to be managed by
the different services. Service users and
carers should be advised on the contact
process for accessing advice after leaving
hospital.
2. Ensuring appropriate and effective use
of medicines in people’s care
A clinical pharmacy service should be
available each day with pharmacy staff
operating as part of the multi-disciplinary
team in inpatient units and as part of the
community teams. They should be involved
in discussions on individuals’ medicines
and identify and instigate changes to
practices to improve the safety, effectiveness
and efficiency of medicines. Staff time
should be targeted to bring maximum
benefit to service users. Regular checks of
the safety and effectiveness of service users’
medicines should take place at appropriate
intervals during their care, starting on
admission. Medication reviews should be
performed at appropriate times.
3. Efficiently and effectively providing and
administering medicines
The supply and administration of medicines
to service users should be safe, efficient and
support effective care. Medicines for
inpatients should be prepared in advance
of the decision to discharge them or to
enable home leave, and medicines should
be available to people in the community at
the time that they need them. People using
mental health services should be unaware
of organisational boundaries and should
receive their long term medicines from
primary care, once their mental state is
stabilised, if this is their choice. The ‘right
medicines’ should be administered by trust
staff at the ‘right’ time. Medicines should be
agreed with the service user and their carer
to support adherence. Medicines-related
errors should be reported so that lessons
are learned.
4. Promoting multi-disciplinary team
working to provide seamless care
Multi-disciplinary team working should be
the norm. Doctors, nurses, allied health
professionals and pharmacy staff should
collaborate and work with those using their
services to deliver safe, effective and
individual medicine-related care.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
65
Conclusions and recommendations – the way forward continued
Ten focus areas for a vision for medicines management continued
5. Co-ordinating care with other service
providers
There should be effective joint working
with other organisations who have
responsibilities relating to service users’
medicines. Appropriate information should
be shared regularly between GPs, care
homes, community pharmacies and the trust
in order to provide safe, seamless care.
6. Governing use of medicines
The medicines and prescribing committee,
which should include representation from
people using services, should ensure that
prescribers take account of the most
appropriate range of medicines that should
be routinely used within their teams. This
should include the place of both newly
introduced medicines as well as providing
advice on medicines that should not be
routinely prescribed. In situations where
national guidance has not been issued, the
medicines and prescribing committee
should assess the evidence on the risks
and benefits of pharmacological treatments
and ensure that any risks associated with
medicines are properly managed. The
committee should consider wider medicines
management issues including prescribing
performance, clinical audit, incidents, safety
alerts and training needs and should
maintain effective medicines-related policies
and procedures.
7. Choosing and prescribing medicines
Electronic guidance, accessible to
prescribers in their everyday duties, should
cover the selection of medicines, the
66
introduction of new medicines and the
removal of medicines that are no longer
appropriate. Electronic prescribing should
operate throughout the trust and the
administration of medicines should be
scheduled and logged. The system should
provide a variety of guidance and alerts to
reduce the risk of making prescribing and
administration errors. Ward staff should be
alerted to any missed doses through the
system. The system should be linked to the
electronic patient record and any known
contraindications or allergies should be
flagged up. The system should be designed
so that safety issues could be addressed
through alert logic enhancements.
8. Ensuring staff are competent to work
with medicines
All staff working with medicines should
receive appropriate training at induction and
refresher training as necessary and should
have their competency checked regularly.
Training should be reviewed regularly and
adapted to ensure that safety lessons are
learned. Training records should be
maintained. Staff should be selected and
trained in areas, such as supplementary or
independent prescribing, based on service
and clinical need.
9. Accurately recording and reporting on
use of medicines
Medicines prescribed and administered
should be accurately recorded in the
(electronic) patient record and these records
should be used to help support safe and
effective care. It should be easy to produce a
medicines history report that enables an
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
Ten focus areas for a vision for medicines management continued
efficient review of medicines. Information
relevant to people’s medicines, including
test results, should be accessible to the
trust,GPs and other providers. Prescribers
and commissioners should receive regular
reports that are easily generated, on the
use of medicines for monitoring their budget
and clinical practice.
10. Supplying and managing medicines in
the trust
Medicines should be managed efficiently
and safely to ensure that costs are
minimised and legal requirements are met.
There should be a low probability of service
users not receiving their medicines.
Medicines waste should be minimised. Stock
systems reports on the use of medicines
should inform ordering and provide audit
trails to support assurance. Dispensing
should be efficient and make appropriate
use of new technology and ways of working.
