Improving care of people with mental health conditions in Scotland

How pharmacists can help

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Foreword

Improving mental health is a priority and the focus of national strategy in Scotland. This policy document describes how pharmacists can improve care for people with mental health conditions and makes six recommendations to enable enhanced roles for pharmacists.

Access to pharmacological and non-pharmacological therapies is critical to the effective and safe management of mental health conditions, yet timely access could be improved. Conversely, it is recognised that people are prescribed medicines for some conditions, e.g. anxiety and depression, for longer than is necessary and this must change.

Increasing numbers of pharmacists working within mental health services and GP practices are using prescribing skills to manage conditions by initiating, reviewing and reducing medication as part of the multidisciplinary team.

Many of the medicines used to treat mental health conditions are complex and associated with acute and chronic health risks and therefore require frequent blood and physical health monitoring, e.g. clozapine and lithium. Side effects vary from mild and short term to long-term and significant for some medicines. Improvement is required in monitoring and follow up to avoid and minimise the impact of medicines on physical health.

Pharmacists’ expertise in medicines could be better harnessed through new approaches to minimise and manage these risks in order to deliver safer care for people with mental health conditions. We have listened to our members, patients, patient representatives, pharmacy teams and other health care professionals and have gathered evidence of best practice and set out recommendations in this policy document that will make a real difference to improving care if implemented.

The expertise, clinical knowledge and accessibility of pharmacists across the NHS should be better used within multidisciplinary teams to support people with mental health conditions to help them live longer and healthier lives.

Executive Summary

One in three adults in Scotland experience mental health conditions in their lifetime. People with a life-long mental health condition are likely to die 15-20 years prematurely because of poor physical health, ¹ much of which is preventable with improved patient care and risk management.

The Scottish Government’s Mental Health Strategy 2017- 2027 has a vision of a Scotland where people can get the right help at the right time, expect recovery, and fully enjoy their rights, free from discrimination and stigma.

RPS Scotland has undertaken a review of pharmacy involvement in mental health and believes that better use of the pharmaceutical care* expertise and skills of pharmacists, better resourcing of existing services and commissioning of new models of care could help to realise the aims and ambitions of the strategy.

Our policy recommendations are aimed at key stakeholders tasked with implementing Scotland’s mental health strategy and primary care transformation, and individual practitioners who have collective responsibility for ensuring they provide the best possible pharmaceutical care for people with mental health conditions.

Pharmaceutical care is a holistic practice which aims to provide the right patient with the right medicines in the right dose at the right time for the right reasons to achieve agreed outcomes. Medicines should have an active indication and be as effective and as safe as possible.

Mental health and physical health – improving outcomes

Recommendations

1. People prescribed a new medicine for a mental health condition would benefit from support from their community pharmacy as part of an integrated model with GPs  Read more
2. The clinical skills of pharmacists working in all settings (community pharmacy, GP practices, mental health services, primary and secondary care) should be further utilised to improve pharmaceutical care Read more
3. To improve access, physical health monitoring and targeted public health initiatives in community pharmacy are needed  Read more
4. Pharmacy teams should be trained in mental health first aid and suicide prevention so they can respond to crisis situations  Read more
5. More specialist mental health pharmacists are required to ensure that existing services are sustainable, and all mental health and primary care teams have access to their expertise through psychiatric pharmacist liaison posts  Read more
6. Pharmacists should have appropriate read and write access to medical records to deliver safe, integrated and effective patient care Read more

Context for change

People with mental health conditions commonly die prematurely. The life expectancy of someone with bipolar disorder or schizophrenia is 15-20 years less than the general population. There are many reasons for this including the challenges of long-term mental health conditions and poor access or uptake of physical health care.

The main preventable and manageable risks associated with premature death in people with mental health conditions are lack of exercise, smoking, obesity, hypertension, diabetes and cardiovascular disease.

The Scottish Government’s Mental Health Strategy aims to improve:

• Access to treatment and joined up accessible services.
• The physical wellbeing of people with mental health problems.
• Prevention and early intervention.

Key priority areas include ensuring parity of esteem between treatment of mental and physical health and helping people with mental health conditions to manage their physical health. There is also an acknowledgement within the strategy that there must be improvements in prescribing and follow-up care.

