Modernising Pharmacy Careers Programme. Review of post-registration career development: Next steps

Transcription

1 Modernising Pharmacy Careers Programme Review of post-registration career development: Next steps Report to Medical Education England Board September 2012 On behalf of Helen Howe and Keith Wilson

2 Foreword The pharmacy professions, comprising of pharmacist and pharmacy technicians, are responsible for the safe and effective use of medicines and for their safe supply. Our review of post-registration career development within pharmacy considers how the existing workforce of pharmacists, pharmacy technicians and their staff can be developed to deliver safer, more efficient, patient-focussed care, centred on medicines optimisation and public health and well-being. Recent and ongoing healthcare reforms driven by changes to the demographic profile of the country and the downturn in the economic environment mean that the pharmacy professions face different challenges in delivering healthcare. Medicines remain the most common treatment offered to patients and are the single highest outlay by the National Health Service (NHS) after salary costs (an estimated 12.5 billion in 2010/11). In an outcome-driven health service, society needs to get maximum effectiveness and value from its investment in medicines and it is clear from evidence, some of which is presented in this report, that there is scope for improvement in the effective use of medicines. Equally important is the need to tackle public health challenges such as rising levels of obesity, alcohol-related harm, high rates of sexually transmitted infections and a relatively high population of problem drug users. Evidence gathered as part of our review highlighted the complexity of the landscape for postregistration career development within pharmacy. Over the past few decades, the practice of pharmacy has evolved to varying degrees from a predominantly dispensing and supply function to a greater emphasis on clinical input, delivering new services to patients and playing a greater role in public health initiatives. However, the pharmacy workforce is diverse and not all pharmacists and pharmacy technicians work in patient-facing roles, or are employed by, or provide services to the NHS. Overall, our conclusion is that career development pathways for pharmacy professionals post-registration are not well defined. We believe there is much potential to improve the confidence and skill-set of the current workforce to enable pharmacists and pharmacy technicians to deliver safer and higher quality services to the public. Our review identified many areas of innovation within the profession by individual employers and through collaborative approaches. However, if pharmacy is to contribute fully to the public health agenda and help patients gain maximum benefit from their medicines we believe that a coordinated and strategic approach is required. We also recognise that emerging areas of policy such as commissioning and the supervision of the sale and supply of medicines will have implications for the outcomes of this review and MPC will need to take account of these in future work programmes. We believe that our proposals for reform of post-registration career development will help to maximise the effectiveness of the pharmacy professions and so ensure that patients gain full benefit from medicines, and that the whole population derives value from its investment in medicines to benefit patients, the public and the NHS. Helen Howe Chief Pharmacist, Cambridge University Hospitals NHS Foundation Trust Keith Wilson Professor of Pharmacy Practice, University of Aston 2

3 Contents Foreword 2 Contents 3 Executive Summary 5 Professionalism and early career development 6 Developing the workforce to deliver medicines optimisation and enhancing the skills of the pharmacy team in the delivery of public health messages 6 Maintaining an appropriate supply of technical, scientific and specialist pharmacists 7 Professional leadership 8 Clinical leadership 8 Developing the clinical academic workforce 9 1. Purpose and background Context Optimising the use of medicines A new educational context Making the case for change Assumptions used in the analysis of evidence 18 Responsibility 18 Two regulated pharmacy professions 18 Skill mix and technology 18 Common competencies and inter-professional learning 18 Commissioning 18 Funding The current pharmacy workforce The regulated pharmacy workforce: pharmacists Pharmacy technicians: a newly registered and regulated profession Professionalism and being a professional core competencies Professionalism and the early years Early Years frameworks Research 28 Proposal Medicines optimisation and public health Enhancing the skills of the pharmacy team in the delivery of public health messages 31 Proposal Technical and scientific services Clinical trials 33 Proposal Professional leadership Corporate level professional leadership 36 Proposal 4 36 Proposal Clinical leadership Development of consultant pharmacists Clinical research leadership 38 Proposal Developing the clinical academic workforce Teaching and learning Pharmacy technician teaching and learning 39 Proposal

4 Proposal Conclusion 40 Annex 1 41 Background and Context 41 Aim of Workstream II: Review of Post-Registration Career Development 41 Objectives of Workstream II: Review of Post-Registration Career Development 41 Deliverables 42 Outcomes 42 Membership 43 Roles and Responsibilities of the Review Team 44 Meetings 44 Wider Engagement and Working Practices 45 Annex

