Improving Medication Safety in Mental Health

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1 Improving Medication Safety in Mental Health Dr Mo Zoha Consultant Psychiatrist & Honorary Senior Lecturer Imperial College and Caroline Parker Consultant Pharmacist

2 Overview Context for today s conference National thinking and developments parity of esteem improving the physical health of those with mental health problems Why reducing the impact of medication side effects is key

3 Parity of Esteem what does it mean? We expect parity of esteem between mental and physical health services More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely More people with physical ill health will have better mental health.

4 Parity of Esteem Why? One in two people experience mental illness during their lifetime (Kessler et al 2005) At least one third of all families (including parents and their children) includes someone who is currently mentally ill. 38% of the population experiences at least one mental disorder each year (Wittchen et al 2011)

5 Parity of Esteem Why? The impact of mental disorder exceeds all other health conditions in the combined extent of prevalence, persistence (starts early) and breadth of impact WHO figures for UK total DALYs (2008) Mental disorder 22.8% Cardiovascular disease 16.2% Cancer 15.9%

6 Parity of Esteem Why? Impact of mental disorder: Poor physical health & reduced life expectancy Health risk behaviours more smoking Smoking is the largest single preventable cause of death 42% of all adult tobacco consumption in England is by those with mental disorder (McManus et al 2010) Health risk behaviours - more alcohol and drug misuse, less exercise, poor diet Less employment Housing Stigma & discrimination

7 Impact of mental disorder One third of people with long-term physical conditions have a co-morbid mental illness, raising the cost of physical health-care by at least 45% Can make existing physical illness worse eg intensifying inflammation, undermining immune system, increasing production of stress hormones eg cortisol etc Can cause physical symptoms which can not be medically explained. Up to 50% of consultations in acute sector have medically unexplained symptoms at a cost of 3bn per year

8 Schizophrenia is associated with: Considerable reduced life expectancy: 20.5 year for men; 16.4 year for women (Brown et al 2010) Increased mortality from all disease (Saha et al 2007) cancer, cardiovascular, liver, respiratory diseases & diabetes Less likely to have had a recent cervical smear, recent BP recording, recent cholesterol level or be on aspirin prophylaxis for stroke 61% smoke v 33% without SZP; 33% obese v 21% without SZP Many psychotropics are associated with weight gain Depression is associated with: 50% increased mortality from all disease (Mykletun et al 2009) At least 50% more disabled than someone with angina, arthritis, asthma or diabetes.

9 However... Only a quarter of all those with mental illness receive any evidence-based intervention, compared with the vast majority of those with physical conditions

10 Parity of Esteem Why? Reduced access to physical health care Reduced access to interventions for health risk behaviours Reduced investment in prevention and promotion 11% NHS budget spent on treatment for MH disorders v 23% disease burden Aims of achieving Parity of Esteem: Prevent people from dying prematurely, with an increase in life expectancy for all sections of society. People with long-term conditions, including those with MI to get the best possible quality of life

11 Parity of Esteem in practice References to MH and mental illness throughout Ensuring NHS is just as focused on improving mental as well as physical health Patients with mental health problems do not suffer inequalities, either because of the mental health problem itself or because they do not get the best care for their physical health problems.

12 Achieving Parity of Esteem Role of Commissioning Several documents refer specifically to the role of commissioning These include specifics on how commissioners will be expected to deliver / be accountable

13 Commissioner plans

14 National Developments RCGP will work to develop & improve GPs knowledge & experience of management of severe mental illness Improving standards of physical healthcare within MH inpatient facilities, to support earlier diagnosis and treatment of common illnesses Allocating 3.8b to help every Health & Wellbeing Board develop its own plan for joined up health and care locally NHSE & PHE will lead on a 5 year action plan on how to reduce avoidable deaths Supporting people with MH problems to take care of their physical health, including improving the understanding of the effects of medication

15 National Developments - RCPsych Valuing mental health equally with physical health. Holistic care the mind and the body should not be regarded separately but integrated the NHS Commissioning Board and clinical commissioning groups (CCGs) should promote widespread adoption of the recently developed Lester UK Adaptation: Positive Cardiometabolic Health Resource. This is designed to help reduce the high rates of type 2 diabetes and cardiovascular disease in psychiatric patients treated with antipsychotic medications

