Evaluation of a Community
Pharmacy Inhaler Check
Service
A Report for NHS Doncaster Clinical
Commissioning Group (CCG)
May 2014
Evaluation of a Community Pharmacy Inhaler Check Service
A Report for NHS Doncaster Clinical Commissioning Group (CCG)
May 2014
Abstract
Aim and Objectives: To evaluate a Community Pharmacy Inhaler Check Service. To identify the
number of patients using the service, inhaler use issues identified and interventions provided by
community pharmacists, exploring patient satisfaction with the service and ideas for service
development/improvement.
Setting: Twenty-nine community pharmacies across Doncaster.
Methods: A mixture of research methods were used for data collection: audit of 616 consultations
and analysis of 577 patient satisfaction questionnaires. Audit and questionnaire results were
analysed using descriptive statistics, qualitative comments using a thematic approach.
Key Findings: A total of 400 patients had an initial inspiration rate (IR) out of the optimum range
for their inhaler device. The majority of patients were prescribed a metered dose inhaler (MDI),
79% of these patients did not achieve the optimum IR on initial assessment. Sixty percent of
patients were using one type of inhaler only, the number of different inhaler devices ranged from 13. A statistically significant relationship (p>0.001) was found between patients prescribed MDIs not
achieving the optimum IR rate on initial assessment and reporting that they had not had any
previous instruction. Following consultation with the pharmacist over 98% of patients achieved the
optimum IR for their inhaler device. Patients expressed a high level of satisfaction with the service.
Conclusion: The evaluation demonstrates the need for regular inhaler technique checks. Many
patients had not achieved optimum IR for their inhaler device on initial assessment, however the
community pharmacists were able to support almost all these patients to achieve the optimum IR
by the end of their consultation. Community pharmacists have a key role in improving inhaler
technique and inhaled medicines use, complying with recommendations made in current guidelines
for asthma and COPD.
The service is beneficial to patients and the wider NHS; improving inhaler use can improve
condition control improving quality of life, reducing hospital admissions and even deaths, funding
should continue.
Acknowledgements
The author of this report would like to acknowledge and thank all those who participated in
and assisted with this service evaluation. Firstly I would like to thank the patients who took the time
to complete feedback questionnaires during the course of the evaluation. I would especially like to
thank Mark Garrison for giving up his time to help promote the service.
I would like to acknowledge all the community pharmacists and their support staff
who engaged with and delivered this service, and submitted data for evaluation. I would like to
acknowledge the work done previously by the pilot Pharmacy Local Professional Network for NHS
South Yorkshire & Bassetlaw, in particular; Matt Auckland, Nicola Gray, Richard Harris and Nick
Hunter, on which this service has been based.
I would like to acknowledge the contributions made by NHS Doncaster Clinical
Commissioning Group in implementation and evaluation of the service, especially; Jonathan
Briggs, Ian Carpenter, Martha Coulman, Dr Andrew Oakford and Emma Smith.
Finally I would like to thank fellow members of Doncaster Local Pharmaceutical Committee
and colleagues at H. I. Weldrick Ltd for their help and support in implementing and evaluating the
service; Paul Chatterton, Michelle Foley, Richard Harris, Nick Hunter, Darren Powell, Richard
Wells and especially Alison Ellis for her hours spent data inputting.
This service evaluation was commissioned by NHS Doncaster Clinical Commissioning Group.
Contents
Page
Introduction
5
Methodology and Methods
10
Results
14
Discussion
29
Conclusions
35
References
36
Appendices
38
For further information regarding this evaluation please contact: doncasterlpc@gmail.com
This report was written by Claire Thomas MPharm, MSc, MRPharmS, GPhC, Doncaster LPC
Member on behalf of NHS Doncaster Clinical Commissioning Group.
1. Introduction
Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common respiratory
conditions in the United Kingdom (UK). Asthma is a multifactorial and often chronic respiratory
condition that can result in episodic or persistent symptoms and in episodes of suddenly worsening
wheezing (asthma attacks/exacerbations) that can prove fatal. Symptoms include; intermittent
presence of wheeze, breathlessness, chest tightness and cough. Airway obstruction results from
airway hyper-responsiveness and inflammation resulting in swelling of airway walls and
accumulation of secretions. Triggers can include viral infections, exercise and allergens. Up to 5.4
million people in the UK are currently prescribed treatment for asthma. During 2011-12 there were
more than 65,000 hospital admissions for asthma in the UK. Asthma is still killing people and the
number of reported deaths in the UK is the highest in Europe.1
COPD is characterised by airflow obstruction that is not fully reversible. The obstruction
does not change markedly over several months and is usually progressive. COPD is predominantly
caused by smoking however occupational exposures may also contribute to the development of
COPD. Exacerbations occur where there is a rapid and sustained worsening of symptoms. The
airflow obstruction occurs because of a combination of airway and parenchymal damage caused
by chronic inflammation that differs to that seen in asthma. COPD is estimated to affect 3 million
people in the UK. It produces symptoms, disability and impaired quality of life.2 One person with
COPD dies every twenty minutes in England, which is approximately 23,000 deaths a year. Death
rates are almost double the average for Europe. 15% of those admitted to hospital with COPD die
within 3 months and around 25% die within a year of admission.3
The mainstay of treatment for both asthma and COPD is inhaled therapy. Short-acting
bronchodilators (‘reliever’ inhalers) are used when required to relieve breathlessness/wheezing.
Maintenance treatment is with ‘preventer’ inhalers such as those containing corticosteroids and/or
long-acting beta2 agonists (LABAs) or long-acting muscarinic agonists (LAMAs) in the case of
COPD.2,4 There is a wide range of different inhaler devices on the market with different
mechanisms of drug delivery in to the lungs. Examples include metered dose inhalers (MDIs) and
dry powder inhalers (DPIs) e.g. TurbohalerTM and AccuhalerTM. Different devices require patients
to use different inhalation techniques and inspiration rates (IR). Many patients are prescribed more
than one different type of inhaler device.
It is widely recognised in primary care that inhaler technique among patients is often poor.5
Whilst prescribing might be optimal, if a patient is not using their inhaler properly this can lead to
poor condition control and medicines waste either lost in to the atmosphere or in to the body if the
medicine is swallowed. Poor condition control can lead to more intensive management such as
unnecessary hospital admissions, increased practice visits, and higher preventer inhaler doses.6
Any drug that gets into the body but not into the lungs is undesirable and can result in side effects.
Beta2 agonists can cause tremor and tachycardia. Inhaled corticosteroids can cause
oropharyngeal candidiasis (oral thrush) and systemic effects such as hypertension and reduced
bone mineral density.
Performing a check of inhaler technique and practical instruction of inhaler use by an expert
should be the first line of action if a patient’s symptoms are not controlled. There is a concern that