5 Executive Summary Post-registration career development within pharmacy needs to be more efficient and effective in preparing pharmacists and pharmacy technicians to deliver safer, more efficient, patient-focussed care, to meet the needs of a growing, older population with increased expectations about what health services can deliver. The sub-optimal use of medicines remains a major challenge and evidence suggests that pharmacy can do more to maximise the benefit that patients derive from medicines and improve the well-being of patients through pharmacy-delivered public health services. The aim of the proposals described in this paper is to maximise the contribution of pharmacists and pharmacy technicians to the healthcare of patients and the public, and in so doing, to optimise the value that the NHS gains from the pharmacy professions. Evidence gathering and feedback from stakeholders informed us that: to deliver a comprehensive approach to medicines optimisation will require development of the current workforce; there is currently a lack of structured career pathways needed to enable pharmacists and pharmacy technicians to move from novice to expert and beyond; pharmacy careers separate at an early stage between the sectors; there are supply side shortages in certain areas of the pharmacist workforce, notably in academia, research and technical specialities; pharmacy technicians are a new professional group and the relationships between them and pharmacists needs to be developed to ensure that these two complementary professions make their maximum contribution to healthcare; research needs to be at the core of pharmacy practice in all sectors to add to knowledge, drive innovation and engender a culture of lifelong teaching and learning amongst pharmacy professionals. This report outlines proposals for a number of areas of work to be taken forward as part of the ongoing Modernising Pharmacy Careers (MPC)/Health Education England (HEE) work programme. Other areas of work have been identified that fall partly or wholly outside the remit of MPC. These may be best taken forward by others such as the professional bodies (the Royal Pharmaceutical Society (RPS) and the Association of Pharmacy Technicians UK (APTUK)), employers, and the General Pharmaceutical Council (GPhC), or by those organisations listed in partnership with MPC/HEE. We are proposing that work is progressed in the following areas: Professionalism and being a professional The further development and use of professional development frameworks to support pharmacists and pharmacy technicians in their early careers Developing the workforce to deliver medicines optimisation and enhancing the skills of the pharmacy team in the delivery of public health messages Maintaining an appropriate supply of technical, scientific and specialist pharmacists and pharmacy technicians Developing clinical and professional leadership Developing the clinical academic workforce. 5

6 Our detailed proposals are as follows: Professionalism and early career development Proposal 1 We propose that the MPC Programme Board develops strategies to enhance the development, performance management and capability assessment of junior pharmacists and all pharmacy technicians. To support this work programme we propose that: the relevant professional bodies review and update the General Level Framework (GLF) for pharmacists and post-qualification pharmacy technician frameworks to reflect changes to service delivery and are informed by the recommendations of the University of East Anglia (UEA) evaluation of professional development frameworks. Appropriate core competencies relating to professionalism, using research results and contributing to research should be developed and embedded within each framework. performance management techniques and capability assessments, including appraisals, are developed, as well as both formative and, where appropriate, summative assessments of performance, reflecting the different levels of complexity and the nature of the decision making for each profession. further work is undertaken to establish with employers, commissioners and the GPhC, whether there is a need for the external validation of assessments of competence. Currently only prescribing by pharmacists is formally regulated post-registration. This programme of work should be taken forward in a way that ensures national ownership of the frameworks and consideration should be given to: continuing with two frameworks for pharmacists and pharmacy technicians, or one framework using common domains where appropriate, but with different levels of competence; how such frameworks can be used for enhancing the early years development of pharmacists and pharmacy technicians; how to build on current and planned work programmes aimed at supporting pharmacy technicians as a newly regulated profession and promoting effective team working between pharmacists and pharmacy technicians; and whether and how a more formal mentoring structure for the post-registration development of pharmacists and pharmacy technicians might be implemented and funded to support the utilisation of the frameworks. Developing the workforce to deliver medicines optimisation and enhancing the skills of the pharmacy team in the delivery of public health messages Proposal 2 We propose that the MPC Programme Board completes a detailed review of current postregistration learning, development and assessments relevant to the delivery of medicines optimisation and public health services. 6