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19 Other National Developments Important role of primary care Delivering MH care & in commissioning Access to information about medication Access to specialist MH pharmacy advice Mental health tariff (formerly PbR) implementation & commissioning specifications Focus on developing and delivering evidence-based (eg NICE) care packages Measurement of quality and outcomes part of tariff

20 How Mental Health Tariff can drive improvements in quality Moving to tariff based funding is in the interest of MH services and patients, as should help protect resources and should improve quality Involves moving from block contract to being paid for each patient, with the price dependent on each patient s complexity & therefore the cost of the required care package The care package should be evidence-based (NICE) and agreed with commissioners as a minimum service response to a set of needs Measurement of Quality and Outcomes integral to tariff implementation

21 Quality Indicators Cluster and/or item specific CLOM & PROM dependant on Must Score and individual need D I S C H A R G E Recomplete at review periods Patient Reported Experience Measure

22 CQUINs & Parity of Esteem? Commissioning for Quality and Innovation (2009) To encourage a culture of continuous quality improvement CQUINs to reflect innovation, and to improve safety, effectiveness, and patient experience 2014/15 National CQUINs N1 Friends and Family Test N2 Improving Physical Healthcare to Reduce Premature Mortality: Cardio metabolic assessment for patients with schizophrenia N3 N4 Improving Physical Healthcare to Reduce Premature Mortality: Communication with GPs NHS Safety Thermometer - Improvement Goal Specification- Locally agreed CQUIN

23 Indicator name Description of indicator Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) CARDIOMETABOLIC ASSESSMENT FOR PATIENTS WITH SCHIZOPHRENIA Cardio metabolic assessment for patients with schizophrenia To demonstrate, through the National Audit of Schizophrenia, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with schizophrenia. The audit sample must cover all relevant services provided by the provider 90.0% The Provider s results from the National Audit of Schizophrenia demonstrate that, for 90% of patients audited, the Provider has undertaken an assessment of each of the following six key cardio metabolic parameters (as per the 'Lester tool'), with the results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions (e.g. smoking cessation programme, lifestyle advice, medication review, treatment according to NICE guidelines or onward referral to another clinician for assessment, diagnosis, and treatment). The six parameters are: Smoking status Lifestyle (including exercise and diet) Body Mass Index Blood pressure Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate) Blood lipids.

24 Cardiometabolic risks - Lester resource Provides a simple framework for identifying and treating cardiovascular and type 2 diabetes risks in patients with psychosis receiving antipsychotic medication, in any service setting Developed by the RCPsych CCQI National Audit of Schizophrenia (NAS), RCGP, and RCN, & fully endorsed by the College of Physicians, HQIP (NCAPOP), Rethink Mental Illness & Diabetes UK Adapted Australian work (Curtis et al, 2012)

25 Indicator name Description of indicator Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) COMMUNICATION WITH GENERAL PRACTITIONERS Communication with General Practitioners Completion of a programme of local audit of communication with patents GPs, focussing on patients on CPA, demonstrating by quarter 4 that, for 90% of patients audited, an up-to-date care plan has been shared with the GP, including ICD codes for all primary and secondary mental and physical health diagnoses, medications prescribed and monitoring requirements, physical health condition and ongoing monitoring and treatment needs. 90.0% Quarter 4 audit demonstrates that, for 90% of patients audited during the period, the provider has provided to the GP an up-to-date copy of the patient s care plan, which sets out appropriate details of all of the following: all primary and secondary mental and physical health diagnosis, including ICD codes; medications prescribed and monitoring requirements; and physical health condition and ongoing monitoring and treatment needs.

26 Physical Health 1a. Complete physical and mental health diagnostic coding (ICD 10) Why are we doing this? People with severe mental illness (SMI) experience worse physical health and reduced life expectancy compared to the general population. Correct coding of the relevant information will help clinicians take action to address the patient's health problems. How will we do this? All relevant physical and mental health ICD-10 codes should be recorded. Diabetes E14.9 COPD J44.9 Obesity E66.9 Hepatitis C B19.9 Coronary Heart Disease I25.9 Hypertension I10

27 Physical Health 1e. Staff training in smoking cessation brief interventions How will we do this? Staff will be trained to provide brief advice. 1f. Patients whose smoking cessation status is recorded How will we do this? Record ICD-10 code: F17.2 Tobacco Dependence 1g. Development of a smoking cessation advisory programme 1h. Electronic reporting system for smoking cessation interventions Smoking cessation and medicine safety interactions with cigarette smoke Interactions with smoking cessation therapies (training implications)

28 Dementia 4b. Development of a cluster 18 shared care/discharge protocol Why are we doing this? To improve on the number of patients in cluster 18 being managed effectively in primary care. 4c. Audit of antipsychotic reviews Why are we doing this? To reduce prescribing of antipsychotic medication to people with dementia. How will we do this? We will carry out regular medication reviews of patients with dementia who are prescribed antipsychotics. Outcomes will be communicated to GPs, patients & carers.

