A National Service Framework for Mental Health

Text and data here may be of use in interpreting the NSF, but should be used along with your own interpretations and local information. This is to help and guide only, and you may well have many other things to contribute. If so, please donate them to the site and the cause!

Initial announcement from September 1999
For the full text version of the NSF, click here
Dr. Dave Branford's article in the Pharmaceutical Journal, 18th December 1999 (full text thereof)
Stephen Bazire's personal thoughts, having read the whole text in November 1999
Peter Pratt's presentation to College of Pharmacy Practice, abstract, from May 2000
Peter Pratt's powerpoint presentation to College of Pharmacy Practice, text thereof, from May 2000
Text from powerpoint presentation by Stephen Bazire, June 2000

Thursday 30th September 1999 - FIRST NATIONAL STANDARDS FOR MENTAL HEALTH
This has now come out and, as suspected, there is no mention of pharmacy anywhere. Rumours that the RPSGB declined to make any input, nor contact any interested parties (such as UKPPG) appear to have been true, judging by the content. What Steve Bazire thinks of the RPSGB Task Force on mental Health can be seen by clicking the link. The press release is as follows:

National standards to drive up quality and cut wide variations in services are set out today in the first National Service Framework for mental health, launched by Health Secretary, Frank Dobson. The framework sets national standards, based on clinical evidence, and sets out best practice for promoting mental health and treating mental illness. It promises national and regional support for health and social services and establishes the progress which should be made within certain timescales. National Service Frameworks fulfil the Government's commitment to tackle significant causes of ill health and disability.

Frank Dobson said:
"In the past, people with mental health problems have been let down by unacceptable variations in health care. I want services that offer the highest quality to everyone, regardless of their gender, age, race or where they live.
"We are providing substantial new resources for mental health - £700 million in this and the next two years in our drive to build modern and dependable mental health services.

"We set out our new vision and policies for safe, sound and supportive care in Modernising Mental Healthand a root and branch review of mental health law is underway. This new framework set the first ever national standards and spells out how to prevent and treat mental illness."

The framework for mental health focuses on services for adults of working age in England. Its seven standards require health and social services to:
promote mental health for all and combat discrimination against people with mental health problems;
identify the needs of patients with mental health problems and ensure they are offered effective treatments;
ensure all services are available around the clock;
ensure that all mental health service users on the Care Programme Approach (CPA) receive care which prevents or anticipates crisis and reduces risk;
provide a hospital bed or suitable alternative bed for those who need it in an environment close to home that protects them and the public;
make sure carers who look after someone on the CPA have their own caring, physical and mental health needs assessed on an annual basis;
reduce the level suicide.

Frank Dobson continued:
"Mental health problems are both common and diverse. As many as one in six adults suffer from mental health problems at any one time. This ranges from depression to rare but severe mental illness, such as schizophrenia.

"Mentally ill people depend on effective mental health care for their own well-being, independence and safety. Despite the public's fears, most seriously mentally ill people are not dangerous and indeed are more likely to harm or kill themselves than anyone else. Each year in England alone around 4,000 people take their own lives. With proper care, intervention and support many of these lives might be saved, and for thousands of others we can help reduce the trauma.

"One way or another, everywhere in the country, mental health services will be challenged by the National Service Framework's new standards. We are now being explicit about our expectations - successes will win praise, serious failures will bring intervention. I believe these new standards give us an opportunity to modernise the way we help and care for the thousands of mentally ill people. It is an opportunity we cannot afford to miss."

The Care Programme Approach is an important aspect of mental health care and in support of the framework, it has been reviewed separately. A policy booklet setting out the changes to the CPA is being published next week. The new arrangements will strengthen care co-ordination, achieve a consistent approach nationally, reduce bureaucracy and achieve greater focus on the needs of those being cared for. Under the new arrangements, Health and Local Authorities will be expected to work together to co-ordinate delivery of care, through explicit, individually tailored care plans, to minimise loss of contact with services and maximise the effect of therapeutic intervention.

The National Service Framework's seven standards are:
Standard One - Health and social services should: promote mental health for all, working with individuals and communities; combat discrimination against individuals and groups with mental health problems, and promote their social inclusion.
Standard Two - Any service user who contacts their primary health care team with a common mental health problem should: have their mental health needs identified and assessed; be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it.
Standard Three - Any individual with a common mental health problems should: be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care; be able to use NHS Direct as it develops for first level advice and referral on to specialist helplines or to local services.
Standard Four - All mental health service users on the Care Programme Approach (CPA) should: receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk; have a copy of a written care plan which includes the action to be taken in a crisis by service users, their carers, and their care co-ordinators, advises the GP how they should respond if the service user needs additional help, and is regularly reviewed by the care co-ordinator; be able to access services 24 hours a day, 365 days a year.
Standard Five - Each service user who is assessed as requiring a period of care away from their home should have: timely access to an appropriate hospital bed or alternative bed or place, which is in the least restrictive environment consistent with the need to protect them and the public, and as close to home as possible; a copy of a written after care plan agreed on discharge which sets out the care and rehabilitation to be provided, identifies the care co-ordinator, and specifies the action to be taken in a crisis.
Standard Six - All individuals who provide regular and substantial care for a person on CPA should: have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis; have their own written care plan which is given to them and implemented in discussion with them.
Standard Seven Local health and social care communities should prevent suicides by implementing the other six standards and: ensure that staff are competent to assess the risk of suicide among individuals at greatest risk; support local prison staff in preventing suicides among prisoners; and develop local systems for suicide audit to learn lessons and take any necessary action.
2. The National Service Framework is based on wide ranging evidence brought together by the independent External Reference Group, chaired by Professor Graham Thornicroft from the Institute of Psychiatry, King's College, London. The group brought together health and social care professionals, service users and carers, health and social service managers, partner agencies and others.
3. The Commission for Health Improvement, the Social Service Inspectorate, and the Audit Commission will rigorously monitor local progress on meeting these standards. Performance will be assessed through a number of national milestones and high level performance indicators. Local health and social care communities will also agree local milestones with the NHS Executive regional offices and social care regions.
4. Media copies of the NSF for mental health are available from the Department of Health Media Centre.
5. The CPA guide aims to make the CPA a more effective and efficient system of modern mental health care co-ordination. It will clarify the role and purpose of the CPA and includes a list of the key changes to the CPA and sets out who is responsible for their implementation. Copies of the CPA booklet are available from DoH, PO Box 777, London, SE1 6XH. Requests can be faxed to 01623 724524 or emailed to doh@prologistics.co.uk