many health professionals do not know themselves how to teach inhaler technique.7 Pharmacists
are all taught as part of their undergraduate course about different inhaler devices.6 Community
pharmacists with their knowledge of inhaler use and frequent contact with inhaler users should be
commissioned to provide services to support patients to optimise the use of their inhaled
medicines.
The pilot Pharmacy Local Professional Network for NHS South Yorkshire & Bassetlaw
developed a respiratory support service that could be deployed within existing Medicines Use
Review (MUR) or New Medicines Service (NMS) consultations. Supported by Barnsley, Bassetlaw,
Doncaster, Rotherham and Sheffield Local Pharmaceutical Committees (LPCs), the project ran
from September 2012 until the March 2013. Evaluation of the service concluded: most people
were not in the optimum inspiration rate (IR) range for their inhaler device, however the
pharmacists helped over 1,000 people achieve the range during one consultation.
There was little need to contact prescribers. Most patients agreed that their knowledge and
confidence had increased. By encouraging people to maintain good inhaler technique it could lead
to a potential reduction in hospital admissions, GP consultations, prescribing and other NHS
costs.6
There are examples of similar community pharmacy respiratory projects across the country,
some of which have demonstrated reduction in prescribing costs and hospital admissions such as
one in the Isle of Wight . The project, involving enhanced consultations for COPD/asthma patients,
reported that reliever therapy (measured by ePACT) showed that within the first year costs of
selective beta-agonists fell by 22.7% - a saving greater than seven times the initial investment by
the PCT. Additionally, within 12 months, the Isle of Wight PCT was able to demonstrate that
emergency admissions due to asthma had reduced by 50%, and deaths by 75%.8
NHS Yorkshire and the Humber evaluated a project where pharmacists and technicians
received advanced inhaler technique training and targeted patients for respiratory MUR or NMS
consultations. The pharmacists and technicians successfully retrained 97.7% of patients who had
been found to be using their inhaler device incorrectly.9 In Wessex, the Inhaler Technique
Improvement Project was able to show improvement in the health of people with COPD and
asthma using the Asthma Control Test (ACT) and COPD assessment scores. Benefits included
secondary care reduction in emergency admission, reduction in medicines waste and reduced
prescribing due to improved symptom control.10 In Greater Manchester a Community Pharmacy
Inhaler Technique service evaluation found that patients seen by a pharmacist showed
improvements in inhaler technique, target inspiration flow rate, asthma/COPD control indicators
and quality of life measures.11
Doncaster has a population of around 302,402.12 Figures from records at GP practices in
Doncaster in 2010/11 show the number of patients registered with a diagnosis of COPD was 7,711
and with a diagnosis of asthma was 21,023.13. Between April 2013 and February 2014 there were
313 emergency admissions for asthma at Doncaster Royal Infirmary with inpatient costs totalling
£306,127. During the same period there were 869 emergency admissions due to COPD with an
inpatient cost of £1,871,651.14 Improved inhaler technique and adherence with prescribed inhaled
medication may help reduce the number of emergency admissions due to COPD and asthma in
Doncaster.
A confidential enquiry published recently; the National Review of Asthma Deaths (NRAD)
calls for an end to complacency around asthma care so that more is done to save lives. This
enquiry from the Royal College of Physicians is the first national investigation of asthma deaths in
the UK and the largest study worldwide to date.1 This enquiry found there was widespread underuse of preventer inhalers and excessive over-reliance on reliever inhalers. There was evidence of
inappropriate prescribing of LABAs with 3% of patients prescribed a LABA without an inhaled
corticosteroid. 10% of patients who died did so within one month of discharge from hospital
following treatment for asthma; at least 21% had attended an emergency department at least once
in the previous year. Nineteen percent of those who died were smokers and others were exposed
to second hand smoke in the home.1
NRAD recommends; better monitoring of asthma control; where loss of control is identified,
immediate action is required. All asthma patients who have been prescribed more than 12 shortacting reliever inhalers in the previous 12 months should have an urgent review of their asthma
control. An assessment of inhaler technique should be routinely under taken annually and when a
new device is dispensed. Non-adherence to preventer inhaled corticosteroids is associated with
increased risk of poor asthma control and should be continually monitored. Where LABAs are
prescribed for people with asthma they should be prescribed with an inhaled corticosteroid in a
single combination inhaler device. There needs to be better education for patients to make them
aware of the risks. They need to be able to recognise the warning signs of poor control and what to
do during an attack.1 Current guidelines for the management of patients with COPD recommends
that patients should have their ability to use an inhaler device regularly assessed by a competent
healthcare professional and if necessary, should be re-taught the correct technique.2
As previous studies have shown community pharmacists have the skills and knowledge to
help improve use of inhaled medication and through opportunistic targeting of patients when they
present at the pharmacy they may be able to provide interventions to patients who may not
routinely access services and support from their GP practices. Doncaster Local Pharmaceutical
Committee (LPC) secured Winter Pressures funding from NHS Doncaster to re-commission the
respiratory support service developed by the pilot Pharmacy Local Professional Network for NHS
South Yorkshire & Bassetlaw in Doncaster from January to March 2014 to improve management of
respiratory conditions in Doncaster. This report is an evaluation of this service.
1.1 Description of Service
The service aims to improve the management of patients with respiratory conditions by
trained pharmacists undertaking targeted inhaler technique training to ensure that patients use
inhalers correctly. Patients aged 18 and over, including those who reside in a nursing/residential
home or are housebound are eligible for the service. Pharmacies target patients who have been
prescribed an inhaler and offer them a face-to-face review with the pharmacist and training in use
of their inhaler, using the In-check DIALTM device. This could be part of a Medicines Use Review
(MUR) or a New Medicines Service (NMS) with patients who use inhalers. The service includes a
discussion about the diagnosis of respiratory disease (specifically asthma or COPD), pattern of use
of different medicines (including inhaled and oral forms), and symptom control as well as
assessment of inhaler technique. Pharmacies also accept referrals from other members of the
health care team who consider that a patient would benefit from this service.
Interventions made as part of an inhaler technique check may, but not exclusively include:
advice on inhaler usage aiming to develop improved adherence, effective use of ‘preventer’
inhalers, effective use of ‘reliever’ inhalers, ensuring appropriate use of different inhaler type,
identification of the need for a change of inhaler type to facilitate effective use and appropriate
referral to GP or nurse prescriber when necessary. The service specification can be found in
Appendix 1.
1.2 Aim:
To evaluate a Community Pharmacy Inhaler Check Service in Doncaster.
1.3 Objectives:

To identify whether community pharmacists can target respiratory patients to provide faceto-face consultations to assess inhaler technique and provide interventions to improve
management of their condition and quality of life.

Identify the number of patients using the service, the types of inhaler devices being used
and technique/compliance issues being experienced by patients and the interventions
being provided by community pharmacists.

Explore any additional advice/patient education provided by pharmacists to improve
condition management and health and well-being.

Explore patient experience/satisfaction with the service.

To explore feasibility of re-commissioning of the service and identify future service
development/improvements.
2. Methodology and Methods
Formative evaluation of the service using mixed methods was conducted to gather
information regarding the structure, processes and outcomes of the service and identify any
benefits.15,16 This was necessary to take account of stakeholder perspectives and evaluate how the
service could be developed/improved.
Quantitative methods were employed to conduct analysis of data collection records made
by pharmacists during consultations and a patient satisfaction survey/questionnaire. 15,17 A
questionnaire/survey method was chosen to explore patient experience rather than
interviews/focus groups because it was felt more honest/open responses would be obtained using
an anonymous questionnaire. There were also other disadvantages of focus groups to consider;
finding a suitable/accessible venue, resources e.g. refreshments, travel for participants and the
associated costs.18 A qualitative approach to explore patient experience was incorporated in to the
patient questionnaire by asking patients to write additional comments.
The audit and patient questionnaire methods were based on positivism and provided
quantitative data for analysis. The additional comment section of the patient questionnaire
provided qualitative data for analysis. 15,19
2.1. Ethical considerations
This project falls within the remit of service evaluation therefore ethical committee approval
was not required.
2.2 Audit
A paper based data collection tool that had been designed and used in the respiratory
support service developed by the pilot Pharmacy Local Professional Network for NHS South
Yorkshire & Bassetlaw previously was used for data collection (appendix 1). Data was collected for
consultations conducted between January and March 2014. The following operational data were
recorded for each consultation in each pharmacy:
Inhaler Check Service Dataset

Pharmacy Code

Date/Month of consultation

MUR or NMS

Presenting condition (asthma or COPD)

Understanding of ‘control’

Any previous inhaler instruction

Current oral, inhaler and other (e.g. nebulised) respiratory therapy

Inhaler type/s used, with In-Check results for each inhaler type

Whether target rate was achieved before leaving, for each inhaler type

Frequency of preventer inhaler use

Frequency of reliever inhaler use

Relevant associated history (oral thrush, chest infections)

Action taken (instruction only / signpost to GP or nurse / contact GP or nurse)

Any other advice given
Data recorded was inputted into an electronic dataset. Data collected was anonymous.
2.3 Patient Questionnaire
A structured questionnaire was designed (appendix 1) including a mixture of closed questions
with pre-coded response choices to enable collection of unambiguous and easy to count answers
providing quantitative data for analysis. Leading questions were avoided reducing interviewer bias.
A mixture of dichotomous and Likert scaled response formats were used. The Likert scale was
chosen because it is easily understood and analysed.15 Information was gathered about patient
sex, age, awareness of service before coming to pharmacy, ratings of understanding of condition
and medicines since review, use of inhaler, explanation by the pharmacist, usefulness of advice
and whether they would recommend the service to a friend.
Questionnaires were given to patients in person at the end of their consultation and asked to
complete it either in the pharmacy or at home. This was an opportunistic/convenience sampling
method. The questionnaire explored the patients’ experience and satisfaction of using the
service.15,20
2.4 Limitations
The methods used may have been limited by investigator bias. The investigator was one of
the community pharmacists providing the service; this may have influenced the results obtained.
2.4.1. Audit:
The audit results may have been limited by information bias and poor piloting of the data
collection tool.15 Due to time pressures to implement the service as soon as possible to make use
of Winter Pressures funding the data collection tool was not piloted as it had been used previously.
Using a paper based method of data collection resulted in some information being left blank.
2.4.2 Patient questionnaire:
Questionnaire design, question wording and scale construction may have influenced the
results. Patients are more likely to report being satisfied in response to a general satisfaction
question using the Likert scale than they are to more open-ended, direct questions and simple
‘yes/no’ dichotomised pre-coded response choices. Codes ranging from ‘strongly agree’ to
‘strongly disagree’ have the potential of leading to a set response.15 Using pre-coded response
choices may not have been sufficiently comprehensive therefore some respondents may have
been ‘forced’ to choose inappropriate pre-coded answers. Despite these limitations the Likert scale
is the most commonly used scale in health research. The results may have also been affected by
recall bias and it was a disadvantage that the interviewer wasn’t present to clarify/probe and some
respondents may not have understood all questions.15
Asking patients to complete the questionnaire in the pharmacy may have introduced
interviewer bias and non-response bias. Patients may not have been as open and honest with their
responses or may have declined to complete the questionnaire if they thought the pharmacist
would see their responses.
2.5 Data Analysis
The data from all pharmacies was inputted into an Excel spreadsheet. The data was then
imported into IBM SPSS statistical software (version 21). This facilitated descriptive and
comparative statistical exploration of the dataset, where this was possible and valid.
3. Results
3.1 Service Activity

Data was provided for analysis for a total of 616 Inhaler Check Service consultations
conducted between January and March 2014.
Chart 1: Number of Consultations
Conducted per Month (n=594)
Number of consultations conducted
249
196
149
January




February
March
There were more consultations provided in February. This could be due to the fact that
pharmacist training for the service was not provided until the middle of January delaying
start up of the service. Some pharmacists may have been providing the service as an
adjunct to a Medicine Use Review (MUR), reaching the 400 MUR target in February or
early March resulting in a drop in service provision for March.
Actual activity was only 37.28% of predicted activity.
The vast majority of service delivery was provided by Association of Independent Multiple
Pharmacies (AIMp) and independent pharmacies.
65 pharmacies signed up to provide the service 50 pharmacies provided the service, 29
submitted data for evaluation. The number of consultations provided by these pharmacies
ranged from 1-155 over the 3 month period with an average of 21 consultations per
pharmacy per month.
3.1.2 MUR or NMS

The majority of the consultations took place within a MUR (80.2%, n=494)
3.2 Costs





Figures obtained from NHS Doncaster relating to payments made to pharmacies for
providing the service between January and March 2014 totalled £5224.
Average monthly spend: £1741.33
Initial set up costs/training plus service evaluation: £2337.50
Overall spend on the service: £7561.50
Estimated cost for the year if the service was to continue and activity levels are maintained:
£20,896
3.3 Patient Demographics
3.3.1 Patient Age:
Chart 2: Ages of Patients Assessed
(=570)
Percentage of Patients
28.1
24.2
20.5
13.3
7.5


2.8
3.5
18-24
25-34
35-44
45-54
55-64
Patient Age (Years)
65-74
75+
86% of the participating patients were aged 45 or over.
The mean age of the participants was 63 years, with a range from 18-98 years.
3.3.2 Patient Sex:

