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Reviewing, prescribing, and delivering medication
Target
a) The CRT team includes staff who can review and prescribe medication daily.
b) The CRT has access to out-of-hours medication review and prescription.
c) The CRT collects and delivers medication for service users up to twice a day where needed.
d) The CRT has written medication policies and procedures which are well understood by CRT staff.
Why this is important
Many service users of CRTs will require medication for their condition, and CRT staff must therefore have ready access to medication review and prescription. As CRT services are intended to provide support outside of normal working hours it is preferable for medication review and prescription to be available at evenings and weekends, and for the service to be able to offer medication collection and drop-off.
Dr David Osborn, consultant psychiatrist, explains in the audio clip below why it is important for CRTs to be able to prescribe and deliver medication.
Ways of doing this well
Listen to the audio clip below of Dr David Osborn, consultant psychiatrist, talking about prescribing and delivering medication.
Experts in this field have made the following recommendations around medication review, prescription, and management:
- Leadership is crucial. A lead clinician should be clearly in charge at the local level to ensure that the CRT effectively manages medication.
- Team working around medication is very important. The knowledge and skills of medical, nursing and pharmacy staff are essential for successful medicines management in CRHT teams. Medication management should not just be the responsibility of nursing staff.
- Effective systems for management should be implemented. These should focus on reconciliation upon admission, and medicine charts should be used to monitor what prescriptions have been made.
- An audit process should be established in order to ensure that medication management systems are being appropriately implemented.
Full details of these recommendations and more detailed suggestions can be found in the following document:
Examples of good practice
In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:
- Islington CRT, Camden & Islington NHS Foundation Trust
- Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- South Camden CRT, Camden & Islington NHS Foundation Trust
- South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
- East South Staffordshire (Tamworth) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Greenwich CRT, Oxleas NHS Foundation Trust
- West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
- Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
- Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
- Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
- South Gwent CRHTT, NHS Wales
- Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
- Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
- North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
- Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
- South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
- Bromley HTT, Oxleas NHS Foundation Trust
- Waltham Forest HTT, North East London NHS Foundation Trust
- Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
- Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
- North West Hertfordshire CAT, Hertfordshire Partnership University NHS Foundation Trust
- Tower Hamlets HTT, East London NHS Foundation Trust
- Redbridge HTT, North East London NHS Foundation Trust
- Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
- Hastings CRT, Sussex Partnership NHS Foundation Trust
- Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
- Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
- West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
- Eastbourne CRT, Sussex Partnership NHS Foundation Trust
- Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
- Manchester North, Manchester Mental Health and Social Care Trust
- Hounslow HTT, West London Mental Health NHS Trust
- Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
- Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
- Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
- South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
- South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
- Ealing CRHTT, West London Mental Health NHS Trust
- Yeovil CRT, Somerset Partnership NHS Foundation Trust
- Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
- Mendip CRHTT, Somerset Partnership NHS Foundation Trust
- Teignbridge CRHTT, Devon Partnership NHS Trust
- Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
- Chichester CRHTT, Sussex Partnership NHS Foundation Trust
- Gloucester CRT, 2gether NHS Foundation Trust
- Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
- Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
- South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
- Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust
Relevant reading
Sainsbury Centre for Mental Health: Crisis Resolution (2001)
Medication reviews
During acute treatment a client's medication may need to be adjusted so it is advisable to have a doctor working full-time with the service. Nursing staff also have a particular role in identifying problems with medication, such as side effects and a failure to respond and should be encouraged to identify and report such problems as they arise. (p.15)
McGlynn (2006) CRHT: A Practical Guide
Medical input
There is no doubt that doctors have a vital role to play in these services, having traditionally had a central role in gatekeeping hospital beds. It would seem important to optimise the use of this experience in the decision-making processes around admission to hospital. Department of Health guidance into new ways of working for psychiatrists has recognised the challenges to the traditional psychiatrist role brought about by the modernisation of services (including the creation of CRHT teams). The guidance suggests that psychiatrists should be at the forefront of this culture change and it clearly indicates a desire to have a clearer, more focused role for psychiatrists within the context of functional multidisciplinary teams:
" New ways of working are about using the skills, knowledge and experience of consultant psychiatrists to best effect by concentrating on service users with the most complex needs, acting as a consultant to multidisciplinary teams and promoting distributed responsibility and leadership across teams to achieve a cultural shift in services." (DH, 2005) (p.16)
Medication management
In the initial phase, medication can calm disturbed behaviour quickly and, importantly, allow everyone to get a good night's sleep. As in a hospital, its effects need to be monitored in case the initial dose is too high or too low and, as in hospital, it is sometimes necessary to make sure that it is really being taken. Where medication is seen as a key element of an individual's care package, the team may have to monitor compliance closely and, indeed, where situations are chaotic the team may need to take control of dispensing. Disturbed behaviour may have to be controlled quickly if a person is to remain in the community before the social network becomes worn out and neighbours become frustrated. Ensuring that everyone has a good night's sleep is often a big help in de-escalating a crisis situation. Criticism has been made that some CRHT teams offer little more than medication monitoring. This may be due to inadequate staffing of teams. In 1997 the Mental Health Act Commission reported that the amount of direct patient contact by staff on wards is often low (SCMH/MHAC, 1997). CRHT staff must engage properly with people on their caseload. (p.18-19)