Medicines Strategy for NHSE Mental Health & Learning Disability Peter Pratt NHSE & NHSI Head of medicines strategy for MH & LD Chief Pharmacist ( associate) SHSC peter.pratt@nhs.net

Disclosure statement Sole income NHS No income or benefits in kind accepted from pharmaceutical industry or its agents Former member several NICE guideline development groups

NHSE Medicines Strategy for MH & LD The Key issue for people with SMI is…. You will die 15 – 20 years earlier than others

Having SMI means You are more likely to HAVE RISPIRATORY PROBLEMS SMOKE BE OBESE DEVELOP DIABETIS & CARDIAC PROBLEMS LOOSE ALL YOUR TEETH SUFFER SOCIAL EXCLUSION

Treating SMI “We” give you drugs to help treat your SMI Antipsychotics Antipsychotics = Good Treat/reduce psychotic symptoms Reduce risk of relapse Antipsychotics = Bad May Increase cardiac/metabolic risks May Increase appetite/weight May Increase sedation/ EPSE

Antipsychotics … the journey Phenothiazines Butyrophenones Depots D2 High Dose Clozapine D2 5HT2 Atypicals Partial agonists Atypical Depot CUtLASS & CATIE NICE Guidance Metabolites NHSE Medicines strategy Long acting depots

Good and Bad antipsychotics Dichotomy = Nonsense ! Old = bad = “Nonsense” New = good = “Nonsense” Typical = bad = “Nonsense” Atypical= good= “Nonsense” First generation = bad = “Nonsense” Second generation = good = “Nonsense” Depots = good/bad = “Nonsense” Oral = good/bad - discuss

Making sense of antipsychotics General statement 80% relapse on no meds – 40% on meds “all as good….or as bad as each other “….. Except clozapine So ..why are depots “difficult “ in primary care? Medicines optimisation = getting best outcomes Individualised use = best outcomes

Community Pharmacy Already part & parcel of primary care services Supporting MH & LD medicines strategy Unblock barriers Depots – often seen as “hospital only” – not sure why Large variation in G.P response to requests prescribe/administer Why not administration through community pcy?

More opportunities for Unblocking barriers Shared care – traffic lights etc Started as safety – now capacity issue Can community pharmacy “unblock” capacity issue whilst maintaining safety? Consider longer term “ prescriptions” with community pharmacist monitoring safety/adherence/pick ups Feedback/alerts for no pick ups – Daily pick ups as alternative to depots Other suggestion welcome

Preventing premature death Community pharmacy Ideally placed to deliver healthier lifestyle messages Smoking – exercise – diet Note meds may exacerbate problems but its NOT just all about meds Switching may /may not help- choice & risks

Pharmacists as part of GP Practices Started in 1990’s Nothing new ! - discuss Expect to see 3,500 more pharmacists working within G.P practices – integrated within teams Relieving pressure on current system bursting at seams Pharmacist – unblocking system depots/shared care review of long term prescribing for “well” ”stable” people

Pharmacists as part of GP practices Review of long term inappropriate and over used medicines STOMP Antipsychotics in people with dementia

Pharmacist in GP practice Undertaking physical health checks Remember poor physical health for people with SMI is not just about medication But Antipsychotic medication may excacerbate problems Screening AND intervening Perhaps could help / overcome problems around “shared care” eg depots Why not clozapine?

Specialist pharmacists as part of CMHT Also need to look at capacity within secondary care Specialist pharmacists – in community MH teams Offer specialist/rapid support to primary care Enables primary care to feel able/confident to mange “complex meds” increasing/decreasing meds eg STOMP, dementia Enable clozapine patients managed in primary care Perhaps specialist pharmacist sessional review within GP practice?

Challenge for primary care To ensure pharmacy adds capacity to system and not simply increases workload for others Biggest impact could be physical /oral health checks How to ensure links with wider health care /clinical information systems Must ensure don’t end up screening/not intervening – or just always referring on to others

Challenge 2 Turning “good ideas” into work in practice Funding / payments systems to support pharmacists Skilled and competent workforce Strengthen mental health elements of general training Strengthen physical health elements of specialist MH training

MH & LD medicines Strategic framework Workforce Need skilled and competent pharmacy workforce Need 3-400 additional specialist pharmacist in MH Need to ensure specialist pharmacists maintain physical health competence Need to ensure wider pharmacy workforce maintain mental health competence CPPE LD CPPE mental health ( expected October 2017)

Mental health first Aid See https://mhfaengland.org Designed to help people: • Spot the early signs of a mental health problem • Feel confident helping someone experiencing a problem • Provide help on a first aid basis • Help prevent someone from hurting themselves or others • Help stop a mental illness from getting worse • Help someone recover faster • Guide someone towards the right support • Reduce the stigma of mental health problems

Data Lots of data available…… but relatively meaningless – discuss No joined up primary/secondary care data Many MH meds used outside MH No…ish links to diagnosis No links to outcomes EPACT2 – hopeful NHS Digital extracts - hopeful

Leadership MH chief pharmacist Ideal position to take leadership role for medicines in mental health Need to be working across boundaries Need to be supporting medicines pathwaygs Need to ensure primary care are supported by specialist MH pharmacists

Meaningful Choice Choice Must be meaningful to make a difference key theme throughout MH 5yr FWD view Key theme through various MH NICE guidance Must be meaningful to make a difference Avoid tokenistic choice Giving information is NOT choice Information can empower people to make choices Choice is meaningful when it feels real for you “Choice means choice”!!

Individualised treatment Holy grail Why do some people respond to MH meds… and some don’t Why do some people develop intolerable side effects to MH meds… and some don’t Why do some people develop life threatening s/e to MH meds & some don’t Can genetics/genomics help us individualise Will support meaningful choice

What have I forgotten to say? Please feel free to email me peter.pratt@nhs.net