PROPOSAL FOR COMMUNITY MENTAL HEALTH PHARMACIST for NMHC Coastal Directorate

WAITING LIST/RELAPSE REDUCTION INITIATIVE

Norfolk Mental Health Care NHS Trust

Rationale:

Drug therapy is proven to significantly reduce or prevent relapse, shown in many papers e.g. in depression (e.g. Kupfer et al, 1992), schizophrenia (Gilbert et al, 1995) and bipolar mood disorder (e.g. Guscott and Taylor, 1994). Reduction in suicide is proven (e.g. Rutz et al, 1997).
Drug therapy is essential for long-term maintenance in many service users, and many relapses are due to patients discontinuing drugs (e.g. Baldessarini et al, 1996)
People will usually only comply with drug therapy if they have a positive attitude towards drugs (Hogan et al, 1983). Failure to comply will result in mental illness recurring and probable relapse or further need for input from the service
Educating people on drugs is both obvious AND has been shown to improve attitude, compliance and hence reduced psychiatric morbidity and relapse (e.g. Kemp et al, 1996), and that the gains persist over at least six months. 91% of people readmitted to Hellesdon with a relapse or recurrence of depression over a six month period had no idea that continuation of antidepressants would provide significant protection against relapse (Hunter, 1994).
Access to, and provision of, such education in the past has not occurred on a planned or organised basis e.g. 60% of UK patients treated with drugs for depression did not know what the drugs were for or what they did, the highest percentage of the 6 European countries studied (Lepine et al, 1997). Provision of "generic" information is thus inadequate. There are very many patients both in primary care and secondary care, who have insufficient education about drugs to make appropriate decisions about continuation therapy. Sufficient fundamental knowledge about drug therapy is essential to provide such specialist education.
Pharmacists are the most appropriate professionals to provide this specialist education about drug therapy. Pharmacists are seen by patients and carers as independent experts on drug therapy and hence more likely to provide better education. Norfolk Mental Health Care NHS Trust Pharmacy has a nationally recognised expertise in this area (e.g. Bazire, 1993, Daly and Bazire, 1996). A "Medication Education" (MedEd) programme, using behavioural and educational techniques, has been developed in Norwich and is run continuously on acute adult wards at Hellesdon.
The Coastal Directorate catchment area has great pressure on in-patient beds and rural deprivation. The Trust pharmacy World Mental Health Day telephone helpline identified a significant percentage of calls from people in the community not associated directly with the service but with important drug therapy problems. Established services in need of further development and support. Provision of substantially improved drug education and counselling services would improve drug attitudes, improve compliance and reduce relapse rates.

Community Mental Health Pharmacist

Community Mental Health Pharmacist, based within the NMHC Coastal Directorate, Great Yarmouth and Waveney.

Areas to be covered:

Calthorpe House, Great Yarmouth and associated services
Alexandra Resource Centre, Lowestoft and associated services
Northgate Hospital, Great Yarmouth (main mental health in-patient beds, liaison)

Roles and tasks:

Running "Medication Education" ("MedEd") programmes for users and carers at Calthorpe House and ARC on a weekly basis, along with individual counselling. These programmes would cover psychotropic drugs modes of action, positive and negative effects, addiction/tolerance/dependence, acute and chronic therapy etc.
Acting as a specialist medication referral point from Occupational Therapists, Physiotherapists, CPNs, Psychologists, GP's, Psychiatrists, Approved Social Workers and Community Pharmacists to provide individual patient counselling and education
Support for relatives and carers, in addition to "MedEd" programme
Developing a drug telephone helpline facility for the Coastal Directorate, either locally (via bleep or mobile phone) or through Hellesdon Hospital Pharmacy
Close liaison with Community Pharmacists in Yarmouth and Waveney to identify people with specific drug-related needs and act as a specialist referral service
Identifying and fulfilling specialist education needs of existing staff, including ASW's, CPNs, GP surgery staff etc. This will aid ensuring that all staff across boundaries are "singing the same song" and giving a consistent message about psychotropic drugs. Mixed or conflicting messages cause concern and distress to service users, and are likely to lead to poor concordance with essential drug therapy
Ensuring those care staff listed above have access to educational material and support for service users appropriate for the needs of their clients
Working with CHUF (Calthorpe House Users Forum) to develop medication education strategies for proposed innovative user-led service in Great Yarmouth (Lottery Funding applied for)
Discussion with nascent Primary Care Groups as to the optimum medication management for people with mental health needs
Investigate whether a "MedEd" programme would be appropriate to also be run on mental health wards at Northgate, as on acute wards at Hellesdon Hospital in Norwich. This would ensure a running medication education programmes for in-patients and ensure secondary care drug treatment plans can be carried through to PCG

Assessment

Assessment of drug knowledge amongst a variety of health care professionals before the post starts and after one year. This would be done by an independent, random telephone sample, asking questions about e.g. antidepressant discontinuation/dependence symptoms, discontinuing lithium, duration of treatments, long-term side effects, antipsychotic side effects, sources of information etc etc. This would be repeated after one year to assess the professionals knowledge of medication and hence the quality of advice given
Use of "Drug Attitude Inventory" (Hogan et al, 1983) to quantify the impact of group medication sessions
Monitoring of outcomes from individual interventions
Documentation of referral rates

One year costs:

Pharmacist grade D £26,500 (inc 11% on-cost)
Travel £5,000
PC, printer, modem link etc £1600 (for drug information and communication)
Printing, stationery, books £500
Office/base costs N/K
Total £33,600 for one year

Support:

The proposal has been developed with the advice and expressed support of:

Directorate General Manager
Directorate Clinical Director
Consultant Psychiatrist at ARC, Lowestoft
Social Work department at Northgate Hospital
Calthorpe House
CHUF
NMHC Trust

