After reading this article, you should be able to:
- Describe the role of pharmacy teams in improving asthma care for children and young people (CYP);
- Describe the CYP national bundle of care and capabilities training for asthma care;
- Describe ways pharmacists can integrate improved asthma care into their practice, including drivers for change and medicines optimisation approaches;
- Outline the updates to the British National Formulary for Children with regards to inhalers.
One in 11 children living in the UK have asthma. The UK has some of the worst outcomes compared with other countries in Europe for asthma, with people from areas of lower socio-economic status having poorer outcomes, especially children and young people (CYP)[2,3]. Most hospital admissions and asthma deaths are preventable, but it is important to note that CYP require a different approach to asthma care than adults.
The main dangers for CYP with asthma relate to:
- Overreliance on short-acting beta agonist (SABA) medicines, which increase the chance of hospital admissions;
- Underuse of inhaled corticosteroids and poor adherence;
- Inability to use an inhaler device effectively.
There is unwarranted variation in CYP asthma care across the UK. Two key reports have been published: the Royal College of Physicians’ ‘Why asthma still kills’ in 2014; and the Healthcare Service Investigation Branch’s ‘Management of chronic asthma in children aged 16 years and under’ in 2022[4,5]. Both of these documents have highlighted fundamental failures in asthma care that resulted in unnecessary deaths and untoward outcomes for patients; they made specific recommendations to prevent this in future. However, the All-Party Parliamentary Group for Respiratory Health published reports in 2020 and 2022 that showed there is still much room for improvement in asthma care[6,7].
The formation of integrated care systems (ICSs) in July 2022 embedded respiratory care as a priority, as per the ‘NHS long-term plan’, which is included in the ICS planning framework. NHS England’s ambition is to reduce asthma-related deaths and hospital admissions and improve the quality of life of CYP with asthma.
Pharmacists are uniquely positioned to drive improved asthma care for CYP. They have the clinical expertise to educate patients on their disease state and the role of asthma medicines; they can assess inhaler technique, teaching how to optimise it; and they are able to identify and address non-adherence to treatment. They can also streamline therapies, answer questions about potential side effects of medicines and optimise asthma care overall.
This article will describe ways pharmacists can integrate improved asthma care into their practice, including uptake of the ‘National bundle of care for children and young people with asthma’ standards, access to training and working with patients to improve medicines optimisation.
For more information on the symptoms, diagnosis and management of asthma in children and young people, see ‘Children and young people with asthma: symptoms, diagnosis and the role of pharmacy‘ and ‘Children and young people with asthma: pharmacological management and monitoring‘.
Raising national standards in asthma care
The ‘National bundle of care for children and young people with asthma’, updated in 2022, is part of a phased approach to improving asthma care for CYP. It provides an evidence-based framework for local system improvement and sets out the road map for delivery of asthma care, including:
- Prevention and diagnosis;
- Environmental impacts;
- Acute and chronic management;
- Severe asthma.
It also sets out how care is organised within systems, data and digital considerations, as well as education and training. The bundle is funded by NHS England, with resources available to aid implementation in the wider system. The bundle has an accompanying standards document for ICS deliverables.
Standards for each element of the bundle have been developed and each standard has attached deliverables, supported by enablers and measures of success. The National CYP Asthma Dashboard is a useful resource to support meeting the standards and benchmarking against other regions and ICSs. It links to index of multiple deprivation and includes:
- Prescribing rates and ratios for preventors, relievers and oral corticosteroids;
- Ethnicity at population level to support admission rates by local population;
- Air pollution data;
- Emergency department admissions, including re-attendance rates.
Access to the Dashboard can be requested by contacting NHS England’s Children and Young People’s Transformation Programme.
The Children and Young People’s Transformation Programme has set up a community of practice, with NHS England-funded resources available to enable uptake of the ‘National bundle of care for children and young people with asthma’ across the country. It also provides a space for healthcare professionals to share learning, best practice and collaborative working with other providers, such as the voluntary sector.
Pharmacists in all sectors should engage closely with this approach and advocate for local adoption of the standards into their practice. As a minimum, all pharmacists should access the CYP training offer via e-Learning for Healthcare, completing tier 1 training (see table below), while those working in more specialist roles can access higher tiers dependent on the care they deliver within CYP asthma care.
Education and training are vital to increasing practitioner competence and confidence in asthma care. ‘The national capabilities framework for professionals who care for children and young people with asthma‘ was developed by NHS England and NHS Improvement in 2022, in collaboration with key stakeholders, including national experts, patients’ families and royal colleges.
The framework is aimed at both healthcare and non-healthcare providers, such as teachers and sports coaches, to ensure high standards of care for CYP with asthma. Training tools are available for each of the five tiers the framework is divided into. The training is not profession-specific, which ensures that standardised information is available to all staff completing it. Although the training is not mandatory in all care settings, it describes the minimum knowledge and skills required for those looking after CYP with asthma and it is considered good practice to have completed it.
