One stated objective of continuing professional development (CPD) programmes is for CPD to be a "condition for the periodic renewal of practising rights"¹ for registration as a practising pharmacist.

Important issues that arise from this include:

• Will I and a currently undefined minority of other pharmacists who do not actively undertake pharmacy practice be eligible to remain on the Register of Pharmaceutical Chemists?
• Will there be one (or more) registers for those who have proved that they have undertaken CPD and demonstrated "fitness to practise" and another for those whose main employment does not involve active practice?
• Will there be separate registers for MRPharmS[C], MRPharmS[H], MRPharmS[I], MRPharmS[A], and MRPharmS[Anything else]?
• How will the requirements for CPD apply to those who do not actively practise in community or hospital pharmacy?

It was reported² that the Royal Pharmaceutical Society in May 2001 submitted its proposals for mandatory CPD to the Department of Health, presumably through a Section 60 Parliamentary Order under the Health Act 1999.³ It was hoped that the Order "would be granted by the end of 2001", but this has not been reported as having been achieved. However, the fact that it has been submitted makes clear the Society's intention to proceed to mandatory CPD as rapidly as possible.

In the meantime, there is to be an initial roll-out of a voluntary CPD framework to approximately 5,000 pharmacists in late 2002.⁴ Pharmacists will be instructed "to keep written or computer-based plans and records of their CPD. Those taking part will also be advised of the fact that in three or five years' time, they may be among the first pharmacists invited, or required, to produce some or all of their CPD records for their revalidation of practice."

What is CPD and why is it important?

Almost all pharmacists would probably agree that there is a need for all health care professionals to undertake CPD. It would be foolhardy to suggest that someone could be admitted to the Register of Pharmaceutical Chemists and believe that their education is complete. However, there are important issues to be considered if the process is to become mandatory and to determine an individual's ability to practise.

A powerful incentive for this requirement to be able to prove "fitness to practise" came from the Kennedy report into excessive deaths in child heart surgery at Bristol Royal Infirmary.⁵ The report stated that patients are "entitled to be cared for and by health care professionals with relevant and up-to-date skills and expertise", and that "CPD should be compulsory for all health care professionals". It went on to say that there should be a system of regulation to ensure that health care professionals acquire and maintain professional competence. It stated that the system of regulation should incorporate:

• Education
• Registration
• Training
• CPD
• Revalidation
• Discipline

Interestingly, the Kennedy report proceeded to stress that "it must be the employer [not the regulatory body] first and foremost who should be able to deal with poor performance and misconduct", and that "professional codes of conduct should be incorporated into health care professionals' contracts".

In spite of this, it seems difficult to correlate a culture of practice in a neonatal intensive cardiac care unit, in which paternalism, poor training, concerns about techniques, and other worries existed, with the practice of pharmacy in any branch of the profession. However, the Government has been convinced of the findings of the inquiry that mandatory CPD should be adopted by all health care professions, however far removed their activities may be from the original impetus.

The Royal Pharmaceutical Society and CPD

The Society's published definition of CPD⁶ correlates with that described by the Bristol inquiry. The Society describes a "good practice cycle" in which there is an audit of a pharmacist's CPD needs, carried out by the individual or a manager, and a determination of what new knowledge or skills need to be acquired. This is followed by a decision on how to meet CPD needs, participation and recording of CPD activities, and evaluation of its outcomes.

An important part of the process is professional audit: self audit, peer audit, or external audit. Audit is necessary to improve standards continually and is one component of the quality assurance of professional standards. Its success depends upon the motivation and commitment of participants. To quote the "Medicines, ethics and practice" guide, "it must therefore be voluntary and non-threatening". (This was written before the planned move towards mandatory CPD.)

The "Medicines, ethics and practice" guide also publishes a national continuing education syllabus for pharmacy, incorporating a core syllabus, and sector syllabuses for community, hospital, industrial, veterinary, and academic pharmacy. The core syllabus is applicable to all pharmacists; the sectoral syllabuses contain knowledge and skills specific to the respective area of practice.

Continuing education or CPD?