References:

Baldessarini RJ, Tondo L, Faedda, GL, "Effects of Rate of Discontinuating Lithium Maintenance Treatment in Bipolar Disorder, Arch Gen Psych, 1996, 57, 441-448.
Bazire, S. "Pharmaceutical Care Awards 1992, Shared Care section, NHA MH&P unit discharge package". Pharm J 1993, 251, 118-122.
Daly C, Bazire S, "Pharmaceutical Care Awards 1995, Shared Care section, compliance package". Pharm J 1996, 257, 16-20.
Gilbert PL, Harris MJ, McAdams LA et al, "Neuroleptic Withdrawal in Schizophrenic Patients", Arch Gen Psych 1995, 52, 173-188.
Greco R, "The medication advocate effect of the consultant pharmacist on medication compliance of chronic schizophrenia", Consultant Pharmacist 1994, 9, 864-871.
Guscott R, Taylor L. "Lithium prophylaxis in recurrent affective disorder", B J Psych 1994, 164, 741-746.
Hogan TP, Awad AG, Eastwood R, "A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity", Psychological Medicine 1983, 13, 177-183.
Hunter, J, Recurrence of depression, MSc Thesis, 1994, University of Belfast.
Kemp et al, "Compliance Therapy in psychotic patients: randomised controlled trial", BMJ 1996, 312, 345-9.
Kupfer DJ, Frank E, Perel JM et al "Five-year outcome for maintenance therapies in recurrent depression, Arch Gen Psych 1992, 49, 769-773
Lepine JP, Gastpar M, Mendlewicz J, Tylee A, Depression in the community: the first pan European study", Int Clin Psychopharmacology 1997, 12, 19-29.
Ruz W, Walinder J, Knorring LV et al, "Prevention of depression and suicide by education and medication", Int J Psych Clin Pract 1997, 1, 39-46.
Saklad, Ereshefsky, Jann and Crismon, "Clinical Pharmacists' impact on prescribing in an acute adult psychiatric facility", Drug Intell and Clin Pharm 1984, 18, 632-4

Draft

Norfolk Mental Health Care NHS Trust

PHARMACY SERVICES

Job Title Community Mental Health Pharmacist

Grade Pharmacist Grade D

Base Northgate Hospital (or Hellesdon Hospital)

Hours Full time - 39 hours per week (exclusive of meal times)

Accountable to Pharmacy Services Director

Managed by Clinical Pharmacy Manager

Liaises With Medical, nursing, pharmaceutical, paramedical, managerial and other professional staff in relation to the provision of Pharmacy Services

Primary Job Objectives a) The provision of a community based clinical pharmacy service to patients and carers of the Coastal Directorate

b) To promote early discharge from hospital, reduce length of stay and reduce re-admissions by:

Optimising drug therapy
Educating patients and carers in the use of medicines
Promoting seamless care on discharge from hospital

Duties and Responsibilities

The postholder will be responsible to the Director of Pharmacy Services for the following duties for Norfolk Mental Health Care NHS Trust, and other units, in accordance with Pharmacy Services and Trust policies and will be expected to work on his or her own initiative within these procedures under the direction of the Pharmacy Services Director and Clinical Pharmacy Manager, Norfolk Mental Health Care NHS Trust.

Medication And Education
The post holder will take a lead role in patient education on drug therapy which will include:
1. Running a regular medicine education ("MedEd") programme at Calthorpe House and ARC to help improve compliance, reduce relapse and foster a positive attitude to drug therapy.
2. Relative support group involvement including pharmaceutical advice and support for relatives and carers.
Seamless Care With Mental Health Support Groups And General Practitioners
The post holder will liaise with Community Mental Health Support Groups, General Practitioners and Community Pharmacists, including any necessary support in the community for clients with medication-related problems e.g. via Drop-in Advice Clinics, domiciliary visits, etc.
Liaison
The post holder will develop appropriate liaison with medical, nursing, pharmaceutical and other staff in the provision and development of Clinical Pharmacy Services and to act on associated problems which may arise.
General Clinical Pharmacy and Departmental Duties
1. The post holder may be required to undertake some occasional general pharmacy duties at Hellesdon in order to ensure the continuity of the Pharmacy Services to the Trust.
2. Appropriate documentation and records e.g. intervention/contribution monitoring, outcome data etc. will need to be maintained

Any Other Duties

The postholder will be required to undertake any other duties which may from time to time be allocated by the Pharmacy Services Director, and which may reasonably be expected to be performed by the postholder.

Research and Development

The post holder will be expected to research the provision of this specialist Pharmacy Service.

Education and Training

The post holder will be expected to encourage and actively participate in all aspects of training and will be expected to participate in the staff education programmes e.g. pharmacists and pre-registration pharmacists and other health care professionals

Health and Safety at Work

The post holder will be required to comply with and ensure that all staff working under his/her supervision comply with Health and Safety at Work policies for the area in which work is being undertaken.

Terms and Conditions of Service

Pharmaceutical and General Whitley Council terms and conditions of service will apply. The postholder must be a member of the Royal Pharmaceutical Society of Great Britain with professional and managerial experience relevant to the satisfactory performance of the duties outlined above.

The postholder must have a valid driving licence and be a car owner.

The postholder may be required to take part in a Saturday morning duty rota (maximum 1 in 4), for which time off in lieu will be given.

Confidentiality

The postholder will have access to confidential information of both a clinical and commercial nature. Disclosure to any unauthorised person(s) will be regarded as a breach of contract and may lead to termination of employment.

Equal Opportunities

The Norfolk Mental Health Care NHS Trust is committed to a policy of promoting equal opportunities. Applicants will be dealt with fairly regardless of sex, race, marital status, religion, age or disability.

This job description is subject to a periodic review in consultation with the postholder