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

Transcription

1 Modernising Pharmacy Careers Programme Review of pharmacist undergraduate education and pre-registration training and proposals for reform Report to Medical Education England Board April 2011 Anthony Smith and Robert Darracott

2 CONTENTS FOREWORD EXECUTIVE SUMMARY PHARMACIST UNDERGRADUATE EDUCATION AND PRE- REGISTRATION: CURRENT ARRANGEMENTS Overall structure and organisation Pre-registration work placement provision Quality management of placements Curriculum design and clinical teaching Assessments of learning and performance Funding Student numbers Weaknesses in current arrangements PHARMACIST EDUCATION AND TRAINING: THE CASE FOR CHANGE Vision for the future of pharmacy Medicines optimisation Long-term conditions Public health and wellbeing Future prescribing roles Educational perspective PHARMACIST EDUCATION AND TRAINING: PROPOSALS FOR REFORM Proposal: the five-year MPharm programme Proposal: joint responsibility for the five-year MPharm programme Proposal: curriculum redesign

3 4.4 Proposal: clinical supplement for teaching Proposal: major work-based placements Proposal: a single application process for major placements Proposal: integrating pharmacy into local infrastructure Proposal: a pharmacy dean Proposal: support for the pharmacist academic workforce PHARMACIST EDUCATION AND TRAINING: POTENTIAL IMPACTS OF PROPOSALS FOR REFORM Impact on students and graduates Impact on schools of pharmacy Impact on employers (NHS and non-nhs) Impact on the regulator Impact on careers in industry and academia Impact on the devolved administrations...62 ANNEX A: ACKNOWLEDGEMENTS...66 ANNEX B: PHARMACIST EDUCATION AND TRAINING: REVIEW METHODOLOGY...68 Background...68 Phase 1: agreeing the principles underpinning change...68 Feedback on principles for reform...70 Phase 2: developing proposals from principles

4 Foreword Pharmacists are experts in medicines. They are educated and trained to understand the scientific basis of medicines, but more importantly their safe and effective use. Medicines are at the heart of modern healthcare and remain the most common treatment offered to patients. Used well, modern medicines are life enhancing, life prolonging and sometimes life saving. This review is based on a modern vision of how and when pharmacists can, and should, make their significant contribution to patient and public health and safety, to ensure that more people use their medicines more effectively more often, and to reducing the possibility that those medicines will cause harm. If pharmacists are going to tackle subtherapeutic use, low levels of adherence, and reduce the likelihood of adverse effects contributing to costly hospital admissions, then their training should equip them first and foremost as clinical professionals, able and confident to support individual decision-making regarding medicines, and playing an active role in maintaining the health and wellbeing of the public. The purpose of this root-and-branch review of initial pharmacy education and training is to examine what can be achieved in a five-year programme to take pharmacists further at the point of registration so that from Day 1 onwards they can take professional responsibility for optimising medicines in use and for supporting the wider public health. Our future pharmacists will face different challenges in delivering healthcare services. The demographic profile of the country is changing due to a combination of increased life expectancy and low birth rates; 1 an estimated 50% of the population will be over the age of 50 by Older people tend to take more medicines than the general population. It will become more common for people to be treated for two or more conditions, making the expert pharmacist view of the potential interactions between different types of medication more important than ever for patient safety. Medicines themselves and the way they are used are set to change as the promise of pharmacogenomics and molecular biology begins to materialise, allowing medicines use to be personalised. The future for pharmacy practice will see pharmacists drawing on their scientific training and their clinical and communication skills to work with other healthcare professionals and patients to optimise the use of medicines 2 in a healthy living environment. Our Day 1 pharmacists will join a clinical profession that will ultimately deliver better care for patients and better value for the public purse. Their core skills will include reviewing medication and instituting changes where necessary, delivering public health through supporting behavioural change, leading the pharmacy team in the delivery of a range of health and well-being services, and contributing effectively to multidisciplinary healthcare teams. It is time to change the formation of pharmacists much more significantly than has been possible over the past 40 years, where the approach to pharmacy has been as essentially a scientific discipline. Our review identified many examples of innovation 1 Department of Health (2010) Healthy Lives, Healthy People: Our strategy for public health in England, para Ibid., para

