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Modernising Pharmacy Careers Programme Review of pharmacist undergraduate education and pre-registration training and proposals for reform Report to Medical Education England Board April 2011 Anthony Smith and Robert Darracott
CONTENTS
FOREWORD....................................................................................................4
1 EXECUTIVE SUMMARY ..............................................................................6
2 PHARMACIST UNDERGRADUATE EDUCATION AND PRE-
REGISTRATION: CURRENT ARRANGEMENTS.........................................12
2.1 Overall structure and organisation ......................................................12
2.2 Pre-registration work placement provision .........................................14
2.3 Quality management of placements.....................................................16
2.4 Curriculum design and clinical teaching .............................................16
2.5 Assessments of learning and performance.........................................17
2.6 Funding...................................................................................................18
2.7 Student numbers ...................................................................................20
2.8 Weaknesses in current arrangements .................................................20
3 PHARMACIST EDUCATION AND TRAINING: THE CASE FOR CHANGE
.......................................................................................................................23
3.1 Vision for the future of pharmacy.........................................................23
3.2 Medicines optimisation .........................................................................23
3.3 Long-term conditions ............................................................................25
3.4 Public health and wellbeing ..................................................................26
3.5 Future prescribing roles........................................................................26
3.6 Educational perspective........................................................................27
4 PHARMACIST EDUCATION AND TRAINING: PROPOSALS FOR
REFORM .......................................................................................................30
4.1 Proposal: the five-year MPharm programme.......................................30
4.2 Proposal: joint responsibility for the five-year MPharm programme 33
4.3 Proposal: curriculum redesign .............................................................35
24.4 Proposal: clinical supplement for teaching.........................................38
4.5 Proposal: major work-based placements ............................................43
4.6 Proposal: a single application process for major placements ..........47
4.7 Proposal: integrating pharmacy into local infrastructure ..................48
4.8 Proposal: a ‘pharmacy dean’ ................................................................54
4.9 Proposal: support for the pharmacist academic workforce...............57
5 PHARMACIST EDUCATION AND TRAINING: POTENTIAL IMPACTS OF
PROPOSALS FOR REFORM .......................................................................58
5.1 Impact on students and graduates.......................................................58
5.2 Impact on schools of pharmacy ...........................................................58
5.3 Impact on employers (NHS and non-NHS)...........................................60
5.4 Impact on the regulator .........................................................................61
5.5 Impact on careers in industry and academia ......................................61
5.6 Impact on the devolved administrations .............................................62
ANNEX A: ACKNOWLEDGEMENTS ...........................................................66
ANNEX B: PHARMACIST EDUCATION AND TRAINING: REVIEW
METHODOLOGY ..........................................................................................68
Background ..................................................................................................68
Phase 1: agreeing the principles underpinning change...........................68
Feedback on principles for reform .............................................................70
Phase 2: developing proposals from principles .......................................72
3Foreword
Pharmacists are experts in medicines. They are educated and trained to understand
the scientific basis of medicines, but more importantly their safe and effective use.
Medicines are at the heart of modern healthcare and remain the most common
treatment offered to patients. Used well, modern medicines are life enhancing, life
prolonging and sometimes life saving.
This review is based on a modern vision of how and when pharmacists can, and
should, make their significant contribution to patient and public health and safety, to
ensure that more people use their medicines more effectively more often, and to
reducing the possibility that those medicines will cause harm. If pharmacists are
going to tackle subtherapeutic use, low levels of adherence, and reduce the
likelihood of adverse effects contributing to costly hospital admissions, then their
training should equip them first and foremost as clinical professionals, able and
confident to support individual decision-making regarding medicines, and playing an
active role in maintaining the health and wellbeing of the public.
The purpose of this ‘root-and-branch’ review of initial pharmacy education and
training is to examine what can be achieved in a five-year programme to take
pharmacists further at the point of registration so that from ’Day 1’ onwards they can
take professional responsibility for optimising medicines in use and for supporting the
wider public health.
Our future pharmacists will face different challenges in delivering healthcare services.
The demographic profile of the country is changing due to a combination of increased
life expectancy and low birth rates;1 an estimated 50% of the population will be over
the age of 50 by 2024. Older people tend to take more medicines than the general
population. It will become more common for people to be treated for two or more
conditions, making the expert pharmacist view of the potential interactions between
different types of medication more important than ever for patient safety. Medicines
themselves and the way they are used are set to change as the promise of
pharmacogenomics and molecular biology begins to materialise, allowing medicines
use to be personalised.
The future for pharmacy practice will see pharmacists drawing on their scientific
training and their clinical and communication skills to work with other healthcare
professionals and patients to optimise the use of medicines2 in a healthy living
environment. Our Day 1 pharmacists will join a clinical profession that will ultimately
deliver better care for patients and better value for the public purse. Their core skills
will include reviewing medication and instituting changes where necessary, delivering
public health through supporting behavioural change, leading the pharmacy team in
the delivery of a range of health and well-being services, and contributing effectively
to multidisciplinary healthcare teams.
It is time to change the formation of pharmacists much more significantly than has
been possible over the past 40 years, where the approach to pharmacy has been as
essentially a scientific discipline. Our review identified many examples of innovation
1
Department of Health (2010) Healthy Lives, Healthy People: Our strategy for public health in England,
para. 1.41.
2 Ibid., para. 4.52
.
