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Since publication of the HOMER study about home
medication review (PJ,
22 January, p71), much has been written about the implications for medication
review by pharmacists but little consideration has been given to the
implications for pharmacy postgraduate education and training.
In the HOMER study, pharmacists could participate if they held a postgraduate
qualification in pharmacy practice or had recent continuing professional
development in therapeutics. All pharmacists participated in a two-day
training course, including lectures on adverse drug reactions, prescribing
in elderly people, improving concordance and communication skills. However,
as a recent correspondent in The Pharmaceutical Journal pointed out with
respect to prescribing, “being trained and being competent are
not the same thing” (PJ, 28 May, p645).
Over the past eight years, the Pharmaceutical Resource Network (PRN)
has delivered high quality, innovative training to pharmacists and prescribers
in many primary care organisations to support the implementation of medication
review. In PRN’s experience, there are three areas of training
provision that are equally important to optimise conditions for delivery
of successful patient outcomes from medication review. They are appropriate
training content, robust competency assessment and a mechanism for ongoing
support during the initial stages of implementing a medication review
service.
Training content
The publication of medication review competencies, initially by the
National Prescribing Centre and NHS Executive in April 2000 and more
recently
for the accreditation of pharmacists to provide advanced services in
the new community pharmacy contract, has helped to streamline training
content and clarify the learning outcomes for training providers.
PRN’s full workshop programme was designed to support practitioners
in undertaking full clinical medication review and it fulfils all the
competencies specified for accreditation of pharmacists to provide advanced
services. Evaluation demonstrates that PRN training gives community pharmacists
the confidence to go back to their clinical roots and return to clinical
practice.
The training programme is in workshop format to facilitate the development
of both clinical and technical knowledge and consulting and decision
making skills. The latter are crucial to ensure that participants are
able to engage with patients and prescribers. The programme comprises
three elements, the first two of which are skills-building and therapeutics-focused
workshops. These are presented by a multidisciplinary team of expert
teacher-practitioners who can combine theory with experience of hands-on
practice in primary care. All materials are updated before every session. Competency assessment
Crucially, the third element of the programme comprises a competency
assessment. This is based on the Objective Structured Clinical Examination
(OSCE) originally developed by the University of Dundee as a tool for
assessing the competence of trainee
doctors. OSCEs are used to test clinical acumen, judgement and practical
skills such as consultations.
PRN’s assessment comprises a series of five activities where knowledge
and skills are examined according to a previously determined marking
scheme. Three activities are written tasks that assess knowledge and
two activities comprise assessment of consulting and decision-making
skills by real patients and GPs. In our anecdotal experience, the use
of patients and GPs in the assessment process is important in determining
competency and is likely to give the most accurate assessment of performance
in the workplace.
Medicines use review (MUR) and prescription intervention, advanced services
in the new NHS community pharmacy contract, require accreditation of
both pharmacist and premises. In the MUR model, pharmacists are likely
to be doing a review of medicines with the patient but without access
to the full clinical record, a scenario similar to that in the HOMER
study.
The HOMER study makes no mention of assessing the competency of pharmacists
undertaking the medication reviews and it is possible that performance
may have influenced the outcomes.
For the purposes of the contract, accreditation of community pharmacists
to provide advanced services can only be granted by a higher education
institute. At present, to the best of my knowledge, no such accreditation
involves face-to-face assessment of pharmacists consulting and decision-making
skills or includes any direct patient or GP involvement. This seems far
from ideal and may have implications for the effectiveness of advanced
services to patients and the NHS.
In order for pharmacists to deliver real benefits from medication review,
we surely need robust assessment tools that are proven to demonstrate
competence and in which the patient’s experience is central. Follow-up
Research about training
programmes in smoking cessation published recently
by NICE identified that pharmacists need more support in translating
training into practice (PJ, 11 June, p698). This mirrors PRN’s
experience in delivering medication review training and underlines
the need for follow-up to training. Since many community pharmacists
work in isolation and do not have access to colleagues with more clinical
experience, PRN has been commissioned to coach pharmacists delivering
new services in primary care. The aim is to use pharmacists who have
experience of hands-on practice in primary care to help training participants
translate learning into practice. The coaches also give feedback on
skills and ongoing problems. We have found that this support is crucial
to the success of implementing new medicines management services in
the community and boosts confidence and motivation. It is not clear
from the HOMER publication if any support was available to the pharmacists
conducting the reviews to discuss ongoing problems and options.
Medication review has become a hot topic in health care since the publication
of standards in the National Service Framework for Older People. More
recently, medication review targets have been included in the new general
medical services contract and MUR has become an advanced service in the
new pharmacy contract. However, reviews can and are being undertaken
by doctors, pharmacists and nurses at a variety of different levels and
it is unclear what components produce the best patient outcomes.
Since effective performance of a review, whoever carries it out, is likely
to be important, it is in pharmacists’ interests to ensure that
postgraduate education and training in this area is indeed fit for purpose.
From PRN’s extensive experience of delivering medication review
training, all three components of appropriate training content, robust
face-to-face competency assessment and a mechanism for ongoing support
are required to ensure successful patient outcomes. The profession needs
to reflect carefully on the implications of the HOMER study for
postgraduate education and training in this area and consider whether
the current arrangements will secure effective pharmacist practitioners. |
The
Pharmaceutical Journal