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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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?

10. 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

11. 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

12. 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

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

14. 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?

15. 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?

16. 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

17. 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

18. MH & LD medicines Strategic framework
Workforce
Need skilled and competent pharmacy workforce
Need 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)

19. Mental health first Aid
See
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

20. 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

21. 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

22. 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”!!

23. 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

24. What have I forgotten to say?
Please feel free to me