Reflections on the role and value of pharmacists in integrated respiratory care

Integrated care is about giving people the support they need, joined up across local councils, the NHS, and other partners, delivered by the most suitable health professional in the most suitable setting. The integrated care approach is finally gathering pace across the NHS and provides an exciting opportunity for the pharmacy profession.^[1]

In this article, I’ll explore the role and value of pharmacists working in respiratory integrated care services, highlighting the opportunities pharmacists have to improve long-term outcomes for populations with respiratory diseases.

With increasing numbers of patients living with long-term respiratory conditions,^[2] integrated care has risen in prominence as a means of enhancing the care of the individual patient with a lung condition and improving outcomes for populations with respiratory disease,^[3] in a patient-centred structured model.^[3] Medicine optimisation is part of this person-centred approach, focusing on patients and their experiences to help patients with: the right medicine at the right time; avoiding taking unnecessary medications; reducing wastage of medicines and safe prescribing.^[4]

Medicines are an important treatment for any patient with a respiratory disease, and it’s essential that patients are part of the shared decision-making process to understand their medicines. Do they know why they’re taking it? Is it clear they know how, when to take it and are they adhering to it? In long-term respiratory conditions, medication non-adherence is a significant concern.^[5]  Understanding a patient’s concerns, knowledge and beliefs about their medicines is very important to improving respiratory care.^[6]

Promoting optimal prescribing of medicines according to guidelines is key, as is ensuring the best option is prescribed in terms of cost-effectiveness and patient safety.^[7] Many patients with respiratory disease don’t just have respiratory illnesses. Comorbidities are common, and therefore the approach to optimising medicine regimens should take a holistic approach.^[4] Due to the complexity of many respiratory patients’ medicine regimens, I find it is important to review and consider deprescribing where possible and make sure patients are only using the medicines they need to be prescribed, avoiding issues with polypharmacy.

This is where the skills of a respiratory pharmacist can support, not only in medication optimisation, but also in enhancing patient care and support, whilst helping to promote safe effective prescribing and aiming to reduce overall prescribing costs.^[8]

Respiratory pharmacists in integrated care

Pharmacists are the experts in medicines and are very well-trained in terms of managing medicines as well as assessing patients.^[9] Many pharmacists are qualified prescribers. From an integrated care perspective, there are a number of opportunities for pharmacists.

Often, in integrated care, patients are discussed between multidisciplinary teams (MDTs) and a pharmacist would look to make sure:^[10]

• Medicines are prescribed as per guidelines for the patient’s respiratory condition and any other co-existing conditions, taking a holistic approach
• Medicine adherence is as good as it can be and to suggest strategies to improve medicine adherence if required
• There are no adverse side effects or potential drug interactions, reducing medicine-related risk
• Patients can administer their medicine optimally
• Non-pharmacological aspects of care are also promoted, such as pulmonary rehabilitation, nutrition, social prescribing

Nationally, there are excellent exemplars where the role of pharmacists in integrated care respiratory services has been demonstrated, significantly impacting the overall quality of care patients receive and improving medicine optimisation of the service in general.^[11]

Unfortunately, the commissioning of pharmacists for integrated care services is not standard and pharmacy services have traditionally been overlooked.^[12] I believe further evaluations identifying and showcasing the role of the pharmacist in such teams needs to occur to ensure that the pharmacist is not forgotten when services are being developed. Engaging with pharmacy stakeholders during the planning and implementation of new innovative services can help to ensure the needs of the service are supported.

Pharmacists can bring expertise to the wider respiratory team around clinical governance, guideline production and medicine information.

Part of my integrated care role is to ensure that community and GP-based pharmacists, GPs and practice nurses are upskilled and educated on respiratory medicines, empowering them to provide the best care for respiratory patients. Education sessions and discussions include optimising medicine prescribing and inhaler technique, as well as promoting the sustainability agenda when prescribing and disposing of inhalers.

The role helps to facilitate transfer of prescribing information between secondary to primary care, improving communication links between healthcare professionals along the patient pathways, supporting safe discharges and appropriate referrals into secondary care. From an integrated care perspective, it’s bringing this expert specialist knowledge into the community, to bring this care closer to the patient.

Integrated care now

Integrated services that have been developed in the past few years have been particularly helpful during the Covid pandemic. Such services have been instrumental in supporting the management of the backlog of patients not recently reviewed due to Covid, as well as supporting primary care.

Integrated care services that have incorporated virtual wards have helped to support patients being discharged from hospital with respiratory conditions, improving patient flow through acute care, providing support post-discharge and aiming to support re-admissions.

The NHS is increasingly introducing virtual wards to support people at home, including care homes. In a virtual ward, support can include remote monitoring using apps, technology platforms, and medical devices such as pulse oximeters. Support may also involve face-to-face care from multi-disciplinary teams, including a pharmacist based in the community or integrated care service.

Multidisciplinary respiratory virtual clinics (RVCs) offer a further innovative way of bringing together hospital respiratory specialists (doctors, pharmacists and nurses) and primary care clinicians to improve the care of people with long-term respiratory conditions such as COPD.^[13] Such reviews take place in the practice and involve discussions of case notes and treatment plans of a number of patients the practice identifies as being a priority for care.