Medicines should be purchased
economically, in the most appropriately sized
packages and where re-packaging is
required, meet the standards for a
manufactured product. Wherever possible
medicines should be provided in a form that
does not require complex preparation before
administration. Errors relating to the supply
of medicines should be reported so that
lessons can be learned.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
67
References
1 Audit Commission, A spoonful of sugar ­
Medicines Management in NHS Hospitals
(18 December 2001)
8 Prescribing Advisory for Mental Health
Combining anti-psychotics. Can it be
justified?
2 Central and North West London Mental
Health NHS Trust’s proposal for a
medicines clinic, citing evidence from:
Weiden P J, Olfson M: Cost of relapse in
schizophrenia. Schizophrenia Bulletin
(1995; 21: 419-429); Weiden P J, Glazer W.
Assessment and treatment selection for
revolving door inpatients with schizophrenia.
Psychiatry Quarterly (1997 winter; 68(4):
377-92); Frequent re-hospitalisation and
non-compliance with treatment. Hospital
Community Psychiatry. (1988, 39: 963-6);
A pharmacoeconomic model of outpatient
antipsychotic therapy in revolving door
schizophrenic patients. Journal of Clinical
Psychiatry (1996; 57: 337-45).
9 Ms Denise Taylor and Dr Jane Sutton,
Department of Pharmacy and
Pharmacology, University of Bath, Report
on the Mental health and Learning
Disabilities Pharmacy Workforce Survey,
(May 2006)
3 Prescribing Observatory for Mental
Health-UK - Contribution by Carol Paton
to the Healthcare Commission’s State of
Healthcare report October 2006
4 Mike Scott, Integrated Medicines
Management Project - Final Report,
(November 2005)
5 Pharmacists in medical Assessment Unit
reduce doctor workload, Calling Time Issue
9, Modernisation Agency
6 Healthcare Commission Adult survey of
users of mental health services (2005)
7 Chris Fox, Ian Maidment, Malaz Boustani.
Medication errors on Older’s People’s Mental
Health in-patient units. Poster at 9th
International Conference on Alzheimer’s
Disease, (Madrid 2006)
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10 Correspondence from David Taylor, Chief
Pharmacist, South London and Maudsley
Trust, (October 2006)
11 Taylor D, Paton C, Kerwin R, The Maudsley
2005-2006 prescribing guidelines, (Taylor &
Francis, London 2005)
12 Audit Commission, Managing the financial
implications of NICE guidance, (8 September
2005)
13 Jed Boardman & Michael Parsonage,
The Sainsbury Centre for Mental Health,
Defining a good mental health service: A
Discussion Paper (29 November 2005)
14 Department of Health, National Service
Framework for Mental Health (30
September 1999)
15 Department of Health, Medicines
management in NHS Trusts: hospital
medicines management framework, (19
September 2003)
16 Ian Maidment, Paul Lelliott, Carol Paton,
A systematic review of medication errors
in mental healthcare. Quality & Safety in
Healthcare. (15,409-413, December 2006)
17 NHS Management Executive, EL(91)127
Responsibility for prescribing between
hospitals and GPs
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
18 Department of Health Guidance for the
Development of Consultant Pharmacist Posts,
(2005)
19 Department of Health, The Way Forward
for Hospital Pharmaceutical Services (1988)
20 Chief Pharmaceutical Officer, Building a
safer NHS for patients: improving medication
safety (January 2004)
21 Royal Pharmaceutical Society of Great
Britain, The Safe and Secure Handling of
Medicines: A Team Approach (March 2005)
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Appendix A: Checklist of recommendations for trusts
1. Involving people in decisions and
management of their medicines
a. Trusts should inform people on the
possible approaches to medicine-related
care and allow them to be involved in
choosing the best approach for their care.
b. Trusts should ensure that the design of
their care plans and advance directives
forms captures appropriate information on
medicines effectively.
c. Trusts need to check that people are being
offered a choice, where possible, of
medicines and their choice should be
recorded in care plans and advance
directives.
d. Trusts should ensure that activity to
support achievement of concordance is a
priority area.
e. Trusts should ensure that they make the
most appropriate information on
medicines available to people, making
appropriate use of the material developed
and shared within the mental health trust
pharmacy community.
f.
Trusts should review with other NHS
organisations in their care community how
best to support people who experience
problems with their medicines after
discharge and ensure that service users
and carers are aware of whom they should
contact if such problems arise.
g. Trusts should offer people the opportunity
to self-administer their medicines if they
are competent or they can reach
competence, and if their stay in hospital
will provide sufficient opportunity for them
to do this.
70
h. Trusts should provide suitable information
explaining off-label and unlicensed
medicines for people who are prescribed
these medicines, and they should consider
the need for a consent process for those
with highest risk.
