The decision by Asda to sell the blue asthma reliever inhalers without a GP prescription is the kind of bold act to extend patient choice envisaged in Liberating the NHS.
It shifts decision making from the health professional to the patient in a more decisive manner than most other recent policies I have seen.
This has big benefits. First, it overcomes the perennial challenge most patients face when you run out of a blue inhaler - or forget one - while away from home. Up to now you either had to do without had persuade a local GP you had never met to prescribe one (if you could get an appointment). Now you can simply pop into the supermarket.
Asda’s pricing is also a bold stroke. By offering two blue inhalers for £7, it undercuts prescription charges by more than 100 per cent for those of us living in England. About a third of people with asthma tell us they sometimes go without one of their prescribed medicines, simply on grounds of cost. Most people with asthma have blue inhalers in case they have symptoms and so the cost of self-management has just got better. And it is proof that business moves faster than government, as the coalition accepted back in 2010 that prescription charges are unfair but has still done nothing about them.
So if the policy is so good, why has it not been done before? This is where questions start to creep in.
Most people with asthma have two kinds of inhaler - the blue reliever inhaler that clears the airways when you have symptoms and a preventer inhaler that stops you getting the symptoms in the first place. It is these preventers that are the mainstay of asthma management but people with asthma still need blue inhalers for emergencies. Asda is using private prescribing rules to sell blue inhalers, without the need for a GP prescription.
Here’s the rub. Excessive use of blue inhalers is a sign that asthma is badly controlled.
The best known medicine is undoubtedly the blue inhaler - yet people who rely on many doses of their blue inhalers at the expense of using their preventers are at risk of a potentially fatal asthma attack. Sadly, many people with asthma do not realise this - which is a particular problem among people on low incomes in disadvantaged areas, a market Asda serves well.
So although Asda is going to make it much easier to get a blue inhaler, cutting out the GP is going to make risk management that much harder.
Medicine use reviews, for example, work when pharmacists spot asthma patients who are using too much of their blue inhalers and refer them to their GP. That will not happen in Asda’s programme as the pharmacist does not notify the GP.
Similarly, GPs wanting to risk stratify their asthma registers do so using information about how many blue inhalers people have been prescribed (among other risk factors). With the Asda scheme, GPs will not have these figures, so risk registers will be less accurate.
Finally, the gold standard in long term conditions management is the asthma review. Yet fewer people might show up for one if the medicine they see as most helpful is available on the weekly supermarket shop, with few real questions asked.
Does this matter? Yes it does, given there are more than three deaths a day from asthma and 70,000 unplanned emergency admissions every year, many of which are among people with badly controlled asthma who bypass primary care. Health professionals are rightly very anxious about the potential implications for patient outcomes.
So is the Asda initiative fatally flawed? No, not necessarily. The benefits of extending patient choice may exceed the risks. This may be a case of the private sector moving the goalposts in a helpful direction.
Yet with no evidence to draw on, it is impossible to know. We will need to await an evaluation in order to see the impact - and in the meantime, the respiratory community will be closely watching to see what Asda does to ensure its programme is safe.
You take a leap in the dark when new policies are developed without any strategic coordination. Extending patient choice and improving risk management are both important policy objectives. But someone needs to hold the ring when you take bold steps in either direction.
Neil Churchill is chief executive of Asthma UK.