Healthcare Improvement Scotland has recognised the risks involved and the requirement to improve physical care in the publication of the Scottish Patient Safety Programme mental health safety principles. ² The principles also highlight the importance of the contribution from all healthcare professionals along the care pathway.

The Future of the Mental Health Workforce ³ by the Centre for Mental Health in England document (2017), recognises that pharmacy is sometimes regarded as a peripheral service in mental health but acknowledges that it is an untapped resource and that both pharmacists and pharmacy technicians working across all areas of the NHS have much to offer.

In Scotland, the National Clinical Strategy⁴ has highlighted the value of other professions working with GPs to improve both quality and capacity. The General Medical Services Contract for GPs has recognised the value of pharmacist prescribing and medication review working within a multidisciplinary team ⁵. There are examples of GP practice pharmacists making a positive impact in reducing long term use of medicines for anxiety and depression. More could be done to accelerate the spread of this good practice across Scotland.

The Scottish Government strategy Achieving Excellence in Pharmaceutical Care⁶ has a focus on integrating care across boundaries. Psychiatric liaison roles which encourage integrated ways of working between specialist and generalists are key to improving seamless care. More mental health pharmacists are required to provide these roles to ensure a national approach with the associated benefits for people with mental health conditions.

The King’s Fund and the Centre for Mental Health found that between 12-18% of all NHS expenditure on long-term conditions (LTC) was linked to poor mental health and wellbeing.⁷ The Scottish diabetes framework has estimated that up to 1 in 5 of people with diabetes suffer from depressive disorders and the risk of clinical depression is even higher amongst those with co-morbidity and complications.⁸ Diabetes UK⁹ has stated that:

"All healthcare professionals should receive training, so they can routinely support emotional and mental health, and can refer to specialist support when appropriate”

It is essential that generalists are appropriately trained and equipped to identify early signs of mental health conditions in people with long term conditions and intervene appropriately.

This policy sets out our recommendations to enable pharmacists and their teams to support implementation of Scottish Government strategies, address gaps in services and improve pharmaceutical care. This policy also builds on the RPS England Utilising the skills of pharmacists to improve mental health Policy¹⁰ and Report, No health without mental health report ¹¹.

Recommendation #1

People prescribed a new medicine for a mental health condition would benefit from support from their community pharmacy as part of an integrated model with GPs.

Pharmacists play an important role in their communities. They provide advice on how best to take medication and how to identify and manage side-effects. They can spot early signs of mental
health conditions, signpost to self-help resources and support people from early diagnosis through treatment to recovery.

Receiving a diagnosis for any condition is challenging. Stigma and other factors can make a mental health diagnosis even more difficult. Additional support from healthcare professionals working together during the different phases of treatment, especially at the start of therapy, is essential to help people:

• Obtain the information they need,
• Get the most from their treatments,
• Minimise avoidable drug-related harms
• Receive the support they need to self-manage their condition

The New Medicine Service (NMS) in England has improved patients’ medicines adherence by 10%, creating short-term savings of over £75 million in the first five years of the service; this will lead to savings of £517.6 million in the longer term. ¹²

To improve support, consistent messaging and follow up, the RPS believes that the principles from the NMS could be applied in Scotland and enhanced by formal links between GP practices and community pharmacies, supported by the New Medicines Intervention Tool and Medicines Care and Review (MCR) service. ¹³

Antidepressant prescribing could be an initial focus of these formal links. It may take a few weeks for some people to experience a noticeable benefit from a new antidepressant treatment. During this period, people often experience some unpleasant side effects and are more at risk of suicide so information, re-assurance, signposting and referral from community pharmacists can provide extra support if needed.

Recommendation #2

The clinical skills of pharmacists working in all settings (community pharmacy, GP practices, mental health services, primary and secondary care) should be further utilised to improve pharmaceutical care.