2. Ensuring appropriate and effective
use of medicines in people’s care
a. Trusts should have adequate expertise to
ensure that appropriate medicines are
prescribed to inpatients with physical
illness, and that systems are in place to
provide results of tests from primary care
to support this activity.
b. People’s medicines should be checked for
potential interactions and for
appropriateness.
c. Trusts should audit their prescribing and
consider participating in the POMH-UK
audit programme.
d. Trusts should increase the amount of time
from their pharmacy staff on clinical
support towards the target time identified
from this review, evaluating the service,
and providing appropriate training to
ensure benefits are realised.
e. Trusts should include clinical pharmacy
support in crisis resolution and home
treatment teams, and pharmacy support
levels should be bought in line with
corresponding inpatient units.
f.
At least one day of clinical pharmacy
support per week should be provided to
all community teams where the team
manages people’s medicines regularly.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
g. Trusts should consider collaborating with
PCTs and community pharmacists to use
the ‘medicine use review scheme’, with
appropriate training, to help ensure that
all people using mental health services in
the community who take medicines have
had a review within the last year.
5. Coordinating care with other service
providers
h. Trusts should have a policy to review
regularly the medicines of people in their
care, which should cover the training and
competency requirements for undertaking
reviews and what would trigger a more
comprehensive medication review.
b. Trusts and primary care providers should
implement processes for sharing working
practices and information on people using
their services, so that they will experience
consistent care wherever they access this
care.
i.
c. Health communities should implement
shared care agreements for a nationally
agreed list of medicines.
Trusts should make available yellow cards
for people to report adverse side effects of
their medicines.
3. Efficiently and effectively providing
and administering medicines
a. Trusts should ensure that dispensing
systems can support the timely provision
of medicines and can provide small
quantities of medicines for home leave or
for people whose care plan involves
picking up medicines regularly.
4. Promoting multi-disciplinary team
working to provide seamless care
a. Trusts’ pharmacy staff should aim to
improve their profile and receive board
level support in doing so, to ensure that
other hospital staff and service users are
aware of how they can contribute to
people’s care.
b. Pharmacists should be permanent
members of multidisciplinary teams.
a. Mental health trusts and PCTs should
ensure that there are robust processes in
place to address the commissioning and
implementation of NICE guidance.
d. People using services should become
overt partners in shared care agreements
and should be made aware of who is
responsible and what to expect from their
care.
e. Trusts and GPs should work with
community pharmacists to implement
arrangements for repeat or repeatable
prescribing for stable service users.
6. Governing use of medicines
a. Trusts should have a medicines
management strategy, which is monitored
and updated regularly.
b. Trusts should have a chief pharmacist
who has the status of a clinical director or
equivalent and is accountable through an
executive board member.
c. The chief pharmacist should be actively
involved in the development of clinical and
operational policy and pharmacy staff
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Appendix A: Checklist of recommendations for trusts continued
should be made key stakeholders in trust
initiatives with a medicines content.
d. Trusts should include a pharmacy and cost
impact statement in the business cases for
any changes in services.
e. If trusts are aware of problems with
services delivered via SLAs, they should
work with their service providers and
commissioners to put in place agreements
that are acceptable to both parties and
provide an acceptable standard of service.
f.
Trusts should implement systems to
record regularly the safety interventions
made by pharmacists and use this
information to identify potential
improvements to the safe and secure
management of medicines.
g. Trusts should ensure that they have
adequate safety reporting mechanisms,
particularly in the community.
h. Trusts should review their performance on
learning lessons from issues explored in
the review and look to increase the safety
barriers where they have shown to be
weak compared to other trusts.
7. Choosing and prescribing medicines
a. Trusts should review current clinical
guidelines to ensure that they provide
clear direction for best practice
prescribing.
b. Trusts should identify and communicate
their requirements for electronic
prescribing systems and review
timescales and local actions required to
ensure that benefits can be realised at
the earliest opportunity.
72
c. Prescribing guidance produced by trusts
should record any unlicensed medicines
and clearly state any agreed controls
required to maintain an acceptable level
of risk.
d. Trusts should encourage the use of
clinically acceptable licensed medicines
to ensure that off-label and unlicensed
medicines are used when they are the
only clinically acceptable options.
8. Ensuring staff are competent to
work with medicines
a. Trusts should maximise the benefits from
independent and supplementary
prescribing by determining where it can
be best used to meet clinical and
operational need.
b. Trusts should develop the roles of
pharmacy technicians to include the
efficient management of medicines stock
and patients’ own medicines, monitoring
the benefits including any reduction in
their medicines budget.
c. Trusts should identify the medicinerelated areas (including concordance),
which are not adequately covered on
training courses for each of the
professional staff groups and put in place
actions to address deficiencies.