7 This work should consider: for the development of the current pharmacist workforce 1 : whether a standard assessment of core competencies can be designed and piloted to inform the development of a flexible learning and development programme to up-skill pharmacists in order to deliver comprehensive medicines optimisation; the most appropriate form of summative assessment to assure patients, the public, other healthcare professionals and employers and commissioners that pharmacists have the appropriate skills, knowledge and behaviours to deliver safe and effective optimisation of medicines and/or prescribing competence; the resources that will be required for the learning, development and assessments needed to deliver the medicines optimisation workforce; the number of pharmacists competent in medicines optimisation that will be needed to deliver a comprehensive service to all patients that need this level of care with their medicines, wherever they might need that care; for the development of pharmacy technicians: the learning and development needs of pharmacy technicians in relation to medicines management to support the delivery of medicines optimisation; for pharmacists and pharmacy technicians: the leadership and management skills development needed within the two professions to maintain the safe and effective running of a pharmacy; and for the development of the whole pharmacy team: the inclusion of teaching, learning and assessments relevant to delivery of public health messages within programmes to enhance the competence of the pharmacy team in consulting. 2 This proposal is seen as an interim measure that will need to be reviewed again if undergraduate education and pre-registration training are reformed to deliver significant clinical focus 3 and/or the prescribing legislation is developed and reformed. Maintaining an appropriate supply of technical, scientific and specialist pharmacists Proposal 3 We propose that workforce planning and post-registration education and training commissioning for technical and other speciality pharmacists and pharmacy technicians is undertaken at a national level by HEE and builds on pre-registration and undergraduate training. This work should include the development of strategies to enhance the number of pharmacists accredited as Qualified Persons (QP). 4 1 Proposal for the reform of pharmacists preregistration education and training, endorsed by Medical Education England (MEE) in June, 2011 will address the future pharmacist workforce. 2 This skillset is relevant to medicines optimisation too. 3 Pharmacist Prescriber Training Working Group Report for the MPC Programme Board: Available: 4 QPs are responsible for the release of a finished medicinal product and must certify the release of each batch. The duties of the Qualified Person (QP) are set out in article 51 of Directive 2001/83/EC and the 'Code of Practice for Qualified Persons in the Pharmaceutical Industry': Available: 7

8 This is a particular issue with pharmacists and therefore the focus in the first instance should be: the development and evaluation of options for developing combined basic clinical and specialist technical education, training and work-based rotations (at bands 6 and 7), including options for joint training with healthcare scientists; the development of opportunities to ensure that undergraduate pharmacy students and pre-registration trainees are exposed to the work of the technical specialities and provided with opportunities to undertake work experience and research projects in the technical areas to encourage uptake of the specialist training rotations; consideration of whether similar extended rotations are needed to train other small and specialist workforces, for example procurement and medicines information; and a programme of work to support the development of competence in research governance and enhance the number of pharmacists seeking accreditation as QPs. Professional leadership Proposal 4 To support the development and achievement of advanced and specialist practice amongst pharmacists at a level that is recognised by peers and accepted by employers and commissioners, we propose that the MPC Programme Board encourages and supports the continued development and use of the Advanced and Consultant Level Framework (ACLF) as the core professional development framework for supporting the development and achievement of advanced and specialist practice. This work should consider the extension of the use of the framework into areas such as the technical services, supply and procurement and how an ACLF may be developed and used to support advanced and specialised practice amongst pharmacy technicians. Proposal 5 We propose that the MPC Programme Board undertakes a programme of work to consider how best to use existing leadership frameworks to support the development of senior pharmacists with corporate responsibilities, such as Trust chief pharmacists and superintendent pharmacists. Clinical leadership Proposal 6 We propose that the MPC Programme Board undertakes a programme of work to consider how formal and sustainable links between employers and academia can be developed to deliver research, teaching and learning to support clinical leadership development. This work should also consider how consultant pharmacists might develop in the future. A programme of funding should be secured to support the development of the research workforce amongst early to mid career practitioners. 8

9 Developing the clinical academic workforce Proposal 7 We propose that the MPC Programme Board undertakes a programme of work to consider how to expand and develop the clinical academic workforce. This work should include the provision of appropriate learning coupled with postgraduate qualifications and the development of formal joint appointments between academia and practice. A programme of funding should be secured to establish a cadre of clinical research leaders with senior university appointments and joint posts linked to clinical research. Proposal 8 We propose that the MPC Programme Board undertakes a complementary programme of work to consider how formal joint appointments between employers, further education colleges and universities can be developed to support the post-registration development of pharmacy technicians. As part of our review, we collected, collated and analysed a huge volume of detailed evidence. This is presented in our background paper Review of Post-Registration Career Development of Pharmacists and Pharmacy Technicians 5. 5 Medical Education England, Modernising Pharmacy Careers Programme Post-Registration Career Development of Pharmacists and Pharmacy Technicians: Available: 9

