Supporting respiratory patients in primary care: a qualitative insight from independent community pharmacists in London

Respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) are examples of long-term conditions (LTCs) that have a high economic burden on the healthcare systems worldwide [1–5]. Inhaler therapy represents the backbone for the management of these respiratory conditions [1, 6]. However, poor adherence to inhaled medications and poor inhaler technique have been repeatedly identified to be problematic issues [1, 7–13]. Community pharmacists (CPs) are well placed to provide services to patients with chronic respiratory conditions [1, 12, 14–16]. In the UK, CPs offer a range of services to promote medicine optimisation in patients with LTCs, such as: the Medicine Use Review (MUR) service which is an adherence/concordance review, with respiratory patients as target group and the New Medicine Service (NMS) targeting patients who are newly prescribed a medication for a LTC [17]. Several studies highlighted the positive impact of CPs’ interventions in optimising inhaler technique and adherence for respiratory patients [18]. However, one of the limitations of the current practice is the use of subjective measures for assessing inhaler technique and adherence [10, 19, 20] . The current standard for inhaler technique assessment is a checklist method which varies between studies [1, 21] and has been reported to be subjective [22]. Strategies used to assess adherence were mainly by self-reporting (questionnaires) or using medication refill rate which in essence does not assess actual medication-taking behaviour [23]. Therefore, assistive technologies to objectively assess inhaler technique and adherence have emerged to address such a gap. However, some of these technologies assess adherence alone through recording the date and time of actuations only, such as: the Neubilizer Chronolog (NC), Smart Inhaler Tracker, SmartTrack, and SmartTouch AV [24]. Whereas, others assess inhaler technique alone, such as the Aerosol Inhalation Monitor (AIM) device [25] and Inhalation Manager (IM) [26]. One of the most recent technologies in this domain is the Inhaler Compliance Assessment (INCA^TM) device. The INCA™ device (Fig. 1) is a novel monitoring device that has the advantage of being an automatic and objective measure of both inhaler technique and adherence at the same time while patients using the inhaler at home [19, 20, 27]. The device is manufactured by Vitalograph Ltd. [28]. It is a small acoustic, battery operated device that can be attached to the dry powder inhaler (DPI) without interfering with the mechanism of drug delivery nor the mechanics of the inhaler use [20, 22]. It provides objective feedback in the form of graphical data showing the patient’s adherence (date and time) and inhaler technique (indicating the most common error type). The feedback generated can serve as a guide for healthcare professionals (HCPs) to manage patients, especially those who are receiving an appropriate medication regime but showing no improvement in their condition [20].

The diffusion of such new technologies into practice requires certain pre-requisites and processes to ensure successful adoption and implementation. Rogers Diffusion of Innovation (DOI) [29] theory describes the process experienced by individuals or units in a social system when a new idea/innovation is presented to them. The characteristics of the innovation itself are particularly important in determining its rate of adoption. According to the theory, the following attributes are essential to facilitate the adoption of any innovation: relative advantage (the extent an innovation is perceived to be better than the current available options/practices), complexity (the degree of difficulty of an innovation in terms of understanding and usage), compatibility (the degree of consistency of an innovation with the already existing values, beliefs, experiences and needs of the individuals/adopters), trialability (the extent to which an innovation can be easily tried/experimented on a limited basis before permanent adoption), observability (the extent to which the innovation’s results/outcomes are visible to others).

This study aimed to assess CPs’ perceptions, experiences and current practice towards the management of respiratory patients with respect to inhaler technique and adherence. In addition, this study aimed to highlight CPs’ perceptions and need for an objective measure of inhaler technique and adherence, using INCA^TM technology as an example, given the increased recognition of the impact that technologies can have on improving patients’ outcomes when incorporated in the wider package of care for patients [30].

The research methods of this study are reported in accordance to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [31] (See Additional file 1).

The findings generated in this study shed the light on several issues that were found to be challenging and problematic in terms of managing respiratory patients in the community. Several barriers have been identified; some of these were related to CPs, such as time, workload, lack of resources, lack of incentives, while others were related to patients, such as patients’ health beliefs, patients’ attitudes and lack of time. These are similar to the barriers cited by CPs while supporting asthma patients in Australia [40].

Fragmented care and lack of communication among HCPs in primary care were perceived by CPs to be negatively affecting care provision. This echoes the findings of previous research which showed that fragmented care and lack of communication among HCPs were perceived as a challenge among COPD patients, informal carers and HCPs in four European countries [41, 42]. This is further escalated by the fact that there is no clear role for the CP in the COPD patient care pathway [43]. In another research focusing on CPs’ experiences as service providers in an implementation trial of a specialist asthma service in Australia, CPs have identified collaboration with GPs as a key challenge [44]. Poor integration with other parts of the NHS has been identified in a recent review by NHS England to be among the barriers to better utilisation of the community pharmacy workforce [45]. This, in return, stresses the importance of tackling the problem of poor integration and communication between HCPs, as a way to enhancing care provided to patients.

