Around half (46%) of people with severe mental illness (SMI) have a long-term physical health condition and are at risk of shortening their lifespan by an average of 10–20 years because of physical ill health.
Despite longstanding evidence regarding the poor health status of this population and the many guidelines and changes to manufacturers’ SPCs [summary of product characteristics] to include physical healthcare monitoring, most providers are failing to deliver. The main barriers to this work are related to in-built systematic issues in the health service, including beliefs about whose responsibility it is to undertake this work and the sharing of data between primary and secondary care.
‘Improving the physical health of adults with severe mental illness: essential actions’, an intercollegiate report involving the Royal Pharmaceutical Society, Royal College of General Practitioners and Royal College of Psychiatrists among others, makes recommendations for changes to ensure that people with SMIs receive the same standard of physical healthcare as the general population. The report, which was launched on 25 October 2016, focuses largely on system level change, placing responsibilities on various parts of the health service to ensure that physical healthcare problems are addressed by those providing mental health services, and that mental health care is appropriately addressed for those with physical health problems.
The report makes a number of recommendations relating to pharmacists. It asks that pharmacists work within the multidisciplinary team and that when pharmacists are involved in the clinical care of patients with mental disorders they should be competent in several areas, including being able to manage drug interactions that may compromise co-existing physical and psychiatric drug treatment, and being able to promote healthy living strategies, such as smoking cessation. For pharmacists with access to the summary care record, future access to laboratory test results will enable them to provide reminders to patients about the need for regular testing.
A recent analysis found that in 2013–2014, people with mental health problems had three times more A&E attendances and five times more unplanned inpatient admissions than a matched control group drawn from the general population. A total of 80% of these admissions were for physical rather than mental health problems. The realisation that people with mental health problems contribute greatly to acute trust bed blocking has led to closer collaboration between mental health trusts (MHTs) and acute trusts with the development of psychiatric liaison services.
Acute trust pharmacy services have been urged to develop similar collaborative arrangements with MHT pharmacy services and for every acute trust pharmacy service to have access to mental health pharmacy expertise as part of the liaison service.
GP practices have a responsibility to maintain a SMI register and receive a quality outcome framework (QOF) payment for healthcare reviews. Pharmacists based in GP surgeries are in a good position to ensure that these reviews take place.
MHTs have been slow to adopt anti-smoking policies but MHT pharmacists can assist by providing help and resources to support smoking cessation. In addition, specialist pharmacists are uniquely placed to take a greater leadership role in the coordination of healthcare reviews and through active participation in projects associated with physical healthcare monitoring. One example of a quality improvement exercise, rolled out by NHS England within secondary care, is for trusts to meet the requirements of the cardiometabolic CQUIN [Commissioning for Quality and Innovation] payments framework. Some may see this as a cynical approach to improving healthcare as there is a financial incentive for care that should be delivered routinely. However, a specialist mental health pharmacist within Leicestershire has lead on the implementation of this CQUIN for the Leicestershire Partnership NHS Trust and it has resulted in measurable changes in physical health care. The rate of cardiometabolic screening has increased from around 24% in 2013, to 99% in 2016.
What is holding pharmacists back from taking a bigger role in the care of people with SMIs? There is no shortage of training for pharmacists around mental illness but there are issues around awareness and confidence in dealing with patients with a SMI. Focusing on the associated physical health issues of an individual with a SMI is a good place to start.