Susan Booth RN, specialist nurse in community neuropsychiatry, Kent and Medway NHS and Social Care Partnership Trust (KMPT)
Introduction
We sometimes forget how relatively recently ‘psychiatry’ was established – its roots can be traced back to many dates and places, but the term itself was only coined in 1808 [1]. Barker and Barker have argued that the meaning of the term ‘psychiatric [or mental health] nursing’ has only really started to lose vagueness in the last four decades or so [2].
Mental health care is evolving in a way which enables us to see the radical changes it is encompassing, unlike other medical disciplines whose long history tends to lead to small, incremental change (with some dramatic exceptions, of course). One of the more recent changes has been the introduction of ‘neuropsychiatry’ into the UK health system.
The common areas within neurology and psychiatry have been acknowledged for a long time, but this comment dates from only 2002:
"The separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway." [3]
Just as ‘dual diagnosis’ has been used to refer both to people with a mental health problem and a learning disability, and substance misuse alongside a diagnosed psychiatric condition [4], ‘neuropsychiatry’ can sometimes be misinterpreted. Patients referred to our service often become quite upset on discovering that they ‘have been sent to a psychiatrist’, when they believed they were coming to a neurological service, which carries rather less of a stigma.
The King’s and Maudsley hospitals website gives this useful summary of their work:
'Our neuropsychiatry service manages the psychological complications of neurological disorders. This includes psychiatric complications of epilepsy, Tourette’s syndrome, movement disorders and other neurological disorders, including; early onset dementias and other memory disorders, depersonalisation, and conversion and dissociative disorders including non-epileptic seizures and other somatoform disorders'. [5]
Background
Our service was set up in 2006, and comprised only a neuropsychiatrist. I joined in 2008, and after finding it difficult to track down other nurses working in the specialism, had the great good fortune to be able to develop the role myself. The team has since expanded to take in two clinical psychologists, a cognitive behavioural therapist, and a second nurse.
A large part of neuropsychiatry consists of medicines management. Patients may have seen representatives of several medical disciplines before being referred to our service, and particularly in the case of dissociative disorders (largely similar to, but not synonymous with ‘psychosomatic disorders’), have been prescribed medicines for signs and symptoms which turn out to have no physical cause.
Psychoactive drugs tend to need careful management; we need to wean people off several drugs, one at a time, whilst introducing new ones (whose dose needs titrating), all the while monitoring the patient carefully.
Being a community-based service (serving 1.6 million people across west and north Kent, including the Medway towns), our patients’ medicines are generally prescribed by their GPs and dispensed by their local pharmacist. If our psychiatrist prescribes a new drug, it will be on FP10. Unlike in the hospital setting, changes in prescriptions may take some time to filter down to the pharmacists, who might continue to dispense repeat prescriptions for a lengthy period before they become aware of any changes.
Medicines management
Such deficits in practice fly in the face of the recommendations of the National Prescribing Society’s document, ‘Ensuring the delivery of prescribing, medicines management and pharmacy functions in primary and community care’ [6]. This document ties into the Quality, Innovation, Productivity and Prevention (QIPP) agenda for medicines management, and highlights some risks involved in medicines management, such as increasing costs, adverse incidents, and non-concordance. Commissioning organisations need to take steps to ameliorate these; provider organisations will have to develop competency frameworks that ensure that services are developed that are patient focussed and that optimise medicine use.
In order to ensure this patient focus and medicines optimisation, organisations and individual providers need to identify and challenge inappropriate variations in practice. Organisations require an appropriate governance structure to ensure control and safety in the use of medicines and monitoring of medicines usage, using quality markers and the NHS Outcomes Framework.
The need for change
I was asked to wean a patient off a cocktail of medications, which included olanzapine, carbamazepine, quetiapine, clonazepam and pregabalin. This had to be done over a period of time, reducing dosages and discontinuing them one by one.
