Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
1. Scheme title and category
Childhood Asthma Education Project
A community pharmacist intervention in schools that will contribute to a measurable improvement
in the inhaler technique, adherence, and associated health outcomes, of children and young people
(CYP) with asthma in primary and secondary school settings.
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To assess, and if necessary improve, inhaler technique for each CYP during one schoolbased pharmacy-led workshop and one follow-up workshop
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To show a reduction at 8-week follow-up in self- and/or parent-reported:
o Number of school days lost
o A&E attendances
o Emergency hospital admissions
o GP / OOH appointments
•
To assess, and if necessary, improve condition control
•
To show an improvement in quality of life – in terms of symptoms, activity limitation and
emotional function – at follow-up
•
To assess, and increase if necessary, the self- and/or parent-reported adherence of CYP
to their asthma therapy
•
To increase the confidence of CYP, parents and teachers in the use of inhalers
The scheme will be delivered with the support of Widnes Vikings, who will provide links with schools,
and player ambassador support for CYP with asthma.
The workshops aimed at primary school children will also make use of technology’s developed by
Manchester University to use with flo-tone trainer devices (i.e. the Rafi –Tone App) which allows
the children to monitor their own inhaler technique using an interactive App.
2. Summary of scheme, which patients/population groups is it targeting and forecast numbers of
people who will be able to use/access the service
The project proposes holding Community Pharmacist led inhaler technique workshops in primary
and secondary schools. Noting the Asthma UK estimate of 2 children with asthma in each
classroom1, we will host workshops for a combined year 4-5 cohort (8-10 year-old students) and
combined year 9-10 cohort (13-15 year-old students).
Participating schools will also be offered a young person’s education event provided by Widnes
Vikings, to be offered to the wider school population , that will focus on respiratory disease in
general.
We aim to engage 4 primary schools and 4 secondary schools in this project. These schools will be
purposively sampled, including schools with whom members of the project team have existing
relationships. Within the sample there will be a diversity of deprivation (as determined by the full
postcode of the school) across the Index of Multiple Deprivation quintiles and a geographical
diversity across the Halton Local Authority areas.
When choosing the schools we will be closely guided by
 The data available on prevalence of asthma in children in the GP surgeries in Halton, and the
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
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surgeries proximity to local schools
The data available on admissions to hospital related to Asthma, for children in Halton.
The school nursing teams, and local authorities.
A letter will be written to the Head Teacher of prospective schools, outlining the project and gauging
their interest. This will be followed up with a phone call. When a school agrees to participate, we will
ask the Head Teacher to nominate a primary liaison teacher for the project team, who may or may
not be themselves.
We propose to engage primary and secondary school CYP to show that it is possible for pharmacists
to teach CYP at different stages of cognitive development, and at times of transition. We will not
work with CYP, who will be taking national exams over Summer 2016 (SATS or GCSEs).
We will recruit CYP from the appropriate age groups with the help of the liaison teacher who may, in
turn, draw upon other stakeholders. These are most likely to include Head Teachers; School Nurses;
Parent Governors; Year Teachers and support staff. The project team will offer to present the project
to the staff / governors at a special meeting before the project begins. The school will be required to
have in place a ‘Managing Medical Conditions in schools’ policy .
An information pack from the project team will be sent by post from the school to all CYP in the
specified classes who have been identified as CYP with asthma by the school. This will contain:
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An information sheet for the CYP (2 separate sheets will be developed for the different
age groups and piloted with CYP)
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An information sheet for the parent/carer
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A parental permission form and a CYP assent form (none of the CYP will be able to give
consent, but can and should give assent)
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A return envelope that should go to the school office.
The information sheet will show the date and time of the initial after-school workshop and the
follow-up workshop. Once CYP and parent/carers return permission forms, the project team will
know whom to expect. The permission form will also ask the parent/carer to tell the team what
types of devices they use. It will include the address of their GP usual community pharmacy. The GP
will then be notified of their patient’s participation in the project through a letter and copy of the
information sheet.
In parallel, four local pharmacists and technicians will be trained in the delivery of the workshop.
Each workshop will be delivered by two pharmacists and pharmacy technicians. This additional
training will draw on the required expertise of how to relate to and engage CYP. To ensure that the
project is successful, a fun and interactive approach will be taken, appropriate to each age group.