As I understand it, continuing education (CE) is an integral part of CPD, in the same way as quality control is an integral part of quality assurance. However, there still exists confusion about the distinction between CE and CPD.

In my views, this has recently been further compounded by The Pharmaceutical Journal promoting a "professional development pilot"⁷ in which a CE article is topped and tailed by boxes exhorting readers to pose "questions to identify gaps in your knowledge", identify "action: practical points", and "evaluate" the learning. Readers who register for the pilot are advised to send their responses to multiple-choice questions based on the CPD/CE articles, to complete one of three practical exercises and produce a 500-word summary of their work on this exercise. The answers and the summary will be assessed by the College of Pharmacy Practice, at no charge to participating pharmacists.

It is a fact, however, that almost all the modules for CE previously published in The Pharmaceutical Journal have been oriented towards aspects of community practice. Where are the CE modules on maintaining aseptic conditions in clean rooms, on the special requirements for patient care in intensive care units, or on the different strategies for registering a new medicinal product via either the centralised or mutual recognition procedures?

Which pharmacists could be adversely affected by mandatory CPD?

The vital issue of which pharmacists could be affected by mandatory CPD has been addressed recently by the Society's Industrial Pharmacists Group.⁸ There was a reluctant admission by the group that there would probably be segregation of names on the Register to denote who had achieved fitness to practise in community, hospital, or industry. It suggested, however, that CPD should be optional for industrial pharmacists since they "are not contracted to provide services directly to patients, and that they should not be required to meet the requirements of the NHS Reform and Health Care Professions Bill".

There are a considerable number of other registered pharmacists who do not provide direct patient services, and questions that arise include:

• Will the Secretary and Registrar be removed from the Register because she has not demonstrated a continued competency to practise?
• What about other pharmacists at the Society: these include those who work in the practice division, the education division, on Martindale, on the British national Formulary, on The Pharmaceutical Journal, and in the library's information service? With all due respect to those working in community or hospital practice, many of these pharmacists are probably as up-to-date, if not more so, in attitudes to current pharmaceutical and medical practice than many others. Why? Because it is their job to be so.
• What about the considerable number who work in the pharmaceutical industry, working in regulatory affairs, as Qualified Persons, in research and development, and in numerous other specialties?
• What about pharmacists in Government agencies: the Department of Health, the Medicines Control Agency, and the Medical Devices Agency?
• What about pharmaceutical advisers to primary care trusts and all those not employed directly in a pharmacy environment but who nevertheless play an important role in supporting pharmacy and medical practice?
• In any branch of the profession, more senior managers will be likely to have less continuous contact with the "sharp end" of practice. However, their ability to be able to participate in regular practice activities remains an important part of their ability to understand and manage their colleagues. How will they be able to demonstrate sufficient "fitness to practise" if practice is carried out only intermittently?

How do you prove that CPD has been undertaken?

It is one thing to read an article, complete a series of questions, and submit the responses for assessment, as is currently being carried out by The Pharmaceutical Journal. Other activities that are undertaken which demonstrate a "fitness to practise" are much more difficult to record:

• How do you prove that you have spent a considerable amount of time reading a textbook on practice matters? Or will there be "required texts"?
• How do you prove that you have dealt effectively with emergency hormonal contraception for 10 women over the past three weeks?
• How do you demonstrate that the changes you have made to a patient's dosage regimen has greatly enhanced their quality of life?

So many aspect of "fitness to practise" are inherent and implicit in the day-to-day activities in a pharmacy that there remains a degree of cynicism about the purposes and effectiveness of CPD. Will pharmacists be expected to maintain a "diary" of special activities they have undertaken each day? Most pharmacists would probably baulk at that idea — when would they have the time to remember what they have done each day? — and yet their failure to do this or something similar could imperil their continued registration.

Who will carry out the CPD assessment?

The expectation is that an undefined proportion of the practising profession will be required to submit their CPD portfolios to the Society on a regular basis. The schedule for this has been variously quoted as being 20 per cent every five years, or 30 per cent every three years, with other multiples also cited.