Full copies can be obtained by clicking here. There is a review article in the BMJ (1999, 319, 1017-8, the 16th October edition) by Professor Peter Tyrer entitled "The national service framework: a scaffold for mental health. Implementation is the key to determining whether it's a support or a gallows."

The Pharmaceutical Journal Vol 263 No 7076 p980
December 18/25, 1999 Broad Spectrum

The national service framework for mental health - where is pharmacy?

By D. Branford

The national service framework (NSF) for mental health has now been published. This important document sets out standards of mental health care together with how those standards should be delivered and performance measured. Although the NSF applies to England, it is likely that similar documents will be published for other parts of the United Kingdom. One of the most striking aspects of the NSF is the almost complete absence of the word "pharmacy".

In this short paper, I will address the contents of the NSF that are relevant to pharmacy, consider what it could have said that might have been rather more useful to pharmacy and, finally, ponder on how such an omission could be avoided in the future.

The NSF focuses on the mental health needs of adults of working age (up to 65 years) who live in England. It aims to drive up quality and remove the wide variations in provision of services. It sets the standards and defines service models for promoting mental health and treating mental illness, puts in place underpinning programmes to support local delivery, and establishes milestones and performance indicators against which progress within time scales will be measured.

Advice

The NSF has been developed with advice from an external reference group. This group contains representatives from nearly all the professions involved in the delivery of care to people with mental health problems, but there is no pharmacist member. It would appear that the external reference group consulted widely, including, one would assume, the Royal Pharmaceutical Society.

Having read the NSF, one could be forgiven for imagining that medicines have little to do with mental health and that pharmacists have absolutely nothing to do with it. This is quite surprising when one considers that treatment with psychotropic medicines provides the most effective method of maintaining the well-being of many people with mental health problems. Also, there are pharmacists, whether in the hospital or community branches of pharmacy, who provide invaluable support and assistance to many such people.

Rather than complain about the lack of input by pharmacy to the NSF, it is probably more helpul to see what lessons or opportunities there are for pharmacists. Probably the most important lesson is around how services are to be organised. Forget the hospital/community divide; the important issue is how best to provide good pharmaceutical care to people with mental health problems. One of the measures of performance of local services will be the extent to which the prescribing of antidepressants, antipsychotics and benzodiazepines conforms to clinical guidelines. Who is to be responsible for the delivery of that local performance will vary from place to place, but I can see the request to audit performance arriving on the desks of many pharmacy advisers and senior hospital pharmacists? The NSF also implies the need for a well-trained and skilled workforce able to meet the challenges presented by people with mental health problems. How well equipped are we within pharmacy? How confident do pharmacists feel about assisting and advising patients about their medicines? Do hospitals have sufficient numbers of well-trained mental health specialist pharmacists to ensure that patients receive optimal therapy? Unfortunately, there is evidence that both hospital and community pharmacists have significant skill shortages when it comes to the drug treatment of mental illness.

One local milestone stipulated is that all service users should be assessed for and receive new atypical antipsychotics where indicated using clinical guidelines. If taken literally, this would involve a huge project just to identify all the people on antipsychotic drugs, let alone assessing whether they should be prescribed the new antipsychotics. The cost implications of such a change would be considerable.

Although these nuggets do provide a foothold for pharmacists, what might the NSF have included that would have been more useful? First, it could have recommended that all mental health trusts appoint a chief pharmacist with responsibilities for maintaining prescribing standards for the whole health community in the same way that the Duthie report makes them central to the procedures for the safe ordering, storage and administration of medicines.

Second, it could have advocated the co-ordination of pharmaceutical services to people with severe and enduring mental health needs by pharmacists specialising in mental health. These specialist pharmacists could purchase patient-focused additional services from either community or hospital pharmacists.
Third, it could have advocated linking patients to specially trained community pharmacists who are paid to maintain contact with those considered to be at risk in the community.

There is no shortage of ideas and there are even well-studied models. Unfortunately, none of them has appeared in the NSF.

One of many

The NSF is to be one of many. I am told that there will be an NSF for elderly people with mental health problems published in 2002. Others will soon be published in other health priority areas. Perhaps then it is time to look at how the contents of the NSFs may best be influenced in the future. After all, the Royal Pharmaceutical Society even has access to a specialist group (the UK Psychiatric Pharmacy Group), which was not asked to comment on this NSF. The Society has recently set up a task force for mental health but the NSF does not seem to be the focus of its work - perhaps it needs to be. If the excuse is that the Society is totally overloaded with requests to comment on an overwhelming array of documents (usually at very short notice), thought should be given to enabling members to know what documents are under consideration, how they might contribute, and what responses the Society has made. The Pharmaceutical Journal could highlight the requests and seek help from interested members or make use of a website on the internet.

