This project demonstrates the impact of a Pharmacist Independent Prescriber (PIP) working within a unique setting – a Learning Disability Community Treatment Team (LDCTT). The role demonstrates safe and cost saving practice that releases psychiatry time and focusses upon quality of life improvement for people with a learning disability, autism, or both.
The clinic model supports people with a mental health condition and a learning disability, to maximise their mental wellbeing, whilst also focussing upon improvement of physical health burden through correct monitoring and access to support services. Monitoring rates have increased from 25% to 84% over a two year period.
The role also delivers a unique and ground-breaking STOMP clinic (stopping over-medication of people with a learning disability, autism, or both), which is the first of its kind in the United Kingdom. Many patients have been supported through the clinic and have clear quality of life improvements linked to medication reduction and discontinuation. The clinic model has been recognised as a NICE shared learning example, and it has been showcased at a number of regional and national conferences.
- To access the impact of the pharmacist in relation to the release of psychiatry time. The pharmacist cost the team £22k for one year, consisting of four clinical sessions per week. Over 60% of the time input resulted in release of psychiatry time, which more than covered the initial outlay (£23.5K released from the psychiatry budget)
- To focus on the balance between mental and physical wellbeing in a patient group that has a reduced life expectancy, which is often preventable
- To ensure correct clinical recording and to model new methods of sharing information with Primary Care in line with NICE guidance
- To reduce caseload numbers for psychiatry and allow quicker access to services. This has been met as the pharmacist has released over 50 cases from the psychiatrist
- To develop and showcase a unique STOMP medication clinic. To date, 22 people have benefited from a medication challenge, with 60% becoming medication free
- To access the opinion of the role from both team members and carers who access the clinic model. Qualitative themes have identified clear support for the pharmacist role.
The pharmacist joined the LDCTT to develop a collaborative model based upon Multi Disciplinary Team( MDT) principles to highlight the role. Caseload management was transferred from the psychiatrist to the pharmacist, with ongoing clinical supervision. The pharmacist developed a two clinic model with specific nurses, to deliver mental health reviews and STOMP medication challenge, for behaviour thought to be challenging
Summary of actions:
- A two clinic model developed with the pharmacist and a dedicated nurse – one for mental health reviews and the other for STOMP reviews
- Discussion with the consultant psychiatrist to identify clients to be transferred to the pharmacists for ongoing review
- Pharmacist to identify the level of competence and confidence and to develop a clear referral criteria
- Pharmacist role clarified with the LDCTT
- Handover period identified for the pharmacist to work with the consultant psychiatrist before caseload handover.
The project identified both quantitative and qualitative outcome measures:
- Specific pharmaceutical intervention data including reviews held, medication changes made, medication information captured, and side effect evaluations
- Amount of psychiatry time released by the pharmacist and a cost release figure.
- In-depth interviews with selected members of the LDCTT regarding the impact of the pharmacist’s role
- In-depth interviews with selected carers who have accessed the pharmacist’s clinic
- Development of themes relating to opinion of the role from both staff and people accessing the service.
The project has been able to demonstrate the release of psychiatry resource at a time of manpower recruitment and retention shortfall that is not likely to be resolved in the short term. This is a significant aspect of the project, demonstrating that the pharmacist can safely release psychiatry time in a cost effective and indeed cost saving manner. Projected savings more than cover the cost of the pharmacist at £22K per annum.
|Hours||% of time||Budget released (£k)|
The project has demonstrated that a Pharmacist Independent Prescriber (PIP) can develop and manage a clinic process that delivers safe and effective patient care around mental health, physical wellbeing, and behaviours deemed to be challenging. The pharmacist has led almost 300 reviews, focussing upon correct recordal of medication information (med rec), physical health monitoring, and side effect management. Over 300 carers have attended the clinic and witnessed the unique role.
The pharmacist role has enabled a greater focus upon physical health and wellbeing linked to the clinic. The monitoring rates within the team have increased from 25% to 85% due to the pharmacist clinical input. This represents a significant impact on the health inequality often felt by people with a learning disability and/or autism where life expectancy is often significantly reduced and physical ill health is frequently thought to be preventable through access to the correct advice and intervention.