10 1. Purpose and background Medicines are at the heart of modern healthcare and remain the most common treatment offered to patients. As the experts in medicines, pharmacists, supported by a new regulated profession, pharmacy technicians, are best placed to encourage and embed the safe and effective use of medicines. Yet it is clear from the evidence considered in our review that there is scope for improvement. A guiding principle of the NHS Constitution is that the NHS will aspire to the highest standards of excellence and professionalism in the provision of high-quality care that is safe, effective and focused on patient experience 6. Emerging Coalition Government health policy, set out in Equity and excellence: liberating the NHS 7 outlines the role of pharmacists working with doctors and other health professionals in optimising the use medicines to support better health. Medicines optimisation encompasses a whole systems approach to ensure the NHS is achieving maximum health gain and least harm from all medicines. It involves maximising the efficient and effective use of medicines in preventing disease or the progression of disease and in improving patient outcomes from the use of medicines. The Government s vision for improving the health and wellbeing of people in England, set out in Healthy Lives Healthy People 8, recognises community pharmacies as a valuable and trusted public health resource and highlights the potential to use community pharmacy teams even more effectively to improve health and wellbeing. Proposals for reform of pharmacists pre-registration education and training aim to establish a five-year programme that will provide pharmacists with the clinical and communication competencies to carry out medicines optimisation services safely, confidently and effectively, and to enable their faster development after registration. These are set out in the advice provided to the Secretary of State by the MPC Programme Board, and endorsed by MEE, in June The purpose of our review of post-registration career development within pharmacy was to consider: how to develop the existing workforce of pharmacists and pharmacy technicians to be capable of delivering safer, more efficient, patient-focussed care, particularly around medicines optimisation and public health and well-being; how to locate this development in the context of a clinically-led commissioning system and a diverse provider sector; and how to prepare for the future development needs of pharmacists who qualify after the reforms recommended for pharmacists pre-registration education and training. The Modernising Pharmacy Careers (MPC) Post-Registration Review Team, comprising of more than 40 individuals recruited from different staff groups, sectors and specialisms within all sectors of pharmacy began its work in January A copy of the review team s Terms of Reference is available in Annex 1. The review team took evidence from a range of stakeholders in June 2011, the detail of which is available in Annex 2. 6 NHS Constitution, 2009: Available: 7 Equity and excellence: liberating the NHS: Available: andguidance/dh_ Healthy Lives Healthy People: Our strategy for public health in England, 2010: Available: 10

11 The review team s work began by considering the vision for the future of pharmacy, set out in Pharmacy in England: building on strengths - delivering the future 9. In the later stages of the work, the team reflected on and responded to Equity and excellence: liberating the NHS as it relates to the optimisation of medicines use, and Healthy Lives Healthy People 10 which recognises the potential to use pharmacy teams even more effectively to improve health and wellbeing. Initial findings from the independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust 11 were also taken into account. Several pieces of independent advice were commissioned, including a review of approaches to career and post-registration development in other professions, and an evaluation of professional development frameworks in pharmacy. The University of East Anglia (UEA) report, An Independent Evaluation of Frameworks for Professional Development in Pharmacy is available on the Medical Education England (MEE) website, together with the Modernising Pharmacy Careers Post-Registration Careers Development - Background Paper, both of which provide a detailed review of the evidence received. The task of generating, gathering and critically analysing data on post-registration career development and engaging more widely with practitioners as appropriate was achieved by dividing the review team into four content-generating sub-groups. Stakeholder organisations, identified by the sub-groups, were invited to attend oral evidence gathering sessions. Outputs from the four subgroups were analysed to identify issues common across sectors and staff groups, resulting in a number of overarching themes. Box A: Issues raised in the evidence gathering sessions 1. Greater clinical care and services delivered by the pharmacy team requires staff to have the necessary core competencies and such services to be commissioned 2. Lack of a structured career pathway to move from novice to expert, and beyond 3. Pharmacist and pharmacy technicians working together as two complementary professions with implications for roles, responsibilities, skill mix and workforce planning across the pharmacy team 4. Separation of pharmacy careers at an early stage from individual sectors and from other healthcare professions 5. Supply side shortages in key sectors, e.g. pharmacists in academia, research and technical specialties 6. Research needs to be at the core of pharmacy practice across all sectors to add to knowledge, drive innovation and engender a culture of lifelong teaching and learning amongst pharmacy professionals. 9 Pharmacy in England: building on strengths - delivering the future: Available: 10 Healthy Lives Healthy People: Our strategy for public health in England, 2010: Available: 11 The Mid Staffordshire NHS Foundation Trust Inquiry, (2010) Robert Francis Inquiry report into Mid- Staffordshire NHS Foundation Trust: Available: 11

12 During the summer of 2012, stakeholder feedback was gathered on a draft discussion paper setting out the current landscape, together with the emerging issues, in order to build consensus on the key issues, to consider where the responsibility for addressing these issues lay and how the work might be progressed. 12