The Register of Pharmaceutical Chemists must contain individuals with specialist knowledge of almost all aspects of medical and pharmaceutical care, and if they did not contribute when given the opportunity there would be no grounds for complaint. The challenge is to influence the contents of documents like the NSFs and to engage the membership of the profession in the process.

Dr Branford is director of pharmacy at the Southern Derbyshire mental health trust

National Service Framework for Mental Health 1999

What is in it for pharmacists? What is in it for service users?

Part one is one person’s thoughts on the NSF, having read all 149 pages of it. Feel free to use these, bearing in mind they are an expression of one persons views, thoughts and disappointments. Note that this NSF is for adults of working age in England, so doesn't apply to Scotland nor (possibly) Wales, although it would give an idea of the way thinking is developing. Part two is what Peter Pratt and David Branford say.

The ten guiding NSF principles include: (p4)

Involve service users
High quality treatment
Accessible services
Offer choices which promote independence
Co-ordination between staff and agencies
Continuity of care

First priorities: (p7)

These include 24 hour staff accommodation, assertive outreach, home treatment and secure beds, 24 hour access to services, as well as recruitment, retention and training of specialist staff – could take up to ten years

There will be a move towards specialist mental health Trusts, especially in inner cities and some metropolitan areas – unlikely to include combined acute-mental health trusts in the longer term (p10), so we will need to make sure these Trusts have adequate pharmaceutical advice

PCGs/PCTs (p10) might be given responsibility for some provision of local specialist mental health care services (CMHTs, residential, domiciliary). If so, they must have an established track record, effective arrangements to manage the interface, a continuing focus on mental health care and Board member(s) with mental health competence.

The standards

Standard one: (p14)

Promote mental health for all
Combat discrimination

Little direct applicability to pharmacotherapy.

Standard two: (p28)

Service users contacting primary care should have needs identified and assessed and offered effective treatment (inc. referral)

Standard three: (p28)

Service users should have 24 hour access to local services and have needs met with adequate care
Be able to use NHS D

irect

Notes:

Effective treatments – evidence-based approach to treatment needed
Round the clock access to telephone helplines – could these be 24 hour? Or extended to 8pm as a starter? Should the local helplines be linked to provide a 24-hour service?
P28 includes the first mention of pharmacists. Many people with mental health problems "contact their GP, or another member of the primary care team, including a nurse or community pharmacist." but fails to develop this further. Do CPs know who to refer on to, who CMHTs are and where they are based? Do they know their specialist local services and specialist pharmacy contacts (if any?)? Has any contact from secondary/specialist care been made to primary care (noting continuity of care requirement)? No mention is made of potential for collaborative working, low-cost use of community pharmacists (Nottingham and Liverpool projects, as well Southern Derbyshire)
Depression (p29) – NSF notes poor recognition by GPs and poor outcomes. Notes "scope for GPs and practice nurses to improve their assessment and communications skills" and for non-drug treatments. However, fails to mention inadequate prescribing of antidepressants here and there is thus a HUGE area of potential for training GPs
Anxiety (p30) – NSF notes that it can mask depression and that benzodiazepines should not be used for more than 2-4 weeks.
Helplines (p31) – another reference in NSF to 24 hour access e.g. notes that a "number of mental health services have developed their own helplines, although hours of availability may be limited." NHS D

Access to specialist services (p33) – again emphasises 24-hour access. If we want to play our part, we will have to look at extending our services beyond 9-5 and strict EDC supply service outside these times

For depression (p32) the NSF notes that:

Most of the 4000 suicides a year are attributed to depression
Antidepressants are effective
Inadequate information received by patients concerning treatment
Antidepressants not always used in correct doses
Clinical guidelines have been commissioned by NHS Executive and will be available in late 2000.

There is thus a huge potential area to improve recognition and treatment of depression in primary care (which secondary care may need to lead), which will have a significant impact on suicide rates.

To achieve standards two and three (p35), Primary care and specialist secondary care need to work together – pharmacist role to train on drug and other management of common mental health problems

They should develop protocols for assessment and management of (initially) depression, then include postnatal depression, eating disorders, anxiety and schizophrenia. Omits to mention bipolar affective disorder.

Performance assessment (p38) will be by reduction in suicide rates, extent to which local prescribing of antidepressants, antipsychotics and BDZs conform to clinical guidelines.

Thus need to prepare guidelines.

Standard four: (p41)

All mental health service users on CPA should have…..

.."access to services 24 hours a day, 365 days a year"

Standard five: (p41)

Refers to environment of care away from home

NSF notes that: (p42)

5 of the top 10 causes of disability in 1990 were mental health i.e. unipolar depression, alcohol misuse, bipolar affective disorder, schizophrenia and OCD. Four of those five are readily treatable with drugs.
Need for abilities for people to speak languages (so let your Trust know if you speak something other than English)
Early treatment of schizophrenia with antipsychotics is supported
Use of newer antipsychotics supported, as reduced side effects. Includes clozapine.
Notes that lower doses of antipsychotics may be as effective as higher doses in preventing relapse of schizophrenia i.e. high doses long-term NOT needed (p44)

Other notes:

"Compliance therapy" is mentioned, as the combination of psychological therapies and drugs can prevent relapse of schizophrenia – this can at least in part be managed by pharmacists (p45)
Pharmacists can talk to patients, carers, parents etc to explain about drugs, individualise therapy and advice, offer help and support e.g. MedEd, talks, leaflets, books, helpline.
Role of CMHTs and assertive outreach is noted
Need for written care plan for individuals, including medication (p53)
Mentions pharmacists in an example of good practice for effective "Bed management", which included "improved medication management (input from specialist pharmacists, compliance aids etc)" (p64)

Performance will be assessed by reduction in suicide rates and antipsychotic prescribing (p66) and local milestones (p67), such as:

Implemented protocols for management of severe mental illness between primary and secondary care.
"Using clinical guidelines, all service users should be assessed for and receive new antipsychotics where indicated"
"All service users assessed as requiring rehabilitation receive access to education" including education about drugs?

