Name of pharmacy: Cadham Pharmacy, Glenrothes, Scotland.
Name of pharmacist: Bernadette Brown.
Why did you start offering the service?
I’ve been offering the service since I opened up Cadham Pharmacy seven years ago, but I have been really specialising in respiratory for the past five years.
I believed that there was a real need for the service, and that another clinician with a pharmacy background could offer a different perspective to the current asthma offering that is available in primary care.
I got the idea because I was seeing prescriptions coming through for lots of salbutamol inhalers and these people weren’t getting a review at that point. I’d also joined the Primary Care Respiratory Society, and that was brilliant because I was mixing in with doctors and nurses once a year at the annual conference. It gave me a feeling that pharmacists really do have a pivotal role to play, and it was important for me to find out how I could support respiratory patients, both with COPD and asthma, from my pharmacy.
I also already had the skillset from working in a GP practice previously, and working with nursing staff. I saw this massive opportunity to find the missing people who weren’t turning up for asthma reviews, but who were re-ordering lots of salbutamol inhalers.
How much did it cost to set up the service?
I bought a FeNO machine, which measures exhaled nitric oxide – and that alone cost £3,500, which was a massive investment back then. On top of that, I’d just put in a beautiful treatment room for clinical services generally, and that cost about £5,000.
The cost of a stethoscope was at least another couple of hundred pounds, because I bought a really good one. Listening to people’s chests is another big part of an asthma review; it isn’t just about inhaler technique. People come in with oxygen stats that aren’t brilliant, and you want to be able to rule out a chest infection, so I skilled up for that too.
There were additional costs for training and an investment in time. I spent time out of hours shadowing doctors and nurses – probably about 20 sessions – to help me develop the skills to run a robust respiratory service.
What, if any, training did you or other team members have to undergo?
I became an independent prescriber in 2009. This was prior to opening up the asthma clinic, but I wanted to invest in myself because I saw the value of being able to do a one-stop experience for the public.
Imagine you are an asthmatic and you are coming in to see me in my clinic. It helps if I have the ability to work with the GPs and support them to change your inhaler. Initially, I would just do a recommendation, but over the years I’ve built up an arrangement with some of my practices where they allow me to switch the inhaler when I’ve got the patient in front of me. It is a better experience for the patient if I can identify that they aren’t using their inhaler correctly or that they need a switch-up in their medications, and I am able to show them that device; check they are able to use it, and then they walk out with a device that I believe they are going to benefit from.
In terms of other training, I started an asthma diploma, and studied quite a few modules, but didn’t actually end up finishing it. What I ended up doing instead was attending a lot of evening courses with prominent professors, and I would travel to many of those to receive lectures and get my education on respiratory. I found this very helpful because it fitted in with my family life. Over a period of years, I would also shadow asthma clinics run by nursing staff, which I really enjoyed and learned a lot from. So, a lot of my training ended up being experiential learning, on top of my own degree and the independent prescribing work that I’d done. It’s about building up a competency. To run an asthma clinic from a community pharmacy, when we are already pharmacists, means that I just needed to really skill up.
A lot of the learning was through the Primary Care Respiratory Society, going to their leaders’ courses and annual conferences. The amount of education provided at those conferences is just phenomenal – you are among leading consultants who are running asthma clinics in secondary care across the globe. When you are in amongst esteemed colleagues – pharmacists, doctors and nurses – who all have the same goal to save lives in asthma and COPD, then it’s amazing how your skillset can improve.
In a nutshell, what does the service involve?
Patients can book online for the service and through our Healthera app.
A big part of what I do is to get to know the patient as an asthmatic – how do they manage their own asthma; what do they think about their asthma diagnosis, and do they believe in it. What I mean by that is do they believe that they’ve got this diagnosis, and if they do, how do they manage it – so it’s very much about the patient telling me about that. That is a big question, and you won’t always get that when you go to a primary care consultation.
A typical response that I get from young adults is: ‘yes I have asthma; it’s pretty mild, and I’ve got it well under control. I use my blue inhaler and I don’t bother with that other one [the preventer inhaler] because I’m okay, and the only time I really get into trouble is when I’ve got a cold or sometimes it might be hay-fever. Then I get a chest infection and need some steroids, but after that I’m fine again.’ I can’t even tell you how many times I’ve heard that story, and it is a typical story seen in the National Review of Asthma Deaths.
From having these discussions, I get a feel for what the patient believes their asthma control is and how they are managing it themselves. At this point I’m not about to judge anybody, I am just there as someone to try and help them understand a bit more about how asthma works, how their body works with asthma, and then I try and use it as a kind of education piece. Once I’ve got a feel for their asthma control and inhaler use, I will offer them a FeNO test, along with a peak flow and an asthma control test (ACT).
A big part of my clinic is knowing your asthma numbers and the FeNO test is pivotal to that, because people can already get their peak flow and ACT scores with their GP. But I’ve learned over the years that a peak flow reading in a very fit adult male doesn’t always tell you that they have poor asthma control. So, while I don’t add it in all the time, if I’ve got a patient over-relying on their salbutamol inhaler then I will always offer them a FeNO test.
