I know 2020 has been all about ‘you know what’ but with vaccine deployment happening my mind turned to the future and also the past.
The topic of asthma deaths used to literally keep me up at night.
I thought I would revisit it and reflect on how things have changed for me but also more widely for community pharmacy in Scotland.
Looking back now five years on from when I wrote the article below I am no less moved by the terrible findings of the National Review of Asthma Deaths (NRAD) in 2014. The truth is we [all health professionals] are still letting people with asthma down.
One of the highlights of running PIP recently was the fact that I got the opportunity to interview and collaborate with Dr Mark Levy. Dr Levy was very much involved in the original NRAD document and continues to be a tireless advocate for the involvement of community pharmacists in the care fo people with asthma. We were therefore very proud that he took the time to contribute to a recent PIP webinar.
I defy anyone to listen to Dr Levy and not be moved by the stories of some of the people who have sadly passed away as a direct result of poorly managed asthma. Many of these people are children. It really is heartbreaking and something must surely change.
But what must change and can community pharmacy help?
Five years ago I wrote about how the Chronic Medication Service (CMS) offered considerable promise in our collective endeavours to literally save the lives of people with asthma who are at risk. The brief intervention model using independent prescribing that I advocated for all those years ago doesn’t seem to have caught on although pharmacists like Anna Murphy have advocated for greater community pharmacy involvement. As I mentioned on a recent webinar with Anna, the Simple Intervention™ she pioneered was work many years ahead of its time.
Rather than significantly invest in community pharmacy across the UK there has been a rush to fund pharmacists to work in general practice.
Not all conditions can be managed optimally via a formal sit down the appointment-based system. Brief interventions are useful and people with asthma, particularly mild asthma (although I hate that term), can benefit greatly by ‘little and often’ interventions. I think this is particularly true when this activity is delivered by a community pharmacist who has the autonomy to make appropriate interventions. Although I need to caveat that by saying that any independent prescribing activity in community pharmacy must be properly resourced. It must not be an opportunity to dump more responsibility on pharmacists with no extra investment in them through training, supervision and financial reward to them.
The article below published originally in January 2015 is a trip down memory lane and describes how I was attempting to put these ideas into practice.
The chronic medication service (CMS) in my view is a necessary step towards securing a future role for pharmacists within the community pharmacy setting in the UK.
There are two sides to the chronic medication service. There is the repeat supply of medicine via serial prescriptions and also the clinical side of the service in which community pharmacists provide pharmaceutical care for the patient. Both have merit. However, if I am being positive neither side has reached its full potential yet.
With this in mind, I presented a positive take on CMS at the recent Scottish National Seminar focusing on the clinical side of the service.
Based largely on the findings of the National Review of Asthma deaths 2014 (NRAD) I decided to exploit the unprecedented access to patients I have as a community pharmacist in an attempt to deliver some clinical returns. Many asthma deaths are preventable so I set about creating a simple plan to first find and then begin to manage the high-risk asthmatics that were failing to properly engage with my local general practice team.
Relationships and co-operation are key to the success of any multidisciplinary service. I did a number of searches of the surgery asthma list kindly facilitated by the practice team and my GP colleagues. I generated three searches:
- Patients who had been prescribed salbutamol in the previous 12 months or had a diagnosis of asthma who had failed to attend their annual asthma review in the practice in the previous 12 months.
- Patients prescribed more than 12 beta-agonist inhalers in the previous 12 months.
- Patients prescribed oral prednisolone in the previous 12 months.
I used these searches in the community pharmacy setting to identify, intervene and conduct a mini asthma review with patients. I found a significant number of higher risk asthmatics that certainly needed support and better management. As part of the CMS service, I fed back my findings to the practice team so that they could be recorded in the patient’s record.
I should make it clear that the patients who did attend the surgery regularly were extremely well managed locally. However, if the patient did not choose to attend the practice, like many others, the surgery team are in a tricky position if they intend to support these patients. My little enterprise was a success because I observed that asthmatic patients were required to visit the pharmacy to collect their reliever medication.