5 by individual schools of pharmacy and employers, who have recognised that the focus needs to change to reflect the formation needs of professionals with a clear and developing clinical focus. However, a strategic and co-ordinated approach is required if pharmacy is to contribute fully to the public health challenges and help patients gain maximum benefit from medicines. We recognise that contemplating this degree of change in the current economic climate is not easy, against a background of calls for complete transparency in the funding streams, and cost-effectiveness in all areas of public funding. An informal alliance exists now in pharmacy education and training between students, employers and public funding, for both higher education and training places in healthcare settings. The Government s proposals for education and for developing the healthcare workforce means that there needs to be a re-balancing of the needs and interests of all the groups, not only to mitigate risks but also to produce the right number of professionals with the skills and behaviours which patients and the public expect and need. Educators and employers will need to develop an active dialogue to anticipate the demands of modern healthcare, and the supply and skills of professionals over the medium and long term, which will require a paradigm shift in the relationships between partners, the NHS and government. The developments we are recommending, especially in relation to clinical teaching, learning and assessment in schools of pharmacy will be more resource intensive than the current methods. We make our proposals in the full knowledge that the Departments of Health (DH) and Business, Innovation (BIS) and Skills will have to consider a business case and impact assessment for the recommendations in due course. It is possible that existing funding for pharmacist education and training could be used differently to implement the proposals, but that work is outside the scope of this review so it is not helpful to compare or extrapolate the costs related to the current programme. We see greater trust between the key partners employers and universities as the critical factor for the successful delivery of reform of pharmacist education and training. We believe that our proposals for a major restructuring in the way that pharmacist education and training is delivered and funded, without extending the length of the programmes will allow patients, the public and the NHS to benefit more completely from the unique contribution that pharmacists as medicines experts make to health, wellbeing and patient safety. Robert Darracott Chief Executive, Company Chemists Association Anthony Smith Chair, Council of University Heads of Pharmacy Schools and Dean of the School of Pharmacy, University of London 5

6 1 Executive summary Education and training needs to be more effective and efficient in preparing new pharmacists for their professional responsibilities and ability to deliver the care and services that patients and the public need and expect, particularly in relation to the use of medicines. The proposals described in this paper for a major restructuring in the way that pharmacist education and training is delivered and funded will allow patients, the public and the NHS to benefit more completely from the unique contribution that pharmacists as medicines experts make to health, wellbeing and patient safety. Chapter 2: Pharmacist undergraduate education and training: current arrangements This chapter sets out the current arrangements for pharmacist formation a four-year undergraduate degree (Master of Pharmacy, or MPharm) followed by a separate year of pre-registration practice-based training leading to registration. It briefly describes the funding arrangements, student numbers and placement provision. MPharm programmes are accredited by the General Pharmaceutical Council (GPhC), as the regulator, and it assures and manages the quality of preregistration training by approving premises, programmes and tutors. Pharmacy, unlike medicine or dentistry, is funded as a science degree, so does not receive a clinical supplement to fund clinical teaching and experience within the degree. Pharmacy students are not eligible for an NHS bursary. It is estimated that over 200 million is invested in educating and training pharmacists in England every year, and it costs an average of 90,000 to educate and train a pharmacist. Between 1999 and 2009, the number of schools of pharmacy in England increased from 12 to 21 and the number of students more than doubled from 4,200 to 9,800. Evidence-gathering and feedback from stakeholders informed us that there are weaknesses within the current arrangements for pharmacist education and training that work against the development of effective, confident clinical professionals who are able to readily apply their knowledge in practice. Student learning and assessment in the first four years are focused predominantly on knowledge and skills and not on developing as a member of a profession and work-based practice. 6

