The Pharmaceutical Journal
Vol 273 No 7327 p779-780
27 November 2004

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What makes pharmacists competent?

What are the knowledge, skills, attitudes and behaviour that pharmacists will need in the future? The answers lie in a report published this week by the Royal Pharmaceutical Society. Clare Bellingham (on the staff of The Journal) reports

Few could deny that pharmacy is undergoing enormous change. Pharmacists in all sectors are developing enhanced roles and providing services that five or 10 years ago would have seemed like impossible aspirations.

The issue for the profession is to ensure that pharmacists have the skills to work in these new ways. This comes down to pharmacists’ training. The Royal Pharmaceutical Society recognised the issue in 2001 and set about devising a competency framework for the future pharmacy workforce. Following a consultation and “reality testing”, the results are being published this week (details on p773).

Framework development

How was the framework developed? Initially, a review of government health policy documents in England, Scotland and Wales was undertaken. From this, policy changes that seemed likely to have an impact on pharmacists’ roles and activities over the next five to 10 years were identified. Next, the competencies — defined as the knowledge, skills, attitudes and behaviour — that pharmacists would need to fulfil these roles and activities were determined and categorised into 20 areas (see Panel below).

In order to ensure that pharmacists’ existing roles were included, the content of the current pharmacy undergraduate degree course and preregistration year were categorised into the same 20 areas. These were added to those competencies identified for future roles and this formed the draft framework which was published last year. It then underwent two types of review: a standard consultation and “reality testing”. This second type of review involved testing the framework with pharmacists who had already taken up new or extended roles in order to check that the framework was realistic for leading-edge pharmacists. The idea was that many of the roles that these pharmacists are doing today would become widespread in the future.

The reality testing included 150 completed questionnaires, 124 mini case studies at workshops and 24 in-depth case studies. A steering group, which is meeting for the first time next week, will make recommendations to the Society’s Council next summer on how to take this work forward.

Findings from the testing phase

Altogether, 266 competencies were identified. Of these, 118 were determined as the common core competencies that apply to the majority of pharmacists regardless of whether they practise in the community, hospital or primary care sector (a separate project is examining future roles in industry, academia and private health care). These 118 competencies will inform what should be included in the undergraduate pharmacy degree course and the preregistration training year. The 10 most commonly-required competencies across all sectors of pharmacy are:

· Working with other professions
· Self-motivation
· Identifying personal development needs
· Managing workload
· Oral and written communication skills
· Effective team working
· Providing information and advice to other health professionals
· Keeping skills and competence up to date
· Planning personal development
· Fulfilling continuing professional development requirements

A point of note is that none of the top 10 are pharmacy-specific competencies. In fact, 112 of the 118 core competencies could be classified as “generic”; in other words they are needed by all health care professionals not just pharmacists. Despite this finding, Eileen Neilson, the Society’s head of policy development, who led the research, points out: “The generic competencies are not about turning pharmacists into generic health care workers. They are what any health care practitioner will need to be able to put their discipline-specific knowledge and skills into practice.”

The six competencies in the 118 core competencies that are pharmacy-specific are:

· Providing medicines information
· Selecting medicines for individual patients
· Advising or providing information to staff
· Knowledge of clinical therapeutic uses of drugs
· Knowledge of adverse reactions, contraindications and interactions.
· Understanding clinical evaluation of drugs

What is important to remember is that there are 266 competencies altogether, so once the 118 core competencies have been taken out, there are still a further 148 to consider. And it is within these 148 competencies that pharmacists’ roles are defined. Instead of being central to all pharmacists, these competencies are specific to each pharmacy sector. What makes a pharmacist a pharmacist, rather than a generic health care professional, are the skills that the pharmacist has developed for his or her particular area of practice.

The top five competencies for community pharmacy are dispensing, making emergency supplies, supplying over-the-counter medicines, managing stock and advising on minor ailments. For hospital pharmacy, key competencies are using research evidence in practice, reviewing drug charts, advising on drug administration, managing clinical services and supervising students. And in primary care pharmacy the most important competencies are reducing health inequalities, developing patient group directions, analysing data, using research evidence in practice and analysing prescribing data.

These skills are not all exclusive to one field of practice; some are required in at least two sectors. What differs is the proportion of pharmacists in each sector who need the particular competence. And this helps to define the key competencies required to work in each field of practice.