4by individual schools of pharmacy and employers, who have recognised that the
focus needs to change to reflect the formation needs of professionals with a clear
and developing clinical focus. However, a strategic and co-ordinated approach is
required if pharmacy is to contribute fully to the public health challenges and help
patients gain maximum benefit from medicines.
We recognise that contemplating this degree of change in the current economic
climate is not easy, against a background of calls for complete transparency in the
funding streams, and cost-effectiveness in all areas of public funding. An informal
alliance exists now in pharmacy education and training between students, employers
and public funding, for both higher education and training places in healthcare
settings. The Government’s proposals for education and for developing the
healthcare workforce means that there needs to be a re-balancing of the needs and
interests of all the groups, not only to mitigate risks but also to produce the right
number of professionals with the skills and behaviours which patients and the public
expect and need. Educators and employers will need to develop an active dialogue
to anticipate the demands of modern healthcare, and the supply and skills of
professionals over the medium and long term, which will require a paradigm shift in
the relationships between partners, the NHS and government.
The developments we are recommending, especially in relation to clinical teaching,
learning and assessment in schools of pharmacy will be more resource intensive
than the current methods. We make our proposals in the full knowledge that the
Departments of Health (DH) and Business, Innovation (BIS) and Skills will have to
consider a business case and impact assessment for the recommendations in due
course. It is possible that existing funding for pharmacist education and training could
be used differently to implement the proposals, but that work is outside the scope of
this review so it is not helpful to compare or extrapolate the costs related to the
current programme. We see greater trust between the key partners – employers and
universities – as the critical factor for the successful delivery of reform of pharmacist
education and training.
We believe that our proposals for a major restructuring in the way that pharmacist
education and training is delivered and funded, without extending the length of the
programmes will allow patients, the public and the NHS to benefit more completely
from the unique contribution that pharmacists – as medicines experts – make to
health, wellbeing and patient safety.
Robert Darracott
Chief Executive, Company Chemists’ Association
Anthony Smith
Chair, Council of University Heads of Pharmacy Schools and Dean of the School of
Pharmacy, University of London
51 Executive summary
Education and training needs to be more effective and efficient in preparing
new pharmacists for their professional responsibilities and ability to deliver the
care and services that patients and the public need and expect, particularly in
relation to the use of medicines.
The proposals described in this paper for a major restructuring in the way that
pharmacist education and training is delivered and funded will allow patients,
the public and the NHS to benefit more completely from the unique
contribution that pharmacists – as medicines experts – make to health,
wellbeing and patient safety.
Chapter 2: Pharmacist undergraduate education and
training: current arrangements
This chapter sets out the current arrangements for pharmacist formation – a
four-year undergraduate degree (Master of Pharmacy, or MPharm) followed
by a separate year of pre-registration practice-based training leading to
registration. It briefly describes the funding arrangements, student numbers
and placement provision.
MPharm programmes are accredited by the General Pharmaceutical Council
(GPhC), as the regulator, and it assures and manages the quality of pre-
registration training by approving premises, programmes and tutors.
Pharmacy, unlike medicine or dentistry, is funded as a science degree, so
does not receive a clinical supplement to fund clinical teaching and
experience within the degree. Pharmacy students are not eligible for an NHS
bursary.
It is estimated that over £200 million is invested in educating and training
pharmacists in England every year, and it costs an average of £90,000 to
educate and train a pharmacist.
Between 1999 and 2009, the number of schools of pharmacy in England
increased from 12 to 21 and the number of students more than doubled from
4,200 to 9,800.
Evidence-gathering and feedback from stakeholders informed us that there
are weaknesses within the current arrangements for pharmacist education
and training that work against the development of effective, confident clinical
professionals who are able to readily apply their knowledge in practice.
Student learning and assessment in the first four years are focused
predominantly on knowledge and skills and not on developing as a member of
a profession and work-based practice.
6Chapter 3: Pharmacist education and training: the case for
change
This chapter sets out a vision for pharmacists at registration to be
professionals whose actions and decision-making are underpinned by a
unique knowledge of the science of medicines, and who will be clinical
practitioners with the capability to apply and communicate this knowledge
effectively for the benefit of patients and the public. There is a need to
develop Day 1 pharmacists who can:
• engage patients and carry out relevant consultations, encouraging and
embedding safe and more effective use of medicines;
• support public health through the promotion of healthier;
• respond to a diagnosis, usually developed by a medical practitioner,
formulate a plan for initial and ongoing treatment in partnership with the
patient, carers and other health professionals as appropriate, applying
prescribing skills where appropriate
• lead the pharmacy team and work effectively within a multiprofessional
team
From an educational perspective, there is a strong case for an integrated
curriculum with opportunities for the student to move between academic and
practice environments to provide the context for learning and embedding
knowledge and skills.
Chapter 4: Pharmacist education and training: proposals
for reform
This chapter details the proposals for reforming pharmacist formation to
produce safe and effective clinical professionals who can deliver medicines
optimisation and other key services to patients from the point of registration.
We propose a single five-year period of teaching, learning and
assessment leading to graduation and registration.
From an educational perspective, experience in other professions such as
medicine and dentistry and pharmacist training programmes in other countries
show that an integrated programme ensures that professionals are able to
contextualise and apply their knowledge and learning in practice situations.
This single recommendation has major implications for accountabilities and
responsibilities – such as ‘sign-off’ to confirm satisfactory completion of
academic learning and professional practice training, assessments and
placement provision – given the way the two phases of formation are currently
structured, managed and funded. Our subsequent proposals in relation to joint
responsibility and integrating pharmacy into the local infrastructures
established to manage quality in major placements address these concerns.