29 Percentage of total national sample POMH Topic 6c: Assessment of side effects of depots General statement regarding side effects Baseline Re-audit Supp 6c Baseline Re-audit Supp 6c Baseline Re-audit Supp 6c Formal evaluation of side effects Movement disorder (EPS) Weight / BMI / waist circumference Sexual side effects Documented evidence of assessment of side effects

30 TNS Proportion of patients POMH Topic 6c: Assessment of side effects of depots Documented physical examination to assess side effects in the last year 100% 80% 60% Supplementary audit 6c 40% Re-audit 20% 0% Trust code

31 Percentage of patients POMH Topic 2f: Patients on antipsychotics screened for aspects of metabolic syndrome 100% 80% 29% 28% 34% 37% No evidence of screening 60% 13% 13% 14% 13% Some reference to screening 40% 58% 59% 52% 50% 20% Test result / measurement recorded 0% Obesity/BMI Blood pressure Plasma glucose Lipid profile

32 National Audit of Schizophrenia Community patients on antipsychotics screened for aspects of metabolic syndrome N = 5091

33 National Audit of Schizophrenia Community patients on antipsychotics NAS N = 2599

34 National Audit of Schizophrenia Community patients on antipsychotics

35 POMH Topic 2f: 100% Patients on antipsychotics who have been offered smoking cessation TNS AOT (help offered) 80% TNS AOT (does not smoke) 60% TNS Adult (help offered) TNS Adult (does not smoke) 40% TNS Forensic (help offered) 20% TNS Forensic (does not smoke) Trust 29 0%

36 POMH Topic 11b: Prescribing antipsychotics for people with dementia - subsample treated for >6 months Proportion of patients who have had medication review in the past six months addressing possible adverse effects (n=935)

37 POMH Topic 7d: Monitoring of patients prescribed lithium The following tests should be conducted: Serum lithium level every 3 months U&Es inc creatinine (or e-gfr / CrCl) & TFTs every 6 months.

38 Patient information Patient responsibility esources/?entryid45=65426

39 NAS: providing patients with information

40 Recent national reports Francis report - commissioned following the Mid-Staffordshire NHS Foundation Trust scandal, published February Sir Bruce Keogh - 2 recent reports Mortality Review published in July Urgent and Emergency Care Review published November Prof Don Berwick - recommendations to improve patient safety in the NHS in England, August 2013.

41 Key themes from the reports Workforce Leadership and Governance Primacy of Quality and Safety Transparency and Candour Professionalism and Accountability Learning

42 Medicines Safety in Your Organisation Immediate / Longer term safety concerns Do you have systems in place? (up & down) Is it an MDT approach? Is there a focus on learning? Who is responsible?

43 Reporting up Immediate medicine safety concerns

44 Communicating down Immediate medicine safety concerns Patient Safety alerts new January 2014 NPSA NPSAS (National Patient Safety Alerting System) Alerts will be disseminated via the Central Alerting System (CAS) 3 stages of alert: 1. Warning, Directive Timeframes will be set for compliance with actions Monthly report published of non-compliant org. CQC will take note of failure to comply

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47 Summary Need to promote parity of esteem, with practical measures Medicines Safety - it s everybody s business commissioners / primary care / secondary care / patients / other agencies Processes in place for immediate and longer term safe medicines use? Leadership in your organisation? It s everybody s business Your role.

48 Any questions?

49 References No health without mental health A call to action: achieving parity of esteem Everyone counts: Planning for Patients 2014/15 to 2018/19 Closing The Gap: Priorities for Essential Change in Mental Health -_17_Feb_2014.pdf Rethink Integrated Physical health Pathway Whole Person Care: From rhetoric to reality Francis R(2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: London stationery office Berwick D (2013) A promise to learn a commitment to act-improving the safety of patients in England. Keogh (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. Available online at: Transforming urgent and emergency care services in England Urgent and Emergency Care Review End of Phase 1 Report. High quality care for all, now and for future generations. Available online at

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