One programme of virtual clinics in primary care – an integrated team that worked across the hospital and community delivering COPD care, oxygen assessments, referral, provision of pulmonary rehabilitation and supported discharge services – reduced acute COPD admissions to hospital by 34%. Total COPD admission reduced by 8%.^[14] Multidisciplinary integrated working offers huge scope to improve the care of patients with long-term respiratory conditions. Virtual clinics are thought to be an innovative way to achieve this.^[15]

The NHS is starting to build back after the pandemic and the opportunity in the new NHS Structure as an Integrated Care System provides opportunities for pharmacists to support building the NHS back better.

Barriers

I believe lack of funding and ensuring the pharmacist role is commissioned within integrated care services are barriers to the successful implementation of integrated pharmacists in respiratory care. However, having a skilled component pharmacist in the position to provide this service could also be an obstacle in some areas.^[15] It is essential that support and professional development are available for pharmacists taking on innovative roles.

I think pharmacists that work in community and in hospital should come together to break down the barriers to primary, secondary and tertiary care. This is about us all working together – improving that consideration of each other’s roles and working for the patient.

One of the key things that I think can be improved is system and collaborative working across pharmacist roles. Improving communication links for pharmacists working along the patient journey will help to support the care patients receive.

Specialist respiratory pharmacists should be supported to work across the ICS, supporting community pharmacists and GP practice-based pharmacists in their specialty. Recent British Thoracic Society (BTS) guidelines on Workforce in the Future have recommended having a minimum of 250 funded specialist Respiratory pharmacists to ensure one specialist lead in each trust for adult respiratory services. In addition, each specialist commissioned respiratory service has a specialist Respiratory Pharmacist embedded within the Multi-Disciplinary Team (MDT).  BTS guidelines also say seven Regional Consultant Respiratory Pharmacists with oversight of above Respiratory services are needed.^[16]

In conclusion

Where there is an integrated respiratory service, I’d like to see more pharmacists embedded within this service – seeing more pharmacists specialising in respiratory from secondary and tertiary care and in primary care, making sure we have a well-trained and knowledgeable workforce to support respiratory patients.

Integrated care is an exciting opportunity and bringing expertise nearer to the patient and to HCPs can be beneficial for all members of MDTs. The more that we, as a team, communicate and collaborate, the better care we can deliver.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] Partridge MR, Baxter N. Integrated care: respiratory medicine ready and waiting. Future Hosp J. 2016;3(1):37-39

[2] Labaki WW, Han MK. Chronic respiratory diseases: a global view. Lancet Respir Med. 2020;8(6):531-533

[3] Patel I. Integrated respiratory care. Clinics in Integrated Care. 2021;6:100053

[4] Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/helping-patients-make-the-most-of-their-medicines.pdf

[5] Blakey JD, Bender BG, Dima AL, et al. Digital technologies and adherence in respiratory diseases: the road ahead. Eur Respir J. 2018;52:1801147

[6] Bourbeau J, Bartlett SJ. Patient adherence in COPD. Thorax. 2008;63:831-838

[7] NHS UK. Medicine Optimisation. Available at: https://www.england.nhs.uk/medicines-2/medicines-optimisation/

[8] Roberts N.J, Ward M, Patel I, et al. Reflections on integrated care from those working in and leading integrated respiratory teams. London Journal of Primary Care. 2018;10:2, 24-30

[9] Dalton K, Byrne S. Role of the pharmacist in reducing healthcare costs: current insights. Integr Pharm Res Pract. 2017;6:37-46

[10] NICE. Utilising the skills of the clinical pharmacist within the MDT for improved medicines optimisation. Available at: https://www.nice.org.uk/sharedlearning/utilising-the-skills-of-the-clinical-pharmacist-within-the-mdt-for-improved-medicines-optimisation

[11] Royal Pharmaceutical Society. Pharmacists and GP Surgeries. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy%20statements/pharmacists-and-gp-surgeries.pdf

[12] Hindi, A. M. K., Schafheutle, E. I., & Jacobs, S. Community pharmacy integration within the primary care pathway for people with long-term conditions: A focus group study of patients’, pharmacists’ and GPs’ experiences and expectations. BMC Family Practice. 2019;20(1). 26

[13] Primary Care Respiratory Update. Multidisciplinary Respiratory Virtual Clinics. Available at: https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/2018-Winter-Issue-16-Virtual-Clinics.pdf

[14] I Patel I, D’Ancona G, et al. The future hospital: integrated working and respiratory virtual clinics as a means of delivering high-value care for a population. Future Healthcare Journal. 2016;3(Suppl 2):s28

[15] Hesso I, Kayyali R, Nabhani-Gebara S. Supporting respiratory patients in primary care: a qualitative insight from independent community pharmacists in London. BMC Health Serv Res. 2019;19(1):5

[16] British Thoracic Society. A respiratory workforce for the future. Available at: https://www.brit-thoracic.org.uk/document-library/workforce/workforce-people-plan/a-respiratory-workforce-for-the-future/