Wendy Ackroyd is the lead pharmacist at the mental health directorate in NHS Dumfries and Galloway. We were delighted to welcome her to share her experiences working as a pharmacist working in the area of mental health.
Why did you become a pharmacist?
The brutally honest truth?
I’m a failed medic, kind of.
I was about 4 years old when I decided I wanted to be a doctor. No one in my family had ever been to university so this was quite the ambition. My parents always encouraged me to believe in myself. So that’s what I was going to do, and I worked hard.
Having always been studious and quite well behaved I became a teenager all of a sudden at about age 16. I got a part-time job and a boyfriend. At that time I took my eye off the goal. I messed up my A levels and withdrew from PCAS in a fit of a teenage strop after a fall out with my parents. My school careers advisors didn’t even know what Pharmacy was. I didn’t know what to do and just gave up a bit. I was just going to get a job.
My form teacher suggested I applied to a pharmacy for a job to stay in a “medical like” field instead. And I did. The local Boots was looking for a trainee dispenser. I passed my Society of Apothecary’s dispensing technician course, and loved training counter assistants and talking to patients. I was told by many pharmacists I worked with that I could easily manage a pharmacy course. And by this time I had a better idea of what it was, so I applied. Most universities wouldn’t touch me with my A level results, but Sunderland took my dispensing qualification into account and gave me a chance.
I loved it.
Could you describe your career pathway so far?
In short falling in at the deep end. Thankfully I can swim. My first manager was a dispenser not a pharmacist, pretty much the only one in Boots back then. I was the only full-timer in the pharmacy department three months into my dispensing training, so was effectively running the department at that point.
My first job once qualified as a pharmacist was in a very busy Boots store in Cleveleys. My technician left a week after I started (not my fault). We did about 450 items a day.
I did relief management in the Lakes region of Boots for a couple of years after that and, frankly, I love patients. I have all the time in the world for them. I don’t like customers much. The shopkeeping part just wasn’t for me and I craved a clinical role. So I took a huge pay cut and a B grade job in Westcumberland Hospital with a 1 in 3 on-call from where I lived – 45 miles away – to get some hospital experience. I loved the hospital role but I couldn’t afford to stay at a B grade for more than a year. It was an £8k difference in salary back then 20 years ago.
So I asked about locally (within 60 miles) to see what was available. I was invited to “come for a chat” at Dumfries hospital pharmacy department. I had said chat with Mike Pratt and was then offered a job, temporary D grade in mental health. Their usual guy was in New Zealand on sabbatical. HR was not quite as involved in recruitment back then. I thought “why not?” and took it.
He saw me coming, or he saw potential, who knows? I had never heard of the Crichton Royal Hospital and it wasn’t mentioned at all in our “chat”. Westcumberland mental health wards were in the infirmary itself. I thought that’s how it worked everywhere. So was somewhat surprised to be handed a passkey and told to go look after “The Crichton”. No induction. No mental health background. And this was a victorian psychiatric hospital with 11 wards left in it, mid-transformation, in a different Trust and nobody could tell me what I was actually supposed to do. I was the only pharmacist for mental health of any kind in the entire region. It was a steep learning curve.
I had a six-month temporary contract. That was in January 2000. I loved it. I still do.
Don’t get me wrong it has almost broken me once or twice. But I love working in mental health. I love the challenge and the patients I work with and I am happy, even proud, to be a voice for what is still a Cinderella service, although it’s improved a lot in 20 years. We now have 2 pharmacists and recently added a part-time addictions post; I am expending our empire bit by bit.
You have an interest in mental health pharmacy. Why?
It’s more than an interest, it’s a passion. What is more fascinating than the mind? How fragile it can be in some, and yet how robust in others. We can all break mentally under the right, or wrong, circumstances. One in three could be affected in their lifetime. And yet it’s poorly studied, funded and supported. I’ve always been a sucker for the underdog. Mental health and wellbeing are multifactorial, it’s hard to measure, and treatments are complex and evidence isn’t always especially robust. Pharmacists are often quite black and white. We like details and guidelines and protocols. It’s about how we’re trained.
