Researchers from Keele University have said there are multiple barriers preventing clinicians from prescribing alternative treatments for asthma patients, despite guidance calling for a move towards inhalers with lower environmental impact. 

Lack of clinician confidence and knowledge around different inhaler device types, concerns about detrimental effects on patient care, and healthcare system pressures are among the barriers to changing prescribing habits for asthma inhalers, the researchers have said. 

The use of pressurised metered dose inhalers (pMDIs) for asthma treatment is thought to be one of the biggest contributors to the NHS’ carbon footprint, with pMDIs making up 70% of inhalers prescribed in the UK, causing 3% of the NHS’s overall carbon emissions.  

As a result the NHS and the National Institute for Health and Care Excellence (NICE) currently encourages healthcare workers to offer lower-carbon alternatives such as soft mist inhalers and dry powder inhalers (DPIs) where possible, but until now there has been little research into the factors which  affect clinicians’ decisions around which inhaler device type to prescribe. 

A new study, published in the British Journal of General Practice by researchers from Keele’s School of Medicine, was the first qualitative study set in UK primary care to explore the factors influencing healthcare professionals’ decisions when prescribing inhaler devices, and the barriers to reducing pMDI use. 

They interviewed 18 different clinicians involved in inhaler prescribing including GPs, Practice Nurses, and Clinical Pharmacists, to learn more about their attitudes towards reducing pMDI prescriptions for asthma to reduce carbon emissions, and the practical factors that might prevent them from prescribing alternatives. 

A range of factors were identified which prevented clinicians from reducing pMDI prescriptions. Clinicians described basing decisions primarily on what is ‘best’ for the patient, but underlying this was a hidden layer of influencing factors including clinician knowledge and confidence (or a lack of), values, system and workload pressures, and assumptions based on patient demographics.  

The researchers say these findings provide a foundation for helping clinicians to prescribe lower carbon inhalers, adding that it will take multiple different approaches at different levels of the NHS to facilitate widespread change. 

Lead author Dr Lauren Franklin said: “This study explores the different facilitators and barriers to reducing pressurised metered dose inhaler prescriptions in general practice. For the NHS to reach its net zero targets, pMDI prescriptions need to be reduced. Understanding clinicians' perspectives and how they make prescribing decisions is a vital step in reaching that goal.”  

Dr Helen Twohig, a GP and co-author of the study, added: “This study has highlighted the complexity of decisions around inhaler device prescribing and the many patient, clinician, and system level factors that affect it. It has also identified a broader need to improve confidence and skills in asthma management in primary care. A key message for clinicians and patients is that well controlled asthma has the least environmental impact, so optimising asthma control has benefits for patients and the environment; the two are not in tension.”