Over-the-counter inhalers are safe

Neil Churchill, the chief executive of Asthma UK, recently wrote a thoughtful and balanced article on the asthma service provided by Asda, which allows patients to buy blue reliever inhalers without a GP prescription through a patient group direction (PGD). This PGD was initiated, developed and written by DrThom, the remote healthcare service.

Whilst well considered and thoughtful, Mr Churchill’s article did include one or two factual inaccuracies. I would like to take this opportunity to respectfully correct these.

There has been some confusion (not limited to Mr Churchill’s piece in HSJ) around the safety and responsibility of granting patients access to reliever inhalers through a PGD, without the need of a prescription from a GP.

It is indeed correct that using an inhaler too often - or buying one too regularly - indicates that the patient’s asthma may not be under optimal control, which in rare occasions can be fatal. However, Mr Churchill’s claim that medicine use reviews “will not happen in Asda’s programme as the pharmacist does not notify the GP” is inaccurate. 

DrThom is well used to dealing with the challenges of treating patients remotely. Our asthma service has been designed to carefully monitor inhaler use. Using our bespoke IT system, the Asda pharmacist enters the patient’s details together with the responses to the criteria of the PGD.  If the patient does not fulfil the criteria set by the PGD, the pharmacy’s IT system will automatically “red flag” the patient - indicating that they are not suitable to purchase an inhaler through our PGD service. The patient is then advised to see their GP for further management of their condition.

The IT system also advises the pharmacist of how many times the patient has used the service, including from other Asda stores. When needed, a message appears on the pharmacist’s screen warning them that the patient may be overusing their inhalers and asking them to contact DrThom for further advice. The pharmacist then telephones our office and provides us with the patient’s details. One of our doctors reviews the patient’s details and may (indeed, usually will) advise the pharmacist that the patient should not use our service but rather visit their GP to discuss how to manage their asthma more successfully. 

We are continually improving this service. As of 1 November, patients are only able to obtain one Ventolin inhaler per visit. Patients will only be eligible for the Asda pharmacy inhaler service if they consent to us contacting their GP, and a letter will be sent to the patient’s GP each time they purchase a reliever inhaler from an Asda pharmacy.

This means that the patient’s GP is kept very much in the loop regarding the number of inhalers a patient is using and therefore how well managed the patient’s asthma is.

I strongly believe many patients get great benefit from remote healthcare services. As Mr Churchill observes, asthma patients should not have to go to the trouble of booking an appointment with their GP each time they lose or use up their reliever inhaler.

Healthcare innovations such as our asthma PGD partnership with Asda require great care to ensure no patient comes to any harm. That is why we actively work with a number of regulators, such as the Care Quality Commission and the Medicines and Healthcare products Regulatory Agency, and welcome critique and debate.

Ultimately I am sure we all want to see innovation to improve the lives of patients.

Dr Tom Brett, medical director, DrThom

GPs are not under strain

Your report on bed numbers in north west London contained a number of inaccuracies which I would like to correct. First, our proposals do not include eight options but three. Second, the proposals do not come from one trust but from the “cluster” of trusts, GPs, and other NHS bodies which all deliver healthcare in north west London.

Third and perhaps most importantly, our proposals would not put “massive strain” on GPs as the professional campaigner John Lister has alleged. The proposals have in fact been drawn up by those very GPs he refers to, as well as hospital doctors and other clinicians, who have an urgent desire to see a sensible, long term plan for better NHS services in the area - something everyone would surely support.

Dr Mark Spencer, GP and medical director, NHS North West London

Why the silence on abuse?

In the maelstrom of stories about poor care and abuse in care homes for older people and those with learning disability, why is there no still strong voice exposing why this keeps happening? This is a national scandal and simply blaming those at the end of the chain is not good enough.

In particular, the Care Quality Commission’s approach of close working with commissioners means that it is not investigating and exposing the clear failure of those who are commissioning these services. Of course staff and managers must be held to account, but so must those who hold the purse strings and should be monitoring the contacts for which they are responsible. It is the equivalent of blaming a junior clinician for something going wrong when they are overworked, there are not enough staff, equipment is old and malfunctioning and so on.

And indeed, at an even higher level, in the case of older people there is the ongoing failure of successive governments to address the funding problems.

But my key point is - why is no one holding the commissioners to account?

Dr Heather Wood, formerly investigation manager at the Healthcare Commission and Care Quality Commission