Slightly more females (58.9%) than males (41.1%) had a consultation (n=555)
Chart 3: Gender Mix in each Age Group

there were more women than men in each age group with the exception of the 25-34 year
olds where there were slightly more men.
3.4 Audit Results
Number of Inhaler Check Service consultations audited: 616
3.4.1 Diagnosis
Chart 4: Diagnosis as reported by
patients (n=595)
Percentage of Patients
66.4
23.4
8.6
Asthma
COPD
Unsure
1.7
Other e.g.
bronchiectesis,
infection
Number of Medicines


Two-thirds of patients reported asthma as their condition (66.4%, n=595), with nearly a
quarter reporting COPD (23.4%).
A significant minority were unsure of their diagnosis (8.6%).
3.4.2 Previous Inhaler Technique Instruction
Most patients had received some previous inhaler technique instruction (68.3%, n=594) (Table 1).
Patient-reported Previous Instruction Type
% of consultations
(n=594)
Verbal instruction
39.2
Practical Instruction
29.1
No previous Instruction
31.6
Table 1 – Previous Inhaler Technique instruction reported by patients
3.4.3 Inhaler Therapy
Chart 5: Type of Inhaler Used
% of patients (n=616)
82.2
28.6
15.9
11.7
5.5
0.3
1.1
MDI any Turbohaler™ Accuhaler™ Easyhaler™ Clickhaler™ Twisthaler™
combination

Other
Inhaler
The vast majority of patients were prescribed a MDI (of these, 74.8% alone, 6.8% with
spacer, 0.6% with spacer and facemask).
3.4.4.Number of inhaler types used
Chart 6: Number of Different Inhaler
Types Used
Percentage of Patients
60.6
34.4
5
1 type of inhaler

2 types of inhaler
3 types of inhaler
60.6% of patients were using one type of inhaler only (n=616). The range was from 1-3
types. Patients could have been using several different inhalers within one type, with
different active ingredients (such as a salbutamol and beclometasone MDI) – but this detail
was not included in the dataset.
3.4.5 Other Respiratory Therapies
A small minority of patients reported having either adjunct oral respiratory therapies (9.6%) or other
adjunct therapies like a nebuliser or oxygen (1.6%). Most oral therapies were not specified, but
some pharmacists added notes that these were long-acting relievers or intermittent steroids. Thus
inhalers were the sole respiratory therapy for most patients.
3.4.6 Patient Performance – Inspiration Rate Change
Table 2 shows how many patients, regardless of diagnosis, were outside the optimum inspiration
rate range at the start of the consultation for each inhaler type. It also shows how many of those
people achieved the target rate by the end of the consultation.
Type of Inhaler
% of patients
% of patients
% of patients
% achieving
Used / Range /
under target
in range
over target
range by end of
Number
at first
at first
at first
consultation
MDI any
3.7
27.1
69.2
98.8
combination (30-60
l/min) (n=483)
Turbohaler™ (30-90 14.7
78.2
7.1
98.7
l/min)
(60-90 l/min)
(n=170)
Accuhaler™
11.9
83.6
4.5
100.0
(30-90 l/min) (n=67)
Clickhaler™
0.0
100.0
0.0
100.0
(>55 l/min) (n=1)
Twisthaler™
0.0
100.0
0.0
100.0
(28-60 l/min) (n=7)
Easyhaler™ (306.7
76.7
16.7
100.0
90L/min)(n=30)
Table 2 – Proportion of patients (with any diagnosis) inside or outside the optimum IR range





72.9% of patients prescribed a MDI (with or without a spacer/spacer with mask) had an
initial inspiration rate out of the optimal target range.
21.8% of patients prescribed a Turbohaler™ had an initial inspiration rate out of the optimal
target range.
16.4% of patients prescribed a Accuhaler™ had an initial inspiration rate out of the optimal
target range.
A total of 400 patients had an initial inspiration rate out of the target range.
Over 98% of patients achieved target range by the end of their consultation.
Chart 7: MDI inspiration rate results

The majority of patients using a MDI were inhaling far too fast and therefore were over the
target range regardless of their diagnosis.
Tables 3a and 3b (overleaf) show how many patients, with a diagnosis of asthma or COPD
respectively, were outside the optimum inspiration rate range at the start of the consultation for
each inhaler type. It also shows how many of those people achieved the target rate by the end of
the consultation.
Type of Inhaler
Used / Range /
Number
MDI any
combination (30-60
l/min) (n=318)
Turbohaler™ (30-90
l/min)
(60-90 l/min)
(n=105)
Accuhaler™
(30-90 l/min) (n=37)
Clickhaler™
(>55 l/min) (n=1)
Twisthaler™
(28-60 l/min) (n=4)
Easyhaler™ (3090L/min)(n=22)
% of patients
under target
at first
2.8
% of patients
in range
at first
23.9
% of patients
over target
at first
73.3
% achieving
range by end of
consultation
98.8
8.6
83.3
10.5
98.9
8.1
86.5
5.4
100.0
0.0
100.0
0.0
100.0
0.0
100.0
0.0
100.0
4.5
77.3
16.7
100.0
Table 3a – Proportion of patients (with asthma only, n=487) inside or outside the optimum
IR range
Type of Inhaler Used / Range /
Number
% of patients
under target
at first
% of patients
in range
% of patients
over target at
first
MDI any combination
(30-60 l/min) (n=106)
Turbohaler™
(60-90 l/min) (n=51)
Accuhaler™
(30-90 l/min) (n=22)
Clickhaler™
(>55 l/min) (n=0)
Twisthaler™
(28-60 l/min) (n=3)
Easyhaler™ (30-90L/min)(n=7)
3.8
31.1
65.0
% achieving
range by end
of
consultation
98.0
27.4
70.6
2.0
97.8
22.7
77.3
0.0
100.0
0.0
0.0
0.0
0.0
0.0
100.0
0.0
100.0
14.3
71.4
14.3
100.0
Table 3b – Proportion of patients (with COPD only, n=189) inside or outside the optimum
IR range




The majority of patients with asthma or COPD using MDIs did not meet the target IR on
their first attempt: most of them were above the optimum IR of 60 l/min.
Over 20% of patients with either asthma or COPD using Turbohalers™ did not hit the range
first time. Many of the Turbohaler™ patients, however, were under target.
A greater number of COPD patients compared with asthma patients did not hit the optimum
range first time, inhaling slower than the target rate.
Patients using Clickhalers™, Twisthalers™ and Easyhalers™ (in much lower numbers)
were largely successful at meeting the target IR on their first attempt.
Chart 8: MDI use and previous inhaler instruction