7We propose that universities and employers should be jointly
responsible for the delivery of a five-year integrated programme,
including joint ‘sign-off’ of satisfactory completion of training.
Delivering a five-year MPharm programme incorporating 12 months of patient
contact and placement learning will require joint ownership of the whole
curriculum, and a strong partnership between schools of pharmacy and
employers in both the NHS and community pharmacy sectors. Joint ‘sign-off’
of satisfactory completion of training in academic and professional
assessments will cement this partnership.
We propose that all schools of pharmacy working with employers
should adopt the principles of integration and assess the merit in the
principle of a spiral curriculum.
To secure maximum benefit from the effort invested in developing the work-
based elements of the integrated five-year MPharm, the curriculum will have
to be designed as a five-year professional formation programme.
The teaching must be delivered in a way that reinforces to students why they
are learning – not just to answer examination questions, but to support their
future professional practice and clinical decision-making.
Our review of curricula at schools of pharmacy across the UK and insights
into professional formation in other sectors convinced us of the value of the
spiral curriculum. In a spiral curriculum, topics, themes and subjects are
revisited throughout the course, at increasing levels of difficulty, with the major
practice placements providing opportunities to be assessed in the workplace.
We recognise that implementation of this level of curriculum reform, especially
if integration of placements is happening in parallel, would require a significant
change management programme at the schools and universities.
We propose that the five-year MPharm programme should be eligible for
at least 12 months’ funding as a clinical subject in addition to the
existing funding as a science-based subject.
Pharmacy undergraduate education is currently funded as a science
programme, unlike medicine and dentistry, which receive an additional clinical
supplement to fund clinical teaching, particularly the small-group skills
teaching. We propose that pharmacy should receive a clinical supplement for
at least 12 months of the five-year MPharm programme and that this
investment should be used to fund a range of hands-on, modes of teaching
(with associated learning and assessment methodologies), often in smaller
groups, and to support the engagement of clinical academic staff.
Opportunities to see and, more importantly, talk to patients and professionals,
and to visit a range of practice settings early in the curriculum, are crucial to
student orientation and the process of developing as a member of a
profession. Current funding of pharmacy as a science programme restricts the
8ability of schools to provide these important visits and placements on a secure
and sustainable basis.
We propose that the current 12-month work-based placement should be
divided into two major placement periods of six months each.
We do not think it appropriate to reduce the current level of placement-based
teaching and learning (12 months). Final decisions on the length of the
placements are critically informed by the requirements set out in the EU
Directive on the mutual recognition of qualifications.
Taking into account EU Directive 2005/36/EC, which requires a minimum of
six months to be spent in a patient-facing role in the last year of a five-year
training period, and the preferences of employers, both NHS and non-NHS,
we constrained the options for placement length to two periods of six months.
However, redistribution of the placement period is only one part of the
strategy to improve professional formation, and must be considered in
conjunction with reforms of teaching and assessment, and joint responsibility
for the whole programme. Simply dividing the placement in two, as in the
current Bradford sandwich model, will not be enough. The GPhC may need to
consider setting national learning outcomes for entry to and exit from each
practice placement
Our preferred option for dispersed practice placements is a six-month
placement at the beginning of year 4 and a six-month placement at the
end of year 5 of the five-year programme, after which students proceed
directly into registered practice.
We propose a single application process for the major practice
placement(s), with the full involvement of employers locally in the
process of selection.
A single application system for major practice placements would retain the
important element of choice for students and employers, and allow maximum
flexibility in location and capacity for training.
We see merit in extending and adapting the existing national recruitment
scheme used in the NHS to appoint pre-registration training posts in NHS
hospitals in England and Wales to all major practice placements across all
pharmacy sectors. The system would have the advantage of including all
placement training provision details at a single point of access, but still give
the final choice to employers.
We propose that pharmacy should be integrated into local infrastructure
established to manage quality in major practice placements.
Our proposals for introducing two placements and extending the learning
outcomes of practice placement to include more clinically focused activities
9will require access to a local system of quality management and development
of the tutor network in terms of capacity and quality.
Any infrastructure for pharmacy will need to include employer representation
from hospital and community pharmacy, and possibly industry, in partnership
with schools of pharmacy.
We concluded that building on an existing infrastructure – such as the medical
deaneries and foundation schools, or potentially the healthcare provider local
skills networks – would minimise costs and create the potential for cross-
cutting benefits with doctors and other healthcare professionals, such as
improvements in prescriber training, assessment and patient safety.
We propose that a ‘pharmacy dean’ should be responsible for signing
off satisfactory completion of assessments in work-based placements
and should be accountable to the regulator for that function.
Registration will continue to be based on satisfactory completion of both
academic and professional education and training in any five-year MPharm
programme. The General Pharmaceutical Council (GPhC) will need to be
assured that any applicant being registered has satisfactorily completed both
sets of assessment, so the pharmacy dean would be accountable to the
regulator rather than the university or employer.
The relationship between practice placement provider and schools of
pharmacy will need to be established and maintained nationally as well as
locally to give students flexibility when seeking placements and a ‘pharmacy
dean’ could play a key role in building these links.
We propose that there should be an urgent review of the academic
workforce including opportunities for pharmacists to undertake PhD and
postdoctoral research, with access to support grants specifically for
pharmacists.
