Johnathan Laird
NOT every environment lends itself well to managing patients with long-term conditions. The work I have done in the past with asthmatic patients in community pharmacy has shown me that there is perhaps a need for community pharmacist independent prescribers to be supported to enable them to care for these people. In Scotland, this may now become reality.
The model of care I used was simple: I used various tools and processes to identify, risk assess and then manage asthmatic patients. The cohort of patients of interest to me were those that were at increased risk of exacerbation. Critically, these are the patients that, for various reasons, our multidisciplinary team colleagues in primary care cannot reach.
I have written previously about the overuse of reliever inhalers, high non-attendance rates at annual asthma reviews and the need to follow up with patients who have previously had an asthma attack.
Payment has not been linked to the quality of prescribing and I suspect this type of practice has not taken off simply because effective prescribing can often mean deprescribing. With a reduction in prescribing volume comes a linked reduction in revenue for the community pharmacy contractor. There is absolutely nothing wrong with these clinics in practice, in fact, they helpfully contribute to relieving the prescribing burden carried by our nursing and GP colleagues. This model of practice, however, does not make a unique case for the survival of the community pharmacy network. The contractual levers now need to be pulled for the extremely positive headlines about community pharmacy prescribing to be realised.
The broad aim of my ambition to become an independent prescriber was to attempt to prove that the unique relationship and footfall of community pharmacy could be converted to positive clinical outcomes for patients. My story began with the need to become an independent prescriber. Without this qualification as a pharmacist, I would not be able to manage a clinical list. Operating as a non-prescriber, the process of identifying the higher risk cohort of asthmatics would be useful, but ultimately I would have to hand care of the patient back to the GP. I never wished to duplicate the great respiratory care work my local GP and nursing colleagues were doing — we are all too busy for that, and besides the care they deliver is excellent.
In making the case for community pharmacy, I had to use the strengths of accessibility, excellent relationships, the flexibility of opening hours we as pharmacists in the community are all familiar with. The key fact that is much underexploited in pharmacy clinically, is that patients have to attend the pharmacy to collect their repeat medicines. However, that same patient must choose to present to the GP surgery based on symptoms. Strategically, case finding higher risk asthmatics within this disengaged cohort was my aim as they collected their repeat inhalers. I think the psychology around the decision of a patient to present to the GP is really interesting. I think it is important for community pharmacists to focus on the cohort of patients that come to the pharmacy but not the GP. I feel community pharmacists should be risk assessing these people and then potentially intervening to deliver pharmaceutical care as pre-cursor to managing them using various tools, including prescribing.
Back when I completed my training to become an independent prescriber, I used the chronic medication service brief interventions to identify this group of more vulnerable asthmatics. Risk assessment was initially done upon receiving and clinically checking the repeat prescription. For example, I would look at the frequency of prescribing of reliever inhalers and preventer inhalers, as well as spotting oral steroids prescribed as a reaction to a recent exacerbation. Based on these parameters, I would decide whether a brief intervention could be of benefit. My local GP colleagues kindly provided me with a list of patients who did not attend the annual respiratory review at the clinic. I used this list to further prioritise my time. It fel a little like going fishing except I was fishing for not for fish but instead unmet pharmaceutical care issues. The key factors I used for identifying higher risk asthmatics as I clinically checked and dispensed their prescriptions were as follows:
1. Patient used more than 12 reliever inhalers in the preceding 12 months.
2. Patient compliance with reliever medicine was poor in the previous 12 months.
3. Patient was prescribed an oral steroid in the previous 12 months.
4. Patient did not attended the respiratory clinic in the previous 12 months.
5. Patient is a smoker.
At this stage, I flagged the need for a pharmacist conversation upon hand our of their repeat medication prescription. The brief interventions are just that, brief. I found the use of the asthma control test was useful in many cases at this stage to convince the patient of the need to present for review. Since then I have found these types of validated questionnaires useful in other clinical areas too.
Once identified, I then invited them to the respiratory clinic where I shadowed the GPs and nurses to help better manage their asthma. I am now running these clinics in the surgery independently in the surgery. I hope the advantage of eventually using remote read/write access to the records within the pharmacy will mean that community pharmacists can increase the level of flexibility in terms of when I run the clinic. It is useful to note that many asthmatics are of school or working age, so a community pharmacy clinic run in an evening or at the weekend may help to increase attendance rates. The main barrier to opening up this sharing of information is the risk attributed to the Cauldicott guardian of making the decision to share patient data with a third party, like a community pharmacist. Also, the cliche that ‘knowledge is power’ rings true here to a certain extent in my view and on occasion protectionism plays a part in freezing third parties, like community pharmacists out.
The whole experience at that time was a tremendous learning opportunity but we found it particularly enjoyable because many of the patients we invited initially were not engaged with the surgery system of review. This problem of non-attendance of asthmatic patients for review is common across the country. During my training time, I managed to source roughly 10 percent of the local asthma list. Many of these patients were, at best, disengaged with the management of their condition or, at worst, required quite urgent care.
Upon qualifying as an independent prescriber I started using the same method to fill my clinical list of patients. To be clear, I have taken a risk in that, to begin with I had no patients on my list. The challenge has been to find them using the method above.
Many of us in community pharmacy will have dabbled with case finding sometimes by using opportunistic clinical tests like blood pressure. However, finding cohorts of patients that are only willing to engage with you as a community pharmacist creates a compelling argument to support this type of practice within the heart of our local communities. If we can then use read/write access to the patient records and skills linked to independent prescribing to manage these patients safely in the community pharmacy we could maybe make a real difference to patients.
It will be interesting to see if those in charge will now pull the contractual levers required to make the community pharmacy environment favourable to solutions such as this or others. I hope they do or else I fear the sector will fall farther behind others and that would e a great shame for our profession but also for patients.
Johnathan Laird is a pharmacist independent prescriber with a special interest in asthma. He is based in Aberdeenshire.
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