13 2. Context It is widely recognised that medicines are at the centre of modern healthcare and the most common treatment offered to patients. After salary costs, medicines constitute the single largest investment that the NHS makes in patient care, representing a total spend of 13bn in England in 2010, and a 5% increase on the preceding year. For an outcome-driven health service performing in a financially constrained environment, there is a clear need to achieve maximum value by optimising the use of medicines and medicines-related services. In 2010, the White Paper, 12 Equity and Excellence, signalled that pharmacists, working with doctors and other health professionals, have an important and expanding role in optimising the use of medicines and in supporting better health. In tandem, the Government intends to move to a system of value-based pricing 13 for NHS medicines to ensure access to effective and innovative treatments and deliver value for money from NHS spending. There are now two registered and regulated pharmacy professions, pharmacists and pharmacy technicians. For pharmacists, delivering medicines optimisation will require them to make clinical decisions, utilising and building on their Masters level education and training. To support pharmacists, pharmacy technicians will need to build on their NVQ level 3 education and training. The mandatory requirement for pharmacy technicians to be registered has only existed for a short time and the new profession will need time to mature. 2.1 Optimising the use of medicines The pharmacy professions have an unparalleled line of sight on the medicines pathway from discovery to market authorisation, from formulation to prescription, from effective use to the potential for waste and from successful outcomes to the risk of misadventure. The insights drawn from this wide awareness confirm a common set of challenges: A growing and relatively older population with an increasing prevalence of long-term conditions Innovation and the potential to expand intervention in health and disease Increasing expectations of patients and the public A need to get the fundamentals right, particularly in relation to older and vulnerable people and the extent of medication misadventures. The pharmaceutical industry and health and healthcare services have played a substantial role in the achievements of the last decade, including a 14% reduction in cancer mortality and a 41% reduction in mortality from circulatory disorders 14. Steps are currently being taken to deliver 20bn of efficiency savings by It is clear, however, that suboptimal medicines use remains to be resolved in a number of areas, as highlighted in Table 1 on the following page. 12 Equity and excellence: Liberating the NHS, July 2010: Cm Response to a consultation on a new value-based approach to the pricing of branded medicines: Department of Health, July, Innovation, health and wealth, accelerating adoption and diffusion in the NHS, DH

14 Avoidable medicines wastage in primary care is estimated to be 150 million per year. 15 NICE reports that 30 50% of medicines are not taken as intended. 16 Ambulatory care-sensitive conditions (i.e. actively managed conditions not normally requiring hospitalisation) account for 1 in 6 emergency admissions at a cost of 1.42bn each year. 17 Adverse drug reactions account for 6.5% of hospital admissions and over 70% of the ADRs are avoidable. 18 A study of the Use of Medicines in Care Homes finds that 70% of residents were exposed to one or more medication errors. 19 An estimated 180,000 people with dementia are treated with antipsychotics each year; of which, it has been estimated that less than 36,000 may derive some benefit from them at a cost of 1,800 additional deaths and 1,620 cerebrovascular events. 20 The General Medical Council s EQUIP study demonstrates a prescribing error rate of 8.9% in medication orders in 19 acute hospitals. The study found that errors are associated with all levels of doctors ,186 medication incidents were reported to NPSA between 2005 and 2010; 16% involved actual patient harm. Delayed or omitted doses (16%) and wrong dose (15%) were found to be the commonest categories. 22 In a small study group of 108 people re-admitted to hospital, documentation of changes to medication was incomplete on two-thirds of previous discharge documents. Readmission was considered to be medicines-related in 41 (38%) of the 108 cases examined and preventable in 25 (61%) of this sub-group. 23 Table 1: Examples of sub-optimal medicines use In this context, medicines optimisation s primary goal is maximising value; the value that a patient derives from their medicines and the value that the whole population experiences 15 Evaluation of the scale, causes and costs of waste medicines. York Health Economics Consortium and School of Pharmacy, University of London, NICE Clinical Guideline CG76 17 Emergency hospital admissions for ambulatory care-sensitive conditions. Identifying the potential for reductions. Kings Fund, Adverse drug reactions as a cause of admission to hospital: prospective analysis patients. BMJ 2004; 329: Care home use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care 2009; 18: The use of antipsychotic medication for people with dementia: time for action. A report for the Minster of State for Care Services, An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study ( GMC, A review of medication incidents reported to the National Reporting and Learning System in England and Wales over six years ( ) Br J Clin Pharmacol (online) Witherington EMA, Pirzada OM, Avery AJ. Communication gaps and readmissions to hospital for patients over 75 years and older: an observational study. Qual Saf Health Care 2008; 17:

15 from the NHS investment in medicines. Optimal medicines use is a crucial step in both improving the quality of care and balancing the costs of healthcare. Improving the use of medicines is also necessary to ensure that avoidable problems do not undermine scientific and technical advances in therapy. Genomic technologies have the potential to transform the delivery of healthcare, meaning more patients receive the right treatment at the right time, and to enhance preventative care and population health. Successful translation from laboratory to care pathway relies, in part, on a workforce that is primed for innovation, and the recent report on genomic technology in healthcare 24 argues that education and training in genetics and genomics should form part of the overall function of Health Education England (HEE), including core educational standards for genomics. It also calls for an immediate review of the existing provision of genomics training and education for each profession. New developments bring new knowledge and skill demands, whilst providing a reminder that the unique body of knowledge in pharmacy (and within that the domains of formulation, preparation and administration) remain important in the education of pharmacy professionals. Nevertheless, it is evident that therapeutic advances will mean little if safe use and patient adherence are not supported. Pharmacists, supported by pharmacy technicians and other members of the pharmacy team are well placed to deliver on medicines optimisation and improve health and wellbeing, with community pharmacy offering over 10,700 points of access to pharmaceutical services in England. An estimated 1.6m people visit a pharmacy each day, of whom 1.2m do so for health-related reasons, and in 2010 over 926m prescription items were dispensed from community pharmacies. 25 Hospital pharmacy services have developed to support the safe use of complex and novel medicines, accompanied by professional differentiation into therapeutic or technical clinical specialties. The EQUIP study referred to earlier noted that almost all of the 11,077 prescribing errors made in 124,260 medication orders in 19 acute trusts were intercepted by pharmacists as part of their routine practice. Interviewees identified pharmacists as being particularly helpful in preventing prescribing errors. Moving beyond the prevention of harm, systematic reviews of the published literature demonstrate that pharmacists furnished with appropriate knowledge, skills and abilities make a positive and measurable impact on patient outcomes in diabetes, hypertension, hyperlipidaemia and cardiac failure. 26,27,28,29,30 A Cochrane database review of 25 studies (16,000 patients) and a further systematic review of 298 studies confirms that pharmacy services improve system efficiency and have positive therapeutic and safety outcomes across the range of healthcare settings. 31,32 These findings support the ambition for the post- 24 Building on our inheritance. Genomic technology in healthcare. A report by the Human Genomics Strategy Group, Community pharmacy. Our prospectus for better health. Pharmacy Voice, Sensitivity of patient outcomes to pharmacist interventions. Part I: a systematic review and meta-analysis in diabetes management. Ann Pharmacother 2007; 41: Sensitivity of patient outcomes to pharmacist interventions. Part II: a systematic review and meta-analysis in hypertension management. Ann Pharmacother 2007; 41: Sensitivity of patient outcomes to pharmacist interventions. Part III: a systematic review and meta-analysis in hyperlipidemia management. Ann Pharmacother 2008; 42: Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006; 166: Pharmacist care of patients with heart failure: a systematic review of randomised trials. Arch Intern Med 2008; 168: Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs and patient outcomes. Cochrane Database Syst Rev

16 registration development of the pharmacy workforce to deliver the goals of medicines optimisation. It is also clear that to enable pharmacists to address complex medicines use problems, a post-registration career and development strategy for pharmacy technicians will be needed as well as an appropriately resourced and trained support staff workforce. As a specific reference to the latter, there is an emerging picture of the value of (non-pharmacist) healthy living champions in the roll-out of healthy living pharmacies, coupled with a growing body of evidence of the benefit of pharmacy-delivered public health services A new educational context This drive for value also mandates improvement in the way the healthcare and public health workforce is developed; specifically that employers, supported by the professions, should have the opportunity to both shape the workforce and the ways in which they develop the people they employ. From an NHS perspective, the key requirement is to develop a capable and flexible workforce in the right numbers to support the delivery of healthcare and health improvement. In the current and anticipated future financial context, workforce development will also need to be focussed on value; literally the outcomes gained relative to the costs incurred in achieving them. Consequently, education and learning need to be linked with improvements in patient and public health outcomes, and the developing NHS Education Outcomes Framework will form the locus for establishing this link. To date, five high level domains of the Framework have been described, as shown in Table 2. Excellent education Education and training is commissioned and provided to the highest standards, ensuring learners have an excellent experience and that all elements of education and training are delivered in a safe environment for patients, staff and learners. Competent and capable staff There are sufficient health staff educated and trained, aligned to service and changing care needs, to ensure that people are cared for by staff who are properly inducted, trained and qualified, who have the required knowledge and skills to do the jobs the service needs, whilst working effectively in a team. Adaptable and flexible workforce The workforce is educated to be responsive to innovation and new technologies with knowledge about best practice, research and innovation that promotes adoption and dissemination of better quality service delivery to reduce variability and poor practice. NHS values and behaviours Healthcare staff have the necessary compassion, values and behaviours to provide person-centred care and enhance the quality of the patient experience through education, training and regular Continuing Personal and Professional Development (CPPD) that instils respect for patients. 32 US pharmacists effect as team members on patient care: systematic review and meta-analyses. Medical Care 2010; 48: Interim report of the outcomes of the Portsmouth Healthy Living Pharmacy Initiative. NHS Portsmouth September,

