Delivering Spirometry in a Community Pharmacy setting, a rural solution?

1. Grampian COPD MCN Delivering Spirometry in a Community Pharmacy setting, a rural solution? Small I (1,2), Clelland J (1,2), Robertson W (1), Freeman D (2). (1)Grampian Respiratory MCN (2)Centre for Academic Primary Care, University of Aberdeen

2. Introduction • NHS Grampian provides primary medical services to a population of 526,000 people(1),across a land area of approximately 6,000 square miles. In this area, there are 84 general practices, with patient populations ranging from a few hundred to >20,000 patients. In such circumstances, a ‘one shape fits all’ respiratory diagnostic service, taking into account national and international quality recommendations and national access targets is unlikely to succeed. • Delivering accurate, reproducible diagnostic and review spirometry, in keeping with proposed national standards (2), near to the patient, is an agreed fundamental element of the NHSG Respiratory MCN. • In order to achieve this, a range of settings have been identified as key to success, and the HCP groups to deliver such services targeted for specific educational projects. • The settings and groups are • General Practice (GPs and Practice Nurses) • Community Pharmacies (Pharmacists) • Secondary Care (Outpatient and Inpatient Nurses) • Specialist Respiratory Laboratory (ARTP specialists)

3. In areas of Grampian with smaller General Practice units (and by definition lower numbers of patients with COPD), pooling of diagnostic and review services is an attractive and deliverable option. Given the complex nature of General Practice, using a third party (such as a local pharmacy) to do so has been agreed as a more likely option to succeed. The new Pharmacy contract(3) has increased the flexibility of community pharmacists to become involved in the management of Long term conditions. • This presentation describes the rationale behind targeting Community Pharmacists, and the project that has been developed.

4. Method • NHSG Pharmacy leads identified community pharmacists expressing interest in delivering COPD care. • An assessment of baseline COPD knowledge amongst this group demonstrated a lower level of knowledge and skill in disease management, inhaler technique and spirometry assessment than was deemed acceptable by the MCN Group • A steering group from the MCN and University of Aberdeen were delegated to prepare and submit a proposal for an accredited course for COPD management and Spirometry. • The accredited course was delivered to the target group.

5. Course Aims • 1. To introduce participants to the theory and practice of COPD diagnosis and management in line with national and international research and guidelines. • 2. To encourage participants to consider the valid integration of this training in their day-to-day clinical practice. • 3. To challenge participants to consider non-drug treatments and broader management issues • 4. To engage participants in peer observation of their spirometry and reflection on their practice. • 5. To engender further a culture of professionalism in approaches taken to the diagnosis and management of COPD in clinical practice.

6. Learning outcomes • 1. Identify an evidence base in COPD diagnosis and management and use it to inform their clinical practice. • 2. Make critically informed decisions over their use of spirometry in COPD diagnosis and management. • 3. Critically review their current and future COPD-related clinical practice with regard to existing national and international guidelines and emerging developments. • 4. Plan and undertake action research in their own clinical practice relating to COPD diagnosis and management. • 5. Reflect on and use the outcomes of observing and being observed in spirometry practice. • 6. Review and reflect further on their own progress and CPD.

7. Course Content • Theoretical and practical knowledge about the role of spirometry in evaluating respiratory disease, including its limitation and when to use other investigations, includes: • Physiology of the lung • Patho-physiology of COPD • Systemic impact of COPD • Clinical guidelines for COPD • - Spirometry training – the “how to” • - Interpretation of spirometry results • - Case studies • Smoking cessation • Oxygen therapy • Non-drug treatment and exercise • Palliative care • Local resources • The patient perspective and self-care advice • Effective practitioner/patient relationships in primary care respiratory disease

8. Attendance and feedback • Two courses have now been completed. The format of the courses is 2 full days, at an interval, followed by coursework and a third half day. • >20 pharmacists and AHP’s have completed the course. • An example from the feedback is as follows • Excellent course. Pitched at the right level. All questions answered appropriately. Course evidence based. Advice given on when to refer and reasons for referral, treatment options and current data from trials. Also appreciated input on working with GP and what GP expects from pharmacist / nurse from spirometry clinic • Approx 10 pharmacists are now providing spirometry as part of COPD review a community setting

9. Conclusions • Pharmacists have an important role to play in diagnosing and managing COPD in small communities • A multi-disciplinary educational course can provide the knowledge and skills needed to allow pharmacists to deliver an acceptable standard of COPD care, including Spirometry • Such a course can be integrated into the overall strategy of a Respiratory MCN

10. References • (1) www.nhsgrampian.org • (2) Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations Levy M et al, PCRJ :2009, 18 130-147 • (3)www.psnc.org.uk