Modernising Pharmacy Careers Programme Review of pharmacist undergraduate education and pre-registration training and proposals for reform ...

 
Modernising Pharmacy Careers Programme

Review of pharmacist undergraduate education and
pre-registration training and proposals for reform

Discussion paper

January 2011

Anthony Smith and Robert Darracott
© Crown copyright 2011
404593 1p Jan 11
Produced by COI for Medical Education England

www.mee.nhs.uk
Contents
Foreword                                                                          5

1   Executivesummary                                                             8

2    harmacistundergraduateeducationandpre-registration:
     P
     currentarrangements                                                         15
     2.1 �    Overall structure and organisation                                  15 �
     2.2 �    Pre-registration work placement provision                           17 �
     2.3 �    Quality management of placements                                    18 �
     2.4 �    Curriculum design and clinical teaching                             18 �
     2.5 �    Assessments of learning and performance                             19 �
     2.6 �    Funding                                                             20 �
     2.7 �    Student numbers                                                     21 �

3   Pharmacisteducationandtraining:thecaseforchange                      23
     3.1 �    Vision for the future of pharmacy                                   23 �
     3.2 �    Weaknesses in current arrangements                                  23 �
     3.3 �    Medicines optimisation                                              25 �
     3.4 �    Long-term conditions                                                26 �
     3.5 �    Public health and wellbeing                                         27 �
     3.6 �    Future prescribing roles                                            27 �
     3.7 �    Educational perspective                                             28 �

4   Pharmacisteducationandtraining:reviewmethodology                       30
     4.1 �    Background                                                          30 �
     4.2 �    Phase 1: agreeing the principles underpinning change                31 �
     4.3 �    Feedback on principles for reform                                   32 �
     4.4 �    Phase 2: developing proposals from principles                       33 �

5   Pharmacisteducationandtraining:proposalsforreform                     35
     5.1 �    Proposal: the five-year MPharm programme                            35 �
     5.2 �    Proposal: joint responsibility for the five-year MPharm programme   38 �
     5.3 �    Proposal: major work-based placements                               39 �
     5.4 �    Proposal: a single application process for major placements         42 �
     5.5 �    Proposal: integrating pharmacy into local infrastructure            43 �
     5.6 �    Proposal: pharmacy dean                                             47 �
     5.7 �    Proposal: curriculum redesign                                       50 �
     5.8 �    Proposal: clinical supplement for teaching                          52 �
     5.9 �    Proposal: support for research and academic career pathways         56 �
     5.10 �   Proposal: support for industry career pathways                      57 �

                                                                                   3
Modernising Pharmacy Careers Programme

6     harmacisteducationandtraining:potentialimpacts
      P
      ofproposalsforreform                                            59
      6.1    Impact on students and graduates                             59
      6.2    Impact on schools of pharmacy                                59
      6.3    Impact on employers (NHS and non-NHS)                        61
      6.4    Impact on the regulator                                      61
      6.5    Impact on careers in industry and academia                   62
      6.6    Impact on the devolved administrations                       62

7    Conclusions                                                        63

     AnnexA:Acknowledgements                                          65

     AnnexB:Placementoptionsforafive-yearintegratedprogramme   67

4
Foreword
Pharmacists are the experts in medicines, 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 and this is where
pharmacists make the most significant contribution to patient and public health and safety.

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, and realise our ambition to take
pharmacists further at the point of registration, enabling them to take responsibility for medicines
optimisation, public health initiatives and new clinical services, which will ultimately deliver better
care for patients. A more patient-focused scientific education and training, with sustainable and
consistent curriculum enhancement in professionalism, communication and clinical decision-
making skills, would enhance pharmacists’ knowledge of medicines and expertise in their use,
for the benefit of patients and the public purse.

The primary reason for making these proposals is our belief that patients and the public will
be best served by pharmacists who are clinical professionals with the ability and confidence to
support their decision-making regarding medicines and play an active role in maintaining the
health and wellbeing of the public.

Medicines use and the role of pharmacists need to be seen in the broader context of the public
health challenges ahead: the unacceptable level of health inequalities, the changing demographic
make-up of the UK, the resultant disease profile of the population, and the need to target effort
and limited resources accordingly.

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. Analysis of prescribing trends shows that 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 tailored to the genetic profile of individuals.