144 patients (30.6%, n=471) prescribed a MDI reported they had not had any previous
instruction. 107 (74.3%) of these patients had an initial IR out of the optimal/target range
(70.1% over target). This was statistically significant (chi-square test, p>0.001).
A large number of patients (161 patients/84.3%) who had previous verbal instruction had an
initial IR out of range.
Patients who reported having previous practical instruction performed better on initial
inspiration with 74 patients (54.4%) out of range.
235 patients (49.9%) who reported having previous instruction (verbal or practical) still had
an initial IR out of range.
3.4.7 Condition Control
Patients with a diagnosis of asthma were asked if they knew what ‘control’ meant. Although there
was a significant amount of missing data for this question (42% non response), the vast majority of
patients (85.9% of the 177 asthma patients for whom data were recorded) said that they
understood what it meant.
Other markers of condition control were embedded within the project. Patients were asked about
usage of preventer and reliever inhalers. Charts 9 and 10 show the reported frequency of
preventer use and charts 11 and 12 the reported frequency of reliever use.
Chart 9: Patient-reported Frequency of
Inhaler Use (all patients)
% of consultations (n=587)
85.3
Regularly
2.9
1.9
1.9
Sporadically
When Required
Not Used
8
Has never been
prescribed a
preventer inhaler
Chart 10: Patient-reported Frequency
of Preventer Inhaler Use (asthma only)
% of consultations (n=385)
86.8
Regularly

3.38
2.08
1.3
Sporadically
When Required
Not Used
There were high reports of regular preventer use from the majority of patients (84.9% of all
patients and 86.7% of patients with an asthma diagnosis).
Chart 11: Patient-reported Frequency
of Releiver Inhaler Use (all patients)
% of consultations (n=549)
31.1
27.9
20.6
13.1
7.3
At least 3 times a Once or twice a 1-3 times a week 3-6 times a week
day
day
Hardly ever
Chart 12: Patient-reported Frequency
of Reliver Inhaler Use (asthma only)
% of consultations (n=359)
31.8
30.6
21.7
9.7
6.1
At least 3 times a Once or twice a 1-3 times a week 3-6 times a week
day
day

Hardly ever
More than one third of patients reported using reliever inhalers at least once a day (44.2%
of all patients and 41.5% of asthma patients).
3.4.8 History of other respiratory problems


Nearly two-thirds (69.99%) of patients reported a past history of chest infections. There was
no association between history of chest infection and knowledge of asthma control in
asthma patients, nor any age-related association (chi-square test, p>0.05).
A quarter (26.3%) of patients reported a past history of oral thrush. There was no
association between having a history of oral thrush and whether a patient’s initial inspiration
rate measured for MDI was out of the optimal target range (chi-square test, p>0.05).
3.4.9 Interventions Provided by the Pharmacist
Recording of whether or not an intervention was required was poor, which may be due to
limitations of the dataset.. Sixty-three percent of patients (n=388) were given at least one
intervention by the pharmacist.
Different Types of Interventions
Delivered to Patients (n=616)
% of consultations (n=616)
57.1
4.2
Inhaler Instruction


10.6
1.6
Signposting patient to Contacting the GP or
GP or practice nurse practice nurse on the
patient’s behalf
Giving other advice
Over half (57.1%) of the patients were given inhaler instruction. There were only 36
instances (5.8% of consultations) where a pharmacist signposted patients to their practice,
or contacted a GP/practice nurse on the patient’s behalf.
‘Other advice’ included information about rinsing their mouth after using steroid inhalers,
smoking cessation prompts, and using preventer inhalers regularly.
3.4.10 Other advice given
A number of themes emerged regarding other advice given to patients by pharmacists:







Difference between inhalers and when to use them
Peak flow readings
Correct dosage
Use of spacer
Timings of doses
Minimising side effects e.g. rinse mouth
Smoking cessation



Flu and pneumonia vaccinations
Allergy advice
Cleaning inhaler/spacer
The most frequently reported was advice about the difference between the inhalers prescribed and
when to use them and how to minimise side effects.
3.5 Patient Questionnaire Results
577 questionnaires were returned for analysis. Response rate: 93.7%
Questions 1and 2 provided information on patient demographics (see 3.3)
Question 3: Knew the Service Existed

Patients were asked whether they had known that the service existed before they used it. A
small minority of patients (14.6%, n=553) had known about it beforehand.
Questions 4-10: Explored patient satisfaction and thoughts regarding the service:
Chart 9: Patient Evaluation of the Service
Would recommend service (n=564)
Advice given by pharmacist was useful (n=565)
Use of inhaler has improved (n=555)
More confident about their medicines (n=564)
Understand more about their medicines (n=565)
Explained how medicines worked (n=567)
Understand more about their condition (n=567)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of Patients
Strongly Agree




Agree
Uncertain
Disagree
Strongly Disagree
98.8% of patients agreed/strongly agreed that they understood more about their condition
following their consultation.
100% of patients agreed/strongly agreed the pharmacist explained how their medicines
worked.
99.1% of patients agreed/strongly agreed that they understood more about their medicines
after their consultation with the pharmacist.
99.2% of patients agreed/strongly agreed that they felt more confident about their
medicines.