Standard six: (p69)

All individuals who provide care for a person on CPA should have their own written care plan and assessment of their own needs, annually

NSF notes that:

Carers find relative support groups useful and effective (p70) – pharmacists need to be involved with these groups, to help carers understand drugs, remove fear and suspicion etc and help improve compliance
The care plan should include "information about the mental health need of the person for whom they are caring, including information about medication and any side effects which can be predicted, and services available to support them" (p72) – a clear role for pharmacists

Standard seven: (p76)

Local health and social care communities should prevent suicide by:

Promoting health for all
Delivering high quality primary health care
Ensuring open access to local services
Making 24 hour services available
Ensuring that staff are competent to assess risk of suicide

Notes:

Target of reducing deaths from suicide by one fifth by 2010 (p76)
That suicide rates are higher in certain occupational groups such as doctors, nurses, pharmacists, vets and farmers …(third mention of pharmacists) (p77)
Risk is higher with depression and in misuse of drugs (p77)
Compliance with effective drugs may be low when discharged, and that 25% people who committed suicide had contacted specialist services in the year before death (p77)
Assertive outreach should be in place for all individuals who may fail to take their prescribed medication and would be at risk of relapse (p78)
Follow-up on discharge is a priority to ensure continuity of care and transfer of information and care (p78)

Local implementation (p83)

This will require systematic and sustained change, strong leadership and clear commitment of managers, clinicians and other practitioners, to determine target resources

Includes:

An integrated approach to service, organization and professional development (p87)
Robust and sustainable mechanisms for implementing NSF
Considerable implications for workforce planning (p88)
NSF lead at health authority and regional levels, along with Regional Implementation Team and regional Mental health Development Plan. (p88)

Implementation will be via: (p90)

Laying groundwork for implementation strategy
Establishing a multi-agency NSF local implementation strategy team (named operational lead) – clear role for pharmacists
Identifying priorities (service map, statement of priorities, plan with milestones)

Organisational fitness (p91)
Professional development strategy (clinical governance requirements, service-led programme of post qualifying training, education and training commissions)

Final strategic plan needed by April 2000, noting service gaps, short-term action, milestones, funding (p92)

Clinical Governance

"Greatest change comes from using multiple, co-ordinated methods for influencing behaviour." (p92) – clear role for pharmacists, both in monitoring prescribing, medicine management (especially if Crown is implemented, allowing dependent or independent prescribing by post-graduate qualified, registered and accredited professionals). The UKPPG proposed College of Mental Health Pharmacists would satisfy these requirements.

Benchmarking may be important as comparing services is mentioned (p95)

Further developments include: (p98)

"Prescribing of antidepressants, antipsychotics and benzodiazepines monitored" through mental health minimum data set
"Protocols agreed and implemented for the management of depression and postnatal depression, of anxiety disorders, of schizophrenia, and of those who need referral to psychological therapies"

National milestones: (p100) include:

A reduction of 2% "in the rate of psychiatric emergency readmissions by April 2002, from 14.3% to 12.3%" – improved compliance would have an effect.
Protocols agreed and implemented (p101) between primary care and specialist services for the management of depression and postnatal depression, anxiety disorders, schizophrenia, those requiring psychological therapies, drug and alcohol dependence, by "All Health Authorities by April 2001" (p101)
"Prescribing rates of antidepressants, antipsychotics and benzodiazepines monitored and reviewed within the local clinical; audit programme" by "All Health Authorities by April 2001" (p101)
Local workforce strategies which ensure matching workforce to local community, retention, training etc. (p102)

Finance (p105)

Early, effective interventions for people with severe mental illness vital – i.e. drugs. £2.4m for antipsychotic medication provided in 1999.

Workforce planning, education and training (p108)

Recruiting across the range of mental health disciplines – no mention of pharmacists, yet then states that "Not all mental health service staff, even those trained relatively recently, have the skills and competencies to deliver modern mental health service. For example, ... Complex medication management." (p108). Workforce planning is needed (p110) and adequately trained and effective pharmacists will be needed.

Research and development: (p113)

Clinical practice and interventions (p116)
Assessing the cost-effectiveness, service user satisfaction and concordance rates of atypical antipsychotics, newer antidepressants, compared to standard management"

Outcome indicators for severe mental illness: (p124)

10. Prevalence of side-effects associated with maintenance neuroleptics…

Pharmacy profession:

The External Reference Group included 43 people, but no pharmacist. The RPSGB allegedly declined to take part when asked as, allegedly, they said that it did not apply to drug therapy. A former President refused to confirm or deny this "accusation". If it is true, this is a dreadful example of our profession shooting itself in the foot.