To have confidence in the validity of the CPD process, the following points need to be addressed:

• Who will carry out this assessment? The Government has laid great stress on the importance of non-professionals people being involved in the assessment of health care professionals.
• Will there be a separate fee to be paid on each occasion that a pharmacist submits a portfolio, in addition to the already increased registration fee, one of the justifications for which was the introduction of CPD?
• Whose property is the portfolio? A future employer will probably be required by law to confirm that a new employee is deemed "fit to practise". If the Society has retained the portfolio, how can someone show this to a prospective employer?

The importance of knowing how many pharmacists are employed in each branch of practice is further emphasised by the potential logistical nightmare of receiving, assessing and returning more than 5,000 CPD portfolios each and every year.

Moving within the profession, and returning to practice

A critical issue for some will be the ability to demonstrate fitness to practise if they wish to move from one branch of pharmacy to another. What employer will wish to take on new pharmacists who need to undertake, say, three months of continuing education before they are deemed "fit to practise"? Competency can only be acquired by practising in the new branch of pharmacy.

• How can community experience be gained while still working in hospital pharmacy, and vice versa?
• Will there be a probation period before someone can be deemed fit to practise and to take sole charge of a pharmacy?
• Who will supervise the new employee?
• Will there be tutors in the same way as there are preregistration tutors?
• What period is deemed minimal for suitable fitness to practise to be demonstrated?

All these issues are also pertinent when someone wishes to return to practice after a break. There is already a severe shortage of pharmacists, and there should be encouragement for those wishing to return to practice, not obstacles through which they must jump.

... and so to the Register

When one accesses the Royal Pharmaceutical Society's website it is disconcerting to note the incompleteness in the data for the numbers on the Register in the different branches. According to the website, "there are 43,000 pharmacists on the Register, of whom 22,000 are in community practice, 5,500 in hospital practice, and 1,600 in the pharmaceutical industry. Others work in research, teaching, in health authorities and in related activities."

These data are clearly incomplete. There appear to be 14,000 pharmacists on the Register, about one third of the total, of whose sphere of practice the Society implicitly acknowledges that it is ignorant. This cannot be a sound basis for any fundamental changes to the way in which the Register is to be compiled. (A further illustration of the vagueness of the data is that the Society's Industrial Pharmacists Group sent out in February 2000 a salary survey questionnaire to 2,055 group members⁹ — a considerably higher number than the 1,600 recorded above.)

Some of the questions that need to be addressed before any changes are made to the compilation of the Register include:

• What number (or proportion) of those on the Register are deregistered each year through death or choosing to retire from the Register?
• How many are there on the Register but not in paid employment?
• How many are within five years of retirement age or who consider it likely that they will retire from practice within the next five years?
• How many are part-time, or who are currently not working but likely to return to practice within the next five years?
• How many are considering moving from one branch of practice to another within the next five years?

At the moment, pharmacists can choose whether to declare their branch of practice on the form they return to pay their registration fees. The Byelaws will need to be amended for it to become obligatory to indicate that practice (if any) is to be undertaken in community, hospital, industry or "other" during the ensuing year. Presumably, failure to give an indication on the returned form would result in the form being returned to the pharmacist in the same way as it would if there was failure to include payment with the form.

The absolute minimum options to be available for declaration might be:

• Practising (community)
• Practising (hospital)
• Non-practising (industry)
• Non-practising (other)
• Retired

However, it seems to create an excellent opportunity for the Society to obtain a regularly updated, accurate picture of exactly what the membership does. To achieve this, it may be necessary to expand the options available. Some of the possible permutations include (in alphabetical order):

• Community (full-time)
• Community (part-time)
• Health authority (pharmaceutical care adviser)
• Health authority (prescribing adviser)
• Hospital (full-time)
• Hospital (part-time)
• Industry (quality control)
• Industry (regulatory affairs)
• Management/administration (other)
• Management/administration (pharmaceutical)
• Publishing (pharmaceutical)
• Retired
• Other (please specify)

Summary

Everyone seems convinced of or resigned to the fact that mandatory CPD is to become a reality in the near future. This in itself should be viewed positively. However, the questions raised above — and there are many more that remain unstated — must be satisfactorily addressed before there develops a commitment to a process that might significantly affect the flexibility and morale of the profession.