However, because the differences between sectors are so visible, how pharmacists can be trained so that they are able to move between sectors (something that is currently commonplace) will need to be addressed in the future. The reality testing found that pharmacists’ careers are changing and there is an increasing blurring of boundaries between sectors. A trend towards pharmacists having two or more jobs at once was found. Linked to this is the fact that more and more jobs involve cross-sector working. In addition, senior pharmacists’ roles often have responsibilities wider than pharmacy and, in primary care, the number of roles for pharmacists is growing.

Underdeveloped competencies

The report also identified competencies that are expected to be important for future roles (as indicated by the home countries governments’ policies) but which are currently underdeveloped. An underdeveloped competency was defined as one that less than half of all respondents currently have.

“The biggest gaps appeared to be in community pharmacy,” says Ms Neilson. A total of 74 gaps were found for community pharmacy, 53 for primary care pharmacy and 44 for hospital pharmacy (see Panel, below).

The common core competencies were also compared with the current undergraduate degree course and preregistration programme. Gaps were also uncovered here, particularly in developing skills to enable team working with other professionals, management and leadership skills, and an ability to use a flexible approach to skill mix. “We are not saying that these competencies are not covered at all in the courses. Many of the pharmacists involved in the review had been in practice for a while so this might explain the gaps,” explains Ms Neilson. But it has helped to identify certain aspects of the undergraduate course and preregistration programme that might need to be strengthened. “It will also help in the development of training packages for pharmacists who are already in practice,” she adds.

The gap analysis highlights a number of issues for schools of pharmacy. Ms Neilson points out that a particular challenge will be how universities can embed the application of clinical skills into the undergraduate course. “There are things that cannot be taught as academic theory, such as working as part of a team and taking a reflective approach to practice,” she explains.

One initiative that might provide an answer to this is to be revealed next week: Green Light Pharmacy, in north London, and the London School of Pharmacy are launching Europe’s first teaching community pharmacy facility in which students can observe live consultations in a community pharmacy. The initiative will be covered in next week’s Journal.

Setting up the new school of pharmacy at the University of Hertfordshire has given Soraya Dhillon, head of the school, a fresh opportunity to examine the pharmacy degree course syllabus. She comments that it is a struggle for universities to include practical components in the degree course. “I would like to see preregistration training coming under the same umbrella as pharmacists’ undergraduate course,” she says. Her suggestion would not mean universities delivering preregistration training but for it to be dovetailed into the final year of the degree course. Students would complete blocks of training lasting two or three months and the preregistration examination could be incorporated into the final exams. “Students would complete their final year and register as a pharmacist at the same time,” she explains. Professor Dhillon adds that an advantage of this suggested modular system is that all students could undertake core training to ensure that they have certain core skills and then choose a further module in a specialist area. If a pharmacist wanted to move between sectors once qualified, they could undertake top-up training for the specialist area.

The report states that further research is required to assess both the science and clinical content required in the pharmacy degree course. Ms Neilson explains that an analysis of exactly what science pharmacists need to know in order to practise should be carried out. The clinical content poses a dilemma since new drugs are constantly coming to market, which can result in a topic becoming out of date quickly. “Therefore, we need to work out what is the best clinical foundation that provides a basis for learning more specific skills as and when pharmacists need to use them,” says Ms Neilson.

Stephen Denyer, head of the Welsh School of Pharmacy, comments: “The undergraduate curriculum needs to encourage students to recognise the core competencies they are developing. It can do this by student engagement with practice throughout the degree period, through problem-based learning, especially in therapeutics, and by embedding assessment methods capable of testing competency. This should occur alongside a knowledge-based element which will give students the confidence to continue their learning beyond the formal degree period.” But Professor Denyer points out that part of the distinctiveness of the pharmacist is a sound grounding in pharmaceutical sciences that can be successfully applied to practice. “This must not be overlooked when seeking curriculum change,” he comments.

Certainly the report recommends that the Society should set clear and explicit standards for the degree course and preregistration programme. It goes further in saying that the Society should ensure that these requirements will produce pharmacists who are fit to practise not just for existing roles but also for those that are emerging in the next few years. “Adding post-registration courses to the initial preparation programmes to prepare pharmacists for even basic-level clinical roles is not a viable or affordable option for the country, the profession or individual pharmacists. It will not deliver a pharmacy workforce fit for the health care environment now emerging,” it states.

Perhaps the biggest challenge of all is how to help existing pharmacists update their skills to match the competencies identified. Professor Denyer says that schools of pharmacy have an important role to play. “This will become of increasing importance if we are to avoid limiting the career ambitions of pharmacists, particularly if these include career change,” he comments.

Such limitations are clearly something that needs to be avoided or else it will lead to pharmacists leaving the profession.