Bridging the mental health gap: the role of pharmacists 

The economic and social costs of mental ill health in England reached £300bn in 2022, according to the independent UK charity the Centre for Mental Health.

Its report ‘Building a mental health workforce for the future’, published in April 2024, calls for expansion and diversification of the mental health workforce to meet growing levels of need​[1]​.

“Pharmacists are very much one of the groups we have in mind that will add to the richness of the mental health workforce,” says Andy Bell, chief executive of the Centre for Mental Health.

“Pharmacists have been undervalued in mental health services, yet they are important members of the multidisciplinary team, and their contribution to promoting equality for people with a mental illness could be very considerable.”

There are more than 500,000 patients in England with severe mental illness (SMI), such as schizophrenia and bipolar disorder, who face well-documented health inequalities, dying an average of 15–20 years earlier than the general population​[2,3]​.

Two thirds of these deaths are from physical comorbidities, such as cardiovascular disease, which could be prevented by access to appropriate treatment and support​[4]​.

“Pharmacists have a vital role supporting people with their physical health, closing the unacceptable 15–20-year life expectancy gap for people with a mental illness,” continues Bell. “Many people with a mental illness are prescribed a range of medications that need to be monitored carefully and that can have significant effects on their physical health.”

Gaps in care

One of the issues for patients with SMI is that they have frequently fallen into a chasm between primary and secondary care — needing more support than can be offered in the community, but not meeting the criteria for referral to acute services.

The ‘NHS long-term plan’, published in January 2019, set out to “ensure there is care and support available for those who do not meet existing thresholds for secondary care, and to avoid people losing care and support following discharge from community mental health teams”​[5]​.

It lays out an ambition for “new and integrated models of primary and community mental health care” to support 370,000 adults and older adults with SMI by 2023/2024.

“The ‘NHS long-term plan’ is about knitting together primary and secondary care, making it easier for patients to get the care they need in a timely way, delivered by the right people,” says Matthew Elswood, national specialty advisor for mental health pharmacy at NHS England.

“That way people don’t fall in between the cracks and end up being hospitalised or detained under the Mental Health Act, when it could have been prevented by providing care earlier in an evidence-based way.”

One of the goals stated in the plan for the new integrated models of care is medicines management for patients with SMI, who are typically prescribed multiple medicines.

“The case for specialist mental health pharmacy support on these teams is clear. You’ve got significant amounts of long-term medication use and we are talking mostly about psychotropic medication,” says Elswood.

“Ultimately, systems need to optimise the use of medicines, including clozapine and other antipsychotics, lithium, valproate and antidepressants.

“You need specialist mental health pharmacy expertise to be able to do that.”

Workforce needs

The ‘NHS mental health implementation plan 2019–2024’, which provides a framework to deliver the mental health commitments of the ‘NHS long-term plan’, identified a need for 260 pharmacist posts in integrated community care teams by April 2024​[6]​.

The plan was backed by £23bn of ringfenced funding for mental health transformation, with all integrated care systems (ICSs) receiving a share. However, there was no ringfenced funding to recruit for specific posts.

A freedom of information (FOI) request sent by The Pharmaceutical Journal in January 2024 to all 49 mental health trusts revealed that, in 2023/2024, there were 160.95 whole-time equivalent (WTE) pharmacists in adult SMI community services across the 43 mental health trusts that responded.

The data also revealed that there were currently 24.28 WTE vacancies for pharmacists in community mental health teams in the 43 trusts, amounting to a total of 185.23 WTE pharmacist roles.

Of the mental health trusts that responded to the FOI request, 36 provided data about the number of pharmacists in post in community mental health teams in 2019/2020 — when the ‘NHS long-term plan’ was launched. At that time, there were 27.0 WTE pharmacists in post in community mental health teams across these trusts, compared with 128.25 WTE in 2023/2024, an increase of more than 100 posts over the five years.

Workforce issues

Although significant progress has been made, the FOI data suggest a shortfall against the target of employing 260 pharmacists by April 2024.

According to Elswood, one reason for this could be that community mental health teams in organisations that provide mental health services have gone through a series of reorganisations over the years, so configuration of these services can vary from place to place.

“Around the country, different organisations will have been at different starting points, so they might have needed to prioritise the investment elsewhere,” he explains.

This is reflected in The Pharmaceutical Journal’s data, which show that, while some trusts have recruited more than ten pharmacists to their adult community SMI services since 2019, others have not recruited any (see Figure).

Avon and Wiltshire Mental Health Partnership NHS Trust says it has chosen not to employ pharmacists in its mental health teams because it ensures that mental health investments are “allocated to the highest priority areas”.

“While we recognise the contribution pharmacy professionals provide to the care of patients, at this point we have confirmed other priorities for local financial allocations,” a spokesperson for the trust says.

At Camden and Islington NHS Foundation Trust, no new pharmacy posts were established as part of the community transformation programme, although the trust already “has a senior pharmacist based in the community teams, who is available to provide expertise and advice and has good network links with primary care network pharmacists based in GP practices,” a spokesperson points out.

Somerset NHS Foundation Trust has also not recruited any pharmacists to its community mental health teams, owing to workforce shortages, which are particularly prevalent in the south west of England.

“The trust received additional funding as part of the ‘NHS mental health implementation plan’ but, despite several attempts, it was unable to recruit into the pharmacist role, so took the decision to repurpose the money into a pharmacy technician role, which was recruited to,” a spokesperson says.