In my spare time, I’m an amateur artist, I think that creativity spills into my work. Once the evidence runs out the question remains “what can we do for people that makes some sense to try – and how can we keep them safe at the same time?” It’s all about the person and their story at the centre of it all.
Every day is different. There are puzzles to solve and problems to fix. It is endlessly fascinating and challenging at the same time. It’s a huge jigsaw puzzle with medication forming a teeny tiny part of all that, but an important piece, and a potentially toxic one if you mess it up. Medicines can’t fix everything but they can have a huge impact on someone’s ability to cope with life.
Have you completed any additional qualifications in the area of mental health?
My postgraduate education route was a bit messy. I was in the first cohort of community pharmacists offered the postgraduate certificate in community clinical pharmacy. I then changed to a hospital diploma and overlapped that with the Aston certificate in psychiatric therapeutics, before finishing my MSc in clinical pharmacy. I did a study on satisfaction with medicines information in mental health. I’m a pharmacist independent prescriber too, but used CVD and diabetes as mental health wasn’t offered at Strathclyde.
My development was very much shaped by the College of Mental Health Pharmacy (CHMP). Their email group for answering questions and absorbing discussions and the conference was a great opportunity for learning. It was a lifeline for someone like me early on with no mental health background, and working in an isolated position. I even did a stint on Council and as Secretary for CMHP a wee while back. We have a group Scottish Pharmacists in Mental Health, for educational activities too, and did my part on the committee for that a few years back too.
Could you describe a typical working day for you?
Not really, no. No such thing. And honestly, I like it that way. There are elements of the week that happens, like ward rounds, and my dispensary duty, but each day is so varied. I’m pharmacy lead for mental health directorate which also includes psychology, substance misuse, and the local prison. This is quite a remit. We have an 80 bedded hospital, 4 CMHNTs and geography of 150 miles by about 60 miles for a population of 150k.
I’ll give you an idea with what’s on my desk just now:
- This week I’ve been involved in my very first interviewing for the addictions pharmacist. That was exciting but quite stressful.
- I’m trying to set up a mental health prescribing subgroup (again) as our new Director of Pharmacy is bringing things up to date.
- Our national contract for Clozapine has changed and I managed the switch for that. I had some paperwork to organise to ensure all teams know what’s going on.
- I’ve answered a variety of clinical questions today on treatment options for a few outpatients and in the infirmary.
- I’ve had dispensary duty in the infirmary this morning for a couple of hours.
- I’ve had an email discussion about managing pharmacist independent prescribers in substance misuse and the appropriate way to direct funding for the medicines prescribed that service.
- I’m considering how we might introduce esketamine if and when it gets its licence.
- I have ADTC this week and have papers to go through for that. Our ADTC is regional so it’s not just mental health. I also sit on our exceptional prescribing panel.
- I had to find info on haloperidol drops to liquid/tablet conversion for someone just here from Poland.
- I’m involved in the, almost completed, review of our alcohol detoxification pathway to ensure it goes through the various governance hoops to go forward for approval.
- I’m trying to figure out how to improve mental health knowledge and confidence in talking to people with mental health problems for the new general practice clinical pharmacists (GPCP). Thinking also how that fits with our new GP based psychiatric nurses and how we get them all working together.
- I’m looking at developing or buying in some joint training but as a first step I want some “talking about suicidal thoughts” input for the GPCPs so I had a meeting about getting that going.
- I need to arrange a 1:1 and review with my junior pharmacist. She’s on holiday just now so I’ve also been clinically checking pass prescriptions.
Are you a member of any professional bodies? Which ones and why are you a member?
I am a supporter and member of Royal Pharmaceutical Society (RPS). I think they do a lot of great work to support pharmacy as a profession and get us seats at tables we wouldn’t always be on. I am an associate member of College of Mental Health Pharmacy. My performance and development plan this year includes credentialing and accreditation for next year. To be honest it’s about time I got on with it. I’m a member because of the education and support they offer in my specialist field. Once I was a newbie needing support and advice, now I have the opportunity to give some of that back at times.