Delivery of our proposals for reform requires a significant increase in the
number of academic pharmacists. Widening access to schemes that offer
support grants for PhD and postdoctoral research could encourage a strong
stream of pharmacists with the appropriate knowledge and skills to help
deliver our proposals, particularly in relation to clinical teaching and curriculum
redesign.
Chapter 5: Pharmacist education and training: potential
impacts of proposals for reform
This chapter acknowledges the potential impact on different partners of
implementing the proposals for reform. Where possible, proposals were
shaped to mitigate the impact but, in many areas, especially in relation to
funding, it is not possible to quantify their impact at this stage.
10Proposals for a five-year programme do not automatically mean students
would require an additional year of student loans to cover a fifth year of tuition
fees and maintenance support, or that they would lose a year’s salaried
employment. The inclusion of pharmacy students in the NHS Bursary and
tuition fee waiver programme while they are on practice placements is an
option for future discussions between the BIS and DH.
We recognise that making the teaching of medicines optimisation, public
health skills and professionalism core components of the curriculum will
require a significant expansion in the number of clinical staff involved in
teaching, learning and assessment.
Our proposal for an urgent review of the academic workforce and recognition
of the need to invest in and develop the next generation of academic
pharmacists, alongside recommendations related to transition arrangements
and funding for clinical teaching and support for PhDs and postdoctoral
research, should go some way to addressing concerns that schools might
have in relation to clinical teaching.
We recognise that integrating clinical practice and contextualising the science
content of the degree in terms of practice may have a negative impact on
research. We would not wish to see research activity at any of the schools
damaged by developments in clinical teaching capacity. Our proposals
relating to developing the clinical workforce and for supporting pharmacists in
developing research capacity should mitigate some of the risk in the teaching
and curriculum redesign proposals we are making.
It is possible that our proposal for a five-year programme could decrease the
attractiveness of English universities for pharmacy students from some parts
of the world. We would not wish to see our proposals disadvantage individual
schools, or prevent English universities competing in an increasingly global
market, but progress for the majority of students and resulting benefits to
patient care in this country cannot be held back by specific current needs to
accommodate international students.
If as a result of our proposals there is a five-year MPharm programme leading
directly to registration, the regulator would need to accredit new programmes
and revise the education and training standards, including learning outcomes
within them.
Although our proposals do not necessarily mean that students will be taught
less science, it is clear that students will be applying their knowledge, largely
in the context of a patient-facing setting, and careers in research and industry
may become less obvious pathways.
We recognise that our proposals for England may impact on the delivery of
education and training in Scotland, Wales and Northern Ireland and the ability
of pharmacy students, pre-registration trainees and registered pharmacists to
move freely between the four countries.
112 Pharmacist undergraduate
education and pre-registration:
current arrangements
2.1 Overall structure and organisation
Initial formation of pharmacists currently comprises a four-year Master’s-level
undergraduate degree (Master of Pharmacy or MPharm degree) followed by a
separate one-year work-based pre-registration training year.
Figure 1: Current arrangements for pharmacist undergraduate education
and pre-registration training
S1 refers to semester 1 (Sept – February) and S2 refers to semester 2 (February to June) in
each academic year
MPharm degrees are delivered by 21 schools of pharmacy based in
universities across England and a further four in Northern Ireland, Wales and
Scotland. Nineteen degree programmes are fully accredited by the GPhC, a
further two are in the final stages of gaining full accreditation, and Durham
University recently announced its plans to launch a pharmacy degree course.
Bradford is the only university currently offering a five-year sandwich
programme where the one-year work-based training is split into two six-month
sandwich placements. The first practice placement is in semester 2 of year 3
and a further placement in semester 1 of year 5, with students returning to
university for the final semester. In this programme, the regulator’s
performance standards are split across the two placements rather than being
integrated into a single curriculum, so the practice and academic elements
remain separate in terms of curriculum, quality assurance and outcomes.
Graduation with an MPharm degree does not lead directly to full or provisional
registration with the GPhC; instead, it acts as the gateway to entering the pre-
registration year, which is completed while working in either a community
12pharmacy (approximately two-thirds of trainees) or hospital pharmacy (one-
third of trainees). There are a small number of joint pre-registration posts
where 6 of the 12 months are spent in the pharmaceutical industry or primary
care and the remainder in community or hospital practice.
Although the pre-registration placement is recognised as a training period, all
employers assume that trainees provide an element of supervised service
provision, which increases towards the end of the year.
Figure 2: Pre-registration trainee distribution in England, 2009/10
There is currently no overarching infrastructure to support work-based
learning and assessment in the pre-registration training year, although the
NHS and larger community pharmacy employers do have regional and
national training arrangements. The pre-registration training tutor signs to
confirm that the regulator’s performance standards have been met and the
individual is fit and proper to enter the register; usually, this information must
be provided by the end of the 50th week of the pre-registration year. The
trainee is also required to pass the regulator’s national registration
examination, which has a multiple-choice question format.
Historically, there has been no tangible link between the MPharm delivered by
schools of pharmacy and the delivery of practice-based learning and
assessment in the pre-registration year. The two parts of the formation
process for pharmacists have been completely separate in terms of
curriculum, quality assurance and outcomes. We welcome the steps taken by
the pharmacy regulator, in its recent consultation on education and training
standards, to link the learning outcomes from the MPharm to those in the pre-
registration training year.