The practitioner can pick the tier of training relevant to the care they deliver. The higher the tier, the more complex the care. For instance, all staff (including non-clinical) can complete tier 1, acute ward staff would require a basic knowledge of tier 2, and specialist clinical staff could complete tier 3, with tiers 4 and 5 aimed at more advanced or consultant-level practitioners. Staff are not expected to complete all tiers in sequence (though may find it useful to read through the content) and can usually start training at the level applicable to them (unless local training requirements state otherwise).
Community pharmacy teams would benefit from tiers 1 and 2. Pharmacists working specifically in CYP roles will find tiers 2 and above are applicable; for example, rotational hospital pharmacists or GP-based pharmacists could complete tier 2, and specialist pharmacists tiers 3 and above. The tier they choose should reflect their level of involvement in CYP asthma care and will be influenced by the sector they work in. Pharmacists working in specialist roles may also wish to use this training to evidence their advanced practice at tiers 4 or 5 and to align with the Royal Pharmaceutical Society’s development frameworks at advanced or consultant level.
Table 1 describes the training and approximate time commitment required to complete it.
The training for tiers 1–3 is free for NHS health and care staff in England. It is accessible through e-Learning for Healthcare and can also be completed by NHS health staff through the electronic staff record. Completing the training this way ensures that the training transfers with the individual throughout their NHS career.
The framework, links to training tools and the template for the portfolio of evidence (useful for tiers 4 and 5) can be found on the CYP asthma page at e-Learning for Healthcare.
Non-NHS health and care organisations which do not qualify for free access can access the training through an Open Athens account. Additionally, the Primary Care Respiratory Society has produced a good practice guide for professionals to facilitate delivery of high-quality respiratory care. The Royal Pharmaceutical Society’s ICS guidance may also be useful for pharmacy teams working to achieve CYP asthma deliverables. As ICSs continue to develop, local leadership and partnerships to strengthen integrated care across care sectors are essential to providing high-quality care. Strong links and good communication with hospital colleagues are naturally part of this, to help ensure joint care and timely sharing of electronically-enabled data and increased patient empowerment.
Pharmacists should undertake training at the tier adequate to the level of CYP care they provide and it can be used as planned continuous professional development. They should also encourage the wider pharmacy support team and non-pharmacy colleagues to complete this training at minimum of tier 1 level (or higher if applicable as outlined above) as it is both beneficial and in line with the principles of the Making Every Contact Count consensus, training for which is also available at e-Learning for Healthcare.
Medicines optimisation and improving disease control
NHS guidance defines medicines optimisation as a patient-centred approach to making sure medicines use is both clinically effective and cost effective, so that “people get the right choice of medicines, at the right time, and are engaged in the process by their clinical team”.
It is a fundamental part of care and pharmacists and their teams are vital to its implementation in practice. Medicines optimisation is underpinned by four guiding principles:
- Understanding the patient experience;
- Evidence-based choice of medicines;
- Ensuring medicines use is as safe as possible;
- Making medicines optimisation part of routine practice.
Pharmacists apply these principles in patient consultations and targeted reviews. Using the correct therapy at the optimal doses (for disease severity), aligning it in shared decision making with the patient, and choosing the correct inhaler device can result in better disease control and reduce exacerbations. Uncontrolled asthma warrants investigation as a priority and onward specialist referral as clinically indicated.
Inhaler prescribing and environmental considerations
Metered-dose inhalers (MDIs) contain greenhouse gases, which have high carbon emissions and environmental impact. Lower-carbon alternatives, such as dry powder inhalers (DPIs), are available meaning that there are clear benefits to increasing the proportion of asthma patients using these types of lower impact inhalers, where clinically appropriate; however, not all patients are able to change devices and blanket switching should be avoided.
DPIs should only be used cautiously in children. Despite manufacturer licensing authorising use of some DPIs in children, they are not generally clinically advocated for patients aged under 12 years, nor during asthma attacks, because younger children may not have sufficient inspiration for therapeutic benefit, which could compromise disease control — the priority.
Inhaler switching may potentially be a contributory factor in the development of an asthma exacerbation. To minimise this and avoid compromising patient safety, inhaler device switches should have occurred in shared decision making with the patient when stable, with safety netting and a follow-up review in place to ensure there has not been any inadvertent destabilisation of disease. For exacerbations resulting in a hospital attendance and/or admission, any potential environmental benefits will be lost given the high carbon footprint associated with hospital stays.
An MDI is preferred for younger children and should be used with a spacer device to increase lung deposition. Inhaler devices should not be changed unless clinically indicated. For more on this topic, see ‘Best practice principles for inhaler prescribing.’
Understanding the differing needs of CYP, the national Greener Practice group is working on a resource to support lowering the carbon footprint of inhalers specifically for children. This has been endorsed by the NHS England Inhaler Working Group and is awaiting publication.
The British National Formulary for Children has also been updated to include:
- Types of inhaler and guidance on their use (in line with National Institute for Health and Care Excellence [NICE] technical appraisals);
- Advice and tools for children and their families, such as dose counters and how to tell if an inhaler is empty, inhaler cleaning and disposal;
- Information on spacers, nebulisers and peak-flow meters;
- Links to useful resources.