Both the pharmacy profession and successive governments have encouraged changes to pharmacy
practice to meet the changing demands of patients and the public and to use pharmacists’ scientific
training more effectively, while developing more clinical service provision, and to some extent the
profession has responded. The future for pharmacy practice will see pharmacists drawing on their
scientific training and their clinical and communication skills to work with other healthcare

1   Department of Health (2010) Healthy Lives, Healthy People: Our strategy for public health in England, para. 1.41.

                                                                                                                        5
Modernising Pharmacy Careers Programme

professionals and patients to optimise the use of medicines2 in a healthy living environment. This
future role will require a level of skill in behaviour change not previously supported by pharmacy
education and training.

Undergraduate education for pharmacists has not changed significantly for over 40 years. Despite
attempts by individual schools to incorporate more clinical skills and practice, undergraduate
education has evolved in a largely piecemeal manner which does not provide national consistency
for patients or future employers. Our review identified many examples of innovation by individual
schools or employers. However, a strategic and co-ordinated approach to the reform of initial
pharmacist formation, which we define as undergraduate education and pre-registration training,
is required if pharmacy is to contribute fully to public health challenges and help patients gain
maximum benefit from medicines. It is time to change the formation of pharmacists much more
significantly than has been possible within the current approach to pharmacy as an essentially
scientific discipline.

The Modernising Pharmacy Careers Programme Board (MPCPB) recognised the need for a strategic
approach and commissioned the review of current undergraduate pharmacy education and
training with a view to developing proposals for change. The MPCPB is now seeking the views
of key pharmacy organisations on proposals for the reform of undergraduate education and
pre-registration training of pharmacists in England.

In the last few months, the Government has, through the NHS and Public Health White Papers,3
set out its vision for the future delivery of healthcare and an NHS for the 21st century. The
organisation of healthcare training will also change to reflect the new architecture and the
Government’s vision for the NHS.4

Any proposals we make must be aligned with the wider changes to the structure of the NHS
in England.5 Strategic health authorities and primary care trusts will be abolished by 2013.
A national NHS Commissioning Board and local GP consortia will undertake commissioning of
services. The Government has been explicit about its intention to put clinicians in the driving seat
and set hospitals and providers free to innovate, with stronger incentives to adopt best practice.

Our proposals for changes to pharmacy education need to be considered in conjunction with
the recent White Paper on healthcare education,6 with its emphasis on an integrated and
multi-professional approach to workforce planning and education. As part of the review of the
formation of pharmacists, we also need to ensure that our proposals encourage pharmacists
to develop their careers in a way which delivers future leaders of the profession.

The current economic climate calls for complete transparency in the funding streams and cost-
effectiveness in all areas of public funding. An alliance exists in pharmacy education and training
between students, employers and public funding, both for higher education and training places in
healthcare settings. The Government’s proposals for education and for developing the healthcare

2   Ibid., para. 4.52. �
3   Department of Health (2010) Equity and Excellence: Liberating the NHS; Department of Health (2010) Healthy Lives, Healthy
    People: Our strategy for public health in England.
4   Department of Health (2010) Liberating the NHS: Developing the Healthcare Workforce. A consultation on proposals.
5   Department of Health (2010) Equity and Excellence: Liberating the NHS.
6   Department of Health (2010) Liberating the NHS: Developing the Healthcare Workforce. A consultation on proposals.

6
Foreword

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.

We are acutely conscious of the potential for our proposals to increase the cost of formation of
pharmacists – costs to the universities, funding bodies, employers, the Department of Health
(DH) and students. The developments that 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, so it is likely that the cost of training per student will increase.

We make our proposals in the full knowledge that DH and the Department for Business,
Innovation and Skills will have to consider a full business case, at a point in the future, and decide
on what are ultimately the most affordable options for reform.

We believe that our proposal 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.

RobertDarracott
Chief Executive, Company Chemists’ Association

AnthonySmith
Chair, Council of University Heads of Pharmacy Schools
Dean of the School of Pharmacy, University of London

                                                                                                     7
1Executivesummary
The Modernising Pharmacy Careers Programme Board (MPCPB) recognised the need for a strategic
review of pharmacist undergraduate education and training with a view to developing proposals
for change.

Education and training needs to be more effective and efficient in preparing new pharmacists
for their professional responsibilities to ensure the ongoing ability of the profession 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.

Based on a review of current arrangements, the vision for the future of pharmacy and
a realistic assessment of capabilities, MPC is using the proposals for reform detailed in this
paper as a starting point for discussions with and action by pharmacy educators, employers
and professional leaders.