7 Chapter 3: Pharmacist education and training: the case for change This chapter sets out a vision for pharmacists at registration to be professionals whose actions and decision-making are underpinned by a unique knowledge of the science of medicines, and who will be clinical practitioners with the capability to apply and communicate this knowledge effectively for the benefit of patients and the public. There is a need to develop Day 1 pharmacists who can: engage patients and carry out relevant consultations, encouraging and embedding safe and more effective use of medicines; support public health through the promotion of healthier; respond to a diagnosis, usually developed by a medical practitioner, formulate a plan for initial and ongoing treatment in partnership with the patient, carers and other health professionals as appropriate, applying prescribing skills where appropriate lead the pharmacy team and work effectively within a multiprofessional team From an educational perspective, there is a strong case for an integrated curriculum with opportunities for the student to move between academic and practice environments to provide the context for learning and embedding knowledge and skills. Chapter 4: Pharmacist education and training: proposals for reform This chapter details the proposals for reforming pharmacist formation to produce safe and effective clinical professionals who can deliver medicines optimisation and other key services to patients from the point of registration. We propose a single five-year period of teaching, learning and assessment leading to graduation and registration. From an educational perspective, experience in other professions such as medicine and dentistry and pharmacist training programmes in other countries show that an integrated programme ensures that professionals are able to contextualise and apply their knowledge and learning in practice situations. This single recommendation has major implications for accountabilities and responsibilities such as sign-off to confirm satisfactory completion of academic learning and professional practice training, assessments and placement provision given the way the two phases of formation are currently structured, managed and funded. Our subsequent proposals in relation to joint responsibility and integrating pharmacy into the local infrastructures established to manage quality in major placements address these concerns. 7

8 We propose that universities and employers should be jointly responsible for the delivery of a five-year integrated programme, including joint sign-off of satisfactory completion of training. Delivering a five-year MPharm programme incorporating 12 months of patient contact and placement learning will require joint ownership of the whole curriculum, and a strong partnership between schools of pharmacy and employers in both the NHS and community pharmacy sectors. Joint sign-off of satisfactory completion of training in academic and professional assessments will cement this partnership. We propose that all schools of pharmacy working with employers should adopt the principles of integration and assess the merit in the principle of a spiral curriculum. To secure maximum benefit from the effort invested in developing the workbased elements of the integrated five-year MPharm, the curriculum will have to be designed as a five-year professional formation programme. The teaching must be delivered in a way that reinforces to students why they are learning not just to answer examination questions, but to support their future professional practice and clinical decision-making. Our review of curricula at schools of pharmacy across the UK and insights into professional formation in other sectors convinced us of the value of the spiral curriculum. In a spiral curriculum, topics, themes and subjects are revisited throughout the course, at increasing levels of difficulty, with the major practice placements providing opportunities to be assessed in the workplace. We recognise that implementation of this level of curriculum reform, especially if integration of placements is happening in parallel, would require a significant change management programme at the schools and universities. We propose that the five-year MPharm programme should be eligible for at least 12 months funding as a clinical subject in addition to the existing funding as a science-based subject. Pharmacy undergraduate education is currently funded as a science programme, unlike medicine and dentistry, which receive an additional clinical supplement to fund clinical teaching, particularly the small-group skills teaching. We propose that pharmacy should receive a clinical supplement for at least 12 months of the five-year MPharm programme and that this investment should be used to fund a range of hands-on, modes of teaching (with associated learning and assessment methodologies), often in smaller groups, and to support the engagement of clinical academic staff. Opportunities to see and, more importantly, talk to patients and professionals, and to visit a range of practice settings early in the curriculum, are crucial to student orientation and the process of developing as a member of a profession. Current funding of pharmacy as a science programme restricts the 8

9 ability of schools to provide these important visits and placements on a secure and sustainable basis. We propose that the current 12-month work-based placement should be divided into two major placement periods of six months each. We do not think it appropriate to reduce the current level of placement-based teaching and learning (12 months). Final decisions on the length of the placements are critically informed by the requirements set out in the EU Directive on the mutual recognition of qualifications. Taking into account EU Directive 2005/36/EC, which requires a minimum of six months to be spent in a patient-facing role in the last year of a five-year training period, and the preferences of employers, both NHS and non-nhs, we constrained the options for placement length to two periods of six months. However, redistribution of the placement period is only one part of the strategy to improve professional formation, and must be considered in conjunction with reforms of teaching and assessment, and joint responsibility for the whole programme. Simply dividing the placement in two, as in the current Bradford sandwich model, will not be enough. The GPhC may need to consider setting national learning outcomes for entry to and exit from each practice placement Our preferred option for dispersed practice placements is a six-month placement at the beginning of year 4 and a six-month placement at the end of year 5 of the five-year programme, after which students proceed directly into registered practice. We propose a single application process for the major practice placement(s), with the full involvement of employers locally in the process of selection. A single application system for major practice placements would retain the important element of choice for students and employers, and allow maximum flexibility in location and capacity for training. We see merit in extending and adapting the existing national recruitment scheme used in the NHS to appoint pre-registration training posts in NHS hospitals in England and Wales to all major practice placements across all pharmacy sectors. The system would have the advantage of including all placement training provision details at a single point of access, but still give the final choice to employers. We propose that pharmacy should be integrated into local infrastructure established to manage quality in major practice placements. Our proposals for introducing two placements and extending the learning outcomes of practice placement to include more clinically focused activities 9

