Lithium Support Service provided by community pharmacists

The service aims were:
1. To provide information to patients, prescribed lithium, from community pharmacists to ensure that NPSA and NICE recommendations are followed.
2. To minimise the risk of harm to patients prescribed lithium.
3. To support existing monitoring provided by secondary care and GPs.

The Northern Ireland Department of Health, Social Services and Public Safety (DHSSPS) published a strategy entitled 'Making It Better Through Pharmacy in The Community' (2014) examining what services could be commissioned from community pharmacies. I wanted to test the feasibility of providing a patient facing service for people prescribed a high risk medication. Lithium was chosen due to the NPSA alert and NICE guidance. Lithium is prescribed by the GP. The patient's lithium therapy is managed either in primary or secondary care via one of three NI lithium care pathways. It is suspected patients might not always receive on going information and education about their lithium therapy. The service had been already trialled the previous year in the Southern Health and Social Care Trust (SHSCT). In that instance the service was offered to all community pharmacies within that Trust. The Choice and Medication website: www.choiceandmedication.org/hscni had been commissioned by the HSCB as a support to community pharmacies enrolled in the pilot. Posters and business cards designed by me and a graphic designer in BHSCT had been sent to all GP practices and community pharmacies in NI.

Funding was obtained from the Belfast Local Commissioning Group to enable a pilot to be carried out in a Belfast integrated care partnership (ICP) area for 6 months. Community Pharmacy NI and Health and Social Care Board (HSCB) agreed a service specification and a proposed payment model. It is estimated there are 900-1000 lithium patients within the Trust (BHSCT). The chosen area contained 35 pharmacies; 26% of all Belfast community pharmacies. Based on prescribing data it was estimated that 38% of patients prescribed lithium lived in this area. An invitation letter was sent to all community pharmacies within the chosen area inviting them to take part and attend for mandatory training. The lithium support service guidance developed by the pilot pharmacist in SHSCT was used. Comprehensive training provided by me included information on bipolar illness; case studies; training on delivery of the service. I acted as a mentor to all pharmacists who participated in the pilot. Community pharmacists displayed business cards and posters advertising the availability of Choice and Medication website. All patients enrolling in the service signed a consent form enabling the pharmacist to share information with the appropriate bodies for the purposes of managing and administrating this service. The lithium support service was offered each time a new prescription was presented by the patient and repeated up to a maximum of five occasions during the pilot. The community pharmacist completed a care plan for each patient detailing the date of dispensing and which areas of information had been provided including any actions taken e.g. contacting the GP. The patient's knowledge in four areas was targeted:
- Adherence - checking understanding of how and when to take their lithium; and encouraging them to carry their alert card from the 'NPSA purple book'.
- Adverse reactions - checking understanding of the side effects and toxicity; of the risks of dehydration, sickness & diarrhoea; and understanding what to do when suffering any symptoms. Referring the patient with more severe side effects or toxicity to their GP.
- Interactions and precautions - offering advice on newly prescribed medications and the number of over the counter medications that should be avoided.
- Monitoring - establishing that the patient is having their lithium levels monitored every three months and their thyroid function and renal function monitored every six months.

19 pharmacies representing 54% of eligible pharmacies enrolled. 13 pharmacies enrolled patients, 6 did not (e.g. patient didn't give consent; no one prescribed lithium currently attended the pharmacy; medication delivered or collected by someone else therefore no face to face contact). By month five of the six month pilot, 47 initial patient encounters were completed. It was estimated there were 110 people prescribed lithium in the participating pharmacies, therefore 43% of the estimated numbers enrolled in the service. 72% of patients received at least one follow up following their initial consultation. 28% had an initial consultation but no follow ups. Reasons given include: the patient did not return to the same pharmacy; the patient did not attend for the follow up consultation; time limit of project. 11 patients reported adverse effects including thirst, frequency in passing urine, dry mouth and tremor. Two were identified who had not attended for lithium levels monitoring for several months. 38% of patients did not have a lithium record book or alert card ('purple book'). These were subsequently issued by GP practices or in some cases the community pharmacists on the GP's behalf. Advice was given on interactions with pain killers where patients were unaware of the interaction with NSAIDs. One patient prescribed both lithium and ibuprofen was immediately referred to their GP as they reported being unusually tired. Feedback from pharmacists stated training had improved their knowledge about lithium therapy and the issues involved; increased confidence in providing advice about mental health; improved their relationship with patients. Benefits for patients included raised patient awareness in the area of adverse reactions and toxicity; a better understanding about the need for monitoring and therefore reducing the risk of them not attending for monitoring; raised awareness of the importance of drug interactions when buying over the counter medication. Limitations of the pilot included:
- Not all patients agreed to enrol in the pilot citing time commitment; no interest; did not feel comfortable talking about their medication.
- Time limited nature of the pilot therefore patients were maybe only consulted once or twice within the period.
- Length of time involved talking to the patient.
- Patients do not present in person to the pharmacy. Medication will be collected by someone else or is delivered, therefore there is no face to face contact.

1. The service met the aims of providing information to patients about their lithium therapy; minimised the risk of harm by discussing adherence, signs of toxicity, drug interactions with OTC medication etc; and supported existing monitoring provided by secondary care and GPs by raising awareness of the importance and reasons for attending for blood tests.
2. Community pharmacists had assumed patients prescribed a long term medication would be knowledgeable about their medication; however this was not always the case. Consideration should be given as to how education to long term patients could be provided.
3. Community pharmacists felt the service improved their relationship with the patient and improved their confidence in providing advice about mental health.
4. The service has provided robust information to inform commissioning.
5. If possible avoid a paper based system. Community pharmacists would prefer to capture the data electronically.
6. If the service continued on a long term basis the number of consultations could be reduced following the initial period of consultations. Carry out long term consultations at an agreed time period e.g. every three or six months.
7. Consideration needs to be given on how to engage with patients who do not collect their medication themselves; who do not want to enrol with the service.