PROPOSAL FOR AUDIT PHARMACIST - MENTAL HEALTH

Background.

The past five years have brought about many changes in the provision of mental health services. The government white paper care in the community in the next decade and beyond has resulted in the closure of many psychiatric beds and changes in the way services are provided. This has had a substantial effect on the way the pharmacy service has developed. In addition, there has been a surge of new products on the market giving hope for persons suffering from schizophrenia and depressive illness. These have put an incredible load on the finances of the trust. The governments strategy document on mental health promises greater access financially to novel treatments. It is of paramount importance that the minimal resources available to the trust for medicine are managed appropriately.

Aims

The aims of the post would be:

Individual areas to audit

The Trust has a responsibility to ensure the safe effective use of psychotropic medicines for all the patients. A key strategy is to ensure that there is a substantial evidence base to all the treatments used. There should be compliance at all times with the requirements of the various professions code of ethics and professional board guidelines. These encompass prescribing, dispensing, clinical standards, trust guidelines and protocols and national guidelines and protocols.

Atypical antipsychotic prescribing

A recent audit by the United kingdom Psychiatric Pharmacy Group showed that many atypical antipsychotics are being co-prescribed with typical antipsychotics.. A study of the literature will show that the major benefits of the atypicals is their lack of potential to produce extrapyramidal side effects. In addition, all clinical trial work is carried out as monotherapy. It therefore appears illogical to co-prescribe atypicals with typical as the major benefits will be negated but the cost will be greatly increased.

High dose antipsychotic prescribing

The Royal College of Psychiatrists have developed guidelines for antipsychotic prescribing. There is evidence of cardiotoxicity and incidences of sudden death in patients prescribed high doses of antipsychotics. It is important to consider the cumulative dose of antipsychotic prescribed i.e. as a percentage of BNF maximums. An audit of high dose antipsychotic prescribing and development of guidelines for monitoring for the trust and subsequent audit of the guidelines is well overdue.

Clozapine

There is currently a rapid increase in the number of patients prescribed clozapine. It is important to ensure that this drug is used within its product licence for the appropriate client group particularly because of the risk of neutropenia.

Audit for clozapine which has been dropped due to lack of pharmacy resources needs to be brought up to date and re-instated.

Unlicensed Use

In psychiatry there are certain indications, particularly bipolar affective disorder, where there is extensive unlicensed use of licensed drugs. e.g. valproate sodium as a mood stabiliser, carbamazepine for aggression, antipsychotics for behaviour controlling learning disabilities. The trust should be aware of these All clients and carers/relatives prescribed unlicensed use of medication should be made aware of the known risks and benefits (or lack of). It is important that due regard is taken to the size of the data base for information on these products and the risks assessed accordingly for each individual client

Trust protocols

The trust has developed several protocols e.g. Pharmacological management of behavioural emergencies, guidelines for lithium. It is important to ensure that these are being appropriately implemented.

Trust Formulary

The trust is in the process of developing a formulary. It is important to monitor the implementation of the formulary. A particular problem at present is the increasing prescribing of the hypnotic zopiclone. This is one of the first areas to audit across the trust. It is important to consider that there are increasing reports of dependence and abuse of zopiclone. In addition, it has never been licensed for long term treatment yet this is becoming a fairly common occurrence within Leeds. This is actually a major problem considering there is no real defence for this blatant ignoring of product license. The trust guidelines on the use of benzodiazepines, including zopiclone have long been in existence.. Obviously this is a problem for the whole of Leeds and an audit pharmacist could be in a position to audit the whole of the city to raise awareness of the problem.

Clinical standards

There are identified standards of practice nationally for psychiatric pharmacy. These are linked to providing pharmaceutical care. They include:

Drug Misuse

In this trust there is a pharmacist run de-toxification clinic. There are guidelines for the clinic. The level of successful outcome is important. It is necessary to understand what outcomes are expected and how to monitor these. In addition, there is substantial prescribing of methadone. It is important to understand how effective this is in reducing illicit substance abuse in Leeds.

Ward based activities

There have been changes in the configuration of many of the sites and therefore the wards. In addition, there is substantial discrepancy in the levels of pharmacy services provided around the trust. In particular, the pharmacy service on the Roundhay Wing is particularly under resourced. Multiple site audit may identify some of the problems faced.

Audit areas:

No of pharmacist visits and length of visits
No of pharmacist interventions (graded for potential outcome)
Availability of discharge/leave medication
Waiting times for patients wanting to go on leave
Availability of medication on the ward
Time taken for nursing staff to acquire medication
Appropriate writing of medicine cards
Implementation of guideline
self medication schemes
use of patients own medication
patient information leaflets

COSTING

ONE D GRADE PHARMACIST

COSTED AT MID POINT OF THE SCALE WITH 20% ADDITION

£28,0000?

TRAINING £400 PER ANNUM

COMPUTER

APPROPRIATE SOFTWARE (required anyway for the pharmacy department)

Job Description

The ideal candidate will have a certificate or diploma in psychiatric pharmacy and will have experience in mental health. Some previous audit experience would be desirable. Some information technology skills would be desirable.

The postholder will:

1) Work closely with the Drug and Therapeutics committee to identify the most important audit areas. Other mental health pharmacists, other healthcare professionals and members of the audit department will be expected to co-operate with the audit pharmacist in the development of audits and collection of data.

2) Work closely with the project pharmacist to develop audits and facilitate their implementation.

3) Co-ordinate audits across the trust including all community psychiatric units as well as XXXX, XXXXX, and XXXX.

4) Take responsibility for the introduction of new products for the trust.

5) Liaise with the Pan Leeds prescribing committee on issues relating to psychotropic medication.

6) Keep up to date on all issues regarding psychotropic medication and in particular raise awareness of the impact of potential new products to the Trust.

7) Be responsible for a clinical area within the trust to keep clinical skills up to date.

8) Identify the Information technology requirements of the pharmacy department and pursue purchase and implementation of these with the chief pharmacist

9) Be responsible to the project pharmacist (or specialist psychiatric pharmacist if you have one)

3/99