10 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 crosscutting benefits with doctors and other healthcare professionals, such as improvements in prescriber training, assessment and patient safety. We propose that a pharmacy dean should be responsible for signing off satisfactory completion of assessments in work-based placements and should be accountable to the regulator for that function. Registration will continue to be based on satisfactory completion of both academic and professional education and training in any five-year MPharm programme. The General Pharmaceutical Council (GPhC) will need to be assured that any applicant being registered has satisfactorily completed both sets of assessment, so the pharmacy dean would be accountable to the regulator rather than the university or employer. The relationship between practice placement provider and schools of pharmacy will need to be established and maintained nationally as well as locally to give students flexibility when seeking placements and a pharmacy dean could play a key role in building these links. We propose that there should be an urgent review of the academic workforce including opportunities for pharmacists to undertake PhD and postdoctoral research, with access to support grants specifically for pharmacists. Delivery of our proposals for reform requires a significant increase in the number of academic pharmacists. Widening access to schemes that offer support grants for PhD and postdoctoral research could encourage a strong stream of pharmacists with the appropriate knowledge and skills to help deliver our proposals, particularly in relation to clinical teaching and curriculum redesign. Chapter 5: Pharmacist education and training: potential impacts of proposals for reform This chapter acknowledges the potential impact on different partners of implementing the proposals for reform. Where possible, proposals were shaped to mitigate the impact but, in many areas, especially in relation to funding, it is not possible to quantify their impact at this stage. 10

11 Proposals for a five-year programme do not automatically mean students would require an additional year of student loans to cover a fifth year of tuition fees and maintenance support, or that they would lose a year s salaried employment. The inclusion of pharmacy students in the NHS Bursary and tuition fee waiver programme while they are on practice placements is an option for future discussions between the BIS and DH. We recognise that making the teaching of medicines optimisation, public health skills and professionalism core components of the curriculum will require a significant expansion in the number of clinical staff involved in teaching, learning and assessment. Our proposal for an urgent review of the academic workforce and recognition of the need to invest in and develop the next generation of academic pharmacists, alongside recommendations related to transition arrangements and funding for clinical teaching and support for PhDs and postdoctoral research, should go some way to addressing concerns that schools might have in relation to clinical teaching. We recognise that integrating clinical practice and contextualising the science content of the degree in terms of practice may have a negative impact on research. We would not wish to see research activity at any of the schools damaged by developments in clinical teaching capacity. Our proposals relating to developing the clinical workforce and for supporting pharmacists in developing research capacity should mitigate some of the risk in the teaching and curriculum redesign proposals we are making. It is possible that our proposal for a five-year programme could decrease the attractiveness of English universities for pharmacy students from some parts of the world. We would not wish to see our proposals disadvantage individual schools, or prevent English universities competing in an increasingly global market, but progress for the majority of students and resulting benefits to patient care in this country cannot be held back by specific current needs to accommodate international students. If as a result of our proposals there is a five-year MPharm programme leading directly to registration, the regulator would need to accredit new programmes and revise the education and training standards, including learning outcomes within them. Although our proposals do not necessarily mean that students will be taught less science, it is clear that students will be applying their knowledge, largely in the context of a patient-facing setting, and careers in research and industry may become less obvious pathways. We recognise that our proposals for England may impact on the delivery of education and training in Scotland, Wales and Northern Ireland and the ability of pharmacy students, pre-registration trainees and registered pharmacists to move freely between the four countries. 11