The project team and the community pharmacists engaged will work in a collaborative way with
parents, school staff, school nurses, Staff from Widnes VIkings and appropriate staff from LAs, CCGs,
GPs and practice nurses.
Workshop Format
Working in partnership with school nurses, teachers, and staff from Widnes Vikings community
pharmacists will attend the schools at pre-arranged times to run a workshop for CYP, parents and
school staff who are interested in finding out more about asthma and inhalers. The workshop format
will be piloted in two schools (one primary and one secondary), with project team leaders present,
and any revisions needed will be made.
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
The workshop content will be guided by staff as to the optimum length for the different age groups,
but inevitably there will be administration time needed at the beginning and end of the direct
engagement time. Staff will advise the team when the session should take place – it is not likely to
be immediately after school (to protect the privacy of the participants), so it is likely to be later in
the evening (6-8pm) or at a weekend. We anticipate that 10 CYP and their 10 parents, with up to 6
staff, will be a good size for the workshop audience.
The workshop will start with an introduction to the service, which will be given by the pharmacist;
this will explain the importance of good inhaler technique. Other elements of the workshop will
include:
• An individual assessment of each CYP current condition control
• An individual assessment of the CYP respiratory technique and where appropriate advice
and demonstration of the correct technique required. Podcasts, with an on-screen
demonstration of correct technique may be used.
• Importance of ensuring CYP has the correct equipment in school at the start of each
term (parent, CYP and teacher responsibility);
• ‘Red flag discussion’ which will include how to deal with asthma attacks / expiry dates of
medication;
• The Vikings Coaches would then deliver active games around respiratory health
messages.
o Don’t Start Smoking
o Antibiotics and Colds/Flu
o Why is exercise important?
o Player Ambassador support from members of the Widnes Vikings/ Liverpool
Ladies team
• Provide each CYP with an Asthma UK pack, factsheets and podcast link;
• Q&A with the Pharmacist;
• ‘Quiz’ activities at milestones during the session (on computers if available in the
workshop room) to gauge knowledge and adherence.
• The workshops aimed at primary school children will also make use of technology’s
developed by Manchester University to use with flo-tone trainer devices (i.e. the Rafi –
Tone App) which allows the children to monitor their own inhaler technique using an
interactive App.
The CYP/parent pair will be encouraged to visit their own community pharmacy if they have any
questions about the inhaler in the period after the first workshop. All community pharmacies in the
study areas will be informed
If an intractable problem is identified with the device during the workshop, the CYP/parent pair will
be shown alternatives and given a double-copy letter to take to their GP and regular community
pharmacist which will ask them to consider a change of device.
The follow-up workshop will be held six-eight weeks later. This will give the CYP/parent pair the
opportunity to show the pharmacy team how they have made progress, and will provide a forum for
questions. Follow-up data collection in the quiz format will also be repeated. It is likely to be shorter
in length than the first workshop. At the end of the second workshop, there will be a discussion
about resources available to CYP and families, with a particular encouragement to visit the
community pharmacist if they need further help and a final referral letter will be given to each family
for their community pharmacy.
The CYP will receive a certificate of attendance at each session to add to their portfolio of
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
achievements. This will maximise attendance from which our evaluation data will be drawn.
3. What benefits and impacts will the scheme bring to the targeted patient/public groups?
According to Asthma UK
 One in 11 children has asthma and it is the most common long-term medical condition.
 On average there are two children with asthma in every classroom in the UK.
 The UK has among the highest prevalence rates of asthma symptoms in children worldwide.
It is nationally acknowledged that the majority of patients, estimated by some authors at up to 90%,
demonstrate a poor inhaler technique resulting in poor health outcomes and quality of life2 3. When
children do not use their inhalers correctly, they gain no - or at best a drastically reduced - benefit
from the treatment, and this does not encourage adherence. Bad habits can be formed early in life
that perpetuate into adulthood, with reduced quality of life.
Parents are partners in care, and work has shown that their knowledge is important in the overall
chance of good outcomes. For 46 children aged 0-12 in one study in the Netherlands, it was found
that in 87% of cases the parent decided when and how the inhaler device should be used, but
mistakes were still being made. The authors recommended that parents should be involved when
instructions for use were being given.
On average, there are 2 children with asthma in every classroom in the UK. As the main place that
children spend time, there is a need to harness this environment to keep children with asthma well.
