It must be remembered that salbutamol is not a cure for asthma. Asthma is an inflammatory lung disease that frequently needs anti-inflammatory medicines, normally inhaled steroids, to control the disease. Salbutamol inhalers are used for the relief of the symptoms of asthma. If you mask the symptoms of the disease, there's the risk of the disease worsening without the patient realising it. Consequently, current recommendations are that if a patient is using their salbutamol inhaler more than three times a week, it's time to increase their preventative asthma medicines, while if a patient is needing it more than ten times a day that could be a sign of very severe or life-threatening asthma.
Now Asda pharmacy apparently believes there is a problem with the existing supply arrangements which could be solved by supplying salbutamol as a private sale. Of course, the business case will be protected due to commercial confidentiality and the only information available is limited to that available in the press release that generated the above news stories, so it is unclear what they believe that this problem is.
Normally asthma medicines would be managed through an asthma clinic at the patient's GP surgery, with referral if necessary to specialist secondary care clinics if necessary. In what circumstances could this break down? Well there are many patients who struggle to attend GP clinics, so there is a convenience/accessibility issue to consider. Supermarket pharmacies are commonly open into the evenings and at weekends, so this makes getting an asthma inhaler easier in these circumstances.
However, the service on offer is not a comprehensive asthma service - it is only for the medicine used at the mildest stage of asthma treatment. There is also the risk of the GP record for patients not having an accurate pricture of how many salbutamol inhalers the patient has used, leading to a more fragmented system if there is not clear feedback to the patient's primary care record every time a supply is made by an Asda pharmacy. One of the important elements of the current NHS set-up is the comprehensiveness of the record which the GP surgery holds on their patients. Most medicines purchased from community pharmacies are for short-term minor ailments, but as treatments for long-term conditions become available, then there needs to be clear two-way access to these (even if it's a "Dear Doctor" letter/patient held list of repeat medicines).
If physically getting prescriptions from the GP is an issue, then there are alternative methods of receiving a supply. GPs can provide prescriptions through a repeat dispensing service that allows up to a year's worth of prescriptions to be kept at a community pharmacy. If an inhaler is needed urgently, then any community pharmacist can provide an emergency supply
So as I am pontificating on limited information, and very possibly worrying about things which are already resolved or mitigated against, here are the questions I have for Asda Pharmacy:
- How does the community pharmacist confirm what asthma management the patient is already receiving?
- Will the community pharmacist be providing additional support, to demonstrate their other skills (i.e. providing inhaler counselling)
- Does the community pharmacist insist on a patient attending an asthma clinic if they are assessed as needing more than just occasional salbutamol relief?
- How does the community pharmacist inform other Asda pharmacies that a patient has been supplied with asthma inhalers or has been refused as having made an inappropriate request?
- How does the community pharmacist inform the patient's GP of this supply, so that at next asthma review it is clear how many salbutamol inhalers were provided?
- What evaluation of this service is being done for public (rather than private in-house) consumption, to help build up the evidence base for the clinical role of community pharmacy?
- What measures are in place to prevent abuse of this service by patients who, for whatever reason, evade normal asthma checks at their GP surgery?
My concern is that by providing 2 salbutamol inhalers for 70pence less than a prescription charge, Asda may inadvertently be promoting the belief that asthma can be managed by symptomatic relief alone. It's good to innovate in healthcare, for the benefit of patients and the wider community. However, it's unclear at this time on a Saturday afternoon how this service provides a direct benefit.
Acknowledgement: Some of the ideas used in this post came up as part of the discussion of this matter with my fellow Pharmacists on Twitter, I hope they won't mind me consolidating them in this post.
Good blog
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