96.8% of patients agreed/strongly agreed use of their inhaler(s) had improved following the
consultation.
99.7% of patients felt the advice they were given was useful.
99.8% of patients would recommend the service to others.
Free text comments from Patients
Patients were encouraged to contribute their own comments about the service at the end of the
patient survey. One hundred and forty-four patients chose to do so. Thematic analysis of these
comments resulted in some interesting categories, as shown in Table 1.10:
Theme
Patient Comments
“Revelation” comments
“Been taking inhaler 20 years and never
been offered information. shows that I
have been using incorrectly. Given me
very valuable new insight”
“Useful as do struggle to control asthma.
Previous inhaler changes have led to
problems (worsened asthma / thrush and
hoarseness)”
“Did not realise I was not using my
inhaler well until pharmacist showed me.
More helpful then the hospital clinic”.
“Thought I was good using inhalers but
learnt a lot from the pharmacist that will
help me”
Pharmacists performance
“No idea that using incorrectly or that
compliance caused such a problem”
“Very easy to understand and helped
with other problems”
“Pharmacist was exceptionally helpful
and explained everything in detail. This
made me feel more confident”
“Very informative”
Inhaler use
“The pharmacist was very helpful and
friendly”
“Felt improved technique”
“I will endeavour to use my inhaler
correctly”
“Surgery have never commented on how
I used inhaler”
“No one ever corrected technique before.
Very useful service”
“First time using inhaler”
“Excellent service - would be
advantageous for health professionals to
revise there technique”
Use of In-check device
“The pharmacist agreed my technique
was good”
“Like breathing tube - helps
understanding”
“Good to be able to check way inhalers
are used”
“Everyone should be tested it is
important”
Patient education/increased knowledge
“Size of mouthpiece on inhaler tester
completely different to those on inhaler
uses - much bigger”
“Didn’t know should be using brown
inhaler daily”
“Too much blowing - now know I should
breathe in”
“Didnt realise MDI/ turbohaler should be
used differently”
“Very informative, learnt something new
today”
“Never been told to rinse mouth before”
“Useful information about rinsing mouth”
Quality of the service
“Useful information”
“Impressed with the service and will bring
son in to test his technique”
“Would recommend to others”
“Excellent service as surgery often too
busy”
“Brilliant”
“Very useful”
“Excellent”
“Big help, well worth doing”
“Good confidential service”
“Excellent and informative”
4. Discussion
Meeting the project aim and objectives
The aim of this project was to evaluate a community pharmacy inhaler check service.
Although the data collection period was relatively short the use of mixed methods increased the
validity of the results. The aim and objectives were met.
Service Activity
Actual activity was less than the predicted activity. It was difficult to accurately predict the
number of patients likely to be recruited. The majority of service delivery was provided by
Association of Independent Multiple Pharmacies (AIMp) and independent pharmacies. It was
disappointing that service delivery from the larger Company Chemist Association (CCA) multiple
pharmacies was extremely low. The short period of time the service has been running has
prevented engagement with CCA senior/regional managers.
Although actual service activity was lower than predicted the number of consultations
provided does demonstrate that community pharmacies can provide and deliver an inhaler check
service. Which is supported by findings from similar projects across England.8,9,10,11
Costs
Overall spend on this service so far has been £7561.50 (including initial setup/training costs).
The estimated cost for a year if service activity levels remain the same is £20,896. The average
inpatient cost for one patient admitted to DRI with asthma is £978, and the average inpatient cost
for one patient admitted with COPD is £2153.80. If nine COPD patients or twenty-one asthma
patients improved their inhaler technique and were prevented from being admitted with an asthma
attack/COPD exacerbation this would cover the cost of the service for one year.
During this three month evaluation community pharmacists helped almost 400 patients who did not
achieve optimal IR on initial assessment to meet the target IR for their inhaler optimising the use of
their inhaled medication. Therefore the number of people who could be prevented from having an
asthma attack/exacerbation could potentially be much greater than the number needed to cover
the costs of the service and therefore could potentially lead to a reduction in inpatient costs,
creating savings for NHS Doncaster.
The short time period that this service has been running for makes it difficult to identify
whether or not this service has had an impact on the number of hospital admissions for asthma
and COPD. Figures provided by NHS Doncaster do show a decrease in admissions for both
asthma and COPD for the period January to March 2014 compared to the same period in 2013
however it must be noted that this winter has been milder which may have contributed to a
reduction in the number of people experiencing exacerbations/worsening of condition control.
Service user characteristics
The Service was used by a diverse group of patients, in terms of age and gender and
respiratory diagnosis. The over-representation of young women reflected what is already known
about pharmacy customer groups. A minority (8.6%) of users who had been prescribed inhalers
were unsure about their diagnosis, and this suggests a knowledge gap that is of significant
concern.
Inhaler Therapy
The majority of patients were using MDIs, which is in-line with current guidelines as
evidence has shown that in adults a MDI with/without a spacer is as effective as any other hand
held inhaler device and is cheaper.4 However it is well documented that patients find these difficult
to use and have a tendency to go ‘over-target’ for IR. Seventy-three percent of patients using a
MDI in this evaluation had an initial IR out of the optimal target range, with 69.2% being ‘overtarget’. The evaluation results suggest that prescribing MDIs is a false economy if inhaler
technique is not checked regularly. With such a high percentage of patients using their devices
incorrectly this will have a negative effect on condition control, increasing requests for ‘reliever’
inhalers and resulting in medicines waste, which may also result in side effects for the patient, as
well as increasing prescribing costs. Some patients were using a number of different inhaler
devices, which could be confusing.
Despite the high percentage of patients out of the optimum IR range on initial assessment
the community pharmacists brought over 98% of these patients into the optimum IR range for their
device/s during the single consultation for the service. Further research (such as follow-up after 6
months) could explore whether the positive technique change can be sustained over time. The
impact on prescribing costs could be investigated over time by analysing ePACT data.
Previous Inhaler Instruction
Almost a third of patients (31.6%) reported that they had not received previous instruction
on how to use their device. A statistically significant relationship was found between patients
prescribed MDIs not achieving the optimum IR rate on initial assessment and reporting that they
had not had any previous instruction.
Patients prescribed MDIs who reported having previous practical instruction performed better on
initial inspiration compared to those with previous verbal instruction or no instruction. However half
of those patients who reported having previous instruction (verbal or practical) still had an initial IR
out of range. These results demonstrate the importance of regular practical instruction and physical
checks of inhaler use to ensure patients’ inhaler use is optimised.
Markers of Control
The high regular preventer use reports were promising however nearly half of patients
(44.2%) reported needing to use their reliever inhaler once or twice daily or more. High reliever use
can be an indicator of poor condition control. Other projects have included the use of the asthma
control test (ACT) and COPD assessment test (CAT) to further assess condition control, the
service could be developed further to include use of such tests.
Oral thrush may be caused by poor technique if steroid powder is left inside the mouth and
not inhaled properly, and might thus be a marker of poor technique – the pharmacist may have an
enhanced role if they had the capacity to add a spacer and facemask as needed, without the need
for referral. Many of the users had a history of chest infections, which may also be a sign of poor
management.
Pharmacist Interventions
Most people were brought into the optimal IR range by the pharmacist, therefore there was
little need for contact with prescribers. The Service is self-contained, and can encourage people to
concentrate on maintaining good technique. People receiving no interventions already had good
technique, thus the interventions seem to have been targeted appropriately.
Patient Feedback/Satisfaction
Patient feedback was extremely positive. The vast majority of patients agreed that their
knowledge and confidence about their medicines had increased, and that they would recommend
the service to others. A number of themes emerged from analysis of additional comments which
included: pharmacists performance, inhaler use, use of the In-check device, patient
education/increased knowledge and quality of the service – all of which were positive. There were
also a number of revelation comments such as “Been taking inhaler 20 years and never been
offered information. shows that I have been using incorrectly. Given me very valuable new
insight” demonstrating the perceived value of this service by patients/service users.
Role for community pharmacists
The evaluation results strongly support the findings of previous projects that there is a role
for community pharmacists in improving inhaler use in patients with asthma and COPD. A large
number of patients were helped to achieve their target IR for their inhaler device optimising the use
of their medication and were provided with interventions, advice and support to maximise their
medicines use, minimise side effects and improve health and wellbeing.
4.1 Limitations
Time pressures to implement the service as soon as possible prevented proper piloting of
the paperwork involved in delivering the service and the data collection tools. There was no time to
develop promotional materials to promote the service to the public which may have impacted on
the predicted numbers of patients seen. The audit enabled information to be gathered regarding
the number of patients identified with suboptimal inhaler use and interventions provided to improve
medicines optimisation, however this method was limited by information and investigator bias and
the poor piloting and design of the data collection record sheet. There is also no information about
any patients who refused to take part in the service, and thus whether there was any selection
bias. Whilst every effort was made to encourage consistency of reporting among pharmacists, the
paper based method of data collection did result in different ways of recording responses and there
were inevitably missing data at submission. A significant amount of data cleaning was necessary
before analysis. Electronic data collection would have prevented any missing data.
The patient questionnaire provided an insight into patients’ views of the service and their
level of satisfaction. The response rate was high minimising bias however the findings were limited
by the questionnaire design and scale structure and by asking patients to complete the
questionnaire in the pharmacy, patients may have been less willing to express dissatisfaction if
they knew that the pharmacist would be reading their responses. This project was a retrospective
analysis of previously collected data, and prospective trials would be required to confirm the results
of this project.
4.2 Recommendations/Implications for practice