13The pharmacy undergraduate programme, and the pre-registration training
year in its different settings, are subject to a process of ongoing adaptation by
schools and employers to meet the changing demands of practice and
revisions to the standards set by the regulator. Schools of pharmacy have
responded to the emergence of new roles for pharmacists in a variety of
different ways and to varying extents; some are bringing clinical experience
into the curriculum through inter-professional working with elements of joint
teaching of medical and pharmacy students, or using a spiral curriculum to
deliver greater integration of science and practice. In a spiral curriculum,
topics, themes and subjects are revisited on a number of occasions
throughout the course, with increasing levels of difficulty, and the major
practice placements provide opportunities to be assessed in the workplace.
Examples of innovation and development in the formation of pharmacists are
provided throughout this paper – often demonstrating how our proposals, or
slight variations of them, are already being implemented by individual schools
or organisations and bringing benefits to students and patients.
However, since pharmacy became a graduate entry profession in 1967, there
has been no significant change in the overall structure or funding of
pharmacist education and training, no fundamental review of its provision
across the two phases and no evaluation of the fitness for purpose of the
current arrangements against the requirements of modern practice. Clinical
teaching by practitioners, increased patient contact, short placement provision
and other initiatives tend to rely on local agreements and arrangements.
Funding for these initiatives is often variable year on year with no guarantee
of ongoing access and provision.
As a result, practice experience has developed in a piecemeal way, so there
tends to be a lack of consistency and sustainability. A strategic and co-
ordinated approach – involving students, universities, employers, the
regulator, professional organisations and patients – is required to
fundamentally change the current structure and organisation to deliver
confident and capable pharmacists who are, from the point of registration,
scientifically knowledgeable, clinically competent, professionally focused and
with the necessary skills to communicate and engage effectively with patients,
public and other healthcare professionals.
2.2 Pre-registration work placement provision
Currently, students are able to graduate with an MPharm degree without also
needing to qualify for registration with the GPhC. Securing a pre-registration
placement position is currently the responsibility of the student.
Placements are advertised by employers based on their independent
assessment of demand for trained staff or on the basis of a tradition of
providing training as part of a recruitment and retention strategy. For other
professional groups, this process of finding placements is carried out either by
the university (which then allocates students into placements) or through a
14national application and selection process (as is the case for foundation year
1 medical trainees currently).
Universities assist pharmacy students in the process of finding a pre-
registration placement, but are not ultimately responsible for a student’s ability
to find a placement and to register. Universities carry no financial risk if
students are unable, at graduation, to find a placement and to complete their
training in order to register. Universities can meet their obligations to students
with no reliance on employers to provide placements.
As there is no link between recruitment to schools of pharmacy and
placement commissioning, student numbers could either run ahead of or lag
behind placement commissioning and workforce demand – resulting either in
students who might graduate but not be able to register or insufficient
registrants to meet workforce demand. Neither situation is helpful to students,
schools of pharmacy, employers or the wider economy.
Although the number of pharmacy students has more than doubled over the
last ten years, lack of pre-registration placements does not seem to have
been a major issue. Even with large increases in pharmacy graduates, there
have been workforce shortages reported in the same period as demand for
pharmacists has increased due to:
• changing public expectations for access to services reflected in longer
opening hours and more pharmacies – many new pharmacies open for
100 hours per week, requiring at least three pharmacists to deliver the
service in one pharmacy;
• an increase in the volume of prescriptions – there has been a 58%
increase in the nine years from 1999/2000 to 2008/09; and
• the increased number and complexity of additional and enhanced
services provided in pharmacies. There has been a 47% increase in
the number of medicines use reviews conducted between 2006/07 and
2008/09, and a 60% increase in delivery of enhanced services, for
example smoking cessation and minor ailments services.
Similarly, there has been a significant increase in NHS establishments, with a
6.5% increase in Agenda for Change band 7 posts and an 8.3% increase in
band 8a pharmacist posts in the NHS since 2009.
However, new proposals currently being consulted on by DH3 could change
the current system for planning and commissioning placements, by ensuring
that placements funded by DH in community pharmacy and DH/the NHS in
hospital pharmacy are commissioned on the basis of demand-led workforce
planning by employers.
Checks and balances in the system could help pharmacy to manage the risks
in the current system of insufficient placements to match student recruitment
3
Department of Health (2010) Liberating the NHS: Developing the Healthcare Workforce. A consultation
on proposals
15at a national level. The new arrangement would also ensure that employers
which do not provide training contribute to the cost of training – this again will
help ensure that, at a national level, placement capacity will match demand.
Therefore, the need for a more consistent and integrated approach to
planning student numbers in conjunction with placement commissions will
become important in the near future, independently of our proposals.
2.3 Quality management of placements
Currently, the GPhC assures and manages the quality of pre-registration
training by working directly with individual training providers to approve
training premises and programmes, and register individual tutors. Tutors
provide educational and clinical supervision for trainees, conduct the
assessments, deliver the training programmes and sign to confirm that the
trainee has met the regulator’s performance standards and is fit to enter the
register. In the NHS and among the national community pharmacy employers,
there are training and development opportunities for their tutors.
This system of quality assurance and management has inefficiencies given
the 2,000 pre-registration trainees currently in the system. Access to a local
system of quality management, which co-ordinates appropriate quality control
among providers of training, will be important if regulation of placements is to
be proportionate.
2.4 Curriculum design and clinical teaching
Schools of pharmacy have a responsibility to ensure that the curriculum is
reviewed and is current in the context of the changing nature of healthcare,
the scientific development of medicines and the developing role of the
pharmacist.