Over the years, pharmacists working in general practices have addressed challenging areas, such as inappropriate long-term use of antidepressants benzodiazepines and z-hypnotics, both as prescribers and non-prescribers. Such work has enabled and supported significant reductions in the use of benzodiazepines and z-hypnotics at a regional and national level. ^14,15

The Royal College of Psychiatrists has recognised that there is an urgent need to do more to identify when people with depression have recovered and treatment can be appropriately stopped or reduced. ¹⁶

Greater use of pharmacist skills and sharing of best practice between Health Boards, Health and Social Care Partnerships, and general practices will enable further appropriate reductions across Scotland.

Pharmacists often see people who have one or more long term condition on a regular basis. They can recognise early signs and symptoms of deterioration in mental as well as physical health and provide the appropriate support.

A small number of pharmacists have developed new prescribing roles for conditions, including attention deficit disorder and bipolar disorder. We believe that more could be done to resource and spread this good practice across Scotland.

The use of psychoactive medicines in older people and antipsychotic prescribing for people with dementia has been a challenging and high-risk area. Despite calls at national level for reductions in their use ^17,18, studies have demonstrated negligible changes in prescribing. ¹⁹ This has been addressed to some extent with polypharmacy reviews, but more could be done.

Specialist mental health pharmacists working with families, carers, care staff, general practice and specialist care of the elderly teams could improve the appropriate reduction of antipsychotics.

Reducing psychoactive medication is a priority area for pharmacists to lead as outlined in our report Putting Residents at the centre of pharmacy care home services .²⁰

Recommendation #3

To improve access, physical health monitoring and targeted public health initiatives in community pharmacy are needed.

People with mental health conditions should be able to access services where and when they need them.

Some medications prescribed for mental health conditions are considered high risk e.g. lithium, require regular physical monitoring and close observation of patients to minimise unintended harm.²¹

Physical health monitoring has two components:

• General physical health monitoring
• Specific monitoring required for the safe prescribing of some medicines used in the treatment of mental health conditions.

Community pharmacists routinely provide advice, support and check for interactions to reduce harm. Use of the high risk medicine clozapine has been made safer through local community pharmacy services for almost 20 years. More could be done to enhance this role, for example to support improvement in the monitoring of other high risk medicines and physical health. The accessibility of pharmacies in the heart of communities is a key strength of these services.

Public health is an intrinsic part of pharmacy practice. Pharmacists working in all settings can support people with mental health conditions by promoting public health messaging on physical and oral health, encouraging exercise, smoking cessation, and lifestyle advice.

Smoking is a recognised high-risk behaviour for people with mental health conditions and contributes to morbidity and mortality. Community pharmacies already provide support through smoking cessation services. More could be done to specifically support people with mental health conditions to stop smoking and to achieve change at the scale required.

Substance use is also a high-risk behaviour that limits the life expectancy and quality of life of people with mental health conditions. The existing community pharmacy services, through which people regularly access opiate substitution therapies could be developed further to improve adherence to treatment and reduce morbidity. Services could also include physical health monitoring, support and review of other long-term conditions.

Pharmacy teams can support with psychological self-help and signpost to local resources and could play an active role in social prescribing. Models of social prescribing by pharmacists need to be developed as a priority to widen access to the associated benefits.

Going forward, community pharmacies should be viewed as primary care public health information hubs and resourced accordingly to improve access, engagement and onward referral to NHS and third sector services.

Recommendation #4

Pharmacy teams should be trained in mental health first aid and suicide prevention so they can respond to crisis situations.

Pharmacists and their teams are at the front line of patient care wherever they are practicing. They can face sensitive or challenging situations and need to be equipped to support patients in distress and be aware of suicide prevention techniques. The COVID-19 pandemic has had a significant impact on the mental health and well-being of our nation. The RPS has made it clear that pharmacy must be at the forefront of providing support and our policy: Role of pharmacy in mental health and well-being through COVID and beyond (August 2020), should be used as a companion document to this policy.

There is a potential role for community pharmacy in preventing suicide and self-harm if properly integrated into the multidisciplinary team and included in suicide prevention strategies. ²⁴

Everyone in patient facing roles should be trained in mental health first aid and should be mandated to access the training now available to all staff working in health and social care to support Scotland’s Suicide Prevention Action Plan. ²⁶

The Distress Brief Intervention (DBI) initiative²⁷ which currently is accessed by some front-line services should be extended to allow community pharmacists to access training and refer directly into the service and the pilots extended to all health board areas.