What is credentialing and why does it matter?
Credentialing is about proving you are working at a certain level. The RPS offers to credential at different levels of practice in general. CMHP offers advanced level but just in mental health. To complete CMHP accreditation is to show I’m a specialist in my field. I’ve considered both RPS and CMHP. I am a staunch supporter of CMHP and I feel it fits me best, and my Director of Pharmacy is in agreement.
I guess we all have that feeling that we’re going to be “found out”, maybe we’re not that great after all – “Imposter Syndrome” it’s been described as. In many ways, I don’t need to prove to my colleagues that I’m good at what I do. They already appreciate what I bring to the table. For me, it’s about proving it to me, about challenging myself and a little bit of masochism perhaps. If I’m honest I’m apprehensive about it but it’s the same for everyone I’m told. It’s also a huge CPD opportunity. If I do find out that I need to improve it’s a way of identifying that. That can only be good for the patients I care for because if I need to do better I will because I owe them that.
Everyone’s reasons for credentialing may be different. Maybe it’s about getting a specific job. Maybe it’s about challenging yourself. Maybe it’s about learning and reflection. You reflect and decide what it is to you.
What are the big issues that concern you at the moment in mental health pharmacy?
There isn’t enough of me to do everything, that’s always been an issue. I need to find creative ways to support and develop mental health knowledge and confidence in managing mental health conditions in a wider audience of pharmacists. Primary care, addictions and acute liaison are areas I’d like to target. We’re making progress bit by bit. I like the jigsaw analogy. I need more pieces of the jigsaw fitted together. A small health board has many challenges but working together creatively is something our pharmacy team is especially good at doing.
The government document Achieving Excellence in Pharmaceutical Care gives us a direction to work towards. Although it doesn’t specifically mention mental health it is entirely applicable to anyone with mental or physical health needs.
Stigma is still a problem. And I feel we could do more to protect the mental health and wellbeing of those that work in healthcare. Austerity and staff cuts take their toll on those of us working in the system and we need to be mindful of that.
What are the risks of pharmacists taking on more responsibility in the area of mental health pharmacy?
I don’t think the risks are greater for mental health necessarily than for any other area of health. Our role is expanding, possibly down to fewer doctors qualifying creating gaps.
We need good governance, across the board to ensure we work appropriately and within our competence. We also need appropriate multidisciplinary skill mix so we have the right people working where their skills and knowledge best meets the needs of our patients. We need to ensure we don’t just absorb the work of other staff groups to stick a plaster over a gaping wound. It is important that we put things in place to improve services for patients and manage risks without losing what makes us unique, our expertise in medicines.
We need to look at risk differently and some of that is down to how our governing body behaves. Doctors accept risk in what they do, pharmacists try to avoid it. But of the two we’re the only ones who can go to jail for making a genuine mistake. If we want pharmacists to work in broader roles and the risks that come with that, we need to fix that disparity.
I think we need to stop thinking of mental health as a separate being and think holistically, and think broader than medicines. Mental and physical health and wellbeing are broader than drugs. It’s also about diet, exercise, smoking, stress, meaningful activity and our social circumstances. Loneliness, family support and many, many other things. Pharmacists have a talent for being able to see the whole individual with regards their treatments, but we need to look broader than the medication.
I went to a public health event a year or so ago when they told us. Mental health patients die on average 20 years sooner than the general population. Like that’s a new thing. That’s not news; I knew two decades ago. What is sad is that the wider audience were surprised by that and that in two decades we haven’t affected it. This is what holistic, patient centred care is about. Not silo-based care fixed around a service or profession but looking at all the needs of the individual and how best to meet them in a way that fits that person.
Are there any particular traits or skills that pharmacists who specialise in mental health need?