Chapter2:Pharmacistundergraduateeducationandtraining:
currentarrangements
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.

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.

8
Executive summary

Chapter3:Pharmacisteducationandtraining:thecaseforchange
This chapter sets out the case for why current arrangements for pharmacist education and
training need to change, in response to existing and evolving roles for pharmacists in medicines
optimisation and public health, and the direction of travel for healthcare and the NHS in England.

Our vision for the future, shared by the Government and profession, is of pharmacists routinely
delivering medicines optimisation, support for patients with long-term conditions and public
health initiatives. Current pharmacist education and training need to respond to these growing
roles and responsibilities.

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 apply their knowledge
in practice.

The current separation between undergraduate teaching and work-based learning seems to be
the most important weakness in the current system. 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.

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.

Chapter4:Pharmacisteducationandtraining:
reviewmethodology
This chapter sets out the process of developing the proposals for reform, from the commissioning
of the work by the MPCPB in 2009 to discussion of the proposals for reform with pharmacy
organisations in spring 2011.

In summer 2009, MPC commissioned a review of the existing model of pharmacist formation
and identified options for change, with a particular focus on achieving meaningful clinical context
and experience.

During the first phase of work, a number of principles underpinning the reform of pharmacist
formation were agreed by the boards of MPC and Medical Education England (MEE). The
principles were:

• a continuous period of formation with registration and graduation at the end of year 5;
• early exposure to practice to support students to make more informed choices about their
  future careers in pharmacy;
• closer collaboration between higher education institutions and employers to support the initial
  formation of pharmacists, and to pave the way for their subsequent professional development;

                                                                                                     9
Modernising Pharmacy Careers Programme

• better integration of the teaching, learning and assessment of science which allows students to
  contextualise their learning; and
• additional teaching and learning in relation to developing clinical decision-making, for example
  communications skills, case-based learning and clinical skills training.

Based on evidence gathered during phase 1, educational theory and feedback from stakeholders,
the option of leaving current arrangements as they are was rejected by the Review team.

Although the benefits of multiple short placements across the five years are clear, the practical and
logistical difficulties led the Review team to deem a fully integrated option unachievable.

During phase 2, the principles were developed into proposals for change, taking into consideration
feedback from stakeholders regarding the practical and logistical difficulties they envisaged with
implementation of the proposals.

Chapter5:Pharmacisteducationandtraining:proposalsforreform
This chapter details the key 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.

Weproposeasinglefive-yearperiodofteaching,learningandassessmentleading
tograduationandregistration.

From an educational perspective, experience in other professions such as medicine and dentistry
and pharmacist training programmes in other countries such as the United States have shown
that an integrated programme ensures that professionals are able to contextualise and apply their
knowledge and learning in practice situations.

We recognise that this single recommendation has major implications for accountabilities and
responsibilities – such as sign-off, assessments and placement provision – given the way the two
phases of formation are currently structured, managed and funded. Subsequent proposals in
relation to joint responsibility and integrating pharmacy into the local infrastructures established to
manage quality in major placements will address these concerns.

Weproposethatuniversitiesandemployersshouldbejointlyresponsibleforthe
deliveryofafive-yearintegratedprogramme,includingjointsign-offofcompletion
oftraining.

Delivering a five-year MPharm programme incorporating 12 months of patient contact and
placement learning will require joint ownership of the whole curriculum, and most importantly will
require a strong partnership to be built between the schools of pharmacy and employers in both
the NHS and community pharmacy sectors. Joint sign-off of completion of training in academic
and professional assessments will cement the required partnership between universities and
employers.

10
Executive summary

Weproposethatthecurrent12-monthwork-basedplacementshouldbedividedinto
twomajorplacementperiodsofsixmonthseach.

We do not think it would be appropriate to reduce the current level of placement-based
teaching and learning (that is, 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 consideration 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 in the first instance.

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.
Simply dividing the placement in two will not be enough.

Ourpreferredoptionfordispersedpracticeplacementsisasix-monthplacementatthe
beginningofyear4andasix-monthplacementattheendofyear5ofthefive-year
programme,afterwhichstudentsproceeddirectlyintoregisteredpractice.

Weproposeasingleapplicationprocessforthemajorpracticeplacement(s),withthefull
involvementofemployerslocallyintheprocessofselection.

A single application system for major practice placements would offer choice to students and
employers, and would 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 principles of this application system are
similar to those used by other pharmacy organisations, and the system would have the advantage
of including all placement training provision details at a single point of access.