17 Widening participation Talent and leadership flourishes free from discrimination with fair opportunities to progress and everyone can participate to fulfil their potential, recognising individual as well as group differences, treating people as individuals, and placing positive value on diversity in the workforce and there are opportunities to progress across the five leadership framework domains. Table 2: Five domains of the Education Outcomes Framework Responsibility for setting up the new system for developing a capable and flexible workforce, which has the ability to support and adapt to innovation, sits with HEE. In turn, HEE will authorise and support Local Education and Training Boards to fulfil their core purpose of defining local development priorities and commissioning education and training to underpin high quality service provision and health improvement. This will be achieved by bringing together all healthcare and public health employers providing NHS funded services with education providers, the professions, local government and the research sector, to develop a skills and development strategy that meets employer requirements and responds to the plans of service commissioners. 2.3 Making the case for change The areas of focus around which our proposals are framed, have been drawn from our evaluation of the published literature, stakeholder contributions and the UEA evaluation of professional development frameworks. Health reform has reignited discussion of the role of innovation and located this in the concept of value. The 2010 White Paper indicated that the community pharmacy contract, through payment for performance, will incentivise and support high quality and efficient services, including better value in the use of medicines through better informed and more involved patients. The recently published Pincer study, a pragmatic randomised controlled trial of 72 general practices, has found that a pharmacist-led screening and review of patient computer records for selected groups of patients at potential risk of prescription errors significantly reduces the frequency of future clinically important prescription and monitoring errors, when compared with simple computer generated screening. 34 Coupled with US literature, 35 there is a substantial amount of evidence that pharmacy can and should aspire to deliver medicines optimisation and public health services. The financial, demographic and system challenges of the present and future have been well described. Healthcare demands provide the opportunity for different delivery models and some aspects of a new paradigm may already be in place, if under-utilised, including pharmacist prescribing, collaborative practice, appropriate delegation of responsibilities, skill mix and the academe-practice bridging potential of consultant pharmacists. The next steps are to work with the pharmacy professions and other stakeholders to build, from the analysis presented in this report, a coherent vision and strategy for post-registration pharmacy careers. 34 A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, clusterrandomised controlled trial and cost-effectiveness analysis. Lancet 2012; 379: Improving patient and health system outcomes through advanced pharmacy practice. A report to the US Surgeon General, Office of the Chief Pharmacist 17

18 2.4 Assumptions used in the analysis of evidence Responsibility Post registration education, training and development will continue to be a matter primarily for employers and individuals, based on professional body guidance where appropriate and not subject to statutory regulation and legislation, although the pharmacy regulator, the GPhC, will keep this under review as roles and responsibilities evolve and practice increasingly moves away from core registration competences. Two regulated pharmacy professions Although there are now two registered and regulated pharmacy professions, the mandatory requirement for pharmacy technicians to be registered has only existed for a short time and the new profession will need time to mature. The two professions have very different educational backgrounds and in terms of their contributions to medicines optimisation, will play different roles with different levels of responsibility. Skill mix and technology Innovative developments in skill mix and technology are likely to continue and these should be encouraged and supported as a means of improving efficiency and productivity whilst enhancing quality and maintaining safety. This is not to pre-empt any future debates and consultations on supervision but recognises a need to build on the evidence that many pharmacy teams are already working very differently across pharmacy under current legislation. Common competencies and inter-professional learning Although our proposals have been focussed around the pharmacy workforce, we would expect any resulting professional development frameworks to incorporate, where appropriate, common competencies and models for delivery, where possible, to include opportunities for inter-professional learning building on existing examples of good practice such as the multidisciplinary training events being developed by the Centre for Pharmacy Postgraduate Education (CPPE). 36 Commissioning The NHS Commissioning Board, due to become operational from April 2013, will work with a range of stakeholders to ensure that services are commissioned in a way that supports consistency of standards nationally. As the process and focus for the new commissioning arrangements for health services becomes clearer, work will need to start to plan how to develop and competence assure the workforce in the new era of commissioning any willing provider. Funding Post-registration education and training funding issues will be key elements of the MPC/HEE work programmes arising from this report. Any proposals for reform accepted by HEE will need funding and, in the current climate will need to meet affordability, sustainability and cost-effective criteria. HEE will need to consider the current investment in these areas and the likely costs of any development in either infrastructure or programmes. This will be 36 Centre for Pharmacy Postgraduate Education workshops Inter-professional learning between pharmacists and GPs. 18