Be compassionate, non-judgemental but boundaried. Negotiate and educate, don’t dictate. See the whole person and their lifestyle and how that impacts on them. Listen. Be open-minded. Be aware of and educate yourself on the illnesses and the treatments. Motivational interviewing techniques wouldn’t go amiss. Be creative if necessary. People don’t always fit in boxes, neither does how they manage.
And be aware of your own triggers. Many pharmacists will also have mental health difficulties. Look after yourself too. I’m not sure any of these are specific to mental health though.
What contribution to caring for people with mental health issues would you expect from a community pharmacist?
The same as they’d have in caring for anyone else. Community pharmacists are the most involved in anyone with a medium or long term condition. They see them more often than a psychiatrist anyway. Ask people how they’re getting on and listen. Be able to give advice on what to do about side effects, or if someone wants to come off their treatment help them weigh the pros and cons. Know where other services are if you need to signpost. Know how to contact someone if you have concerns.
Do you think suicide prevention techniques should be taught to community pharmacists?
Absolutely. And everyone else. Just like we should all learn CPR. In some ways working in mental health is about having confidence and compassion, to want to have difficult conversations and know how to deal with them.
It is not someone with a mental health problem in front of us. It’s a person.
People get thoughts of suicide. They don’t need a mental health diagnosis for that. Asking someone if they have those thoughts does not make them more likely to die by suicide. People have them or not. You can’t make someone suicidal by asking them about their thoughts. But you need to have some idea how to respond appropriately if they say they do. Asking and responding to the situation could give that person the pause that changes their mind.
What has been your proudest moment so far as a pharmacist?
I was walking my dog a couple of years back and I bumped into another dog walker and got chatting, as you do. He said he expected I didn’t recognise him (and I didn’t) but he’d been at a meeting I was at when his daughter was an inpatient in our mental health hospital.
He said I’d said something to her that had really helped her and it made a huge difference to how she felt. I’d helped her understand what the medicines could do for her but also was honest about what they couldn’t do, and as a consequence, she decided to start taking them and they made a huge difference to her. At the time of this conversation with her Dad, she was well and planning her wedding.
We all have days when we wonder if we really achieve anything, but knowing I made a difference to that one person makes it all worth it. We don’t often set the world on fire as pharmacists, and may not always see the impact we have but something small, said with honesty, compassion and confidence can make a huge difference to that one person.
As a profession how should we reward pharmacists for outstanding practice?
I know a lot of pharmacists who like gin. Perhaps not in keeping with health lifestyle advice though. I don’t know, we’re awful as a profession for blowing our trumpets. I think that harkens back to what I’ve said before. A mix of imposter syndrome and not recognising the impact we can make. Most of us don’t do it for rewards or recognition. Acknowledgement at least challenges us to feel better on the days we wonder what we do it for, and boosts us to keep doing better. It makes us feel like we matter.
Are you optimistic about the future of pharmacy in the UK?
Yes, absolutely, we’re taking over the world. Pharmacists have lots of skills and we are adept at finding solutions to gaps in services, to adapting to different environments and bringing something unique and meaningful.
What’s next for you?
Short term – I’ve been writing this for ages. I think I’ll eat, take a walk, maybe do some painting; that’s how I look after my mental health and wellbeing. I’m trying to develop my oil painting skills.
Professionally – CMHP accreditation next year (eek!) and then probably some leadership stuff after that. We’re working as a team on how we can meet Achieving Excellence in Dumfries and Galloway. I’ve got a new addictions pharmacist starting soon to get up and running. I’d like to see if we can develop a liaison psychiatry pharmacist role here. Developing primary care skills, knowledge and confidence in mental health management is on my list too.
Longer-term I’ve got a yearning for a role in patient advocacy, perhaps in the Mental Welfare Commission. They don’t currently employ a mental health pharmacist, but I think they should.
What advice would you give to pharmacists who wish to pursue a career in mental health pharmacy?
All pharmacy involves mental health pharmacy, but if you want to specialise or just want a taste of what specialist mental health is, speak to your local specialist pharmacist, join CMHP, and get on with it. I love it.