There are three mentions for pharmacists in the NSF:

People with mental health problems first presenting to community pharmacists (but fails to develop this by suggesting how this could be strengthened)
Example of improved bed management by better medication management using specialist pharmacists (as an example, but the Sainsbury Centre were unable to provide further details)
We have a higher suicide rate

Some negative points:

Very little mention of the appropriate role of medicines in mental health care and role of pharmacists in improving this, sad bearing in mind that psychotropic medicines are the single most effective method for maintaining the well-being of many people with mental heath problems and that drugs prevent or minimise relapse, improved compliance/concordance reduced relapse
Well known deficiencies in assessment and particularly management of depression not addressed
Bipolar is mentioned only once, as one of the top 10 causes of disability, but no mention of improved management

Some positive points:

Need for audit and guidelines requirements for depression, schizophrenia
Use of newer antipsychotics

The NSF could have:

made Mental Health Trust chief pharmacists or if in District General Hospitals, mental health directorate pharmacists, central to maintaining prescribing standards in the same way that the Duthie report makes them central to the procedures for the safe ordering, storage and administration of medicines.
advocated co-ordination of pharmaceutical services to people with severe and enduring mental health needs by pharmacists specialising in Mental Health who could purchase patient focused additional services from either community or hospital pharmacists.
advocated linking patients to specially trained community pharmacists who are paid to maintain contact with those considered to be at risk in the community. There is no shortage of ideas and there are even well studied models.

My thoughts:

Ensure that all (new) mental health Trusts or Trusts with mental health services have a dedicated pharmacy service and/or accredited leader of the mental health part, of high quality, providing clinical services to patients/service users and support to staff across the whole catchment area (not just in-patients) and playing a key role in development of services (i.e. not purchased in with an inadequate SLA from a non-specialist service or no service at all)
Consider round the clock access to pharmacy telephone helplines – could these be 24 hour? Or extended to 8pm as a starter? Run on a national or regional basis? (standard one)
Develop professional communication and liaison with community pharmacists e.g. make sure they know about CMHTs, specialist pharmacy contacts, collaborative working (e.g. as Liverpool, Nottingham, South Derbyshire) (standard one)
Widespread education and training of ALL health care workers AND patients about effective treatment strategies for depression e.g. effective dosing, duration, discontinuation. Likely to give the biggest and most cost/time-effective impact on reducing suicide rates. (standard seven)
Must take key role in developing protocols for drug component of the management of depression, then postnatal depression, eating disorders, anxiety and schizophrenia. We must then audit to see if these have been implemented. The protocol for schizophrenia should strongly recommend lower maintenance doses of antipsychotics, which may be as effective as higher doses in preventing relapse of schizophrenia. (standard four)
We must attract money for increased use of newer antipsychotics (to facilitate standard four)
Pharmacists must expand their role in education of users and carers about drugs therapies. Pharmacists must talk to patients, carers, parents etc to explain about drugs, individualise therapy and advice, offer help and support e.g. run Medication education programmes, provide talks, leaflets, books, helplines etc. This should include people requiring rehabilitation receiving education about drugs, and carers, who should have information about medication and any side effects which can be predicted, and services available to support them (standard six). This will help improve compliance, and hence reduce suicide rates (target of reducing deaths from suicide by one fifth by 2010) (most standards)
Pharmacists need better under-graduate education about mental health issues (illnesses, pharmacotherapy, management, concordance issues), fully implemented post-graduate education (including general clinical diplomas and MSc) and continuing education, as well as manpower planning. "Not all mental health service staff, even those trained relatively recently, have the skills and competencies to deliver modern mental health service. For example, ... complex medication management."
People with mental health needs will require individualised, co-ordinated, continuing and open pharmaceutical care and education about drugs, drug therapy and the consequences of taking and not taking long-term therapy. Mention of this single most important aspect of care is conspicuous by its absence in the NSF.

Personal notes of Stephen Bazire, Pharmacy Services Director, Norfolk Mental Health Care NHS Trust, 20.11.99

Abstract

This presentation will outline the background to the Mental Health NSF and the implication for pharmacy and pharmacists.

The NSF was developed as part of the governments vision for modernising health care in the U.K. The intention was to improve the quality of health care and provide a better service to patients.

An inclusive process was ensured by the establishment of a multi-agency reference group to develop the NSF. This group included professionals, carers, managers and users of mental health services. They devised a series of guiding principals upon which the NSF was based.

Seven national standards were set. These defined the issues to be tackled, the service models and provided an evidence based approach to dealing with issues such as treatment and other interventions. Time scales for achieving milestones were also set.

The NSF was launched in a way that delivered a co-ordinated and constant message on how mental health services should be modernised. Clinical governance, professional self regulation and lifelong learning would underpin the delivery of care within mental health. Progress would be monitored by the commission for health improvement and a national survey of patients. Additional resources were also made available to enable this modernisation of mental health services. People with severe and enduring problems were prioritised, whilst recognising the more common mental health problems still required attention.

Pharmacy and pharmacists received little mention within the mental health NSF. A literal interpretation would suggest the roles of pharmacy and pharmacists were confined to directing where people should go for help with their mental health problems, being "available" to support mental health teams and helping with the in patient use of beds.

A more enlightened view of the mental health NSF would reveal the central role pharmacists have in getting the drug treatment element of patient care "right".

In addition to developing drug treatment protocols, the pharmacist's skills should be used in the management of those individuals who require complex drug treatment and whose needs cannot be met through adherence to these standard protocols.

As part of the process of getting drug treatment "right" pharmacists should also be leading clinical audits on the use of medicines within mental health. They should also be ensuring patients and careers have the information they need about psychiatric medicines in a way that is both understandable and relevant.

