PPRT publishes study that evaluates pharmacist provision of clozapine

According to a study which evaluated alternative models for the delivery of clozapine services, published by the Pharmacy Practice Research Trust (PPRT), there is scope to review the team configurations needed to deliver community services in a cost-effective manner and to provide opportunities for improving the services provided to patients.

Evaluating the pharmacist provision of clozapine was co-led by Dr Denise Taylor and Dr Jane Sutton from the Department of Pharmacy and Pharmacology, University of Bath working with the Health Economics team from University of Surrey. The study, funded by the Pharmacy Practice Research Trust as part of its multi-professional grants programme, looked at different models of care for the delivery of clozapine for people with treatment resistant schizophrenia (TRS) in an NHS Trust in the UK via seven community-based clozapine clinics. The staffing configuration of these clinics varied across sites with some having nurses, pharmacists or doctors or a combination of these.

Patients attending clinics where services were delivered by a team of professionals (doctor, pharmacist and nurse) reported better health, wellbeing and self efficacy than those attending clinics run only by nurses. However, patients attending nurse-led clinics reported higher satisfaction in some other domains. It was difficult to attribute the specific contribution of pharmacists because when they were present, so were doctors and nurses. The research also found, from both patient and professional perspectives, that the pharmacists' role at present is unclear to patients, is underused in the view of some pharmacists and that more responsibilities could be transferred to pharmacists.

"Each of the pharmacists in the study played a different role at the clinic they attended and since there was no clear job or role description for their input, they did the tasks that they felt most comfortable with" says Dr Sutton. "Regarding their extended role, pharmacists said they would prescribe for side effects but did not want to prescribe for clozapine and one said that this was because they did not want to take the responsibility for prescribing in this area."

"Consultation observations suggested that the healthcare professionals seemed to be largely focussed on completing physical examinations and gathering information relevant to their regular clinic tasks. These physical checks were, of course, essential but some patients' concerns about social or welfare issues were overlooked."

Amongst key findings from the patient participation observation and face to face interviews were that communications within consultations were generally not patient-focussed and therefore did not elicit patients' individual problems; privacy of consultations was often compromised; and the institutionalisation of clinic services provided impacted negatively on participants, who perceived that no-one was listening to their concerns.

"As this study progressed," reports Dr Sutton, "it became apparent that there was no real philosophy of care underpinning service delivery. Without an understanding of the philosophy of care, staff cannot work together to achieve common goals that are embedded in that philosophy. Although such a philosophy should originate at the top with those responsible for service design, planning and delivery it should never be a one way process. Listening to the staff and patients' views and identifying concerns from both must be fed back up to senior level. If a philosophy of care is to be developed and implemented, staff must be trained to work within its framework and then to put that training into action to provide optimum benefits to patients. The majority of staff interviewed for this study wanted to do the best they could within the resources they had but that very lack of resources and their seeming inability to ask for more, was preventing them from improving the service they gave."

Recommendations for practice from the study include:

1. The Philosophy of Care Delivery to Service Users: a philosophy of care should be implemented that places patient well-being and an individualised approach to care at the core of clozapine provision.

2. Management of Services to Service Users: management structures should be clarified and include a budgetary framework, aims and objective and measurable outcomes of the service intervention. Each member of the team needs a clear role with transparent managerial links; appropriate training and equipment to deliver the aims of the service and clinical supervision.

3. Integrating Pharmacist Input to these Services: consideration should be given to the better integration of pharmacy services and the use of pharmacists' expert skills and training.

4. Models for Delivering Clozapine: alternative models of care for the delivery of clozapine services should be explored.

In conclusion Dr Sutton says: "Further research is needed to identify the optimal service delivery model and skill mix for community clozapine services which should include consideration of the role that pharmacists might play, within multidisciplinary team configurations, in the monitoring of patients and prescribing and distribution of medication."