It is an exciting time to be a respiratory pharmacist — and we need more of them 

Improving respiratory care in England was one of the top clinical priorities of the ‘NHS long-term plan’ when it was published in 2019^​1​. Affecting one in five people in England, respiratory disease is also the country’s third biggest cause of death, which has put tremendous pressure on the NHS, both in terms of finances and patient demand^​1​.  

Hospital admissions for lung disease alone rose at three times the rate of all admissions between 2010 and 2017, with the annual economic burden of asthma and COPD in the UK estimated at £3.0bn and £1.9bn, respectively^​2,3​. Taken alongside an ageing population and increasingly challenging winter pressures, this is a clinical area that will continue to put more pressure on our healthcare system as the years progress. 

To better support those with respiratory disease, reduce hospital admissions and ease costs, the ‘NHS long-term plan’ committed to ensuring patients “receive and use the right medication”^​1​. 

However, meeting this ambition for all respiratory patients requires a robust workforce of specialist respiratory pharmacists, which is currently lacking in England and Wales. 

Staffing levels

In November 2024, the National Respiratory Audit Programme (NRAP) published its organisational audit on the resourcing and organisation of asthma and COPD care in acute hospital respiratory services and pulmonary rehabilitation services across England and Wales between 2022 and 2024^​4​. For the first time, this was accompanied by a ‘data deep dive’, providing specific data points of interest within the audit — one of which was on current specialist respiratory pharmacist staffing levels in these services. 

The data collected show that 39.0% (53/136) of audit participating services had a respiratory pharmacist in post, with a total number of 61.2 full-time equivalents (FTEs) across 53 services. Where a service reported having a respiratory pharmacist in post, numbers varied from 0.1 FTE to 5.3 FTE. Of the hospitals with a severe asthma service, 48.2% (27/56) reported access to a respiratory pharmacist. Of the hospitals that prescribe biologics for asthma, 42.6% (29/68) reported access to a respiratory pharmacist^​5​.

These staffing levels are well below the recommended levels defined by the British Thoracic Society (BTS) in ‘A respiratory workforce for the future’, published in 2022, which recommends a minimum of 250 funded specialist respiratory pharmacists in England^​6​. This would be enough for one specialist lead for adult respiratory services in each trust, as well as seven regional consultant respiratory pharmacists. The report further advises that there is one pharmacist within each specialist commissioned respiratory service multidisciplinary team^​6​. These recommendations are also supported by NHS England’s national service specification for specialised respiratory adult services for severe asthma in England^​7​. 

There may be limitations to the data collected by NRAP, which should be acknowledged. Across England and Wales, 70.8% of eligible hospitals that registered for the audit submitted complete data^​4​, meaning reported numbers may not be representative of the true number. There may also be different interpretations of the questions, or a lack of knowledge of posts within the respiratory team, dependent on the staff member who submitted the audit data. 

However, despite these potential limitations, this is the most current information we have and gives an indication of respiratory pharmacist staffing levels for nearly three-quarters of hospitals across England and Wales. The low number of respiratory pharmacists in post highlights the challenges the workforce faces in delivering high-value respiratory care to a large cohort of patients within the NHS. 

The case for more respiratory pharmacists

Respiratory specialist pharmacists in secondary care are in the ideal position to support the optimal prescribing of a range of medicines, including inhaled therapy, and to deliver patient education on correct inhaler technique, which is deemed a high-value intervention by NHS England^​3​. 

For example, respiratory pharmacists will be crucial in leading on the substantial changes to national guidance set out in the recently published joint NICE/BTS/SIGN guideline for the management of chronic asthma^​8​. The guideline now recommends the use of anti-inflammatory reliever (AIR) and maintenance and reliever therapy (MART) for patients on low-to-moderate dose inhaled corticosteroids^​8​. Respiratory pharmacists will be needed to influence prescribing practices and deliver patient education to reduce short-acting beta-2 agonist over-reliance. Doing so will reduce the carbon footprint of inhaler prescribing, which currently accounts for approximately 3% of the NHS carbon footprint^​9​.

Respiratory pharmacists are also ideally positioned to influence local guidance to increase prescribing of lower carbon footprint dry-powder and soft-mist inhaler devices, and reduce prescribing of pressurised metered dose devices, supporting the ambition to deliver a net-zero NHS by 2040^​9​. 

Without these leaders in the specialty, addressing these medicines optimisation recommendations, which are highlighted in the ‘Respiratory — Getting it right first time’ report, published in March 2021, is harder to achieve^​10​.

Alongside inhaled therapy, respiratory pharmacists can also focus on preventative measures for patients. This may include recommendations for seasonal immunisations, smoking cessation support, consideration of prophylactic antibiotics, rescue packs and medicines adherence education. With the NHS currently facing record levels of influenza cases throughout the 2024/2025 winter season, the work of the pharmacist to support the management of respiratory patients is more important than ever^​11​. 

Pharmacist shortage

The lack of pharmacists across the UK is a well-known problem, not just within secondary care but across all sectors. This owes to several factors including increasing workload, burnout and lack of job satisfaction. With the extreme pressures hospitals currently face, it can be difficult to deliver the core services of the pharmacy department with pharmacist shortages, so the creation and recruitment into new specialist roles may not be a priority or seem unachievable. 

However, with a focus on best prescribing practice and patient education, the work of the respiratory specialist pharmacist addresses preventative measures to respiratory care, which can be important in hospital admission avoidance. A specialist post can also address the lack of job satisfaction, to help with recruitment and retention of staff and inspiring early years pharmacists. Overall, this is a role worth investing in. 

It is an exciting time to be a respiratory pharmacist given the continuous developments in terms of asthma biologic treatments. Prescribing of these treatments for eligible severe asthma patients was found to be variable across integrated care systems in England, between 2–29%, with a notably low median of 16%^​12​. However, NHS England’s ‘Rapid uptake products’ programme has set a priority to increase the uptake of prescribing these treatments for severe asthma patients^​13​. 

It is therefore the ideal time for the development of enhanced roles for respiratory pharmacists; this role may include the identification and referral of suitable inpatients for assessment for biologic treatments, the delivery of adherence assessment and support clinics and the prescribing of biologics^​14​. With appropriate prescribing, a reduction in the number of asthma exacerbations requiring hospital admission is expected. 

A NICE technology appraisal is currently in process for dupilumab for moderate-to-severe COPD, potentially presenting another exciting opportunity for pharmacists to get involved with horizon scanning for new medicines and the implementation of biologic prescribing to a new clinical area.  

Next steps

The next steps for pharmacy teams across the UK should include reviewing their local respiratory pharmacist staffing numbers against the BTS recommendations. Supporting the development of enhanced roles, including roles involving outpatient involvement, is likely to attract new pharmacists to the specialty. Discussions with individual respiratory teams can identify the areas where a specialist pharmacist post may have the greatest benefit; for example, for conditions involving high-cost biologic prescribing. 

Respiratory pharmacist staffing levels are likely to be well below the current recommendations outlined by BTS. Pharmacists within the speciality provide a vital role, leading on medicines optimisation and adherence support. With the changing landscape of asthma and COPD treatments, it is an exciting time to be a respiratory pharmacist, and the creation of new roles may attract pharmacists to the speciality.