Much has been written on curriculum development and organisation, and
there is no evidence to suggest that there is a ‘best’ template for curriculum
design.4
What is fundamental is that any curriculum meets the following principles:
• It tells the learner what to expect and how they will be supported.
• It advises the teacher on what to do to deliver the content and to
support the learners in their personal and professional development.
• It assists the institution in setting appropriate assessment of student
learning and support evaluation against externally applied standards,
such as those set by the regulator.
• It tells wider society how the provider upholds high standards.
Schools of pharmacy adopt a curriculum based on the principles of one or
more of the following:
4
Grant J (2006) Principles of curriculum design. Understanding Medical Education
16• integrated teaching of all relevant science into themes;
• a robust scientific baseline, building the depth and breadth of
knowledge year on year in its application to medicines design and
development and evidence-based practice (‘spiral model’)5;
• modular delivery of subject matter; and
• achieving the core syllabus outcomes which are currently part of the
regulator’s standards, with an opportunity for optional studies.
These models are not mutually exclusive and curricula may include elements
of each.
Currently, across the schools there is significant variation in access to, and
provision of, short practice visits and placements: some schools offer as few
as two days across the four-year programme.
A number of community pharmacy employers put significant resource into
vacation work experience programmes and schools of pharmacy encourage
students to participate in them and also where possible gain experience in
other sectors. Some employers consider the performance of students on
these programmes when offering pre-registration training positions. Students
gain great benefit from participating in these programmes however they are
not linked in any formal way with the undergraduate curriculum or the learning
outcomes of the regulator and, of course, participation is voluntary.
In the current arrangements, unless students undertake voluntary vacation
work in pharmacy, they will rarely see pharmacists at work or talk with
patients and they will not have had an opportunity to practise the skills they
are learning until the fifth and final year of their training which is after they
graduate with an MPharm degree.
2.5 Assessments of learning and performance
Currently, teaching and learning in the first four years is typically separated
into eight academic semesters, which include a range of different
assessments from written exams and multiple-choice questions through to
simulation-based assessments in dispensing and, in some places, the use of
observed structured clinical examinations (OSCEs). Work-based
assessments are difficult to include in the assessment profiles because of the
scarcity of placements available.
The second period of learning – the fifth year which is undertaken in the
workplace – is more focused on professional performance using tutor ‘sign-off’
against performance standards as the assessment method. Here, success is
defined in terms of professionalism and work-based confidence and
capability. However, this period of training tends to be overshadowed by the
return to an academic-style assessment in the final registration exam, which is
5
Harden RM and Stamper N (1999) What is a spiral curriculum? Medical Teacher 21: 141–3.
17a multiple-choice questionnaire format, scheduled towards the very end of the
pre-registration year.
In the final year, trainees will be concentrating on learning to be a pharmacist
and on studying for the regulator’s final registration exam. Not only are the
students focusing on two different end points in the fifth and final year, so are
the teachers and tutors. It is therefore of little surprise that newly registered
pharmacists struggle with understanding what good professional practice
looks and feels like, communicating and engaging effectively with patients,
and with delivering high-quality care with confidence.
2.6 Funding
In 1997 the MPharm undergraduate programme moved from three to four
years in length (and from a Bachelor’s to a Master’s-level qualification), but
continues to be funded as a science degree followed by a separate one-year
vocational training year.
The Higher Education Funding Council for England (HEFCE) provides funding
for pharmacy as a science/laboratory-based subject (band B). Medicine and
dentistry receive an additional clinical supplement from the HEFCE (band A
level) for two years, which is more than double the corresponding allocation
for band B. Additional funding for placements during medical and dental
undergraduate education comes from the NHS through the Multi-Professional
Education and Training (MPET) levy. There is no funding for clinical teaching
or placements in the pharmacy degree from either the HEFCE or the NHS
and, as a result, opportunities for patient contact, orientation visits, placement
teaching, learning and assessment, and small-group skills teaching are
limited. They often rely on goodwill, personal relationships and dedicated
individuals.
Hospital pre-registration salary costs are funded partly or wholly from the
MPET levy (via the strategic health authority education and training
commissioning process) with individual trusts contributing in some places but
not others. Strategic health authorities use the MPET levy to support training
in a variety of ways, for example residential courses or tutor support.
Community pharmacy contractors receive a grant for training as part of the
Community Pharmacy Contractual Framework, and they invest additional
resources in training costs and salary from within their business resources.6
It is estimated that £200 million is invested in educating and training
pharmacists in England every year. Around £100 million is invested in
undergraduate education – approximately £60 million from the HEFCE7 and
£40 million8 from tuition fees paid by students. A further £50 million9
6
Based on estimates of training costs provided by a number of contractors
7
Based on the band B funding level minus the assumed fee income multiplied by the number of
students enrolled at universities in England
8
Based on current tuition fees (£3,290 per year).
18is invested by the DH/NHS for the pre-registration training year. Students pay
for the cost of accommodation, travel, living expenses, books etc., which adds
at least a further £40 million to the investment.10. Pharmacy students unlike
medical, dental and nursing students are not eligible for NHS bursaries.
Based on the 2010 registration cohort (that is, trainees who entered schools
of pharmacy in 2005) and 2009/10 figures for maintenance loans, salaries
etc., it is estimated that the cost of educating and training a new pharmacist is
around £90,000 in total. Employers (DH/NHS and community pharmacy
employers) invest around £40,000 per trainee, the HEFCE £22,000 per
student, and students themselves some £28,000.
