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Risk management service: ‘It provided insight into patients with greater complexity’

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By Saša Janković

26 Jul 2021

Clinical pharmacist Liz Foster from Pharm-Assist (Healthcare) Ltd in Leeds, talks to Saša Janković about providing risk management and service development at Little Woodhouse Hall Children and Young Peoples’ Mental Health Service inpatient unit, a secure Adolescent CAMHS unit.

Service type: Risk management and service development

Name and location of pharmacy: Little Woodhouse Hall Children and Young Peoples’ Mental Health Service inpatient unit, Leeds

Name of pharmacist: Liz Foster

When did you start offering this service?

Leeds Community Healthcare Trust (LCHT) contracted Pharm Assist to provide this clinical service in January 2020, and it ran until June 2021.

Why did you start offering this service?

I had been working on behalf of Pharm Assist with the medicines management team at Wetherby Young Offenders Institute – which my colleague Martin Paterson Brown now leads – and I was planning to retire. Then my boss Ashley Cohen was approached by LCHT as they wanted a regular pharmacist in attendance on the unit at Little Woodhouse Hall, which they hadn’t had for quite a while, and I decided to do it.

What, if any, training did you or other team members have to undergo?

As pharmacists, we are used to working with a variety of medicines, but I had to become much more familiar with the mental health medicines in use on the unit, understanding how certain morbidities are treated within the NHS (e.g. NICE Guidance) and where to source information on the optimisation and safe use of these medicines (some of which is off-label in the adolescent group) from the BNFC, Maudsley Prescribing Guidelines etc. I also had to learn a whole new area in relation to the law around mental health medicines use – The Mental Health Act 1983 – and how this dictates medicines provision to Sectioned patients in England.

One of the psychiatrists recommended a book to me which I bought and read to help familiarise myself with this complex area, and I linked up with specialised mental health pharmacists working elsewhere in the NHS in Leeds who were very helpful whenever any complex queries arose that were outside my competence. I also had access to another NHS Trusts MHA Administration Office who could provide advice and support as needed, which was key. This is the law and any breaches result in the unlawful treatment of patients against their consent or in the absence of appropriate safeguarding procedures. I soon learnt the importance of this, and how my role has a key role in monitoring and flagging any concerns in this area, working closely with the consultant psychiatrists to prevent errors.

In a nutshell, what does the service involve?

The overall objective is risk management: to ensure any risks inherent in the provision of the mental health care are safe, lawful and patient-oriented.

Aside from risk management, my role included service development with the interests of staff and/or patients at its core. I used my expertise to write standard operating procedures; design, conduct and report audits to confirm the level of compliance with the governance framework; and provide staff training. As we were commissioned to provide the service by the NHS Community Trust we also looked at opportunities to directly minimise waste and contain costs without compromise to service.

Antipsychotic medications are powerful medicines, so it is important that safety in their use is paramount, not only at the point of prescribing but as treatment continues. There are clear safety monitoring parameters recommended in this area so clinical safety monitoring is performed as needed and acted on when appropriate, and another of my roles was to ensure this was actively undertaken.

There are also some procedures in this arena that are high risk. One of these is Rapid Tranquilisation which does exactly what it says. Although not often deployed on the unit, when it was it was important that the correct drugs, doses etc were used and any safety monitoring adhered to, so I needed to know what the RT guidelines recommended.

Although I was really only involved with those patients on medication, medication is actually only one component of the treatment strategy used within the unit. For example, eating disorders were the issue for most if not all patients on the unit. Never before had I come across patients who went to such lengths to avoid taking medication due to the perceived calorie content of the drugs, or because they wanted only vegetarian compliant medication. This meant nasogastric tubes were often used to facilitate drug administration, which necessitated me providing the prescribers and staff with detailed information on the safe administration of medication via NG tubes, which is almost always ‘off label’.

How have patients responded to the service?

I didn’t have a great deal of interaction with the young people themselves as they did not cope well with not knowing people and it takes them a long time to build up trust with staff on the unit. I’d speak to families more than patients, but this gave them someone to talk to about prescription medicines and they appreciated that.

Roughly how often each month do you carry out the service?

Pharm Assist was contracted for four hours a week to provide the service, which meant I had to think carefully about how to deploy my time effectively.

My involvement ended in June and the service moved to the Leeds & York Partnership NHS Foundation Trust. They are currently developing a £20m unit, known as Red Kite View, at the St Mary’s Hospital site in Armley, Leeds to accommodate a new enhanced Children and Young People’s Mental Health Inpatient Service with 22 inpatient beds, set to open in December 2021.

However, Ashley hasn’t let me off the hook and I’m now doing Covid vaccinations for him two days a week.

Would you recommend offering this service to other contractors?

I would recommend it to any other pharmacists given this opportunity. Working with a great MDT providing focused and safe care to a complex group of patients allowed me to use my understanding of safe medication management and medicines optimisation in a new environment, and learn in more depth about mental health medicine.

As a community pharmacist we dispense mental health medications every day but this provided an insight into patients with greater complexity, a more specialised service and an enhanced level of understanding of these medicines and how they are used. I think most of all it allowed me once again to count my blessings and realise that life for these patients and their families is not easy.

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