Weproposethatpharmacyshouldbeintegratedintolocalinfrastructureestablishedto
managequalityinmajorpracticeplacements.

Our proposals for introducing two placements and extending the learning outcomes to include
more clinically focused activities will 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 prescribing training, assessment and patient safety.

                                                                                                     11
Modernising Pharmacy Careers Programme

Weproposethatapharmacydeanshouldberesponsibleforsigningoffsatisfactory
completionofassessmentsinwork-basedplacementsandshouldbeaccountableto
theregulatorforthatfunction.

Registration will continue to be based on satisfactory completion of both academic and
professional education and training in any five-year MPharm programme. The GPhC will need
to be assured that any applicant being registered has satisfactorily completed both sets of
assessment.

The relationship between practice placement provider and schools of pharmacy will need to be
established and maintained nationally as well as locally, with a national set of learning outcomes
being applied to entry as well as exit from placements, as described in the placement proposal,
and a pharmacy dean could play a key role in building these links.

Weproposethatallschoolsofpharmacyworkingwithemployersshouldadoptthe
principlesofintegrationandassessthemeritintheprincipleofaspiralcurriculum.

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 on a number of occasions 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.

Weproposethatthefive-yearMPharmprogrammeshouldbeeligibleforatleast
12months’fundingasaclinicalsubjectinadditiontotheexistingfundingasascience-
basedsubject.

Pharmacy undergraduate education is currently funded as a science programme, unlike medicine
and dentistry, which receive an additional clinical supplement to fund clinical teaching orientation
visits, placement teaching, learning and assessment, and 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 simulation, clinical academic staff
and small-group teaching.

12
Executive summary

Opportunities to see and 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 ability
of schools to provide these important visits and placements on a secure and sustainable basis.

WeproposethatthereshouldbeopportunitiestoundertakePhDandpostdoctoral
research,withaccesstoaschemetosupportgrantsspecificallyforpharmacists.

Our proposal to invest in and develop the next generation of academic pharmacists, by 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 for reform.

Weproposethatvisitstothepharmaceuticalandbiotechnologyindustries,
work-shadowingopportunitiesandvisitingindustrylecturersshouldbeincluded
inthecurriculum.

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.

Our proposal for increased visits to industry and work-shadowing opportunities would not only
give context to the science underpinning the discovery and development of medicines, but would
also highlight career pathways.

We believe that an intercalated year could be offered after year 3, in the five-year model that
we are proposing, for those students with an interest in developing further their specialist
pharmaceutical science knowledge.

Chapter6:Pharmacisteducationandtraining:potentialimpacts
ofproposalsforreform
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.

By moving to a five-year integrated programme, there is the unwelcome potential for creating an
additional year of student loans to cover a fifth year of tuition fees and maintenance support, and
possibly losing a year’s salaried employment. This could be mitigated by inclusion of pharmacy
students in the NHS Bursary and tuition fee waiver programme, an option for future discussions
with the Department for Business, Innovation and Skills (BIS) and the Department of Health (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. Development of
the academic aspects of NHS consultant posts offers an opportunity to develop and reward
involvement in teaching and learning.

                                                                                                   13
Modernising Pharmacy Careers Programme

Our proposal to invest in and develop the next generation of academic pharmacists, alongside
recommendations related to transition arrangements and extra 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 the need 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.

We recognise that our proposals may impact on the delivery of education and training in Scotland,
Wales and Northern Ireland, so we have updated the devolved administrations through their
observers on the MPCPB and will be seeking further advice regarding the likely impact that these
proposals could have on the workforce and delivery of pharmacist education and training in
these countries.

14
2Pharmacistundergraduate
educationandpre-registration:
currentarrangements
2.1Overallstructureandorganisation
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.

Figure1:Currentarrangementsforpharmacistundergraduateeducationand
pre-registrationtraining

                                                                            Pre­registration year;
                  MPharm degree; university based
                                                                                 work based

       Y1              Y2                   Y3                Y4                      Y5
                                                                        +
  S1        S2    S1         S2        S1           S2   S1        S2           P1          P2

                                                                        Graduation                   Registration with GPhC

S1 refers to semester 1 (September to 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 with a further two in the final stages of gaining full accreditation.

Only one university, Bradford, currently offers a five-year sandwich programme where the one-
year work-based training is split into two six-month sandwich placements. In this programme,
the regulator’s performance standards are split across the two placements rather than being
integrated into a single curriculum.