Figure 3: 2009/10 annual funding proportions
The funding environment in higher education is set to change dramatically
from 2012/13 when much of the public funding for teaching will be withdrawn
and replaced by tuition fees (£6,000 and capped at £9,000) set by universities
and subject to Access Agreements being approved by the Office of Fair
Access. These tuition fees will be paid up front by government and repaid by
means of a graduate contribution subject to earnings thresholds and a 30-
year limit.
9
Based on the current grant paid to pharmacy contractors (£18,440 per year) plus pre-registration
salary and on-costs, and an estimate of training costs in the NHS and for current pre-registration
trainees in each sector
10
Based on the current average maintenance loan per student (£3,610 per year) and current student
numbers enrolled in universities in England.
192.7 Student numbers
The number of students in schools of pharmacy is not currently subject to
control. Universities are free to open new schools of pharmacy and to
increase student numbers in established schools as the applicant market
determines. Pharmacy continues to be a popular course. As a result, the
number of schools of pharmacy in England increased from 12 in 1999 to 21 in
2009 and pharmacy student numbers over the same period rose from 4,200
to 9,800.11. Durham University and the University of Birmingham recently
announced their plans to launch a pharmacy degree programme.
In the five years from 2004/05 to 2008/09, the number of students entering the
first year of MPharm programmes increased by over 40%. This compares with
a national increase in the numbers of first year university students of around
15%.12
Currently, around 14% of undergraduate students attending schools of
pharmacy in England are overseas students (those who are not from Great
Britain or the EU) and the majority complete the full four-year MPharm
programme here. Five universities in England have established, or are
establishing, ‘two plus two’ partnerships with branch campuses overseas,
where students complete years 1 and 2 abroad before transferring to England
to complete years 3 and 4. The GPhC accredits these programmes and
graduates are eligible to undertake their pre-registration training in England. It
is not clear how many overseas students continue after graduation to
complete the pre-registration year and register with the GPhC.
In contrast to medicine and dentistry, the number of overseas fee-paying
pharmacy students is not capped.
2.8 Weaknesses in current arrangements
The current arrangements for education and training of pharmacists provide
newly qualified pharmacists with an excellent scientific knowledge of
medicines upon which to build their professional practice.
However, evidence-gathering and feedback from stakeholders informed us
that there are weaknesses within the current arrangements which work
against the development of clinical professionals who at the point of
registration are confident to take professional responsibility for the care of
patients, particularly in relation to the safe and effective use of medicines.
Employers described gaps in the knowledge of pharmacists in the workplace
during their early years in practice and in the pre-registration year, often in
areas where material had been taught in the MPharm curriculum. We were
told that trainees and newly qualified pharmacists were struggling to apply
11
Royal Pharmaceutical Society of Great Britain, personal communication, 2009.
12
Higher Education Statistics Agency (2010) Students in Higher Education Institutions, Statistical First
Release 142, Table 2a
20their knowledge of medicines and science to solving clinical problems and
communicating with patients. Employers found that trainees were not always
demonstrating capability and confidence in the application of the knowledge in
the workplace, when dealing with other professionals and patients. Indeed,
students themselves, in evidence submitted by the British Pharmaceutical
Students’ Association (BPSA) to the Review team, raised these points
specifically.13
In many cases, late exposure to practical clinical experience gives students a
view of pharmacy practice that may not be matched by the reality of the
workplace.14 More generally, students complained of a lack of context for
theoretical learning1313. We think it is significant that the anecdotal experience
of students and academic staff following the first placement within the
Bradford sandwich programme is largely positive. Early experience in practice
enables students to contextualise prior learning, interact with patients, and
adds a practical focus to studies on their return to the university. However a
difficulty with the current sandwich placements on the Bradford course is that
the practice elements sit outside the MPharm curriculum and are not
integrated with teaching and learning in the university.
The current arrangements for pharmacist education and training have a major
gap in how the concept of ‘professionalism’ is developed and nurtured within
the MPharm. Students should have a clear understanding of their
responsibilities as trainees and then as members of the pharmacy profession,
but students and employers tell us that this is not currently the case.
It seems to us that, in many ways, it is the separation of both educational
purpose and responsibility for academic and professional success, as well as
the separation in time, between the undergraduate teaching and the work-
based learning, which presents the most important weakness in the current
system. Across all five years, students need to focus on achieving success as
a professional clinician as well as success as a scientist. Professional and
academic achievement should be experienced as part of a continuum of
success across all five years not separated in time, geography and
educational purpose, as is currently the case.
We have seen that the current system fosters a situation where assessments,
and therefore student learning, in the first four years are focused
predominantly on knowledge and skills and not on developing as a member of
a profession and work-based practice. This is exaggerated by the lack of
clinical placements within the degree. Assessment in the pre-registration year
is of professional performance by the tutor against the regulator’s standards
but, in the absence of an infrastructure to support consistency and quality
across all placement providers, the year concludes with an academic style
(multiple-choice question) assessment (the national registration exam) before
registration. It also seems clear that the registration examination (and
preparing for it) adversely dominates the final year of practice-based learning.
13
Evidence submitted by the British Pharmaceutical Students’ Association, 2009.
14
Pharmacy Practice Research Trust (2010) Work, employment and the early career years of the 2006
graduate cohort students.
