Author Ingrid Torjesen, BSc, is medical writer.
When a community mental health team decided to audit their practice against NICE guidelines they found new ways of working to improve patient care. Ingrid Torjesen explains.
In 2005, the Gillingham Community Mental Health Team began reviewing and auditing the NICE guideline for schizophrenia (NICE, 2002a) and its (2002b) technology appraisal for atypical antipsychotics.
Belinda Garnett (pictured), a senior nurse practitioner for the team, which is part of the Kent and Medway NHS Social Care and Partnership Trust, explains that the team had looked for a set of standards to assess its practice against. The team chose the guidelines because they were the first from NICE on mental health and were applicable to a community mental health team working with people with severe and enduring mental illness.
The team determined which standards were applicable to a community mental health team of nurses, occupational therapists, social workers and doctors, then tried to incorporate elements of New Ways of Working for Everyone (Department of Health, 2007) and Essence of Care (DH, 2001). It then decided to assess antipsychotic medication, physical health review and nurse prescribing first and developed an audit tool. Ms Garnett had worked on an antipsychotic medication audit previously in East Kent, so was able to base the tool on that experience, which was a huge help.
Ms Garnett explains that: ‘The first audit we did was for the clozapine clinic, because we wanted to look at whether service users had access to services, choice of where they came to a clinic and choice in treatment.’
People on clozapine, an antipsychotic drug, attend the clinic either once, twice or four times a week. It was decided that four nurses who had been trained to prescribe would care coordinate those who needed medication management because it was more time and cost effective. Previously care of these patients might have been coordinated by a social worker, but they would still have to be seen at clinic by a nurse.
Ms Garnett says: ‘That has given nurses within the team a real focus on nursing skills because they are doing medication management and prescribing and, because we also do physical well-being, we take bloods within clinics.’
The audit showed 100% of service users preferred attending the clinic over other methods of monitoring and had physical health checks there. Problems with blood tests and obtaining clozapine diminished, while service-user satisfaction increased.
A schizophrenia clinic was set up to ensure antipsychotic prescribing practice was in line with NICE guidance and service users’ physical health was assessed and monitored with appropriate interventions offered where necessary. Those prescribed antipsychotics were identified, and those with schizophrenia were filtered out for the audit.
The results showed prescribing practice and assessment of physical health improved but attention needed to be paid to data management. Also, no one person was identified as responsible for patients’ physical health reviews in the care plan. Results indicated an exercise group was needed for women, which has now started. The team now wants to start and audit a similar clinic for those with bipolar disorder.
The schizophrenia clinic coincided with the introduction of nurse prescribing, and so provided an ideal vehicle for this to be evaluated. Ms Garnett says the nurses were using supplementary prescribing because the trust had not ratified independent prescribing. The audit showed that a lot of prescribing was occurring in the clinics, was carried out safely and service users were satisfied with non-medical prescribing.
The trust’s nursing strategy stated the team should look at physical well-being. Before setting up regular physical assessments, the team contacted primary care teams to ensure it would not be duplicating services.
A nurse and an occupational therapist run the healthy lifestyle and physical well-being groups and another team member has been trained in smoking cessation. These and other activity groups are run to coincide with physical well-being checks and clozapine and depot administration clinics to make the service a one-stop shop. The clinic has a point-of-care haematology machine and hopes to get a pharmacy technician to dispense, which will improve the service further.
‘People could come to get their clozapine bloods and monitoring done, have their physical well-being checked but then also go into a healthy lifestyle group, an exercise group or they might look at smoking cessation as well,’ Ms Garnett says.
The audit also included some of the standards for essence of care, such as self-care, record-keeping, personal and oral hygiene, and food and nutrition.
A support worker and two volunteer service users run a football team, which has proved very successful. A survey showed that all service users report feeling healthier and being 100% less troubled by voices and disturbing thoughts while playing football.
Cognitive behavioural therapy/ family therapy
One nurse who has undertaken the Thorn training for health professionals caring for people with severe mental illness has been facilitated to offer cognitive behavioural therapy (CBT) and family interventions alongside the clinics. The aim is for at least 10 CBT sessions over at least six months to be offered to anyone with schizophrenia and especially those with persistent psychotic problems.
The audit identified insufficient capacity to give interventions to all those waiting, so the team wants to develop a social worker role to resolve this. Audit data has been used to make its case.
Mental health services aim to help users live as ordinary a life as possible, which includes supporting employment opportunities. The Gillingham team set up a ‘buddy scheme’ (www.thebuddyscheme.co.uk), which offers service users paid employment mentoring nursing students, occupational therapists and social workers. This won a Community Care Award in 2006 and a National Endowment for Science, Technology and the Arts grant to produce training manuals and a DVD, disseminate the scheme locally and nationally, and allow time for its evaluation and publication.
Learning from experience
Ms Garnett says the team used the results of the audits to make recommendations and set out an action plan. ‘We saw things that we were not doing and put them right. We hope to re-audit to show that we have ticked literally all the boxes.
‘It has made us think of doing things perhaps differently, finding out where there is a service shortfall and addressing it, really looking at improving practice.’
She recommends having a champion in the team to lead clinically, explaining that: ‘It is about engaging practitioners and looking at new ways of doing things, making people think they can do things and change their way of working.’
She adds it is also vital to think creatively about funding. A major hurdle was that the team could not do everything it wanted to in working hours, so Ms Garnett got extra funding from the pharmaceutical industry to pay for clinic time on Saturdays. Such funding goes into a central trust ‘pot’ and projects are approved and funded accordingly (Bristol Myers Squibb funded this project). Ms Garnett stressed such support does not affect prescribing practice. The team sought funding from the local rotary club for their football strip.
The team is now focusing
in more depth on depot antipsychotics regarding patient choice of treatment and
‘If you look at NICE guidelines as a way of providing care, we are meeting nearly all the standards for schizophrenia. We were way off on physical care before we started, we still need to audit on assertive outreach team and advance directives,’ Ms Garnett says. ‘A lot of teams are probably doing a lot of good work and meeting the standards but not everybody audits it to show that.’
NICE (2002a) Schizophrenia. Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. London: NICE.
NICE (2002b) Guidance on the Use of Newer (Atypical) Antipsychotic Drugs for the Treatment of Schizophrenia. Technology appraisal. London: NICE.
Department of Health (2001) Essence of Care. London: DH.
Department of Health (2007) Mental Health: New Ways
of Working for Everyone. London: DH.
Advice for implementing the guidance
- Identify standards most appropriate to the care your team provides and audit these;
- Think creatively and don’t be afraid to do things differently, if appropriate, in order to achieve desired outcomes;
- Pursue a wide range of options, such as charities and private companies, to secure funding and other support for projects;
- Re-audit to see progress and where more work needs to be done;
- Enable team members to develop their skills and focus on their interests where possible.