Introduction
With 'Care in the Community', more mentally ill patients are being cared for in their own homes. They are long term users of polypharmacy, and hold a great potential for mismanagement of their medication, which is known to potentiate a revolving door of care(1). The Audit Commission has recently found mental health services for older people to be patchy and inconsistent. Carers often lack support and information. Joint working by health professionals was recommended(2).

Phase 1 of this project was a randomised-controlled trial. 24 pharmacists received specialised training, became integrated into the Community Mental Health Teams (CMHTs) and provided joint domiciliary visits with the key workers to 26 patients in the active group. The pharmacists reviewed medication regimes, counselled on the use of medicines, side effects and the importance of adherence. A pharmaceutical care plan was developed and many interventions were made, including the provision of compliance aids and collection and delivery services, where necessary. In Phase 2 (30 patients) the control group was abolished and the paperwork streamlined.

Method

Questionnaires obtained the views of all CMHT key workers concerning this project and pharmacists undertaking domiciliary visits at the end of Phase 1, in March 1999. 23 (85%) replies were received.

At the end of phase 2, in November 2000, a focus group was held with a representative sample of nine key workers (8 community psychiatric nurses and one occupational therapist) from four of the CMHTs. All the CMHTs were invited to send representative key workers to the focus group. It was stressed that a range of views was needed and consequently attendance was needed from key workers who had or had declined to refer patients into the study. A researcher, who was not known to the key workers, moderated the group.

Results
The views were similar from both the questionnaires and focus group and are summarised as follows:

• All replies and comments indicated that domiciliary visiting is an appropriate role for pharmacists and that they would like this study to be developed into a service - with a few 'key pharmacies' in each area.
• The main problem, at the end of Phase 1, was the existence of a control group and at the end of both phases, was the amount of paperwork for completion. They commented that it was difficult explaining the concept of a control group to these vulnerable people and it was disappointing to both the key worker and the patient, when the patient was randomised into the control group.
• A further reason for not referring patients was that an additional person visiting could have caused more confusion, particularly if several others are visiting and are involved in the care process.
• The advantages for the patient or carer were that there was time to discuss medication problems on a one to one basis in the privacy of their own home and that it eased worries of elderly carers concerning the use and supplies of medication, particularly where compliance aids/delivery services had been arranged.
• The main advantages for the key workers were -increased contact with the pharmacists (previously there was little/no contact), -improving compliance by providing MDS for patients with confusion/memory problems, improving safety for prompting by home helps and also by simplification of regimes and quantities.

Discussion
The views of the key workers expressed in earlier questionnaires of open questions were very similar to those obtained at a focus group, held 20 months later. The key workers liked the increased contact with the pharmacists, valued the assistance that they could provide and would like this developing into a service.

References

1. Drug Compliance and Community Care. J Drug Dev. 1994; 6(4):151-152
2. 'Forget Me Not': Mental Health Services for Older People, Audit Commission, Jan. 2000.