21The mismatch this creates in terms of how students should focus their
learning and development is one of the most limiting consequences of the
current ‘four plus one’ arrangements. Students struggle to apply their expert
knowledge in medicines by the time they have to use it in the workplace, to
communicate with patients, the public and other healthcare professionals.
Early exposure to patients and workplace settings are a vital part of this
process of professional development, as well as managing what are
sometimes widely differing expectations of employers, students, and patients,
about what is required and expected of a pharmacist on registration.
Pharmacists’ practice has changed significantly in recent years, but the
education and training demands that this has posed have largely been met
through post-registration postgraduate courses, particularly in secondary care.
We believe that our proposals for reform of education and training will address
the existing weaknesses, significantly reduce the need for post-registration
courses and their associated cost to the NHS, and ensure patients benefit
from the expertise of pharmacists from Day 1 of registration.
223 Pharmacist education and
training: the case for change
3.1 Vision for the future of pharmacy
Our vision is for pharmacists at registration to be professionals whose actions
and decision-making are underpinned by a unique knowledge of the science
of medicines, and who will be clinical practitioners with the capability to apply
and communicate this knowledge effectively for the benefit of patients and the
public. The recent Public Health and NHS White Papers1,15 confirm that the
direction of travel for health policy will bring our vision for pharmacy into reality
in the very near future.
Our proposals for reform are driven by the need to develop Day 1 pharmacists
who can:
• engage patients and carry out relevant consultations, encouraging and
embedding safe and more effective use of medicines;
• support public health through the promotion of healthier lifestyles and the
delivery of public health services, including aspects of behavioural change;
• respond to a diagnosis, usually developed by a medical practitioner,
formulate a plan for initial and ongoing treatment in partnership with the
patient, carers and other health professionals as appropriate, applying
prescribing skills where appropriate
• lead the pharmacy team and work effectively within a multiprofessional
team
3.2 Medicines optimisation
Medicines are at the heart of modern healthcare and remain the most
common treatment offered to patients. After salary costs, medicines are the
single highest outlay by the NHS (an estimated £12.5 billion in 2010/11) and
as experts in medicines, pharmacists are best placed to encourage and
embed safe and effective use of medicines.
Our proposals are designed to increase opportunities for students to develop
the skills they need to apply their knowledge of medicines in their practice on
the day that they register. Medicines optimisation from registration will be a
key new skill which relies on enhanced communication, influencing and
motivating skills to support medicines adherence and wellbeing.
In an outcome-driven health service, where patients are placed at the centre
of care, society needs to get maximum effectiveness and value from its
armoury of medicines and it is clear that there is scope for improvement in
medicines optimisation:
15
Department of Health (2010) Equity and Excellence: Liberating the NHS
23• Avoidable medicines wastage in primary care is running at about £150
million per year16.
• The National Institute for Health and Clinical Excellence reports that
30–50% of medicines are not being taken as intended, resulting in a
loss in health gain of billions of pounds.17
• The Care Quality Commission NHS Inpatient Survey 2009 found that
almost one in ten patients (9%) felt they had not been given enough
information about the purpose of the medication they were to take
home18.
• Preventable adverse effects of medicines account for 4–5% of all
hospital admissions.19
• The Care Home Use of Medicines Study found an unacceptable level
of errors in prescribing, dispensing, drug administration and drug
monitoring when medicines are used in care homes.20
• A report on the use of antipsychotics in dementia shows unacceptable
levels of prescribing of these medicines.21
• The General Medical Council’s (GMC’s) EQUIP study demonstrated an
unacceptable level of prescribing error across all grades of hospital
doctors.22
• The recently published NHS Atlas of Variation in Healthcare shows
stark variation in the use of some medicines across different areas of
England.23
In secondary care, pharmacists’ medicines optimisation roles routinely involve
prescribing – either the modification of existing drug therapy or independent
prescribing against a diagnosis. This requires problem-solving, team-working
and communication skills of a different order than can currently be achieved at
registration. Currently, pharmacists entering secondary care practice
immediately need to embark on further postgraduate study to perform these
roles effectively24 and we believe our proposals for reforming education and
training would enable pharmacists to carry out medicines optimisation tasks at
the point of registration.
16
York Health Economics Consortium/School of Pharmacy, University of London (2010) Evaluation of
the Scale, Causes and Costs of Waste Medicines.
17
Horne R, Weinman J, Barber N et al. (2005) Concordance, adherence and compliance in medicine-
taking: Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D
(NCCSDO).
18
Care Quality Commission 2009 NHS Inpatient Survey, coordinated by Picker on behalf of
CQC, published May 2010
19
Pirmohamed M, James S, Meakin S et al, Adverse drug reactions as a cause of admission to hospital:
prospective analysis of 18,820 patients. British Medical Journal 2004, 329: 15–19
20
Alldred DP, Barber N, Buckle P et al. (2009) The Care Home Use of Medicines Study.
21
Banerjee S (2009) The use of antipsychotic medication for people with dementia: Time for action. A
report for the Minister of State for Care Services by Professor Sube Banerjee
22
Dornan T, Ashcroft D, Heathfield H et al. (2009) An in-depth investigation into causes of prescribing
errors by foundation trainees in relation to their medical education. EQUIP study
23
NHS Right Care (2010) The NHS Atlas of Variation in Healthcare: Reducing unwanted variation to
increase value and improve quality
24
Agenda for Change Knowledge and Skills Framework, December 2009
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