19 challenging as the current funding streams are disparate and complex. The cost of not investing in medicines optimisation or public health will need to be part of the case for change. 19

20 3. The current pharmacy workforce Taken across all sectors (hospital, community, primary care, academia and industry) the pharmacy workforce is neither small nor is it simple. There are over 39,000 pharmacists and approaching 18,000 pharmacy technicians registered with the GPhC and practising in England. 37,38 The professional staff are supported in their work by at least 100,000 trained, but not registered, pharmacy assistants working within teams across all sectors of pharmacy. The pharmacy workforce is made up of individuals with expertise in three broad areas of practice: procurement and supply (including operating safe and effective pharmacies); clinical and public health (including strategic medicines management advice) and technical services and research (including health sciences research in universities and academic health science centres). All three groups share professional and leadership competency sets and are underpinned by core professional, scientific and professional knowledge. The groupings and areas of practice used in this report and summarised in Figure 1 below represent one way of describing the workforce. There are many others adopted by the GPhC in their various standards, by professional bodies in their various frameworks and by the NHS in its Agenda for Change (AfC) framework. This broad horizontal analysis, which works for the purposes of this piece of work insofar that it allows the emerging issues for both pharmacists and pharmacy technicians to be considered in parallel, can be mapped onto all the various profession specific standards and frameworks. Fig.1: Summary of groupings and areas of practice for the pharmacy workforce 37 General Pharmaceutical Council, Hassell K, (Mar 2012) Analysis of GPhC Pharmacist Register Available: 38 General Pharmaceutical Council (August 2012). Personal communication re pharmacist and pharmacy technician registration numbers. 20

21 Most individuals will have roles that cover more than one competency area. Many midcareer roles in the pharmaceutical industry, academia or strategic advisory areas build on core clinical and public health practice experience. A range of employers will employ individual practitioners from large foundation trusts and multi-national corporations, through to small independent pharmacies and family businesses. They will be working in teams of varying sizes with different and changing skill mix arrangements. They will be working within widely differing cultures with different approaches to, and resources for providing training and development and capacity to monitor and provide feedback on clinical performance. The roles and responsibilities described in this section illustrate the diversity of the workforce, employment arrangements and career development pathways. We have not set out to describe the sector as a whole and many other examples could have been cited. The Modernising Pharmacy Careers Post-Registration Careers Development - Background Paper 39 document provides more detail of the current landscape. 3.1 The regulated pharmacy workforce: pharmacists Traditionally, the pharmacist s role was focussed around the supply of medicines or, in the community sector, the safe and effective running of a pharmacy. In recent decades, pharmacists roles have shifted and are now much more clinically focussed. Community pharmacists increasingly deliver clinical and health and wellbeing services, and within the hospital sector, medicines supply is often managed by pharmacy technicians enabling hospital pharmacists to undertake a range of specialist clinical and technical roles. Despite the difference in the academic levels of their initial education and training, the roles of senior pharmacy technicians often overlap with those of junior pharmacists, with pharmacy technicians playing a supervising or mentoring role. Example 1: A community pharmacist has responsibility for the safe and effective running of a small to medium sized pharmacy providing core sale and supply services. The pharmacist contributes to the dispensing and sale of medicines and delivers clinical services including medicines use reviews and the new medicine service. The pharmacist manages and leads a small team with one pharmacy technician and two assistants, one of whom is trained as a healthy living champion, 40 proactively promoting health and well-being support to the public. They work with at least one locum pharmacist to cover one day a week. Their employer is a small family-run business with three pharmacies, two of which are run by family members. Example 2: A community pharmacist is responsible for the safe and effective running of a high volume dispensing practice with a team of one additional full-time pharmacist, three or four pharmacy technicians and up to ten assistants. They deliver a range of clinical services and employ a 39 Modernising Pharmacy Careers Post-Registration Careers Development - Background Paper, Medical Education England (June, 2012): Available: 40 Health Champions will have achieved, as a minimum, the Royal Society for Public Health s level 2 award in Understanding Health Improvement. 21