The NSF recognises that many of the staff currently working within mental health services need to develop their skills and competencies in order to deliver modern mental health care. Specialist pharmacists can play their part in developing the mental health workforce by passing on their knowledge, skills and awareness of medication to their colleagues through structured training programmes.

For pharmacists the national services framework mental health simply reinforces the importance of getting drug treatment "right". If pharmacists can do that, they will be seen as one of the main drivers for the successful implementation of the NSF. If they can't, they have no role in a modern mental health service.

Peter Pratt, May 2000

Text from powerpoint presentation to Northern region pharmacists, Harrogate. 7.6.00, organised by Lynn Haygarth, supported by Janssen-Cilag.

The National Service Framework for mental health - implications for Pharmacists

Stephen Bazire,
Pharmacy Services Director,
Norfolk Mental Health Care NHS Trust,
Norwich

Government’s master plan
"The new NHS" - "A first class service"

NHS standards set by:
NSF sets service standards
- improve quality, minimum variation
NICE set clinical standards for new treatments
Quality service delivered by:
Clinical Governance, underpinned by professional self regulation and lifelong learning
Monitored by:
Commission for Health Improvement, Social Services Inspectorate, Audit Commission
Performance assessment framework
Annual National survey of patients

Background to NSF’s

HSC 1998/074:
start of NSFs and a real service plan
"Safe, sound and supportive"
Practical and tangible evidence of "change"
requirement for a "feel-good" NHS
Success will bring praise, failure will bring intervention
we will need to come up with the goods
- NSF for Mental Health:

Led by Reference group (Chairman Prof Graham Thornicroft):
Included professionals, carers, managers and service users, to "adopt an inclusive process to engage the full range of views"
- No pharmacy input

NSF remit

Set national standards
Define service models
Provide evidence on effective and efficient interventions
Provide evidence on effective and efficient organisational arrangements
Issues to be tackled
Time-scales for achievement

Service providers know standards, what to achieve, when to start, when to achieve them by (30.9.09), and that we will be measured in providing them

Guiding values and principles

Ten developed by External Reference Group to shape decisions on service delivery:

involve users and carers
high quality care known to be effective and acceptable
non-discriminatory
accessible - where & when its needed
Promote safety of patients public and staff
offer choices which promote independence
well co-ordinated between agencies
continuity of care for as long as it is needed
empower & support staff
be properly accountable to public, service users and carers

Other key messages

Service provision based on knowledge and partnership
£700m more on mental health 2000-03
Prioritised:
People with severe and enduring illness
24 hour staffed accommodation, assertive outreach, home treatment & secure beds
Standards will only be achieved by:
recognising that change must be systematic and sustainable
measuring changes
building an ambitious and realistic programme
applying concerted action

The seven standards

NSF and drug therapy
Standard 1

Health promotion:

Health and Social Services should:

promote mental health for all
combat discrimination against individuals and groups with mental health problems and promote social inclusion

NSF and drug therapy
Standards 2 & 3

Primary care and access to services - people presenting to primary care should have needs assessed and then needs provided

Need for effective (evidence-based) treatments
NSF notes poor outcomes from depression
High proportion of suicides from depression so needs improved care
No mention inadequate antidepressant prescribing
Performance assessed by audit of antidepressant, antipsychotic and benzodiazepine prescribing

NSF and drug therapy
Standards 4 and 5:

Effective services for people with severe mental illness

Early treatment of schizophrenia with antipsychotics
Atypical antipsychotics supported
"lower side effects"
"Lower doses may be as effective as higher doses in preventing relapse"
"Compliance therapy" mentioned
Protocols between primary and secondary care management of severe mental illness needed

NSF and drug therapy
Standard six:

Caring about carers

NSF notes that:

Carers find relative support groups useful
The care plan should include "information about the mental health needs of the person for whom they are caring, including information about medication and any side effects which can be predicted, and services available to support them"

NSF and drug therapy
Standard seven:

Action to achieve suicide target in "Our healthier nation"

Risk is higher with depression and misuse of drugs
no mention of high suicide rate in bipolar mood disorder
Compliance with effective drugs may be low when discharged (p77)
Assertive outreach available for all individuals who may fail to take their prescribed medication and would be at risk of relapse (p78)
Follow-up on discharge is a priority to ensure continuity of care and transfer of information and care

National milestones

2% reduction "in rate of psychiatric emergency readmissions by April 2002, from 14.3% to 12.3%"
improved compliance would have an effect.
Protocols agreed and implemented between primary care and specialist services for the management of

- depression and postnatal depression

- anxiety disorders

- schizophrenia

- those requiring psychological therapies

- drug and alcohol dependence

Targets for all health authorities by April 2001

Further developments

Prescribing rates of antidepressants, antipsychotics and benzodiazepines monitored through NHS Executive regional offices health improvement programs and local clinical audit programmes by minimum data set by "All Health Authorities by April 2001" (p101)
What would prescribing rates show of value?