This service should be continued. Patients were highly satisfied with the service and the
advice they were given by the pharmacist. Many patients had not achieved optimum IR for
their inhaler device on initial assessment, however the community pharmacists were able to
support almost all these patients to achieve the optimum IR before the end of their
consultation. The service is beneficial to patients and the wider NHS; improving inhaler use
can improve condition control improving quality of life, reducing hospital admissions and
even deaths. By continuing to fund this service NHS Doncaster would be complying with a
number of the recommendations made by the Royal College of Physicians in their
confidential NRAD enquiry.

To develop an electronic reporting system or make use of an existing system such as
PharmOutcomes to improve the completeness and consistency of the dataset.

To implement a ‘fast-track’ referral system to the GP or practice nurse for patients who do
not know their diagnosis, or who continue to struggle to use their inhaler despite pharmacist
intervention, including a feedback loop to the pharmacist.

To explore how to maximise the coverage of the Service by engaging more pharmacies in
activity, so that patients consistently get recruited when they need it - whichever pharmacy
they visit.

The service should be promoted to raise public awareness of the service to help improve
patient recruitment.
Future service development:

To empower the pharmacist to supply a spacer with/without mask during the consultation –
without referral - where this might further improve patient MDI performance;

To extend the service with one follow-up visit with the patient, in person, a month after the
initial consultation, to check whether they have maintained their changes in inhaler
technique and their performance for optimal IR. Patients should then be reviewed yearly.

To see the patient again after any asthma attacks or exacerbations of COPD. Patients
could be referred following any A&E attendances.

To explore expansion of the service to include use of the Asthma Control Test (ACT) and
COPD Assessment Test (CAT). To assess condition control more comprehensively. A
follow-up consultation should then be conducted after 6 months to review performance with
inhaler technique ad any improvement in ACT/CAT scores to measure patient outcomes.