The pharmacist has developed a unique clinic to consider the needs of the STOMP (Stopping Over-Medication of People with a learning disability, autism or both) agenda, with many clients experiencing an improvement in their quality of life, linked to cautious medication challenge and deprescribing. This is of national importance as NHS England attempts to challenge organisations within Health and Social Care to commit to the STOMP agenda. The pharmacist, being part of the NHS England STOMP team, has enabled a far wider recognition and spread for this project. To date, over 50 people have had their medication reviewed in line with STOMP, and 18 people have become medication free, with a further 16 undergoing active reduction. This has led to a fall in side effect burden of 71% improving quality of life.
The project has enabled the work of the Positive Behavioural Support (PBS) Team to be showcased as a method to enable deprescribing in the STOMP clinic. This has led to members of the team being invited to showcase their clinical work at a national psychology conference (The Seattle Club) and with an article in the Tizard Centre Review, which is a renowned outlet for psychology research.
The clinic structure has received recognition as a NICE shared learning example and via the Academy of Fabulous Stuff. These have led to increased interest in the clinic work, with 9 NHS Trusts asking for the clinic process, three practitioners visiting the clinic, and a number of opportunities arising to showcase the work including the National Autistic Society Conference and the Royal College of Psychiatry – Northern Ireland division. Recently, the pharmacist showcased the clinic model at the College of Mental Health Pharmacy Conference, where the work was given the Alistair Tinto Award for best presentation of innovation in mental health practice.
The evaluation of the role has enabled wider spread within the Trust as two further clinics have been developed in different Learning Disability Treatment Teams. The pharmacist has been able to develop two colleagues to operate these clinics, based upon the project principles.
The evaluation has shown that the PIP is a highly valued member of the MDT, providing resource and support for other members which was reported to be instrumental in understanding and addressing the needs of a complex group of patients and their carers.
- A Pharmacist Independent Prescriber can develop a personal caseload of clients to release psychiatry time and improve quality of life for vulnerable people in a safe and collaborative manner.
- The clinic structure and unique role requires time to develop, and a “heart and mind” winning input to ensure that it is universally supported. The buy-in of other professionals is key to understanding the purpose of the role and to support its development
- The pharmacist needs to be clear on level of confidence and competency, and needs to create a safe, supportive network of clinical and emotional supervision.
- Resilience is a factor to success and this needs to be factored into the role development, together with the wider MDT
- STOMP reviews can be safely led by a pharmacist with an understanding of learning disability and autism despite a lack of guiding evidence. The success rate for deprescribing becomes increasingly relevant with underpinning support from the Positive Behaviour Support Team.
- Medication reduction can lead to a significant reduction in side effect burden – over 70% reduction within the STOMP clinic. This has a significant impact upon quality of life and ongoing monitoring requirements in people with an already reduced life expectancy and a burden of physical ill health.
- Running educational sessions with paid and family carers, as well as the people who take medication, has proved invaluable to raising awareness of the role and allowing an element of client led service development.
The project is being showcased in the following ways:
- Processes uploaded and captured on ATLAS
- Submitted for consideration as an oral presentation at the following conferences:
- National Advocates Conference – October 2018
- Northern Care Quality Commission Inspectors’ Conference – December 2018
- Learning Disability Liaison Network – December 2018
- National STOMP Healthcare and Social Care Conference – January 2019
- Carer Forum Event – February 2019
- A number of articles about various aspects of the project are to be completed in the next three to six months. These will focus upon the different aspects of the project, including quantitative data and qualitative outcomes of the role. Journals to be targeted include specialist publications within the field of learning disability, the pharmaceutical press, and psychological and behavioural research publications.
- Plans for a workshop to showcase the role to other specialist providers of learning disability and / or autism services.
- This will include a workshop to be potentially held locally for all other providers of specialist services including NHS Mental Health Trusts and independent providers for both health and social care.
- Rollout to primary care via a number of local workshops and discussion with commissioning groups.
David Gerrard, Advanced Pharmacist Practitioner, Northumberland, Tyne Wear NHS Foundation Trust
T: 07507 567751