They add that “recruitment of mental health pharmacy colleagues continues to be very challenging, but this is regularly reviewed”.

Ringfenced funding issues

Some trusts were not able to access the funding they needed to create pharmacist roles.

In its FOI response, Dorset Healthcare University NHS Foundation said that no pharmacist roles have been created in adult community mental health teams because the trust “did not receive any funding for these roles”.

However, a spokesperson for the trust says that it will be including pharmacists in its community teams as part of its mental health transformation in 2024/2025.

Other trusts have been forced to cut the pharmacist roles that they had created when short-term funding came to an end.

Worcestershire Health and Care NHS Trust (now Herefordshire and Worcestershire Health and Care NHS Trust) successfully bid for Health Education England funding in 2019 to run a pilot for a pharmacist-led “complex medicines service” within its community mental health teams.

The six-month pilot, which went live in April 2019, offered a service one day per week, using the trust’s existing pharmacy workforce.

“It was a service for people with mental health disorders, suffering complex problems with their medicines, such as polypharmacy, treatment resistance, complex side effect profiles and adherence problems,” says Andrew Down, chief pharmacist at Herefordshire and Worcestershire Health and Care NHS Trust.

“I think that there is huge value in having pharmacists and pharmacy technicians available and working directly with community teams in collaboration with the doctors, nurses, psychologists and other staff.

“It not only means you’ve got a specialist dealing with medicines issues, it also frees up the other clinicians to be able to deal with their work,” Down says.

Despite receiving positive feedback about the impact of the service, the trust was not able to continue it after funding for the pilot ended.

In 2023, Down was able to access reallocated funding originally intended for other healthcare professionals to allow 2.0 WTE pharmacist roles to support with medicines management and the prescribing guidance in the multidisciplinary team.

However, that funding finished at the end of March 2024, meaning that the pharmacist roles have not been able to continue.  

“When you don’t have ringfenced funding for individual professions, the funding will often go to services considered to be the core workforce, such as nurses, social workers and doctors,” Down says.

“Without pharmacists in the team, you don’t necessarily get the same degree or quality of medicines advice and the opportunity to work with patients to individualise their therapy.”

Demonstrating pharmacy’s role

Karen Shuker, president of the College of Mental Health Pharmacy (CMHP), agrees that this lack of ringfencing for specific posts in mental health teams could affect the ability of trusts to recruit for pharmacist roles.

“Despite pharmacists being included in the ‘NHS long-term plan’, these roles might not have always come to fruition because there was variation in how people were able to access funding.

“I know that CMHP members trying to access the funding [for mental health transformation] that was initially released have reported trying to find out where the money had gone.

“A lot of it went into the clinical commissioning groups’ or the ICSs’ baseline funding, so it didn’t directly reach the trusts or pharmacy teams.”

Shuker believes that the vital role that pharmacists play in mental health services needs to be highlighted by NHS England. 

“We need a clear, consistent role descriptor of pharmacists in these services, which says that pharmacists are an integral part of the team, and you should be funding them year-on-year.”

She adds that mental health trusts were frequently having to present business cases to ICSs to advocate for funding for pharmacist posts.

In its FOI response, Cambridgeshire and Peterborough NHS Foundation Trust said that it has put forward a business case requesting 5.0 WTE pharmacist roles because it “did not have funding for the expected pharmacist roles”.

“We have currently received funding for 2.0 WTE roles. We have no unfilled vacancies at this time; however, there are currently 3.0 WTE roles which have not yet been funded in the ICS,” it adds.  

Evaluating impact

Shuker says convincing teams of the benefits of pharmacists can be challenging.

“If teams haven’t experienced working with a pharmacist before, they may not necessarily always be aware of the input and role that pharmacists can have,” she says (see Box).

“I think there is a need to be able to evaluate the impact of pharmacists, bring that data together and define what level of service there should be from pharmacy into community mental health teams to improve the establishment of these posts.”

To this end, Elswood is planning to carry out an evaluation of mental health teams to “bring together a summary of what has been learned through the implementation of pharmacy roles”.

He intends to use this research to develop a policy evidence document “to support systems to make their own investment decisions about the roles”.

Training needs

Going forward, Shuker believes that it is important that NHS England continues to provide funded training routes, such as the ‘Specialist mental health pharmacy training pathway’ at the University of Bradford.

“NHS continuing professional development funding doesn’t include pharmacy teams, so there’s no protected money.

“If we don’t have access to training programmes funded by Health Education England [now NHS England], the only alternative is paid courses, and people might find it difficult to access the appropriate funds.”

Shuker also believes education is important to ensure a future pipeline of mental health pharmacists.

“Mental health training doesn’t start if you move into a specialty role; it should already be part of your foundation training core competency relating to mental health,” she says.

The Royal Pharmaceutical Society and CMHP published a draft curriculum for consultation to support advanced practice for mental health pharmacy in February 2024.

Elswood says that he is “really encouraged” by the progress that has been made over the past five years and is also “simultaneously hungry to see more development and growth in the sector”.

“It’s about getting specialist mental health pharmacy support into the teams, embedding those roles, [and] optimising and finding out what’s going to work in different locations. The job has begun and, over the next three to five years, it’s about turning that into a job well done.”