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The management of schizophrenia

Published on 14/10/03 at 05:07pm

The publication of NICE's clinical guidelines on the management of schizophrenia in December marks a significant milestone - the first ever guidelines NICE has put together itself, ie, not inherited from other sources. This means the guidelines will be the first ever to dovetail with a NICE technology appraisal, in this case, the atypical antipsychotics.

It is now up to the NHS to implement this comprehensive mental healthcare plan - a challenge everyone knows should not be underestimated. The guidance is particularly welcome at a time when the prescribing of atypical antipsychotics, the most effective pharmacological treatments to date for schizophrenia, appears to remain patchy. NICE recommended the atypicals as first-line treatment for newly diagnosed schizophrenia in June, but a survey by mental health charity Rethink found many PCTs are still not providing the drugs for patients.

The drugs, such as AstraZeneca's Seroquel and Eli Lilly's Zyprexa, have been praised for their greater efficacy and safety profile than older medicines, reducing the need for hospitalisation and giving patients more independence and a greater quality of life. While the initial up-front costs of the drugs, at around £1,220 per patient per year, are far higher than for more traditional medicines, NICE concluded that these were more than offset by reduced length of in-patient stays, with estimated savings of £1,000 per patient per year.

But according to the Rethink survey one in five trusts still has to implement the NICE ruling and only around half have increased the choice of medication available to patients. Unsurprisingly, 78% of PCTs have been placed under additional financial pressure as a result.

Rethink's Director of Public Affairs, Paul Farmer, said this illustrated that people with mental health problems were still being seen as "second class citizens" and that the whole area of mental health was the "Cinderella service" of the NHS. The charity estimates that the NICE ruling will not be fully implemented until October 2005 and is lobbying the Government to ensure the guidance is implemented sooner.

NICE admitted some PCTs would find it tough to meet its recommendation of the atypicals, with Chief Executive Andrew Dillon saying trusts would need to look carefully at how they can fit it around other priorities.

Wendy Broderick, Chief Pharmacist at County Durham and Darlington Priority Services Trust, says the move towards atypicals began before the NICE recommendation, but in some instances PCTs may not yet have formally allocated money towards the NICE ruling. Norman Evans, Chief Pharmacist, Wandsworth PCT, agrees. "These atypicals have been out for a long time  PCTs might not have implemented the NICE guidance fully but certainly theyve been doing something around the atypicals," he says. "I would find it very surprising if any health authority or mental health authority was still using older drugs and not the atypicals."

Pressure on PCTs to increase their prescribing of atypicals is also being applied from the provisional  and controversial - performance indicators and key targets for 2003. The PIs build on the Mental Health NSF, stating that prescribing rates for atypicals (as well as anti-dementia drugs, antidepressants and benzodiazepines) are an indicator of improving performance and should therefore be rising.

Norman Evans says that although they entail a lot of work, most PIs are common sense and many PCTs would already be working towards them. Both Wendy and Norman agree that while the NICE schizophrenia guideline is welcome, it is just supporting and complementing individual schemes that trusts have already developed to a greater or lesser degree.

"Its nothing new but it brings together a cohesive policy," says Norman Evans. "Most PCTs have already developed guidelines for working with schizophrenia, either with shared care across primary and secondary care or policies around the atypical antipsychotics. The NICE guidance reinforces the work were doing."

Funding and other issues

Funding is, of course, always an issue for PCTs, with atypicals having to compete with other NICE-endorsed therapies, such as drugs for Alzheimer's, multiple sclerosis and cancer. "Funding is an issue, and the drug choices are being challenged," says Norman. "For example, local guidelines suggest that consultants should consider using the most cost-effective, ie, cheapest, atypical, but they're not." He adds that there is a need for more head-to-head trials of the atypicals. "We're using surrogate markers and theres a need to establish whether any of the atypicals are superior. All we have at the moment is differences in side-effects."

Some of the funding pressure may be eased by the Department of Health's decision to scrap the limiting one-year service and financial frameworks and introduce a three-year budget. The new deal gives PCTs £148 billion - a 30% average increase  but there are serious concerns that the majority of this will be swallowed by rising staff costs.

"It would appear to be a very generous increase, way ahead of inflation, but, of course, all costs will have to be met with that, including staff costs," says Norman Evans. "The reality is that it's an awful lot of work to plan for three years, particularly in prescribing, because you dont know what drugs are going to come out that you may well have to provide for."

Even if trusts have the money to fund the prescribing recommendations, they may not necessarily have the experts needed to implement other requirements. The NICE schizophrenia guidelines recommend an early referral to secondary care services for assessment but some trusts simply don't have the psychiatrists to offer the quick service required.

Harry Cronin, Director of Mental Health and Nursing at County Durham and Darlington Priority Services Trust, says one of the biggest challenges is finding the right skill base. "While we've been relatively successful in recruiting consultant psychiatrists, whats more difficult is training and developing staff as we offer new services such as crisis resolution and early intervention schemes. That's probably a national rather than a local issue, but the Government is being proactive in that respect, with the establishment of the Workforce Development Confederations and its 'Agenda for Change' paper on NHS pay structure."

How pharma is involved

The need for communication across all layers of the health service and between the health and social services illustrates that management of mental health illnesses, more so than any other area, is much more than just prescribing the newest drug. Medicines account for only round 5% of the estimated £1 billion in direct costs of treating schizophrenia in England and Wales.

The industry has recognised that it can have a more beneficial role than simply supplying medicines and lobbying for their uptake on the NHS, and is actively looking at how it can enter into meaningful partnerships with healthcare providers.

The benefits of such partnerships in mental health have already been acknowledged in Meeting of Minds, a joint publication from the National Institute for Mental Health in England and the ABPI Mental Health partnership - a group of pharma companies with a stake in the mental health market. Published in June, the compendium contains examples of best practice in implementing mental health policy across the country, and how pharma companies can work with primary and secondary care, social services and other mental health stakeholders to improve and refine services.

Eli Lilly and AstraZeneca are two companies that have worked with the health service in the area of schizophrenia to identify best practice, redesign services and establish management pathways with great success. AstraZeneca collaborated with mental health stakeholders in North Essex to develop a consensus guideline for managing schizophrenia across primary and secondary care, in accordance with policies such as the Mental Health NSF. Support was provide through an AstraZeneca sponsored psychiatric pharmacist and the guideline has been recommended to others.

Lilly, meanwhile, worked with various trusts in County Durham on a strategic level, conducting an evidence-based review of current services, training staff and establishing a schizophrenia disease register to help identify and track patients.

Harry Cronin says Lilly's support proved very helpful. "Although we could feasibly have developed the pathway without Lilly, working with them gave our people some headroom in which to work, which is difficult to find in the NHS these days with having to develop new services, meet targets and so on. Lillys support, such as organising events and training staff, gave people the time to look at and examine the evidence and gave us the energy to do the work."

The trust's partnership with Lilly has now ended, though the company still offers support, such as continued staff training. Harry Cronin doesn't rule out working with another pharma company in future. "There are some ethical issues involved in working with pharma companies - you need to have very clear boundaries about how you enter into these agreement, what the limits are. But if a company could support us and help us to improve patient outcomes I would work with them. I think it would be silly not to."

Norman Evans says such partnerships should be looked at seriously. "We would look very closely at any co-operation suggested by a pharma company. I think we can be as creative as we can be in this area  theres potential for win-win situations." Certainly, with the increasing numbers of targets and guidelines emerging from the DoH and NICE, PCTs will need all the help they can get.

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