Service type: Inhaler technique
Name of pharmacy: Manor Pharmacy Group, Hertfordshire
Name of pharmacist: Graham Phillips
How long have you been offering this service?
It was an area of specialist interest for us about 10 years ago, so we’ve been doing this for at least 10, if not 15, years.
Why did you start offering the service?
I think partly because at the time — and this will have been overwhelmed by diabetes now — the increase in asthma was unbelievable. It was going up, and up. Also, the figures were around 2,000 annual deaths for asthma, of which I think 80 per cent were believed to be preventable. So, people were dying needlessly, and offering this service is a low-tech intervention. You don’t need very sophisticated equipment to do a global assessment of asthma, then make an intervention and reassess.
How much did it cost to set up the service?
The cost was our time really; we didn’t need to invest. It’s a cheap service to provide, but the consequences in lives saved are enormous.
What training did you or other team members have to undergo?
We all read the Royal College of GPs’ materials on the Global Assessment of Asthma Control. We also looked at the National Review of Asthma Deaths — it’s long out of date now but the principles are still true. It was a brilliant document, looking at the number of asthma deaths per year and the number of those deaths that should have been prevented. We used the CPPE information too, which is very good.
In a nutshell, what does the service involve?
In normal circumstances, we would offer the patient a structured medicines use review, specifically aimed at the respiratory function –knowing from their patient medication record that they are likely asthmatic or bronchitic, or clearly have respiratory issues. We would print out their medication record, and do the medicines use review.
In the consultation, we would discuss their ongoing medication and their understanding of the reasons for each of the medicines they have been prescribed. We would then ask them about their symptoms and how well controlled their condition is. We would ask about both symptoms and side effects, so are they getting thrush, for example, are they getting wheezy, and how often are they using their rescue inhaler.
We would basically target people who were using their rescue therapy (overuse of blue inhaler) a lot, but not very consistently collecting their preventative therapy (underuse of brown inhaler). We would then assess their understanding of how to use the inhaler and their ability to do so.
It may well be that all the patient needs is to understand the right technique to use their inhalers, which order to use them, how frequently to use them, and whether they have been given a management plan. Every asthmatic should have a management plan. They should also know what to look for too. For example, have they been given a peak flow meter, are they using it, and do they know what to look for? Have they been given a spacer inhaler and if yes, are they using it? If they haven’t been given one, then they should be. A lot of people have them but don’t use them, because they don’t understand the benefit.
We go through all of this, get the patient to show us the inhaler technique they use, and then try and give them some coaching. I’m a huge fan of the In-Check DIAL device, which is very good at assessing what would be the most appropriate form of inhaler for any one individual.
If, following the consultation, we think the patient may need different medication, we will contact their GP, sharing our observations, and the changes that they might want to consider.
Are there any opportunities to sell over the counter or prescription products during the consultation or after it?
So much asthma is related to nutritional status, but I’m not really trying to sell things. We would offer advice on nutritional status and conceivably supplementation, but in most cases they just need to get their diet right. We should be focusing on their diet, not focusing on selling them vitamins that they may not need.
How have patients responded to the service?
What’s interesting is the level of satisfaction. When we do our annual survey, we are regularly getting 98-100% satisfaction. I’ve just never had a patient be dissatisfied with a pharmacy service. They love it.
Once patients understand it [inhaler technique], it can be quite transformational, and they come back to thank you. I normally say to patients do come back and tell me how you get on — and then a month later they come back. You can’t always remember the conversation, but they queue for 20 minutes, just to tell you how much better things are.
How often each month do you carry out the service?
In normal circumstances, we carry this out at least daily.
How much do you charge for the service?
It’s free to patients.
Roughly, how much a month do you make from offering the service?
If you’re doing medicines use reviews or a new medicines service then you will get the appropriate fees, which are slightly less than £30. But if you compare it [this service] with the cost of running a pharmacy, it’s minimal. Is it going to keep the pharmacy open? Absolutely not.
Would you recommend offering this service to other contractors?
Absolutely. It’s fundamental — it’s such an easy service for a pharmacy to provide and it’s such a beneficial service for a patient to receive.
This service is nationally commissioned, but what could be commissioned is a much more enhanced service. What I would like to see is level three medicines use reviews, proper clinical reviews, independent prescribing — you could have a brilliant enhanced service.
I was recently talking to a pharmacist recovering from Covid-19 — he’s asthmatic and diabetic and it nearly killed him. He said to me that any community pharmacist who is also an independent prescriber could have dealt with him and staved the need to call an ambulance. He possibly needed some antibiotics; he needed global assessment; he needed an increased use of his inhaler; and some steroids.
In the current climate, almost any competent pharmacist could have done that if it was a national service. We could be saving lives on the frontline today if the NHS would commission us to do stuff like that. It doesn’t require that much training to get to that point — but of course the NHS only wants to close pharmacies, it’s not interested in sustaining us.
Is there any way pharmacies can use the clinical services they already have to support people affected by the Covid-19 outbreak?
If we were given the support, time and resources we could absolutely do that. But the NHS is providing us with absolutely nothing, so it’s not going to happen. We’ve got all these people coming in — they come in for a salbutamol inhaler, some amoxicillin and some sort of brown inhaler. That assessment has been done on the phone; we could do that.