12 2 Pharmacist undergraduate education and pre-registration: current arrangements 2.1 Overall structure and organisation Initial formation of pharmacists currently comprises a four-year Master s-level undergraduate degree (Master of Pharmacy or MPharm degree) followed by a separate one-year work-based pre-registration training year. Figure 1: Current arrangements for pharmacist undergraduate education and pre-registration training S1 refers to semester 1 (Sept February) and S2 refers to semester 2 (February to June) in each academic year MPharm degrees are delivered by 21 schools of pharmacy based in universities across England and a further four in Northern Ireland, Wales and Scotland. Nineteen degree programmes are fully accredited by the GPhC, a further two are in the final stages of gaining full accreditation, and Durham University recently announced its plans to launch a pharmacy degree course. Bradford is the only university currently offering a five-year sandwich programme where the one-year work-based training is split into two six-month sandwich placements. The first practice placement is in semester 2 of year 3 and a further placement in semester 1 of year 5, with students returning to university for the final semester. In this programme, the regulator s performance standards are split across the two placements rather than being integrated into a single curriculum, so the practice and academic elements remain separate in terms of curriculum, quality assurance and outcomes. Graduation with an MPharm degree does not lead directly to full or provisional registration with the GPhC; instead, it acts as the gateway to entering the preregistration year, which is completed while working in either a community 12

13 pharmacy (approximately two-thirds of trainees) or hospital pharmacy (onethird of trainees). There are a small number of joint pre-registration posts where 6 of the 12 months are spent in the pharmaceutical industry or primary care and the remainder in community or hospital practice. Although the pre-registration placement is recognised as a training period, all employers assume that trainees provide an element of supervised service provision, which increases towards the end of the year. Figure 2: Pre-registration trainee distribution in England, 2009/10 There is currently no overarching infrastructure to support work-based learning and assessment in the pre-registration training year, although the NHS and larger community pharmacy employers do have regional and national training arrangements. The pre-registration training tutor signs to confirm that the regulator s performance standards have been met and the individual is fit and proper to enter the register; usually, this information must be provided by the end of the 50th week of the pre-registration year. The trainee is also required to pass the regulator s national registration examination, which has a multiple-choice question format. Historically, there has been no tangible link between the MPharm delivered by schools of pharmacy and the delivery of practice-based learning and assessment in the pre-registration year. The two parts of the formation process for pharmacists have been completely separate in terms of curriculum, quality assurance and outcomes. We welcome the steps taken by the pharmacy regulator, in its recent consultation on education and training standards, to link the learning outcomes from the MPharm to those in the preregistration training year. 13

14 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. 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 coordinated approach involving students, universities, employers, the regulator, professional organisations and patients is required to fundamentally change the current structure and organisation to deliver confident and capable pharmacists who are, from the point of registration, scientifically knowledgeable, clinically competent, professionally focused and with the necessary skills to communicate and engage effectively with patients, public and other healthcare professionals. 2.2 Pre-registration work placement provision Currently, students are able to graduate with an MPharm degree without also needing to qualify for registration with the GPhC. Securing a pre-registration placement position is currently the responsibility of the student. Placements are advertised by employers based on their independent assessment of demand for trained staff or on the basis of a tradition of providing training as part of a recruitment and retention strategy. For other professional groups, this process of finding placements is carried out either by the university (which then allocates students into placements) or through a 14

15 national application and selection process (as is the case for foundation year 1 medical trainees currently). Universities assist pharmacy students in the process of finding a preregistration placement, but are not ultimately responsible for a student s ability to find a placement and to register. Universities carry no financial risk if students are unable, at graduation, to find a placement and to complete their training in order to register. Universities can meet their obligations to students with no reliance on employers to provide placements. As there is no link between recruitment to schools of pharmacy and placement commissioning, student numbers could either run ahead of or lag behind placement commissioning and workforce demand resulting either in students who might graduate but not be able to register or insufficient registrants to meet workforce demand. Neither situation is helpful to students, schools of pharmacy, employers or the wider economy. Although the number of pharmacy students has more than doubled over the last ten years, lack of pre-registration placements does not seem to have been a major issue. Even with large increases in pharmacy graduates, there have been workforce shortages reported in the same period as demand for pharmacists has increased due to: changing public expectations for access to services reflected in longer opening hours and more pharmacies many new pharmacies open for 100 hours per week, requiring at least three pharmacists to deliver the service in one pharmacy; an increase in the volume of prescriptions there has been a 58% increase in the nine years from 1999/2000 to 2008/09; and the increased number and complexity of additional and enhanced services provided in pharmacies. There has been a 47% increase in the number of medicines use reviews conducted between 2006/07 and 2008/09, and a 60% increase in delivery of enhanced services, for example smoking cessation and minor ailments services. Similarly, there has been a significant increase in NHS establishments, with a 6.5% increase in Agenda for Change band 7 posts and an 8.3% increase in band 8a pharmacist posts in the NHS since However, new proposals currently being consulted on by DH 3 could change the current system for planning and commissioning placements, by ensuring that placements funded by DH in community pharmacy and DH/the NHS in hospital pharmacy are commissioned on the basis of demand-led workforce planning by employers. Checks and balances in the system could help pharmacy to manage the risks in the current system of insufficient placements to match student recruitment 3 Department of Health (2010) Liberating the NHS: Developing the Healthcare Workforce. A consultation on proposals 15