In the current study, CPs did not clearly recognise their clinical role within the MUR, and perceived a need to promote this role, which highlights lack of recognition of inhaler technique as a clinical intervention among CPs. For some CPs, the clinical role was restricted to stepping treatment up and down for patients. However, for respiratory patients, having correct inhaler technique is pivotal for optimal drug delivery to the lungs [46]. Errors in inhaler technique result in no drug or a reduced amount of drug reaching the lungs [21, 47]. Consequently, rectifying inhaler technique is a purely clinical aspect which can be done by the CP in an MUR. Therefore, this raises an important question about the CPs’ negative perception of the extent of their clinical role. A previous research highlighted that hospital pharmacists identified themselves more with the clinical practitioner identity as compared to CPs [48]. Hospital pharmacists defined clinical work as that undertaken at the patient’s level which involves applying knowledge about medicines to a person’s condition. Even though CPs described their role as spending time with patients talking about symptoms and treatment, they did not explicitly refer to it as being ‘clinical’ [48].

CPs do not usually have full access to the clinical history of the patient and the Summary Care Record (SCR) accessible to UK CPs may not contain adequate information [45, 49]. This was highlighted as a limitation to effective service delivery for respiratory patients. The importance of having full access to clinical information has been previously emphasised [45, 50–52]. Similarly, in a study interviewing CPs about their role in dementia care in the UK, CPs echoed the lack of clinical role in this area and attributed that to isolation, lack of access to patients’ clinical records, poor integration into the healthcare system and being viewed as shopkeepers which provided a sense of inferiority [49]. This in return provides a supportive explanation as to why CPs perceived their clinical role to be lacking, since fragmentation of care and lack of access to patients’ clinical records were raised as problematic issues. Furthermore, a previous research in Scotland indicated that patients with LTCs had more trust in the GP regarding their disease management, due to their access to the full medical history, and were less likely to approach CPs, as the services offered were perceived to be incomplete [53]. This in return highlights the importance of granting CPs’ access to the clinical records of patients. In fact, the rollout of SCR into community pharmacies started in England in mid-2015 and was expected to be completed by end 2017 [54, 55]. Despite that SCR do not include enough information as highlighted earlier, yet CPs should recognise this initiative as a potential opportunity to promote the way they engage with patients and promote the clinical aspects of the services they deliver. The recent update as per May 2018 indicates that more than 93% of community pharmacies have access to SCR and more than 24,000 pharmacy professionals completed their SCR e-learning [56]. Another approach which would also enable CPs to embrace a greater clinical role [57–59] would be pharmacy independent prescribing, which has been introduced in the UK since 2006 [58, 60]. However, the implementation of pharmacist prescribing is poor in community pharmacy setting compared to other sectors, such as hospital and primary care (GP surgeries) [57]. Whilst some barriers to independent prescribing are common across all pharmacy sectors, CPs face additional challenges [57, 58]. In the current study, none of the respondents have reported to be qualified as an independent prescriber.

Poor adherence to inhaled therapy is directly associated with poor clinical outcomes and increased healthcare expenditure [13, 61, 62]. In fact, most participants indicated that patients’ inhaler technique and adherence were a challenge. This is well documented in the literature [9, 11, 13, 18]. Responses of CPs reflected positive attitudes towards the INCA^TM technology and demonstrated the need for such a technology as illustrated by Rogers DOI theory [29] in terms of the attributes that are essential for the adoption of new innovations. The INCA^TM technology was perceived by CPs as an educational tool [20] that provides objective feedback on patients’ inhaler technique and adherence level in real-life situations, compared to the subjective measures used currently [10, 19, 20]. This technology can help CPs in providing personalised advice that is tailored to patients’ needs during consultations, which can support the notion of a clinical role within the MUR. Thus, the introduction of assistive technologies such as the INCA^TM technology can be of particular potential, given the poor engagement and adherence to treatment reported among respiratory patients in the literature [13]. The provision of tailored education using quantitative feedback has been associated with a higher magnitude of improvement in comparison to the current best practice education [63].

Despite perceiving and advocating such potential opportunities, yet CPs willingness to provide new services or upgrade existing services with technology was mainly driven by finances (proper funding and correct re-imbursement). Pertaining to this comes the dual professional/commercial role of CPs, which has been a subject of continual discussion [64] and their professional identity. The study of Elvey et al. [48] showed that while pharmacists were trying to distance themselves from being viewed as shopkeepers, being a business person was an important part of the identity due to the satisfaction attained by having their own business and autonomy. It is clear that although GP and pharmacy services are commissioned in a similar fashion in the UK, the work setting adds to the business perception of pharmacy. Two qualitative studies in the UK [65, 66] reported how the professional identity of CPs underpinned many of the perceived barriers to provision of services to patients with LTCs, including lack of remuneration and the retail environment of community pharmacy.

The current study highlighted some factors affecting the management of respiratory patients in community pharmacies in London, such as fragmentation of primary care and perceived lack of clinical role. Issues pertaining to professional identity, notably remuneration, appeared to be a major driver for willingness to offer new services or promote existing services. The study also highlighted some measures that can augment CPs’ practice while managing respiratory patients, such as the use of technologies, for example the INCA^TM technology, to promote objective counselling to patients regarding inhaler technique and adherence. The study also highlights the need for clinical role recognition and facilitation through accessibility to patients’ records to enable CPs to have a more recognised role in respiratory patients’ care pathway.