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 pharmacy (approximately two-thirds of trainees) or hospital
pharmacy (one-third of trainees). There is a small number of joint pre-registration posts where six
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.

                                                                                                                              15
Modernising Pharmacy Careers Programme

Figure2:Pre-registrationtraineedistributioninEngland,2009/10

2,500

2,000

1,500
                                        Industry
                                        Other community
1,000
                                        Boots and Lloyds
                                        Hospital
 500

     0

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 organisation and delivery of 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
regulator, in its consultation on education and training standards, to link the learning outcomes
from the MPharm to those in the pre-registration training year.

The 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.

16
Pharmacist undergraduate education and pre-registration: current arrangements

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 and professional organisations – is required to fundamentally
change the current structure and organisation to deliver confident and capable pharmacists who
are scientifically knowledgeable, clinically competent and professionally focused.

2.2Pre-registrationworkplacementprovision
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 national
application and selection process (as is the case for foundation year 1 medical trainees currently).

Universities will 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 in either 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 or employers.

Although the number of pharmacy students has more than doubled over the last ten years, lack
of pre-registration placements has not 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;

                                                                                                    17
Modernising Pharmacy Careers Programme

• 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 ailment services.

Similarly, there has been a significant increase in NHS establishments, with a 6.5% increase in
Agenda for Change band 7 and an 8.3% increase in band 8a pharmacist posts in the NHS
since 2009.

However, new proposals currently being consulted on by DH 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 at 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.

2.3Qualitymanagementofplacements
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
the current tutor network.

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.

2.4Curriculumdesignandclinicalteaching
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.

18
Pharmacist undergraduate education and pre-registration: current arrangements

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.7

What is fundamental is that 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:

• 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’);8
• modular delivery of subject matter; and
• achieving the core syllabus outcomes which are currently part of the regulator’s standards, with
  an opportunity to study an option.

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. Many students undertake vacation work but this is ad hoc and not linked in any
formal way with the undergraduate curriculum or the learning outcomes set by the regulator.

In the current arrangements, unless students undertake voluntary vacation work in pharmacy,
they will rarely see pharmacists at work or talk with patients; they will not have had an opportunity
to practise the skills they are learning until the fifth and final year of their training and after they
graduate with an MPharm degree.

2.5Assessmentsoflearningandperformance
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 paucity of placements available.

7   Grant J (2006) Principles of curriculum design. Understanding Medical Education.
8   Harden RM and Stamper N (1999) What is a spiral curriculum? Medical Teacher 21: 141–3.

                                                                                                          19
Modernising Pharmacy Careers Programme

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 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 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 and with delivering high-quality care with confidence.

2.6Funding
The MPharm undergraduate programme moved from three to four years in length (and from
a Bachelor’s to a Master’s-level qualification) in 1997 but continues to be funded as a science
degree with 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.

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 in a
variety of ways to support training, 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.9

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 HEFCE10 and £40 million11 from tuition fees paid by students. A further £50 million12

9 Based on estimates of training costs provided by a number of contractors.
10 Based on the band B funding level minus the assumed fee income multiplied by the number of students enrolled at universities
   in England.
11 Based on current tuition fees (£3,290 per year).
12 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.

20
Pharmacist undergraduate education and pre-registration: current arrangements

is 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.13

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.

Figure3:2009/10annualfundingproportions
            200

            180

            160

            140
                                                      Community pharmacy (employers)
            120
£ million

                                                      DH Community Pharmacy Contractual Framework grant
            100
                                                      DH MPET levy
            80
                                                      Student living expenses
            60
                                                      Student tuition fees
            40
                                                      HEFCE
            20

             0

The funding environment in higher education is set to change dramatically from 2011/12
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 meeting access and widening
participation targets. These 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.

2.7Studentnumbers
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. 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 9,800.14

13 Based on the current average maintenance loan per student (£3,610 per year) and current student numbers enrolled in
   universities in England.
14 Royal Pharmaceutical Society of Great Britain, personal communication, 2009.

                                                                                                                         21
Modernising Pharmacy Careers 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%.15

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. Three universities in England have established, or
are establishing, ‘two plus two’ partnerships or 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.

Unlike medicine and dentistry, the number of overseas fee-paying pharmacy students is
not capped.

15 Higher Education Statistics Agency (2010) Students in Higher Education Institutions, Statistical First Release 142, Table 2a.