16 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. 2.3 Quality management of placements Currently, the GPhC assures and manages the quality of pre-registration training by working directly with individual training providers to approve training premises and programmes, and register individual tutors. Tutors provide educational and clinical supervision for trainees, conduct the assessments, deliver the training programmes and sign to confirm that the trainee has met the regulator s performance standards and is fit to enter the register. In the NHS and among the national community pharmacy employers, there are training and development opportunities for their tutors. This system of quality assurance and management has inefficiencies given the 2,000 pre-registration trainees currently in the system. Access to a local system of quality management, which co-ordinates appropriate quality control among providers of training, will be important if regulation of placements is to be proportionate. 2.4 Curriculum design and clinical teaching Schools of pharmacy have a responsibility to ensure that the curriculum is reviewed and is current in the context of the changing nature of healthcare, the scientific development of medicines and the developing role of the pharmacist. Much has been written on curriculum development and organisation, and there is no evidence to suggest that there is a best template for curriculum design. 4 What is fundamental is that any curriculum meets the following principles: It tells the learner what to expect and how they will be supported. It advises the teacher on what to do to deliver the content and to support the learners in their personal and professional development. It assists the institution in setting appropriate assessment of student learning and support evaluation against externally applied standards, such as those set by the regulator. It tells wider society how the provider upholds high standards. Schools of pharmacy adopt a curriculum based on the principles of one or more of the following: 4 Grant J (2006) Principles of curriculum design. Understanding Medical Education 16

17 integrated teaching of all relevant science into themes; a robust scientific baseline, building the depth and breadth of knowledge year on year in its application to medicines design and development and evidence-based practice ( spiral model ) 5 ; modular delivery of subject matter; and achieving the core syllabus outcomes which are currently part of the regulator s standards, with an opportunity for optional studies. These models are not mutually exclusive and curricula may include elements of each. Currently, across the schools there is significant variation in access to, and provision of, short practice visits and placements: some schools offer as few as two days across the four-year programme. A number of community pharmacy employers put significant resource into vacation work experience programmes and schools of pharmacy encourage students to participate in them and also where possible gain experience in other sectors. Some employers consider the performance of students on these programmes when offering pre-registration training positions. Students gain great benefit from participating in these programmes however they are not linked in any formal way with the undergraduate curriculum or the learning outcomes of the regulator and, of course, participation is voluntary. In the current arrangements, unless students undertake voluntary vacation work in pharmacy, they will rarely see pharmacists at work or talk with patients and they will not have had an opportunity to practise the skills they are learning until the fifth and final year of their training which is after they graduate with an MPharm degree. 2.5 Assessments of learning and performance Currently, teaching and learning in the first four years is typically separated into eight academic semesters, which include a range of different assessments from written exams and multiple-choice questions through to simulation-based assessments in dispensing and, in some places, the use of observed structured clinical examinations (OSCEs). Work-based assessments are difficult to include in the assessment profiles because of the scarcity of placements available. The second period of learning the fifth year which is undertaken in the workplace is more focused on professional performance using tutor sign-off against performance standards as the assessment method. Here, success is defined in terms of professionalism and work-based confidence and capability. However, this period of training tends to be overshadowed by the return to an academic-style assessment in the final registration exam, which is 5 Harden RM and Stamper N (1999) What is a spiral curriculum? Medical Teacher 21:

18 a multiple-choice questionnaire format, scheduled towards the very end of the pre-registration year. In the final year, trainees will be concentrating on learning to be a pharmacist and on studying for the regulator s final registration exam. Not only are the students focusing on two different end points in the fifth and final year, so are the teachers and tutors. It is therefore of little surprise that newly registered pharmacists struggle with understanding what good professional practice looks and feels like, communicating and engaging effectively with patients, and with delivering high-quality care with confidence. 2.6 Funding In 1997 the MPharm undergraduate programme moved from three to four years in length (and from a Bachelor s to a Master s-level qualification), but continues to be funded as a science degree followed by a separate one-year vocational training year. The Higher Education Funding Council for England (HEFCE) provides funding for pharmacy as a science/laboratory-based subject (band B). Medicine and dentistry receive an additional clinical supplement from the HEFCE (band A level) for two years, which is more than double the corresponding allocation for band B. Additional funding for placements during medical and dental undergraduate education comes from the NHS through the Multi-Professional Education and Training (MPET) levy. There is no funding for clinical teaching or placements in the pharmacy degree from either the HEFCE or the NHS and, as a result, opportunities for patient contact, orientation visits, placement teaching, learning and assessment, and small-group skills teaching are limited. They often rely on goodwill, personal relationships and dedicated individuals. Hospital pre-registration salary costs are funded partly or wholly from the MPET levy (via the strategic health authority education and training commissioning process) with individual trusts contributing in some places but not others. Strategic health authorities use the MPET levy to support training in a variety of ways, for example residential courses or tutor support. Community pharmacy contractors receive a grant for training as part of the Community Pharmacy Contractual Framework, and they invest additional resources in training costs and salary from within their business resources. 6 It is estimated that 200 million is invested in educating and training pharmacists in England every year. Around 100 million is invested in undergraduate education approximately 60 million from the HEFCE 7 and 40 million 8 from tuition fees paid by students. A further 50 million 9 6 Based on estimates of training costs provided by a number of contractors 7 Based on the band B funding level minus the assumed fee income multiplied by the number of students enrolled at universities in England 8 Based on current tuition fees ( 3,290 per year). 18

19 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. 10. Pharmacy students unlike medical, dental and nursing students are not eligible for NHS bursaries. Based on the 2010 registration cohort (that is, trainees who entered schools of pharmacy in 2005) and 2009/10 figures for maintenance loans, salaries etc., it is estimated that the cost of educating and training a new pharmacist is around 90,000 in total. Employers (DH/NHS and community pharmacy employers) invest around 40,000 per trainee, the HEFCE 22,000 per student, and students themselves some 28,000. Figure 3: 2009/10 annual funding proportions The funding environment in higher education is set to change dramatically from 2012/13 when much of the public funding for teaching will be withdrawn and replaced by tuition fees ( 6,000 and capped at 9,000) set by universities and subject to Access Agreements being approved by the Office of Fair Access. These tuition fees will be paid up front by government and repaid by means of a graduate contribution subject to earnings thresholds and a 30- year limit. 9 Based on the current grant paid to pharmacy contractors ( 18,440 per year) plus pre-registration salary and on-costs, and an estimate of training costs in the NHS and for current pre-registration trainees in each sector 10 Based on the current average maintenance loan per student ( 3,610 per year) and current student numbers enrolled in universities in England. 19

