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

2 Disclosure statement Sole income NHSNo 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 & LDThe 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 PROBLEMSSMOKE BE OBESE DEVELOP DIABETIS & CARDIAC PROBLEMS LOOSE ALL YOUR TEETH SUFFER SOCIAL EXCLUSION

5 Treating SMI “We” give you drugs to help treat your SMIAntipsychotics 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 journeyPhenothiazines 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 antipsychoticsDichotomy = 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 antipsychoticsGeneral 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 servicesSupporting 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 barriersShared 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 deathCommunity 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 PracticesStarted 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 practicesReview of long term inappropriate and over used medicines STOMP Antipsychotics in people with dementia

14 Pharmacist in GP practiceUndertaking 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 CMHTAlso 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 careTo 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 practiceFunding / 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 frameworkWorkforce 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 AidSee 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

20 Data Lots of data available…… but relatively meaningless – discussNo 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 pharmacistIdeal 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 differencekey 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 treatmentHoly 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