22
3Pharmacisteducationand
training:thecaseforchange
3.1Visionforthefutureofpharmacy
At the heart of our proposals lies the core vision of the pharmacist as a professional, a clinician
and a scientist. This vision has been helpful for us in predicting what newly registered pharmacists
should be able to do in practice over and above what they are able to do now. We visualised how
the optimisation of medicines use, supporting patients with long-term conditions and a greater
role in public health will be what the pharmacy profession routinely delivers for patient care and
the public in the future. The recent NHS and Public Health White Papers16 confirm that the direction
of travel for health policy will bring our vision for pharmacy into reality in the very near future.

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:

• engage patients, encouraging and embedding safe and more effective use of medicines;
• support public health through the promotion of healthier lifestyles;
• align, and work in partnership, with other healthcare professionals, to deliver medicines use that
  is safe, efficient and effective, and an integral part of a patient-focused healthcare service; and
• form a powerful clinical leadership alliance with medical and other healthcare professions,
  enabling patients to take decisions and make informed choices about their own care.

3.2Weaknessesincurrentarrangements
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 effective,
confident clinical professionals.

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 use their knowledge of medicines and science and apply it to solving clinical
problems. Employers found that trainees were not always demonstrating capability and confidence
in the application of the knowledge in the workplace. Indeed, students themselves, in evidence
submitted by the British Pharmaceutical Students’ Association to the Review team, raised these
points specifically.17

16 Department of Health (2010) Equity and Excellence: Liberating the NHS; Department of Health (2010) Healthy Lives, Healthy
   People: Our strategy for public health in England.
17 Evidence submitted by the British Pharmaceutical Students’ Association, 2009.
                                                                                                                               23
Modernising Pharmacy Careers Programme

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.18 More generally, students
complained of a lack of context for theoretical learning.19 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 and adds a practical focus to studies on their return to the university.

The current arrangements 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 pharmacists, 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.

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.

The 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
simply cannot apply their expert knowledge in medicines by the time they have to use it in the
workplace.

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.

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
and students about what is required and expected of a pharmacist on registration.

It also seems clear that the registration examination (and preparing for it) adversely dominates the
final year of practice-based learning.

18 Pharmacy Practice Research Trust (2010) Work, employment and the early career years of the 2006 graduate cohort students.
19 Evidence submitted by the British Pharmaceutical Students’ Association, 2009.

24
Pharmacist education and training: the case for change

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. We believe that our proposals for reform of education and training will address the
existing weaknesses and significantly reduce the need for post-registration courses.

3.3Medicinesoptimisation
Medicines are at the heart of modern healthcare and remain the most common treatment
offered to patients; as the experts in medicines, pharmacists are best placed to optimise use of
medicines. Used well, modern medicines can be life enhancing, life prolonging and sometimes life
saving. Modern medicines can also drive the design of NHS service delivery – for example, recent
developments of oral formulations of chemotherapy will relocate service delivery from hospitals to
primary care. After salary costs, medicines are the single highest outlay by the NHS (an estimated
£12.5 billion in 2010/11).

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. Recent research suggests
that there is room for improvement in medicines optimisation and pharmacists, as medicines
experts, have an important role to play:

• Avoidable medicines wastage in primary care is running at about £150 million per year.20
• 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.21
• The Care Quality Commission NHS Inpatient Survey 2009 found that many patients receive
  insufficient information about medicines they are asked to take.
• Preventable adverse effects of medicines account for 4–5% of all hospital admissions.22
• The Care Home Use of Medicines Study23 found an unacceptable level of errors in prescribing,
  dispensing, drug administration and drug monitoring when medicines are used in care homes.
• A report on the use of antipsychotics in dementia shows unacceptable levels of prescribing of
  these medicines.24
• The General Medical Council’s (GMC’s) EQUIP study25 demonstrated an unacceptable level of
  prescribing error across all grades of hospital doctors.
• The recently published NHS Atlas of Variation in Healthcare shows stark variation in the use of
  some medicines across different areas of England.26
20 York Health Economics Consortium/School of Pharmacy, University of London (2010) Evaluation of the Scale, Causes and Costs
   of Waste Medicines.
21 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).
22 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.
23 Alldred DP, Barber N, Buckle P et al. (2009) The Care Home Use of Medicines Study.
24 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.
25 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.
26 NHS Right Care (2010) The NHS Atlas of Variation in Healthcare: Reducing unwanted variation to increase value and improve quality.

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