A survey by Asthma UK found that 64% of children with asthma have at some point been unable to
access a working inhaler in school, and 62% have had an asthma attack while at school. There have
been recent changes to school medicine policies to enable salbutamol inhalers to be held as stock in
schools for emergency use8. If staff and pupils do not know the correct technique, then the efficacy
of this potentially life-saving medicine will be reduced.
Interventions with children regarding inhaler technique have been reported. The literature shows a
better chance of correct inhaler technique for them where:
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There are repeated instruction sessions4
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Where the patient has the opportunity to demonstrate their inhaler use5
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Where the children had the opportunity to ask their own questions about their medication
A paediatric medicine study from the Netherlands6 specifically compared the efficacy of a single
instructional session from the GP with repeated pharmacy checks for newly-diagnosed patients aged
1-14 years6. They found that 79% of the pharmacy cohort performed essential steps correctly, as
opposed to 39% of the GP session cohort (p<0.01). Moreover, a short video intervention about
inhaler technique for children showed improvement over control immediately after seeing it, but
not at follow-up11. The themes across all these papers seem to be that children would benefit from
repeated inhaler technique instruction, that their parents should be involved, and that the school
environment is also a place to promote more knowledge about these issues.
4. How will the scheme help contribute towards improving Halton residents’ access to a GP?
The scheme will improve the inhaler technique, and adherence to medication regimes, of CYP with
Asthma, leading to an overall improvement in the control of their symptoms.
Improved control will reduce the need to access GP appointments due to deterioration in symptoms,
reducing the demand on GP appointments.
The scheme will demonstrate the effect of a condition focused education programme for CYP in
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
schools, the benefits of which could be sustained by future programmes for asthma education or
education around other conditions.
5. How will be scheme success be evaluated and what key metrics will need to be collected?
All data will be recorded on a bespoke electronic PharmOutcomes service database to ensure
consistency and the ability to produce individual reports. The preference is to complete the data
input during the session before leaving the school where internet accesses is possible. If internet
access is not available the data from the workshops will have to be collected on well-designed paper
forms and stored securely on the school premises until such time as the pharmacy staff completing
the sessions can collect and transport the data to the pharmacy, the data will subsequently entered
onto the database by the pharmacist and their accompanying staff member and paper copies
destroyed.
We have suggested a trio of condition- and inhaler-related tools to use in the service:
• The Childhood Asthma Control Test (C-ACT) (primary) and Asthma Control Test
(secondary) – These short surveys are nationally recognised and help us to understand
the control of the condition. They have cut-off points to indicate different levels of
control – those with good control score over 20 on the Test. Everyone else is in one
group. The C-ACT, however, has also been studied for a lower cut-off point to indicate
very poor control12; they found that 12 or less was a score range in which there was
very poor control. This service proposes to adopt 3 zones of scores – 0-12 = very poor;
13-20 = poor and >20 = well controlled. This service should move a CYP into the next
zone up i.e. one initially scoring 0-12 moving to at least 13-20, and initially scoring 13-20
moving to >20.
• The Mini Paediatric Asthma Quality of Life Questionnaire (PAQLQ)13 is a shortened
version of the original PAQLQ. It has 13 questions covering symptoms, activity limitation
and emotional function. It has been developed with children aged 7-17 years.
• The Brief Evaluation of Medicines Influences and Beliefs (BEMIB, adapted)14 – even if a
CYP improves their inhaler technique, underlying non-adherence will still limit condition
control. This may result from family beliefs about the effectiveness of the medicine,
side-effects etc.
The metrics collected will include
Demographics and contact details
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Name, address (with full postcode) and telephone contact number of the CYP and of their
primary parent / carer (which may be different)
Current age of CYP
Sex of CYP
Ethnicity of CYP
Name and address of the School
Name and address of the GP
Name and address of the usual community pharmacy (if one can be identified)
Asthma history
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Age at diagnosis with asthma
Inhaler device/s used (past as well as current)
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
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Inhaled medicine/s used for asthma (inhaled and oral)
Any other concurrent long-term conditions
Clinical Indicators
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In-Check result – before and after training
Visual assessment of technique - before and after training
Condition control - C-ACT result – at first session and follow-up
Quality of Life - Mini PAQLQ result – at first session and follow-up
Adherence - Paediatric Inhaler Adherence Questionnaire result - at first session and followup
Device appropriateness – is the patient able to use the device?