9. Accurately recording and reporting
on use of medicines
a. Trusts should allocate budgets down to
a level where they can influence the
behaviour of those prescribing and they
should share data on expenditure on
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
medicines with budget holders, ideally
once a month, so that any unexpected cost
issues can be identified and appropriate
and timely action taken.
b. Trusts should review the content of
existing medicines reports with their
stakeholders and agree jointly how the
content of the report could be improved to
meet the needs of stakeholder
commissioning.
10. Supplying and managing medicines
in the trust
a. Trusts should review their policy on
controlled drugs to determine how it
complies with the perceived custom and
practice of an independent pharmacy audit
of controlled drug stores to reconcile
usage and stock and to check for any
irregularity in usage every three months.
b. Trusts’ risk management committees
should review their audit policy on
controlled drugs and ensure that the
policy and resources are reviewed to
enable the audit policy to be met and to
receive sufficient assurance that controlled
drugs are being used appropriately and in
accordance with appropriate regulations.
c. Trusts should ensure that stocks of
medicines held in clinics or wards are
managed and audited appropriately and
that if these stocks are used for
dispensing medicines (rather than
administering), they are appropriately
labelled and paperwork is in order.
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Appendix B: Recommendations for national
organisations
There are some issues raised in this report
where it would be a poor use of resources,
and a failure to learn from existing practice,
if each trust were to develop their own local
solutions. For example, developing competency
checking for healthcare professionals in the
use of medicines. There are a number of
national bodies and many regional and national
groups who could take issues forward and
recommendations have been targeted at
appropriate groups. It is important that
pharmacy leads in strategic health authorities
monitor progress on these recommendations
and communicate this to trusts. The
Psychiatric Pharmacy Group (UKPPG) could
also support this monitoring and
communication role.
Department of Health and SHAs
a. The Department of Health should consider
an initiative, for example, to improve the
quality of antipsychotic prescribing, using
a model similar to that used to improve
the quality of antimicrobial prescribing in
acute trusts.
b. To reduce the inconsistencies across the
country on how people are able to access
care, a nationally agreed list of medicines
suitable for shared care should be
produced.
c. Consideration should be given to using the
qualities and outcomes framework (QOF)
to encourage GPs to engage in shared care,
and in particular to assess and monitor the
physical health of service users.
d. The existing national mechanism for
sharing risk assessments for unlicensed
medicines should be reviewed and if
necessary improved to ensure maximum
74
learning across trusts and best use of
pharmacists’ time.
National Institute for Mental Health in
England
a. NIMHE should consider developing a tool
for evaluating the contribution of the
pharmacy to community teams and acute
wards and, if possible, funding and
evaluating pilots of the proposed models.
b. Consideration should be given to working
with the UKPPG to develop special training
for technicians working in mental health
to support the introduction of new roles.
NHS information centre
a. Consideration should be given to
developing a wider set of comparator
indicators for regular monitoring of
prescribing for care communities, feeding
any requirements for data to support this
activity into the NHS connecting for health
secondary user service requirement.
Connecting for Health programme
a. The Government should ensure that
electronic prescribing is available at the
earliest opportunity as part of the National
Programme for IT.
b. NHS Connecting for Health should consider
working with a small number of trusts who
wish to be early adopters of electronic
prescribing, this could help speed up the
time to the first implementation and allow
learning to be built into solutions before
they are shared across the NHS.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
NHS Purchasing and Supply Agency
a. The NHS Purchasing and Supply Agency
should work with trusts to identify areas
where pre-packs could be of significant
benefit and work with the pharmaceutical
industry to make available a wider selection
of pre-packs, ensuring that trusts are
aware of the pre-packs that are available.
National Prescribing Centre
a. The medicines management collaborative
should share lessons learned on the
implementation of self-administration in
mental health trusts.
b. The national prescribing centre should
publish definitions and guidance on the
different types of ‘medication reviews’,
linking in with the Skills for Health work
which is identifying the competencies
required to undertake a medication review.
c. The National Prescribing Centre should
lead a national exercise to develop tools to
test the medicines-related competencies
of staff in identified high risk areas. These
tools should be suitable for assessing all
professional groups involved in prescribing
and handling medicines. Existing best
practice should be sought at the start of
this work.
d. A suitable mechanism should be introduced
for sharing model shared care agreements
to assist development.
Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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Healthcare Commission Talking about medicines: The management of medicines in trusts providing mental health services
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