20 2.7 Student numbers The number of students in schools of pharmacy is not currently subject to control. Universities are free to open new schools of pharmacy and to increase student numbers in established schools as the applicant market determines. Pharmacy continues to be a popular course. As a result, the number of schools of pharmacy in England increased from 12 in 1999 to 21 in 2009 and pharmacy student numbers over the same period rose from 4,200 to 9, Durham University and the University of Birmingham recently announced their plans to launch a pharmacy degree programme. In the five years from 2004/05 to 2008/09, the number of students entering the first year of MPharm programmes increased by over 40%. This compares with a national increase in the numbers of first year university students of around 15%. 12 Currently, around 14% of undergraduate students attending schools of pharmacy in England are overseas students (those who are not from Great Britain or the EU) and the majority complete the full four-year MPharm programme here. Five universities in England have established, or are establishing, two plus two partnerships with branch campuses overseas, where students complete years 1 and 2 abroad before transferring to England to complete years 3 and 4. The GPhC accredits these programmes and graduates are eligible to undertake their pre-registration training in England. It is not clear how many overseas students continue after graduation to complete the pre-registration year and register with the GPhC. In contrast to medicine and dentistry, the number of overseas fee-paying pharmacy students is not capped. 2.8 Weaknesses in current arrangements The current arrangements for education and training of pharmacists provide newly qualified pharmacists with an excellent scientific knowledge of medicines upon which to build their professional practice. However, evidence-gathering and feedback from stakeholders informed us that there are weaknesses within the current arrangements which work against the development of clinical professionals who at the point of registration are confident to take professional responsibility for the care of patients, particularly in relation to the safe and effective use of medicines. Employers described gaps in the knowledge of pharmacists in the workplace during their early years in practice and in the pre-registration year, often in areas where material had been taught in the MPharm curriculum. We were told that trainees and newly qualified pharmacists were struggling to apply 11 Royal Pharmaceutical Society of Great Britain, personal communication, Higher Education Statistics Agency (2010) Students in Higher Education Institutions, Statistical First Release 142, Table 2a 20

21 their knowledge of medicines and science to solving clinical problems and communicating with patients. Employers found that trainees were not always demonstrating capability and confidence in the application of the knowledge in the workplace, when dealing with other professionals and patients. Indeed, students themselves, in evidence submitted by the British Pharmaceutical Students Association (BPSA) to the Review team, raised these points specifically. 13 In many cases, late exposure to practical clinical experience gives students a view of pharmacy practice that may not be matched by the reality of the workplace. 14 More generally, students complained of a lack of context for theoretical learning We think it is significant that the anecdotal experience of students and academic staff following the first placement within the Bradford sandwich programme is largely positive. Early experience in practice enables students to contextualise prior learning, interact with patients, and adds a practical focus to studies on their return to the university. However a difficulty with the current sandwich placements on the Bradford course is that the practice elements sit outside the MPharm curriculum and are not integrated with teaching and learning in the university. The current arrangements for pharmacist education and training have a major gap in how the concept of professionalism is developed and nurtured within the MPharm. Students should have a clear understanding of their responsibilities as trainees and then as members of the pharmacy profession, but students and employers tell us that this is not currently the case. It seems to us that, in many ways, it is the separation of both educational purpose and responsibility for academic and professional success, as well as the separation in time, between the undergraduate teaching and the workbased learning, which presents the most important weakness in the current system. Across all five years, students need to focus on achieving success as a professional clinician as well as success as a scientist. Professional and academic achievement should be experienced as part of a continuum of success across all five years not separated in time, geography and educational purpose, as is currently the case. We have seen that the current system fosters a situation where assessments, and therefore student learning, in the first four years are focused predominantly on knowledge and skills and not on developing as a member of a profession and work-based practice. This is exaggerated by the lack of clinical placements within the degree. Assessment in the pre-registration year is of professional performance by the tutor against the regulator s standards but, in the absence of an infrastructure to support consistency and quality across all placement providers, the year concludes with an academic style (multiple-choice question) assessment (the national registration exam) before registration. It also seems clear that the registration examination (and preparing for it) adversely dominates the final year of practice-based learning. 13 Evidence submitted by the British Pharmaceutical Students Association, Pharmacy Practice Research Trust (2010) Work, employment and the early career years of the 2006 graduate cohort students. 21

22 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 struggle to apply their expert knowledge in medicines by the time they have to use it in the workplace, to communicate with patients, the public and other healthcare professionals. Early exposure to patients and workplace settings are a vital part of this process of professional development, as well as managing what are sometimes widely differing expectations of employers, students, and patients, about what is required and expected of a pharmacist on registration. Pharmacists practice has changed significantly in recent years, but the education and training demands that this has posed have largely been met through post-registration postgraduate courses, particularly in secondary care. We believe that our proposals for reform of education and training will address the existing weaknesses, significantly reduce the need for post-registration courses and their associated cost to the NHS, and ensure patients benefit from the expertise of pharmacists from Day 1 of registration. 22