|
Stuart Anderson, senior lecturer at the London School
of Hygiene and Tropical Medicine
|
The consultation exercise around pharmacy education, together with the discussion and opinion pieces that have appeared in The
Journal, have provided the basis for a welcome and timely debate around pharmacy education. The exercise has involved a thorough review of the principles that should underpin pharmacy education in the future. The challenge now is to translate those principles into reality. The key factors that will drive changes in both pharmacy education and practice are now much clearer.
Growing demand
There will be a growing demand for pharmaceutical expertise, particularly
in the community as the shift from secondary to primary care, and the
focus on self-care, continues. The specific needs of the NHS will increasingly
be prescribed in an ever more detailed contractual framework. The focus
will be on both patient safety and value for money. At the same time
universities will be constrained by existing and pending agreements
made at the European level.
There is now widespread acceptance that pharmacy is a science-based
clinical profession, and that high level clinical skills are required
to deliver
many aspects of the NHS contract. Not surprisingly there have been calls
for pharmacy pre-qualification training to be funded at the higher clinical
level rather than the current laboratory sciences level. This sounds
reasonable enough in principle. However, the current difference between
these levels is around £12,000 per student per year (£20,000
as opposed to £8,000, see PJ, 16 December 2006, p747).
Given that the number
of first year students on MPharm courses in the
summer of 2006 was 2,761 (PJ, 10 February, p172) the additional
cost of providing clinical training for all these students for just one
year
is over £33m. For the whole four years to be clinical, as well
as the preregistration year, the extra cost becomes more than £166m.
Yet one of the issues raised at consultation meetings has been the need
for pharmacy to demonstrate that is it offering not only a safe service
but also one that is value for money. If this is an issue under present
arrangements, how much more will it be if the cost of pharmacy education
were to rise substantially?
For universities one of the factors being considered in reviewing pharmacy
education is the impact of the Bologna Process, by which the countries
of Europe will move towards uniform arrangements for higher education
by 2010. The basic format agreed is “3+2+3” (three-year bachelor,
two-year master, three-year doctorate). For the UK the debate is largely
about whether master’s level pharmacy education should take the “4+1” route
(four years at university followed by one year of preregistration training)
or the “3+2” route, with the master’s degree being
awarded after a total of five years’ study.
Both options result in the production of a single category of clinically
trained pharmacist after five years. With some 26 schools of pharmacy
each producing over a hundred new recruits each year the issue of value
for money will become increasingly important. The Government not only
funds most of pharmacists’ education but is also the main customer
(directly or indirectly) for their services once they qualify. Most will
continue to work in community pharmacy.
The new community pharmacy contract has set the precedent for a tiered
structure of pharmacy services, with its division into essential, advanced
and enhanced services. The division between them can be changed; lines
once drawn can be repositioned. Essential services as currently defined
require the application of substantial clinical skills and knowledge.
They also include dispensing and repeat dispensing, the electronic prescription
service, and the disposal of unwanted medicines, activities with which
pharmacy technicians are already involved.
Essential services will remain at the heart of the pharmacy contract.
Is it really sustainable that this work is undertaken by clinical pharmacists
trained over five years? Perhaps possible alternative workforce configurations
are worthy of consideration. With some limited realignment between essential,
advanced and enhanced services, and changes to supervisory functions,
it seems at least feasible that such competencies could be developed
within a three-year rather than a five-year
period.
As John Ferguson has
pointed out (PJ, 17 February 2007, p190)
any proposal to weaken the science base of a course leading to qualification
as a
pharmacist will fall foul of current European agreements. Any individual
trained to a less scientifically rigorous level could not, therefore,
be called a pharmacist.
But the factors outlined above suggest that the possibility of a return
to a two-tier profession, with one group trained over three years to
bachelor’s level, and a second over five years to master’s
level, should at least be seriously considered.
The titles to be used, and the balance between the two groups, are matters
for the profession. But for the moment let us call those completing core
training in three years “prescriptionists” and those completing
the five-year course “pharmacists”. Entry to all schools
of pharmacy would be to a three-year bachelor’s degree in pharmaceutical
services. Its purpose would be to provide students with the knowledge,
skills and competencies required to deliver NHS essential services: nothing
more, nothing less. At the end of the third year students would both
graduate and register with the Royal Pharmaceutical Society as “prescriptionists”.
Such people would provide the bulk of essential services under the NHS
contract.
Prescriptionists wishing to progress to pharmacist would need to apply
for a two-year master’s course at a school of pharmacy. Not all
schools of pharmacy would offer the master’s course. The course
would include training in the advanced and enhanced services described
in the NHS contract, and basic training in hospital pharmacy. It would
also include the additional science content necessary to meet the European
directive on recognition of professional qualifications. Pharmacists
would receive their master’s degree and registration with the Society
at the same time. Fast-track courses
Anyone calling themselves a pharmacist in future would, therefore,
have received training in the provision of essential, advanced and enhanced
NHS services. Alternative and additional master’s programmes
may be appropriate. A prescriptionist wishing to pursue a career in
industry might, for example, prefer to take a more specialised master’s
in pharmaceutical sciences. Transitional arrangements will be necessary.
Clearly many current pharmacy technicians would be excellent candidates
for registration as prescriptionists, and fast-track courses may be
appropriate for them.
Such an approach requires rather more radical thinking about pharmacy
education than we have seen so far. Clearly such a reconfiguration presents
enormous challenges to all involved. But a pharmacy education strategy
that provides for a triple register (pharmacy technicians, prescriptionists,
and pharmacists) offers the prospect of real flexibility, assurance of
patient safety, compliance with European directives, as well as demonstrating
that the pharmacy profession is providing real value for money. Any alternative
strategy will need to demonstrate that it does all of these things better. |
The
Pharmaceutical Journal