Other points

Finance

Early, effective interventions for people with severe mental illness vital

Research and development:

"Assessing the cost-effectiveness, service user satisfaction and concordance rates of atypical antipsychotics, newer antidepressants, compared to standard management"

Outcome indicators for severe mental illness :

Prevalence of side-effects associated with maintenance neuroleptics

NSF and pharmacists

1. Glossary - definition of a Community mental health team as "a multi-disciplinary team offering specialist assessment, treatment and care to people in their own homes and the community. The team should involve nursing, psychiatric, social work, clinical psychology and occupational therapy membership, with ready access to other therapies and expertise, for example specialist psychotherapy, art therapy, and pharmacy. "

2. People with mental health problems may first present to community pharmacists

3. Example of improved bed management by better medication management using specialist pharmacists

4. Pharmacists have a higher suicide rate

NSF implementation

Chief Officers NSF Project Group
sub-groups on workforce planning etc.
Regional NSF implementation leads
Each local health Authority has an NSF local implementation team (LIT) who will set framework
"All staff should be engaged in shaping services"
LIT should have wide membership inc. service users
Proposals will form part of local Health improvement Plan (HImP)
Trusts will have an NSF implementation lead and team

HAS 2000

Health Advisory Service 2000

New role as baseline NSF assessors within localities:
Diagnostic visit
Data collection
5 day visit by 8 people to assess current services against the seven NSF standards

- Assessment based on meetings with medical staff, nurses/wards, managers, clinical professions, service users, Social Services, Community (GPs/PCGs etc)

Immediate verbal response, then written report on services
Follow-up visit later

Workforce planning, education and training

Enabling staff to develop modern mental health skills and competencies
Not all mental health service staff, even those trained relatively recently, have the skills and competencies to deliver modern mental health services. For example, psychological interventions, such as cognitive behaviour therapy, and complex medication management
Clear role for specialist pharmacists, using e.g. US models
Workforce planning bodies now looking at this for professions

NSF and depression

Issues raised by NSF:

Poor recognition by GPs and poor outcomes
Use of ineffective antidepressant doses
Anti-depressant medication is not always prescribed in correct doses. Anti-depressant medication may also be over-prescribed.
Protocols for use of drugs
Inadequate information about drugs
"However, people with depression often feel they do not receive adequate information concerning their treatment.
Role for non-drug treatments

Depression protocols

Protocols agreed between primary and secondary care
First-line drug, alternative first-line and the second-line treatments should be agreed
Improved recognition
Emphasis on drug, dose and duration
Appropriate patient education about risks and benefits of antidepressants
Advice on switching drugs - how long to wait, how to switch
Place of newer drugs e.g. venlafaxine/mirtazapine
How and when to discontinue

NSF and antipsychotics

Issues raised by NSF:

Early treatment supported
Lower doses may be as effective as higher doses in preventing relapse
Atypicals, with a different range of side effects, offer scope for improving the effectiveness of treatment and reducing side effects
Side effects may lead to treatment discontinuation, and relapse is higher with non-compliance
"… all service users should be assessed for and receive new antipsychotics where indicated"

Schizophrenia protocols

Use of typicals in therapeutic dose first?
Lower doses have less side effects than higher doses
Use of optimum doses of atypicals
acute dose may not necessarily be maintenance dose
Depots not available yet
Use for unlicensed indications where no evidence
Funding for new drugs must include primary care
"risperidone to thioridazine" etc
Education of PCG pharmaceutical advisers
Need for agreements between primary and secondary care
treatment duration, "well" patients etc

Recommendations - 1

Get a copy of the NSF and take time out to read it:
www.doh.gov.uk/nsf/mentalhealth.htm
£700m extra over next three years to fund improvements
Join the UK Psychiatric Pharmacy Group
visit website - www.ukppg.co.uk/support.html
Join UKPPG e-mail discussion group
Use peer support and mentorship scheme
Make sure pharmacists make contact with:
Trust NSF leads
LIT/local implementation officer
(Regional Implementation lead)

Recommendations - 2

Make sure you know about the local NSF processes and offer your services
active involvement in protocols
know what you’re doing
Look at Trust pharmacy services and compare with the NSF standards:
Patient centered with quality and effective counselling/support?

Pharmacists available to patients on wards (not just MDTs)?
Is any Medication Education provided routinely?
Are Relative support groups seen regularly?
Pharmacists have name badges and carry business/helpline cards?
Is a Telephone helpline run?
Think... where would a patient go for information on a drug? You?

Recommendations - 3

Access to pharmacy services?
24 hours? (uncomfortable thought)
Community Mental Health Teams ?
Community Pharmacists? CPPE?
User involvement in pharmacy service provision?
Does anyone ever ask user council, WMHD, user groups?
Does this routinely happen in a planned way?
Are other clinical staff supported re: drugs?
continuing education and training?
written support material and telephone support?

Recommendations - 4

Community liaison
Do GPs get information on a patients drugs on discharge?
Are issues discussed formally between Trusts and PCG/PCT prescribing leads?
Are you working with primary care?
Are pharmacists up-to-date and knowledgeable about psychiatric drugs?
CPD/lifelong learning requirement?
Are pharmacists making use of the opportunities?
Funding applications made?
UKPPG support material?

Conclusion

There is nothing presented on a plate for pharmacists
but…
the whole NSF is based around providing quality services for service users
Our pharmacy services must be focused towards service users and the NSF standards
we must make sure we play an appropriate role in the development of accessible and patient-orientated services providing quality pharmaceutical care

The National Service Framework for Mental Health

Peter Pratt

Chief Pharmacist

Community Health Sheffield

Background to NSF’s

The White paper "THE NEW NHS"
Modernising health care
Better service to patients
Improved quality
HSC 1998/074 announced the start of NSF’s
Practical and tangible evidence of "change"

Development of NSF’s

Reference group
Professionals
Carers
Managers
Users (patients)
"The reference group will adopt an inclusive process to engage the full range of views"

The Theory of NSF’s

Set NATIONAL standards
Define service models
Provide EVIDENCE on effective and efficient interventions
Provide EVIDENCE on effective and efficient organisational arrangements
Issues to be tackled
Timescales for achievement

Mental Health NSF

September 1999:

We now know what to do
We know how to do It
We know where to do it
We are being measured against it
We know when it will be done

So, we know everything!