Recommendation #5

More specialist mental health pharmacists are required to ensure existing services are sustainable and that all mental health and primary care teams have access to their expertise through psychiatric pharmacist liaison posts.

Specialist mental health pharmacists use their skills and expertise to individualise treatments to get the best outcomes for people in the care of mental health services. They could also be involved in analysing, monitoring and researching psychotropic prescribing trends or working with prescribing advisers and community prescribers to ensure use of evidence-based medicine, to address inappropriate medicines use.

Providing leadership and education and assuring the best use of medicines in mental health are the core roles of the specialist mental health pharmacist.

Currently, the size and capacity of specialist mental health pharmacy teams varies across Scotland; for example, some NHS Boards have only one specialist mental health pharmacist. Resources are finite and demand for specialist services exceeds capacity.

A core priority of the NHS mental health programme is to support community services to deliver high quality, evidence-based interventions which improve outcomes and enable recovery. Having a specialist mental health pharmacist as part of the community mental health team will facilitate this.

RPS believes that every mental health team, including Child and Adolescent Mental Health, should have access to a specialist mental health pharmacist whether based in community teams, mental health hospital wards or acute hospitals.

There are an increasing number of Psychiatric liaison pharmacists in Scotland. Their role includes dealing with complex medication queries, advising on appropriate medicines choice, providing prescribing clinics and supporting GPs and wider mental health teams.

In implementing Achieving Excellence²⁸ and the Scottish Government Mental Health Strategy ²⁹ we would like to see resources for a greater number of pharmacy liaison roles to support primary care teams. This would inform, support and enable colleagues working in general practice, care homes or community mental health teams to address many of the prescribing issues raised in this policy. This will require changes in workforce planning and promotion of mental health pharmacy as a specialism or area of special interest.

Recommendation #6

Pharmacists should have appropriate read and write access to medical records to deliver safe, integrated and effective patient care.

Patients expect health professionals to have all the necessary information to keep them safe and to be aware of their personal care plans without repetition at every stage.

Pharmacists have been able to access more patient information during COVID-19 to support and improve patient care and the capacity of other healthcare colleagues. While access to patient health records, laboratory results and the care record, is available to pharmacists working in hospitals and primary care, it is not routine for community pharmacists.

Access would enable pharmacists to:

• Give patients better advice with no delays
• Make more informed clinical decisions
• Improve pharmaceutical care
• Reduce the number of medicine related errors that contribute to unplanned hospital admissions.

A YouGov public survey showed 85% of respondents want healthcare professionals treating them to have secure electronic access to key data from the medical record.

Several different prescribers can be involved in patient care and access to accurate information is essential for patient safety and in delivering more effective pharmaceutical care. Reducing medicines related errors, improving medicines adherence and improving a person’s understanding of their medicines can prevent relapses which contribute to unplanned admissions to hospital.

Enabling the sharing of information between health professionals must be prioritised by Scottish Government to provide optimal patient safety systems in the ever increasingly complex area of therapeutic treatment.  

Conclusion

During the review process, the RPS recognised that there are pockets of best and excellent practice across Scotland and beyond.

However, it also identified gaps in services, care and approaches, that integrate pharmacists and pharmacy services in mental health care.

It is critical that best practice is shared and new models are developed, evaluated and scaled up quickly to deliver improvements to mental health care across Scotland.

The Scottish Government mental health strategy has committed to testing and evaluating the most effective and sustainable models of supporting people with mental health problems in primary care, and we are calling for pharmacy to be part of this.

Next steps

The Royal Pharmaceutical Society in Scotland is committed to working with Scottish Government, the NHS and other partners to explore how pharmacy teams can maintain and improve the mental health and physical health of the citizens of Scotland.

Acknowledgements

This document was developed in partnership with the Scottish Specialist Mental Health Strategy Group, and we would like to thank everyone who contributed. 

Special thanks to those who attended the RPS mental health roundtable, hosted by Emma Harper MSP, where the discussion informed the recommendations for this policy.