Patients and carers should be reminded that all inhaler devices, whether part used, empty or expired, should be returned to their local pharmacy for disposal or recycling, regardless of the type of inhaler.
Addressing uncontrolled asthma
Patients with features of uncontrolled asthma warrant further review and treatment optimisation. Poor disease control may often be the result of non-adherence to therapy, which can usually be addressed and corrected in partnership. The NHS has a useful website that lists the symptoms of a severe attack.
Pharmacists can optimise asthma care in several ways, including:
- Monitoring prescriptions and addressing reasons for non-adherence, which may be unintentional;
- Teaching correct inhaler technique;
- Matching inhaler devices to the patient’s ability and preference.
Pharmacists should also perform a clinical review, looking at symptoms, objective tests and prescribing history, to ensure inhaled (steroid-containing) maintenance therapy is prescribed and administered in an optimal way, to reduce reliance on SABA and minimise exacerbations.
There is also an important associated stewardship role around appropriate antibiotic and oral corticosteroid use. People in this role can give advice and education to minimise side effects from medication, as well as on care and disposal of inhalers and spacers. They can also empower patients to self-manage by use of personalised asthma action plans, including stepping-up therapy as well as de-escalation where needed. As holistic practitioners, they are able to offer health and wellbeing advice, including for smoking cessation.
Despite optimisation, as described above, some patients may still have poorly controlled asthma and potentially require further phenotyping or treatment with biologic agents. They should be referred on to secondary care in a timely manner for further specialist review. The ‘Consensus pathway for managing uncontrolled asthma in adults‘ may also be useful, with the oversight of a CYP asthma specialist for treating adolescents with features of uncontrolled asthma, who may be approaching the transition into adult services. Pharmacists are often a first and constant point of contact for patients, and a trusted medicines safety expert; these factors and rapport with patients enable valuable input to quality patient care. They should ensure that both clinical and medicines information is reconciled, facilitating comprehensive review.
Pharmacists should be aware of red flags and the signs and symptoms of uncontrolled asthma, and educate patients to recognise these with prompt action and thresholds for escalation within their personalised management plan. Uncontrolled or more complex patients should be highlighted for multidisciplinary team review and discussion, and to engage with specialists before onward referral. Pharmacists should also ensure regular reviews of patients; this can be done proactively through patient database searches as well as following them up post exacerbation or hospital admission. Some patients may miss their appointments, hence outreach and persistence is important to engage them and to avoid them being lost to follow up.
In view of the changing landscape of ICSs, pharmacists should ensure they are familiar with local asthma pathways, prescribing guidelines and infrastructure for referral when needing to escalate patient care, especially in view of the delegation of severe asthma services to some ICSs from 2024/2025. It is also important to create and work with a local directory of respiratory specialists (including pharmacists) across the ICS and region, facilitating ease of access and communication with experts. This fosters closer links and encourages integration to discuss and resolve clinical cases across sectors. Additionally, shadowing and clinical supervision with peers and experts can complement training by providing assurance, peer review and increasing confidence, as well as competence. Pharmacists should also join any local networks of communities of practice for CYP asthma care.
Pharmacists contribute to asthma care in several ways: strategically, in direct clinical practice and through incentive schemes in primary care; for example, in community pharmacy (the Pharmacy Quality Scheme) and across the ICS (national bundle of care and ICS deliverables, as well as NHS England’s medicines optimisation opportunities guidance).
Pharmacists can also provide important health and wellbeing education for CYP and their families, helping to provide the information, tools and support necessary to recognise their triggers for asthma and empower them with an ability to manage their asthma effectively and safety netting.
Pharmacists can also engage with and promote asthma related campaigns, such as the annual #AskAboutAsthma campaign, run by NHS England. In 2023, the campaign is running 11–17 September 2023. This campaign encourages CYP and their carers to better control their asthma by focusing on four factors:
- Having an asthma action plan in place;
- Understanding how to use inhalers correctly;
- Scheduling an asthma review — every year and after every attack;
- Considering the impact of air pollution on lung health.
- Ask children and young people (and their carers) about asthma triggers, including housing conditions, to record these and potentially refer for allergy testing;
- Understand the risks associated with poor indoor air quality and be able to discuss these, including offering smoking cessation advice and treatment for patients and families;
- Understand the sources and dangers of air pollution with this cohort and discuss potential mitigation strategies;
- Offer diet and lifestyle advice to patients, including on managing stress and hay fever, and remaining physically active and maintaining a healthy weight, emphasising how, why and when to use their asthma medications;
- Continue to monitor prescription records for the number of SABA and inhaled steroid prescriptions per patient per year.
Early and accurate diagnosis is important, as is optimisation of fundamentals of asthma management. The impact of wider determinants of health upon disease, such as housing, mould and air quality, including smoking, should not be underestimated and should be taken into account and addressed where possible (recognising it may not be feasible to improve these factors fully).
Pharmacists are an essential component of the multidisciplinary team, with a unique skillset and evolving roles, including advanced and consultant practice. They are well placed to deliver quality outcomes and improve the health and wellbeing for patients with asthma, positively impacting both patient and planetary health.
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