The reality of Mental Health NSF

Full PowerPoint presentation on the mental health NSF
Co-ordinated and consistent message
People who talk about Mental Health NSF all say same thing

www.doh.gov.uk/london/mentalhealth/slides/index.htm

Key Messages (Buzz words)

NSF (& NICE) set STANDARDS
Clinical Governance
Professional self regulation & lifelong learning
Monitored by CHImp, Performance assessment framework & National survey of patients

DOH key messages

Based on knowledge
Based on partnership
£700m more on mental health 2000-01
Prioritise
People with SEVERE & enduring illness
24 hour staffed accommodation, assertive outreach, home treatment & secure beds
then common MH Problems

Values & Guiding principals

Developed by EXTERNAL REFERENCE GROUP
involve users & carers
high quality care KNOWN to be effective and acceptable
non discriminatory
accessible - where & when its needed
Promote safety of patients public and staff

Values & Guiding principals (cont.)

offer choices which promote independence
well co-ordinated between agencies
continuity of care for as long as it is needed
empower & support staff
be properly accountable to public, service users & carers

7 National Standards

Mental Health Promotion (one)
Primary care & access to services (two & three)
Effective services for people with severe mental illness (four & five)
Caring about carers (six)
Action to achieve suicide target in "Our healthier nation" (seven)

Where does Pharmacy fit in?

NSF 150 page document
Glossary - definition of a Community mental health team

A multi-disciplinary team offering specialist assessment, treatment and care to people in their own homes and the community. The team should involve nursing, psychiatric, social work, clinical psychology and occupational therapy membership, with ready access to other therapies and expertise, for example specialist psychotherapy, art therapy, and pharmacy.

No other mention of PHARMACY

Where does the pharmacist fit in?

Standard three - Access to services

People with mental health problems, including individuals making contact for the first time, approach health and social services in a variety of ways. Many contact their GP, or another member of the primary health care team, including a nurse or community pharmacist.

Whatever the point of contact, the principles of The new NHS should apply. Individuals in need should be able to access services which are responsive, timely and effective. All services should be sensitive to cultural needs, including the needs of people from black and minority ethnic communities.

Where else does the pharmacist fit in?

Standards four and five
Effective services for people with severe mental illness
Example of good practice
Bed management

Improved medication management (input from specialist pharmacists , compliance aids, increased frequency of contact with care co-ordinator)

No other references to a pharmacist

(Don’t) Take the NSF literally

Pharmacy and pharmacists have no significant place in the mental health NSF
Pharmacy is something the community mental health team has access to (like art therapy)
It’s somewhere people go when they have mental health problems (and need to be told where to go)
Specialist pharmacist can help bed management (like compliance aids)

What is pharmacy?
Pharmacy is drug treatment

Pharmacists "get drug treatment right" (Pratt P)

Where do drugs fit in the NSF?

Standards four & five services for people with severe mental illness
Examples of good practice

Home treatment

The Psychiatric Emergency Team in north Birmingham manages people with affective disorders and psychosis who have been referred because they present a risk to themselves or to others. A package of treatment and care ( drug treatments and psychological therapies) is delivered.

Where do drugs fit in the NSF?

National milestones

Protocols agreed and implemented between primary care and specialist services for the management of

- depression and postnatal depression

- anxiety disorders

- schizophrenia

- those requiring psychological therapies

- drug and alcohol dependence

Targets for All health authorities by April 2001
Monitored through NHS Executive regional offices health improvement programs

More drugs in the NSF

National milestones

Prescribing rates of antidepressants, antipsychotics and benzodiazepines monitored and reviewed within the local clinical audit program

By all health authorities by 2001
Monitoring data -NHS Executive regional offices monitoring of health improvement programs

More drugs and the NSF

National Research priorities

..assessing relative cost-effectiveness, service user satisfaction and concordance rates of;

- atypical antipsychotic drugs

- newer antidepressants

Primary mental health care

The most common mental health problems are depression, eating disorders, and anxiety disorders. Many of these disorders can be treated effectively in primary care, but some will need fast referral to specialist services. Effective interventions include medication and psychological therapies, alone or combined.

Evidence - who’s evidence? and the NSF

Evidence based treatments

Type I evidence - at least one good systematic review, including at least one randomised controlled trial
Type II evidence - at least one good randomised controlled trial
Type III evidence - at least one well designed intervention study without randomisation
Type IV evidence - at least one well designed observational study
Type V evidence - expert opinion, including the opinion of service users and carers.

Drug treatment & the NSF

Benzodiazepine medication reduces severe and disabling anxiety, but should be used for no more than two to four weeks (V).

Obsessive-compulsive disorder is effectively treated, at least in the short term, by antidepressant drugs (I)

More drug treatment & the NSF

Anti-depressant medication is an effective treatment for depression (I). Different groups of anti-depressants (tricyclics, SSRIs etc) have all been shown to be more effective than placebo in treating depression(I). However, people with depression often feel they do not receive adequate information concerning their treatment ( V, IV).

Anti-depressant medication is not always prescribed in correct doses (V, IV, I). Anti-depressant medication may also be over-prescribed (III, IV).

A number of second-line treatments such as lithium and electroconvulsive therapy (ECT) provide effective treatment of chronic and severe depression (I, V, I).

And more medication and the NSF

Even more medication ..

Standard five
Care planning and review

Yet more on medication

Standard 6
Helping carers