Pharmacist recommendations (from first session) and whether implemented (from second
session)
The metrics stated will be used to evaluate the impact of the session on the disease management of
the CYP. In order to evaluate all the aims and objectives of the service the following further
evaluation methods are suggested.
 A follow-up self-completion paper survey pack sent to each CYP/parent pair 2 weeks after
the initial session, including an invitation to take part in a telephone interview – this will
explore their experience of the session and any action taken since then
 A shorter follow-up self-completion paper survey pack sent to all attending CYP/parent pairs
in the second session, and all the non-attenders, to explore why each group did or did not
attend and to explore ongoing experience of inhaler use and condition control
 A short survey completed by teachers and other school staff at the workshops
 A short survey completed by pharmacists delivering the service.
6. Stakeholders – identify all relevant stakeholders involved in this and any existing services who
will need to be involved/made aware
Key Stakeholders:
 Halton CCG
 Halton GP Services
 Halton Borough Council
 Halton Schools
 Halton Community Pharmacies
 Widnes Vikings
 Manchester University
 Various children / family support groups – Children’s Centres.
 Specialist services
7. Timescales – set out headline timescales and anticipated commencement date
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
We will ask for expressions of interest during August with recruitment of pharmacies by midSeptember. It is anticipated the scheme will go live during the Autumn term.
8. How will the scheme be marketed/communicated to ensure high uptake?
The scheme will promoted by direct invitation to schools and CYP and their parents/carers to
participate.
9. Anticipated budget required and breakdown of headline costs (e.g. staffing, room hire,
equipment, advertising/marketing, IT)
Project management Cost
Widnes Vikings involvement
Printing and Postage
Training Event
Room Hire
Trainer
Refreshments
Payment to attendees for locum cover
Cost
£150 x 4 (based on £25 per hour max 4hrs for
pharmacists and £12.50 per hour max 4 hrs for
technicians)
Total costs for pharmacy training event (one
event held in each locality)
Staff Costs:
Cost per School Session
Total ( 8 schools x 2
sessions two
pharmacists two
technicians at each)
£150 per pharmacist
£75 per technician
Based on (£25/£12.50 per hour- allowing preparation time, 1.5 hours to
deliver session and time to record outcomes)
Facilities:
Product
In-Check DIAL 6 T&S
Flo-tone Device
Regular (box of 10)
Flo-Tone Device
Cost per unit (with
discount) excl VAT
Numbers required
Total cost
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
Circular (box of 10)
Trainhaler (inc 1 FloTone)
Adult Disposable One
Way Valve
Mouthpieces
Inspiratory
Total Cost ex VAT
Sale tax 20%
Total
PharmOutcomes
Product
Cost excl VAT VAT 20%
Total cost
Cost per service
(based on spreading costs over 4)
One commissioner
user
36 providers
Evaluation costs
Licence Fees
Project Evaluation Fees
Total
Total Project Costs
10. Who will lead the delivery of the scheme?
Project management team
11. Identify potential risks to delivering and achieving the stated benefits and timescales
Lack of engagement from community pharmacies
Lack of engagement from schools/participants
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
12. What are your thoughts and considerations about sourcing funding to make the scheme
sustainable, if successful?
13. Organisations involved in delivery
Community pharmacies in Halton
Vikings Sports Foundation
Halton CCG
Halton, St Helens and Knowsley LPC
1
Asthma UK. Asthma Facts and FAQs (web page). Accessed on 3 December 2014. Available at
http://www.asthma.org.uk/asthma-facts-and-statistics
2
De Oliveira MA, Bruno VF, Ballini LS, BritoJardim JR, Fernandes AL. Evaluation of an educational program for
asthma control in adults. J Asthma 1997; 34: 395–403.
3
Plaza V, Sanchis J. Medical personnel and patient skill in the use of metered dose inhalers: a multicentric
study. CESEA Group. Respiration 1998; 65: 195–8.
4
Kamps AWA, Brand PLW, Roorda RJ. Determinants of correct inhalation technique in children attending a
hospital-based clinic. Acta Paediatr 2002; 91: 159-63.
5
Sleath B, Carpenter DM, Ayala GX, Williams D et al. Communication during pediatric asthma visits and child
asthma medication device technique one month later. J Asthma 2012; 49: 918-25.
6
Kamps AWA, van Ewijk B, Roorda RJ, Brand PLP. Poor inhalation technique, even after inhalation instructions,
in children with asthma. Pediatr Pulmonol 2000; 29: 39-42.