Four months into this programme, long after a letter had gone to her GP about the changes, the patient informed me that she was still being given drugs on her repeat prescription that had either been discontinued, or were still at the higher doses. I contacted the pharmacist, informed him of what changes had been made to date, and what was planned for the future. He appeared relieved to have been given this information, and expressed thanks, before contacting the GP.
It was obvious to me that this was a problem that needed tackling. It was not merely the sheer waste of money that the dispensed but unused drugs represented, but the very real possibility of serious drug errors and attendant harm to patients. Clearly, we were falling short in terms of meeting the patient’s clinical need and in meeting the recommendations of the NPC.
The solution
Discussions with various interested parties, including the consultant neuropsychiatrist, the Trust’s head of pharmacy, the manager of inpatient services, and line managers up to Director level, made it clear that apparently simple solutions were more complex than they appeared, and possibly unworkable. For example, it seemed obvious that if all stakeholders had access to local pharmacy contact details, this would ensure that changes to medication could be communicated more effectively. However, since the demise of primary care trusts, while some medicines management teams may have a centrally-kept list of pharmacists, few do. Building our own database (from the phone books of each area in our patch) would not only be time-consuming, but would also need administrative support to keep it up to date; each pharmacy would have to be contacted to see if it had a secure email or safe-haven fax, and this information would then need to be recorded and updated.
So we asked the General Pharmaceutical Council if they had such a list, explaining carefully what it would be used for. Their response: “The GPhC does not provide details of our registrants to any third parties due to data protection issues so we would be unable to assist with your enquiry”.
The compromise solution I arrived at is a pro-forma (Appendix 1) to be sent to from the unit to the pharmacist, informing them of changes to patients’ medications. The first draft of the operating policy stated that when a patient’s medication is changed, two copies of the pro-forma would be completed by the specialist nurse. One form would be given to the patient to give to their pharmacist, the other would be held at base, copied to the GP and finally uploaded to RiO [the electronic record of patients’ notes, used by all professionals within my employing authority].
Whilst obviously neither perfect nor foolproof, it seemed to have the advantage of being simple and low-tech, without the added complexities that could lead to error.
Implementation
Before anything is introduced into practice, we had to identify which stakeholders to discuss this with and consider the impact any change could have on their policies and practice. No practitioner wants to introduce more paperwork into existing systems unless it has efficiency gains attached.
Of course, the first person to be consulted was the head of community pharmacy, but I also assumed that as the form contained confidential information, it would need to be cleared by information governance and/or the Caldicott champion(s). I also welcomed any suggestions they had for improvement.
The legal status of the pro forma was questioned. I suggested that it was merely an advisory form – telling the pharmacist that a change in the patient’s regimen had been prescribed - pharmacists would not treat it as a prescription. The onus is on the pharmacist to confirm any variation to the information currently held, which would mean contacting the GP. They can, of course, contact the person whose name appears on the form (i.e. me, in this instance), if there are any apparent discrepancies, but ultimately, they would not be dispensing anything without a signed FP10. However, in order to remove any doubt, I thought it simplest to add the line ‘This alert is for information only, and does not constitute a prescription’ at the bottom of the form.
Another matter raised was the potential for forgery; while the pro-forma would not be seen as a prescription, in order to remove any potential, any blank space remaining after completion is blocked out. I also add the line ‘Total number of entries: x ‘ in full, as in controlled drug prescriptions.
The idea for this alert was approved by the relevant parties; so we then conducted a random telephone survey of High Street pharmacists. The idea was met with universal approval. We have since feedback from GPs that they appreciate the speed at which they are now updated. A letter was also published in the Pharmaceutical Journal [7], seeking comments from pharmacists nationally.
Conclusion
I was surprised not to be able to find any evidence of something similar in use elsewhere; specialist nurses in fields like Parkinson’s disease or multiple sclerosis, where medicines management is crucial, must regularly encounter the same problems as I do.
If anyone has implemented something simpler and better than my idea, it would be worth sharing.