Exacerbation management for COPD patients. Pharmacists could ensure patients
recognise when they need to start antibiotic treatment and ensure prompt access to
antibiotics without the need to contact a GP.
5. Conclusion
The evaluation demonstrates the need for regular inhaler technique checks. Many patients
had not achieved optimum IR for their inhaler device on initial assessment, however the community
pharmacists were able to support almost all these patients to achieve the optimum IR by the end of
their consultation. Community pharmacists have a key role in improving inhaler technique and
inhaled medicines use, complying with recommendations made in current guidelines for asthma
and COPD.
The service is beneficial to patients and the wider NHS; improving inhaler use can improve
condition control improving quality of life, reducing hospital admissions and even deaths, funding
should continue.
References
1. Royal College of Physicians (RCP) Why asthma still kills. The National Review of Asthma
Deaths (NRAD). Confidential Enquiry Report. RCP May 2014.
2. National Institute of Health and Care Excellence (NICE). Clinical Guideline 101: Chronic
Obstructive Pulmonary Disease (update). NICE 2010.
3. National Health Service (NHS). The NHS Outcomes Framework 2013/14. Department of
Health. 2013
4. Scottish Intercollegiate Guidelines Network (SIGN) and the British Thoracic Society (BTS).
101 British Guideline on the management of Asthma. A National Clinical Guideline. May
2008. Revised Jan 2012.
5. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient
education. Respir Care 2005; 50: 1360-74.
6. N.J. Gray. Report of the NHS South Yorkshire and Bassetlaw Community Pharmacy
Respiratory Project. Sept 2013.
7. Baverstock M, Woodhall N, Maarman V. Do healthcare professionals have sufficient
knowledge of inhaler techniques in order to educate their patients effectively in their use?
Thorax 2010; 65(Suppl 4): A118.
8. NICE. Isle of Wight Respiratory Inhaler Project (Shared Learning Database). Available at
http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/exampleso
fimplementation/eximpresults.jsp?o=461
9. C. Hayward. NHS Yorkshire and Humber. Breathing in Success Project NHS Hull and NHS
East Riding of Yorkshire. Oct 2013 – April 2013
10. The Cambridge Consortium. Evaluation of Inhaler Technique Improvement Programme.
Cambridge Institute for Research Education and Management (CiREM). Aug 2012
11. N.J. Gray, N.C. Long, N. Mensah. Report of the Evaluation of the Greater Manchester
Community Pharmacy Inhaler Technique Service. Community Pharmacy Manchester. April
2014.
12. Doncaster Together. Doncaster Data Observatory. Census 2011. Available at:
http://www.doncastertogether.org.uk/Doncaster_Data_Observatory/Census_2011.asp
<accessed 11/5/14>
13. NHS Commissioning Board. Outcomes benchmarking support packs: CCG Level. NHS
Doncaster CCG. 2012
14. Information provided by Jonathan Briggs, Performance and Intelligence, NHS Doncaster
CCG Jonathan.briggs@doncasterccg.nhs.uk
15. Bowling A. Research methods in health. Investigating health and health services. 2nd
Edition. London: Open University Press; 2007.
16. Tritter J. Mixed Methods and Multidisciplinary Research. In Health Care. In: Allsop J, Saks
M, editors. Researching Health qualitative, quantitative and mixed methods. London: SAGE
Publications Ltd; 2007. p.301-318
17. Calnan M. Quantitative Survey Methods in Health Research. Allsop J, Saks M, editors. In:
Researching Health, Qualitative, Quantitative and Mixed Methods. London SAGE
Publications Ltd; 2007 p.174-196
18. Green J. The Use of Focus Groups in Research into Health. Allsop J, Saks M, editors. In:
Researching Health, Qualitative, Quantitative and Mixed Methods. London SAGE
Publications Ltd; 2007 p.112-132
19. Davis P, Scott A. Health Research Sampling Methods. In: Allsop J, Saks M, editors.
Researching Health qualitative, quantitative and mixed methods. London: SAGE
Publications Ltd; 2007. p.155-173
20. Alderson P. Governance and Ethics in Health Research. In: Allsop J, Saks M, editors.
Researching Health qualitative, quantitative and mixed methods. London: SAGE
Publications Ltd; 2007. p.283-300
Appendices
Appendix 1: Service Specification
Service specification for delivery of inhaler technique review and training
Period: 1st January 2014 to 31st March 2014
Introduction
This service specification outlines the service to be provided.
The specification of this service is designed to cover enhanced aspects of clinical care of the patient,
all of which are beyond the scope of essential services.
No part of the specification by commission, omission or implication defines or redefines essential
or additional services.
The pharmacy providing the service must fully comply with the The National Health Service
(Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 for the delivery of Essential
Services and be registered with the GPhC.
All staff working in the pharmacy providing the service must conform to the NHS code of practice
on confidentiality. All staff working in the pharmacy providing the service must conform to the
Data Protection Act.
Background
The aim of this specification is to enable pharmacy to play an even stronger role at the heart of
more integrated out-of-hospital services for patient’s that deliver better health outcomes, more
personalised care, excellent patient experience and the most efficient use of NHS resources.
Service Outline
This service aims to improve the management of patients with respiratory conditions by trained
pharmacists undertaking targeted inhaler technique training to ensure that patients use inhalers
correctly.
This service should be offered to patients who meet the criteria and who are over 18 years of age.
This includes patients who reside in a nursing or residential home or are housebound.
This could be part of a Medicines Use Review (MUR) or a New Medicines Service (NMS) with
patients who use inhalers.
Pharmacies should also accept referrals from other members of the health care team who consider
that a patient would benefit from this service.
The inhaler technique check will be carried out face to face with the patient in the community
pharmacy or in the patient’s usual place of residence.
The part of the pharmacy used for the provision of the inhaler check must meet the requirements of
the MUR specification for consultation areas:
•
•
•
The consultation area should be where both the patient and the pharmacist can sit down
together
The patient and pharmacist should be able to talk at normal speaking volumes without being
overheard by any other person (including pharmacy staff)
The consultation area should be clearly designated as an area for confidential consultations,
distinct from the general public areas of the pharmacy.
Inhaler technique checks must only be provided for patients who have been using the pharmacy for
the provision of pharmaceutical services for at least the previous three months. The next regular
inhaler technique can be conducted 12 months after the last one, unless in the reasonable opinion of
the pharmacist the patient’s circumstances have changed sufficiently to justify one or more further
consultations during this period.
An inhaler technique check should not be undertaken on a patient who has, within the previous six
months, received the New Medicine Service (NMS), unless in the reasonable opinion of the
pharmacist, there are significant potential benefits to the patient which justify providing further
training to them during this period.
Interventions made as part of an inhaler technique check may, but not exclusively include:
•
•
•
•
•
•
Advice on inhaler usage aiming to develop improved adherence
Effective use of regular inhalers
Effective use of ‘when required’ inhalers
ensuring appropriate use of different inhaler type
Identification of the need for a change of inhaler type to facilitate effective use
Appropriate referral to GP or nurse prescriber
The pharmacy will target patients who have been prescribed an inhaler and offer them a review and
training in use of their inhaler.
The pharmacy will provide and maintain all equipment and consumables necessary for the delivery
of this service
Accreditation
The service shall be provided by a practising pharmacist, registered with the General
Pharmaceutical Council of Great Britain pharmacists who has attended and completed the Inhaler
technique workshops (or equivalent that have been accredited by the Local Professional Network).
Payment
The payment will be £10 per patient reviewed in the pharmacy.
A supplementary fee of £5 per patient will be paid for home visits for patients who reside in a
nursing or residential home and £10 will be paid for patients who are visited at their home address
(i.e. not in a nursing or residential home).
The pharmacy will be paid monthly for the number of reviews it has undertaken.
Invoices should be submitted within 14 days of month end for activity undertaken in month
Invoices for March 2014 should be submitted within 7 days of month end. DCCG reserve the right
to withhold payment on invoices not received within these time scales.
Monitoring
The Pharmacy should retain a copy of Appendix A and Appendix B for their records. NHS
Doncaster CCG reserves the right to review and/ or audit data in relation to payments processed for
this service.
Monthly monitoring should be sent to the CCG by way of an invoice detailing the following
information:





Number of patients reviewed
The registered practice of the patient
Age of patient
Diagnosis
Outcome; i.e. advice, treatment referred to GP, referred to another service
ATT: Appendix A&B
Appendix A
Respiratory Medicines Use Review Service - Patient Feedback Form
Thank you for having your medicines reviewed at your local pharmacy. To see if you found the review useful, we would be grateful if you could answer a
few short questions. All replies are strictly confidential and it is not possible for anyone to identify you.
If you have any questions about your review please talk to your pharmacist.
Some Questions about you
1) I am Male/ Female (Please Circle)
2) I am………years old
3) Before your Medicines Use Review today at the pharmacy did you know that this service existed?
Please rate how strongly you AGREE or DISAGREE with each of the statements below:
4) I understand more about my condition since speaking to the Pharmacist
5) The Pharmacist clearly explained how my medicines work
6) I understand more about my medicines since speaking to the Pharmacist
7) I feel more confident about my medicines since speaking to the Pharmacist
8) The way I use my inhaler has improved since speaking to the Pharmacist
9) The advice given to me by the pharmacist was useful
10) I would recommend this service to others
11) Please write any other comments you have about this service:
Thank you for your help with this. Please return to the pharmacist on completion
YES / NO
Please rate the statements below by ticking one box for EACH statement
Strongly
Agree
Disagree
Strongly
Uncertain
Agree
Disagree
Appendix B
Respiratory Service Dataset
Pharmacy Code
(Please tick)
Date
MUR/NMS*
Delete as appropriate
Asthma
COPD
Unsure
Other (Please state)
Diagnosis
Understands
'control'?
Has had previous
Inhaler
Instruction?
Yes- Previous Verbal Instruction
Yes- Previous Practice
Instruction
No Previous
Instruction
Other Respiratory treatments
Tablets
Type/s
Used
by
patient
Other egg. Nebuliser
Initial
Inspiration
Rate
MDI
MDI+ Spacer
MDI+ Spacer with facemask
Accuhaler
INHALER TYPE
Turbohaler
Clickhaler
Twisthaler
Easyhaler
Other
How often do you
use your preventer
Inhaler?
Regularly
History of Oral Thrush?
Sporadically
History of Chest Infections?
When Required
Intervention required?
Not Used
Inhaler Instruction only?
Not Prescribed
Signposted to GP/ Nurse
Contacted GP/ Nurse
How often do you
use your
reliever Inhaler?
At least 3 times daily
1-2 times a day
1-3 times a week
42
Other advice given
Target
Rate
is achieved
before
leaving?
3-6 times a week
Hardly Ever
43