We will come up with a care plan, and I would hopefully send any patient away with a real feeling of how well they are doing themselves, giving them the toolkit, skills and experience to change up their asthma control and get themselves to a much safer place with this disease. If I need to change their medication, and it’s a practice where I can change the prescribing, then I will do that there and then. I formally write to the patient’s GP afterwards, with full details of the consultation, my findings, and my recommendations.
The patient is invited for a follow-up and I make a conscious effort to send them a reminder through my PMR system. It’s all about empowering the patients, but at the same time reminding them and making sure I follow them up. When patients come back for a follow-up and see their readings come down, it gives them a sense of hope. It encourages them to follow the care plan; get into new habits and into new ways of thinking about their asthma.
There are some case studies of people I’ve helped on my website. We won the Scottish Pharmacy Awards Respiratory Award in 2018 and the Corporate Livewire NHS Asthma Clinic of the Year (UK) Award in 2019.
Are there any opportunities to sell over the counter or prescription products during the consultation or after it?
In Scotland we’ve got a brilliant minor ailments service, so if somebody does need an antihistamine, we send them out with an NHS prescription for that.
But, if I wasn’t based in Scotland and someone has allergic-type asthma, then as a duty of care I would absolutely be making sure that we are sending them out not with a sale of something, but with a medicine that they need. It’s probably cheaper for them to purchase that in England than go to the doctor and get a prescription. For example, you’re doing an amazing service if you are able to offer them a nasal spray that they can purchase. If the medication is required for their particular type of asthma and it’s available as an OTC product, then that’s a way you can support asthmatics to self-treat.
How have patients responded to the service?
In general, the feedback is unbelievable in terms of patents feeling more safe about controlling their own asthma and feeling more in control of their own health as a result of attending our clinics. They are pleased with the professional service and the standard of care they receive. We are able to teach them life skills, as well as what the disease is and how the medicines that they are using impact on that disease. If you give people the right education and tools, and provide a motivational way of them controlling their own disease, then they are empowered to change their habits.
Roughly, how often each month do you carry out the service?
In normal circumstances, I see a lot of asthma patients because I am identifying them through their prescriptions, or they are booking online with me for the clinic. So, I would see patients every day for this service, but not all of them necessarily need the same level of support. If a patient has someone taking an interest in how often they are using their blue inhaler, then hopefully that makes them feel that we care enough to spend a little bit of time with them. Out of that we might find that they just aren’t using their inhaler correctly, or maybe they do need a review and some further investigations, in which case I would be offering them the FeNO test.
How much do you charge for the service?
The service is free of charge. The FeNO test does cost me money every time I do it, probably around £5, so it’s not a huge amount. You may ask why I am not charging privately for this, but when someone comes into my clinic I want them to have an experience that says ‘this is an NHS clinic’. In Scotland, you don’t charged if you go to a nurse or for any testing in primary care. So I took a big decision early on that, for the sake of a fiver and the cost of the machine (which gives me the tools I need to help patients see how bad their asthma is), I didn’t want to charge for it. For me it was about – ‘if you come to me, I am going to help you for free’ and in return I guess I get the loyalty of that family, and their wider family and friends. There is no price that you can put on that: it is a small fee to me and a massive impact on their lives. In the end, it saves the NHS money, because patients are no longer ordering salbutamol inhalers all the time.
Other pharmacists might want to charge for the FeNO test, in which case that might be something they can do and still cover their costs.
Roughly, how much a month do you make from offering the service?
We’ve got busier and our business has grown, and it’s not just one clinic in isolation [that’s achieved that]. I think it is overall patient experience and that we are willing to offer professional services that really cater for their needs. It’s person-centred so you get to know the patient, their families, and they get to trust you. Like their family GP, I’m their family pharmacist and therefore when their asthma is out of whack, they’ve got a chest infection, and for all minor illness they come to me first.
After the asthma clinic, I set up a service level agreement in my town and I was the first one to have seven GP practices approve my clinic for acute care. So, the asthma clinic led to an acute care clinic, which meant that I could see a patient for their asthma, but also when they were unwell with a chest infection. I could treat them for that, and they could walk out of the pharmacy knowing got their asthma and chest infection under control that bit quicker. That service level agreement means I can look after 50,000 people in my town whenever they have an acute asthma exacerbation, or indeed quite a few other things – throat infections, tonsillitis, shingles. That all came off the back of the asthma clinic, building up the skills and the relationships with GPs, nurses, and the public.
Would you recommend offering this service to other contractors?
From a professional standpoint, I think we should all be doing it. I think if every community pharmacy took up the asthma cause, we could save thousands of lives and avoid unnecessary, preventative deaths, and that is my mission in life. I want to encourage anybody to take this up as a cause and not to see it as something they need funding for before doing it.
Obviously, in an ideal world, we would all be funded for everything that we do, and you don’t have to go the level of a FeNO machine, though I have personally found that to be an absolute godsend. But even if we could find one person at a time to talk to about inhaler technique, and just take 10 minutes, it would make a difference.
It has been difficult with Covid, because we are all a bit scared about bringing people into the pharmacy. But as we come out of lockdown and get our PPE in place, then I think it would be an enormous benefit for all of us to take a little bit more care – even if that’s just having those conversations about how patients are managing their asthma, taking time to get to know them, and helping them understand that they need to use their preventer every single day.