Back in 2010, NICE published an updated edition of their schizophrenia guideline, to guide the treatment and management of patients with schizophrenia in primary and secondary care.
The National Schizophrenia Audit is a new initiative led by the Royal College of Psychiatrists and involving 8 other partner organisations including various professional membership organisations and 2 leading charities (Mind and Rethink Mental Illness).
The audit aims to assess the quality of health service care and compare what is happening locally with the national standards recommended by NICE. It is hoped that all mental health trusts will eventually be included in the audit. Sixty trusts and health boards have been included in this first round of assessment.
The key aims of the audit were to measure:
- Service users’ experience of care and treatment and outcomes
- Carers’ satisfaction with the support and information they have received
- Practice in the prescribing of antipsychotic medications
- The use of psychological therapies
- The quality of physical health monitoring and interventions offered
Nearly a quarter of a million people in England and Wales have a diagnosis of schizophrenia and research has shown that having a severe mental illness such as this can take 15-20 years off life expectancy.
Schizophrenia accounts for a significant chunk of the national spending on adult mental health and social care services (about 30% in 2007). Our understanding of the illness, and the best way to help people live with it, has improved enormously over recent years, but there remains a significant gap between what we know and what is sometimes provided in practice.
Each of the participating trusts and health boards in this audit were asked to submit data on a representative sample of 100 adults under their care with diagnoses of either schizophrenia or schizoaffective disorder and who had been under the care of specialist mental health teams in the community for at least 12 months. Data was gathered through surveys, anonymous patient records and via an audit of practice tool produced by the Prescribing Observatory for Mental Health.
Here’s a brief summary of what they found:
- Only 29% of people with schizophrenia were offered a comprehensive physical health check
- While clinical staff reported that they thought they had involved service users in the choice of medication in 62% of cases, only 41% of service users felt their views were taken into account
- Only 38% of people found it easy to understand the information they were given about their prescribed medications and treatment
- Appropriate treatment guidelines were followed for most patients, but 43% of treatment resistant patients had not been offered clozapine and had no documented reason for this
- 16% of patients were being prescribed >1 antipsychotic drug at a time. This is only recommended in exceptional situations
- 5% of patients were also prescribed medication in higher doses than recommended in the BNF, without clear documentation of the reasons
The report makes the following recommendations:
Experiences of people using services and experiences of carers
- Mental Health Trusts and Health Boards should involve local people who use services and carers in developing a local action plan for improving care and support offered
- For the next audit the minimum requirements for experiences and outcomes should be raised so that services continue improving
Shared decision making
- Health professionals should review the written information they provide to people affected by schizophrenia, and their carers, about medication and check that it is clear and easy to understand
- Professionals who prescribe medication should have the appropriate skills to involve service users in decisions about medication. This should include the ability to talk about the benefits and risks associated with treatment
- Psychiatrists must recognise that antipsychotic polypharmacy is only rarely appropriate and if used requires clear documentation of the reasons
- Psychiatrists should be aware of the upper dose limits for prescribing antipsychotic medication. If they prescribe above this level they should have a clear and documented reason for doing so
- Trusts/Health Boards should make sure that health professionals understand the guidelines for the prescribing of antipsychotic medications and guidelines for prescribing outside the usual licensed indications
- Trained clinical pharmacists should be available to offer advice on prescribing to other professionals
- Providers and commissioners of mental health services must ensure that there is good access to psychological therapies for people with schizophrenia, particularly cognitive behavioural therapy, family therapy and other evidence-based treatments
- Trusts/Health Boards should identify and address the barriers they face in offering and delivering these therapies
Management of physical health issues
- All health professionals working with people affected by schizophrenia should have training on common physical health problems experienced by this group. This includes how to assess physical health and identify any problems, and knowledge of interventions for treating these problems
- Mental health services should have access to the correct equipment to monitor a person’s physical health. If treatment is needed for physical health problems, staff in mental health services should help to ensure that people receive this
- Mental health services and primary care services need to work together to agree who will monitor and treat physical health problems among people with schizophrenia
Report of the National Audit of Schizophrenia 2012 (PDF). Royal College of Psychiatrists, December 2012.
Executive Summary: Report of the National Audit of Schizophrenia 2012 (PDF). Royal College of Psychiatrists, December 2012.
National Audit of Schizophrenia: What you need to know (PDF). Rethink Mental Illness, December 2012.