Buy one salbutamol, get another free

According to BBC news this morning, and apparently the Daily Express yesterday, as of Tuesday Asda will be selling salbutamol inhalers (the blue reliever medicines sometimes called Ventolin(R) ) for the relief of asthma.

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:

1. How does the community pharmacist confirm what asthma management the patient is already receiving?


2. Will the community pharmacist be providing additional support, to demonstrate their other skills (i.e. providing inhaler counselling)


3. Does the community pharmacist insist on a patient attending an asthma clinic if they are assessed as needing more than just occasional salbutamol relief?


4. 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?


5. 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?


6. 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?


7. 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.

Reflections with the Black Mirror

A few strands in my pharmacy life are all knitting together in one direction, and for that I need an app.  An appeal on Twitter hasn't seen a huge response so let me explain in more detail here my thoughts about Reflecting with a Black Mirror.

Of course, I'm overdramatising this a bit.  By Black Mirror, I mean smart phone or other digital device; and by reflecting I'm talking about the process of healthcare professionals thinking about what they're doing and how they can make it better.

Earlier this week, I attend a talk by one of the technologists at Leeds medical school.  They're issuing medical students with iPhones, and have developed there own apps for assessing students to the apparent long-term vision of medical students spending their lives learning with patients and their iPhones rather than attending lectures

Compare this with qualified doctors, at another hospital in West Yorkshire, clinical staff are being given iPads.  This opens the door for a massive expansion of medical app use in direct patient care.

Separately, I'm trying to inspire my team of 3-5 year qualified pharmacists as to their future careers in a world where the future of the NHS is uncertain, especially coping as the long-expected increase in demand from demographic changes such as the increasing number of elderly patients, whilst the number of jobs available has plummeted.  What can I offer in the way of careers advice?  Well, there's a big push to use the CODEG advanced and consultant level framework to develop individuals' clinical practice.  UKCPA's critical care group has led the way on this, adapting the standard template to show how a pharmacist wishing to specialise in intensive care environments might demonstrate their competence to do so.

So what I'm after at this stage is: a means of easily yet comprehensively getting evidence of a healthcare professional's contribution to healthcare - both as a means of building up a portfolio of practice to demonstrate that they're capable of  being employed as a specialist when the job market opens up and as a means of generating ideas for how to further develop themselves.

Does anyone have an app for that?

Why discharge medication takes so long

It's 9am, the patient has been told by their doctor they're fit to go home. They leave, unhappy, at 4pm - apparently it's Pharmacy's fault they've spent a day waiting. Why is it that medicines the patient takes home (known in the trade as TTOs (To Take Outs)) take so long?

The quick answer is: it's a much more complex system than you might imagine, where the cogs don't line up as often as they should. Let me take you on through the steps, and then I'll explain how pharmacy, nursing and doctors have made the system less problematic.

When a patient is decided to be medically fit to go home, the following steps need to occur:

1. The patient is informed, often by one of the senior doctors.
2. A discharge letter needs to be written. Normally this is done by the most junior member of the team - the Foundation Year 1 doctor. Normally it's one of many jobs they're handed when a patient is seen by their senior and it's often considered lower priority than booking tests or doing further examinations of the patient.
3. This discharge letter needs to be seen by a pharmacist, as a second check on the clinical appropriateness of the medicines.
4. The discharge letter is then assessed for which items need supplying
5. The pharmacy dispensary then supplies which items are required.
6. A copy of the discharge letter is sent back to the ward
7. A nurse does a final check that everything is there and then hands it to the patient.
8. The discharge letter is then sent (sometimes by post, sometimes by fax) to the patient's GP, so that they're informed of what medicines have been stopped or started, what doses have changed - as well as other medical and social care information.

Of course, medicines aren't the only things to be processed during a patient's discharge. There are many other specialities - social care, physiotherapy, district nursing to name a few - to determine whether a patient is safe to go home and to arrange any necessary follow-ups.

So if the above process only takes up 8 steps, why doesn't it always go smoothly - the main issue is that each of the people involved are doing many things at the same time; so they have to prioritise. And this means doing paperwork that is necessary for the next step along has to wait before more urgent things.

Now there's many ways we can get around some of these steps. For example

• Clinical pharmacists at some hospitals are heavilly involved in ensuring patient's medicines are written up correctly during the admission and sometimes writing the medicines section of the discharge letter. This speeds up steps 2,3 and, because they're there on the ward with the patient, they can ask the patient what medicines they need/are willing to wait for. So if a patient is happy they've got all their medicines at home, pharmacy wouldn't waste the patients time nor the hospital's in dispensing extra; so steps 4-6 are taken out or minimised.
• If the medicines for discharge are routine (and boring), then a "pre-packed medicine" protocol can be use by the ward nurses. For example, it's expected that most day surgery patients will need some paracetamol (or stronger painkillers) to take home with them. So, a pre-printed discharge letter is completed by the surgeon and the nurses use this to issue packs of paracetamol to the patient.
• There's increased awareness by doctors of the importance of writing adequate discharge letters, and the delays to patient care that can arise from not doing them. Of course, being aware of the importance of something and being able to do something about it are different things.
• Electronic prescribing solutions are being rolled out, which solve the problems of actually moving pieces of paper between different healthcare professionals. Unfortunately they sometimes add other problems - such as there not being enough terminals for everyone that wants or needs them, or that you need to move from the patient's bedside to a desktop terminal to do something on computer that you could easily write with the patient in front of you.
• Better communication of real urgency to pharmacy before the discharge letter becomes really urgent. Some discharge letters take priority over others - where a discharge is dependent on a once-daily hospital transport service leaving in half an hour for example. If pharmacy know which need doing now and which can wait until later. And pharmacy need to know this when the discharge letter arrives, not be told 2 hours later that it's needed now (aside from taking a member of staff away from dispensing to answer a phone call and rearrange the workflow ).
  As an aside, this hinges on a poorly understood fact about prioritisation. Prioritisation isn't just about what you do first - it's about what you've agreed to do later to do that thing first. Prioritizing one thing means deprioritising everything else - hence a cause of delays.
• Similarly, there needs to be a realistic expectation from both pharmacy and the ward of what can be expected from the other. Pharmacy needs to anticipate the times that there are peak demands on it (with additional dispensary staff to cover them) and the wards need to understand the necessary legal and safety checks require time to process.

These are my thoughts this Friday evening, based on 10 years watching this go right and wrong in various NHS hospitals. Let me know what I've missed in the comments below

Pharmakeus

The ancient Greek term "pharmakos" later became the term "pharmakeus" which refers to "a drug, spell-giving potion, druggist, poisoner, by extension a magician or a sorcerer." A variation of this term is "pharmakon" (φάρμακον) a complex term meaning sacrament, remedy, poison, talisman, cosmetic, perfume or intoxicant. From this, the modern term pharmacology emerged.

-- Wikipedia