The starting point for the development of a human-rights based approach to medication use in people with intellectual disability and behaviour disorders is that people with intellectual disability and behaviour disorders are full human beings who are entitled to rights (Flood, 2013b). Considering mental health in terms of human rights would call for changes in the medication use process that go beyond quality of care to include both legal and services reforms for the population with intellectual disability and behaviour disorders.
People with mental illness are not always in a position to assert their rights. Amnesty International urges the Irish government to acknowledge and respect the right of all people with mental illness to the best available mental health care (Amnesty
International, 2003). There are however very few, if any, measures of mental health or well being in the population with intellectual disabilities. Pharmacists can help improve the physical and mental health of this vulnerable patient group and support them to take their medicines (Flood, 2013b).
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1.5.4 Pharmacy
Pharmacy in many ways has become an isolated profession. However its ability to break out of this isolation will largely determine the success or otherwise of its public health role in the future (Anderson, 2007).
Pharmacists should have and should also look for a role in the care of vulnerable people with intellectual disabilities. It has been suggested that they should challenge themselves to develop and implement realistic health plans to reduce health
inequalities in people with intellectual disabilities. The involvement of pharmacists is key, as medicine use is a major therapeutic intervention in this population. Some opportunities for pharmacists to help improve the quality of the medication use process have been identified (Flood, 2013c):
• Providing medicines in a form suitable for patients with dysphagia.
• Ensuring that carers are confident in using any prescribed epilepsy rescue
medicines.
• Providing accessible medicines information for patients or their carers.
• Monitoring for changes in body mass index if antipsychotic medicines are being
taken.
• Ensuring that patients on antiepileptic medicines have their bone mineral
density monitored.
• Ensuring the effectiveness of any prescribed and “over the counter” medicine. • Monitoring for side effects of psychotropic medication, the misinterpretation of
which can, in turn, lead to increases in the use of psychotropic medicines. Many people with intellectual disabilities and high support needs live in residential centres in Ireland. However, patients in these centres rarely have access to full time pharmaceutical care and do not currently use pharmacists to a substantial degree or at all. This is in part the result of current financial models for payment in Ireland which do not make it easy for providers to justify employing pharmacists in residential care settings for people ageing with intellectual disability. To establish the value that pharmacists can bring to the care of people with intellectual disabilities, information on service provision will be required. Following the publication of the first IDS-TILDA Report, contact was made with the lead author on the report and a suggestion made that the Wave 2 questionaire include a question about pharmacy. Consequently, the
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Wave 2 Report of IDS-TILDA contained a question about pharmacy, and replies indicated that pharmacy services were one of the top four health and social care services used by respondents (McCarron et al., 2014a). The others were chiropody, residential and day services. General Medical Practitioner (GP) visits, however, were recorded for more than 90% of the respondents. It would be expected that the vast majority of GP visits by people with intellectual disabilities result in the prescribing of medication. This may throw some doubt on the accuracy of self-reported use of pharmacy service by just 58% of the respondents. It may also indicate that people with intellectual disabilities living in residential care did not have access to a pharmacist. A number of other multi-disciplinary professionals and allied health professionals justifiably feel that they are playing important roles in the care of people ageing with intellectual disability, such as nurses, social workers, psychologists, care coordinators, dietitians, speech and language therapists and others. These groups will be competing for scarce resources in the care of people ageing with intellectual disability.
Pharmacists must get involved to justify their role in the care of vulnerable populations and should aggressively promote research in this area. A former Irish Ombudsman, Emily O Reilly has suggested that
‘We all have to prove that the outcomes we achieve justify our existence and we all have a duty to make the public aware of what our contribution is’ (O Reilly, 2009a).
The NIDD, mentioned previously, has been silent in relation to the need for
pharmaceutical care for the vulnerable population with intellectual disability in Ireland (Flood and Henman, 2010).
In England, The Spread Programme was designed to engage a number of service providers across England in testing, developing and implementing new, changed or extended ways of working in mental health pharmacy that deliver impacts on
components of medicines management (Branford, 2007). Some key points identified following the Spread Programme were that although significant changes to roles within pharmacy can achieve some improved services to service users, major changes are dependent on the capacity of a pharmacy workforce. The Spread Programme demonstrated a wide range of potential impacts on service user care and treatment that can be achieved by the various grades of pharmacy staff and recommended that most Mental Health Trusts (MHTs) need to develop a pharmacy strategy with a clear developmental programme that ensures increased staffing and service provision over a
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3 - 5 year period. In England, a work force survey identified that for most MHTs, the pharmacy workforce is too small to provide effective medicines-related services to service users with mental health and intellectual disabilities (Taylor and Sutton, 2006) with subsequent clinical governance issues (Taylor and Sutton, 2009). This situation is likely to be replicated in the Republic of Ireland.
The Irish Mental Health Policy, A Vision for Change (DOH&C, 2006), identifies the mental health professionals who should comprise the core multidisciplinary team to deliver mental health services to adults with intellectual disability and a mental health problem and/or challenging behaviour: one consultant psychiatrist, one doctor in training, two psychologists, two clinical nurse specialists (CNS) and registered nurses with specialist training, two social workers, one occupational therapist and
administration support staff.
The policy does suggest that other mental health professionals and health
professionals such as creative therapists, speech and language therapists should be brought in as required to address other needs. However that need for a pharmacist in a population group where medication use is the main therapeutic intervention is not recognized. This situation was also replicated in a recent draft document, National Clinical Programme for Older People Specialist Geriatric Services Model of Care Part 3: Mental Health Service Provision, that was open for public consultation.