Key learning points

  • Providing asthma clinics in a community pharmacy may offer an opportunity to reduce the workload on GP surgeries while improving outcomes and quality of life for patients with asthma
  • Sharing the results of tests such as fractional exhaled nitric oxide (FeNO) testing can help patients understand that their asthma needs managing even if they feel well to improve their health and reduce the risk of asthma attacks
  • Pharmacists are well placed to help identify problems that patients may have with concordance with asthma medication and adjust their treatment to better fit their lifestyle
  • The community pharmacy may be a better option for patients who are not able to visit the GP surgery during normal working hours

Introduction

Cadham Pharmacy Health Centre is a community pharmacy in Glenrothes, Scotland. As part of ongoing independent prescribing clinics undertaken at the pharmacy health centre, a focus on respiratory disease enabled independent pharmacist practitioners to work to improve patients’ healthcare outcomes with the aim of relieving the burden on primary care.1

Glenrothes is an ex-mining town, which means a high prevalence of respiratory disease. This has led to demands on respiratory services in primary care and patients have had problems accessing annual respiratory reviews, as well as GP/nurse appointments when experiencing acute exacerbations.

The pharmacy and neighbouring GP practice serves a local population of around 10,000 people, with 50,000 people in the town as a whole. The town has a lot of young professionals who prefer weekend appointments and frequently do not attend at their GP practice.

Asthma consultations

The clinic was set up to provide local people with quick access to acute asthma care and reduce the demand on primary care services. It was designed using guidance from the RCP’s National Review of Asthma Deaths.2 The aim was for pharmacy staff to use their expert knowledge of medicines, along with motivational consultation skills and assessment skills, to support patients to change the way they manage their asthma.

Box 1 summarises the main goals of the clinic.

Box 1: Main goals of the clinic

  • Influence patients to take their life-saving medicines regularly
  • Provide written asthma plans and teach patients what to do in an emergency
  • Change a patient’s therapy if needed to find the best inhaler device that fits their lifestyle
  • Educate patients about the dangers of asthma and the fact that asthma can be fatal
  • Provide regular follow-up and inhaler technique guidance
  • Provide easier access to an NHS healthcare professional in the community
  • Reframe patients’ beliefs about asthma and their behaviours when they feel ‘fine’
  • Identify a patient’s triggers and numbers to influence their mindset and how they choose to control their asthma

Patient consultation

A new treatment room was created to be able to carry out consultations. The room is equipped with tympanic thermometer, pulse oximeter, blood pressure monitor, peak flow meter and FeNO machine.

Pharmacy staff provide a thorough physical examination, take a history of symptoms and past medical history and measure peak flow, oxygen saturations and pulse. They also determine if patients require antibiotics, steroids or a combination of these medicines to stop them from developing a severe acute life-threatening asthma attack.

Pharmacy staff are able to support long-term care by teaching patients inhaler technique using placebo inhaler devices and educating them about why they should use life-saving preventer inhalers every day even when they feel fine.

The results of the assessments help to guide prescribing decisions and formulate effective patient management plans. The ACT score3 is used to assess disease control and to guide a discussion with the patient regarding how their respiratory disease affects their life. Box 2 summarises what is included in an asthma patient’s consultation.

Box 2: What is included in an asthma patient consultation

  • ACT score
  • History
  • Peak flow
  • Oxygen saturation 
  • Inhaler technique
  • Discussion on current practice from patients on how they manage their asthma
  • Motivational and educational discussions on asthma beliefs
  • Written action plan
  • Regular follow-up and planned appointments suiting patients’ lifestyle
  • Chest examination if appropriate
  • CRP testing if appropriate
  • Prescribing acute and long-term care
  • FeNO test if necessary
  • Temperature if necessary

Role of pharmacy staff

All pharmacy staff have undergone training to ensure they have up-to-date skills in respiratory prescribing, are competent to carry out consultations, including taking a detailed history and have the practical skills to assess patients with asthma. The multidisciplinary team works in collaboration to provide acute care and to help train all pharmacy staff in assessing and treating patients.

The team involved in creating patient management plans follow local and national guidelines for prescribing to ensure that treatment plans are evidence-based. The pharmacists conducting asthma clinics use a patient-centred approach to consultations and involve patients in the decision-making process regarding their clinical management plans. This inspires patients to take responsibility for their condition, improves concordance with prescribed treatments with the aim of improving healthcare outcomes.

Written asthma action plans are used, as advised by the RCP’s National Review of Asthma Deaths report, which found that their use can reduce asthma attacks fourfold.2 Staff regularly reinforce the message to patients, even for those with mild asthma, that they understand their triggers and know what to do in an emergency.

Outcomes

There have been a number of positive outcomes from the asthma clinic:

  • It has helped identify patients at high risk of over relying on their short-acting beta agonists
  • Patients’ inhaler and breathing techniques have been optimised
  • Pharmacists have worked with nurses and GPs to recommend inhalers that patients can and will use
  • It has provided regular monitoring in an accessible way for patients, with a walk-in clinic and online bookings
  • It has taught patients emergency asthma planning, also teaching the patient’s family what to do in an emergency
  • Using FeNO testing and other measures has demonstrated to patients the impact of asthma inflammation on their airways, clarifying for them how ‘sick’ they really are
  • Using facts about how many lives can be saved by asthma prevention measures has been useful in motivating patients to change
  • There have been demonstrable improvements in health outcomes and quality of life for asthma patients

Outlook

As more evidence is produced, it is hoped that the community pharmacy might become a referral primary care hub to support local GPs and patients, and that other pharmacies will replicate the model.

Bernadette Brown, superintendent pharmacist, Cadham Pharmacy Health Centre, Glenrothes, Scotland

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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