The Commission -- a healthcare system watchdog group -- recommended that pharmacists become more involved in mental health patient care, and management improve its treatment of patients, calling its findings "concerning."
"Managing medicines safely, effectively and efficiently is central to the delivery of high quality care that is focused on the patient and gives value for money," said Healthcare Commission CEO Anna Walker.
Walker appealed to primary care trusts and mental health trusts (public-run health facilities) to re-examine their management of patient medications. Mental health patients in trusts also told the Commission they were not involved in their own medication decisions as much as they would like, Walker said.
"This needs to be addressed if trusts expect service users to take their medicines as prescribed," she said.
The Commission's report found that when pharmacists reviewed patients' medications, 70 percent of cases resulted in a change in the patient's medication, while 46 percent of patients whose medication was reviewed were found to be taking their doses improperly.
The report also found that while 14 percent of patients in acute trusts were not visited by pharmacy staff members, 24 percent of mental health trust patients received no visits. In addition, 64 percent of acute trust patients visited with pharmacy workers more than five hours per week, compared to 14 percent of mental health trust patients.
Professor Louis Appleby, National Clinical Director for Mental Health, said safe and effective medicine management is vital to proper mental health patient care.
"This report will help services address a very important issue and ensure that patients are fully involved in decisions about -- and get the most from -- their medicines," he said. "We are not complacent and more work is needed to ensure that all Trusts reach the standards of the best."