There has been much talk recently of pharmacists working in GP practices. I think this, along with any other scheme that utilises the unique skill set of the pharmacist, is an excellent idea. However, I am much more in favour of the profession encouraging pharmacists to work in pharmacies to deliver clinical returns for patients and be paid accordingly for doing so.
I am now in the final planning stages of planning independent prescribing clinics to manage, amongst other groups, asthmatic patients within the community pharmacy. Combining these clinics with the CMS case finding the activity of high-risk asthmatic patients I have described above, will hopefully mean that my clinical list will be comprised largely of patients who cannot be reached by the GP practice team. Therefore I am not duplicating the good work that already takes place.
On the contrary, I am going after the higher risk asthmatics that require additional support.
I am hopeful that by taking the best bits of community pharmacy, unprecedented access, and combining them with a little basic clinical work I can deliver positive results for patients.
Reading that again I reflected on the urgency in my words. Time has passed but I still feel very strongly that community pharmacy must get organised and deliver a coherent set of services with the aim of literally preventing the deaths of people with asthma.
If I’m honest, trying to innovate and seize any form of professional autonomy at that time was exhausting. And all this activity before I met Dr Levy five years later who thought what I was doing was absolutely excellent. The result of this exhaustion was my move into the arms of my local GP practice where I worked for three years shortly after this. It is possibly a topic for another article but the speed of my professional development rocketed in this supportive environment where professional development was seen as the norm. And there was the investment to support this which to this day I really appreciate.
Back in 2015 the leadership noises coming out about CMS nudged me towards the promised land of managing people with asthma in the community pharmacy.
But was CMS a roaring success?
No, I don’t think so but I do think it was a necessary step to enable community pharmacists like me and encourage us to think more deeply about how our role needs to change. Some aspects of the service were fabulous and I know those behind it worked tirelessly to make progress with it.
For example, the notion that a community pharmacy should develop a registered population of patients was groundbreaking. I think the clunky computer system and the lack of simple focussed objectives meant the service petered out and reverted basically to become a repeat prescription service.
The launch of the NHS Pharmacy First service is a clever move for a number of reasons and was not on the go back in 2015 when I wrote this original article. The ‘lie of the land’ has changed and for various reasons, the direction of travel has moved away from supporting people with long term conditions towards more of a responding to symptoms approach. There is nothing wrong with this approach and I hope it is a great success but I do think to deliver the ambition will require much more investment than what is being offered despite the fact that the funding in Scotland for this service and others is much more generous than other areas in the UK.
We need to find ways to drive additional investment into community pharmacy in Scotland.
The confidence and competence required for a community pharmacist to work autonomously is significant. It takes time to develop consultation and clinical skills. As an optimist, I’m sure the structures around this will develop over time.
Much like the outset of CMS, I think NHS Pharmacy First is a necessary step and it is a very positive step in the right direction.
For me, pharmacy practise is about impact. What positive impact or contribution can I make to the patient in front of me? As a community pharmacist, you have the opportunity to keep hundreds of people safe, give sound advice, refer as appropriate and manage their condition if you are competent to do so.
Five years on I hope the next Chief Pharmaceutical Officer for Scotland looks again at the community pharmacy estate and leads them towards focussing on supporting people with long term conditions in the community.
I was wondering what I would like to achieve in five years and revisit this article again then. I think the answer to this is the fact that we currently have very little idea of what happens to medicine after it leaves the dispensing bench. The relationship between medicine and the patient still remains a mystery in my view.
In five years I would like to think pharmacists will have real-time data about how medicine is being used. Sure, this data will be patchy and incomplete, to begin with, but we need to use the community pharmacy network to go in search of these insights together and democratise that information.
There is no point identifying a high-risk asthmatic, making an intervention like increasing their inhaled corticosteroid dose if, in fact, their adherence is poor. Wouldn’t it be interesting to intervene months later and reengage that patient about their inhaler digitally if necessary.
Pharmaceutical care is no longer enough. The world has changed but the community pharmacy section of our profession is developing too slowly in my view. The shiny ideas like remote consultations benefit are the ‘red herrings’.
The future must involve a new speciality in pharmacy practise.
Johnathan Laird is a pharmacist, independent prescriber, occasional agitator and eternal optimist.