Prescribing courses — one size fits all?
Views on why pharmacists should prescribe, what training
they should receive, how supplementary prescribing will work in practice
and what
legal responsibilites prescribing brings were all presented at the seventh
annual Hospital Pharmacist conference held in London on 30 October. Gareth
Jones and
Rachel Graham (on the staff of Hospital Pharmacist) report
Duncan McRobbie: a national assessment for pharmacist prescribers should be developed |
Does “one size fit all” for the supplementary
prescribing courses? This was the question posed by Duncan McRobbie,
principal clinical services pharmacist at Guy’s and St Thomas’ Hospitals
NHS Trust, referring to the diverse backgrounds of those being taught
to be supplementary prescribers. He is currently on a training course
for pharmacists and nurses at King’s College, London. He had consulted
fellow pharmacists to present a reflection of the views of students enrolled
on the courses.
Mr McRobbie described the course that he is undertaking. King’s
College has been running independent nurse prescribing courses for 18
months, so they have previous experience in training prescribers. It
is a self-directed web-based course. It requires 16 two-hour tutorials
at flexible times, but a lot of pre-course work. The amount of time that
this self-directed learning takes should not be underestimated. Assessment
is through objective structured clinical examination (OSCE), demonstration
of competence via portfolio and examination. According
to Mr McRobbie, it is not clear if this methodology of assessment has
yet been tested for pharmacists.
Mr McRobbie tried to get some information from other providers of the
supplementary prescribing courses about their course content. He said
that they had not been forthcoming and this created an impression that “we
are making this up as we go along”.
Mr McRobbie said that the current students represent a “who’s
who” of hospital pharmacy, with many of the leaders in the sector
represented. All are highly experienced and recognised experts in their
field of practice. His class has 33 pharmacists, and a similar number
of nurses. The variety of practice is huge and includes neonatal nurse
consultants and people specialising in care of the elderly as well as
generalists (district nurses and community pharmacists). The variety
of practice experience is also large. Course content is the same for
everybody, which raises a number of questions about how the course can
be tailored towards the individual needs of those doing them.
The course caters for both pharmacists (community and hospital practitioners)
and nurses, all with different levels of experience. There would seem
to be little value in a pharmacist spending time in a tutorial on the
absorption, metabolism and excretion of drugs, as this is covered in
the pharmacy undergraduate course. It is, however, valuable for the nurses
to learn this. It is also useful for pharmacists to spend time learning
some of monitoring skills that are second nature to nurses, eg, blood
pressure monitoring and other physical assessment skills. These courses
should therefore allow exemption from some aspects, so only the material
of benefit would be completed, suggested Mr McRobbie. There should probably
be a prior assessment to get everyone to the same level.
Mr McRobbie then asked how consistent is the delivery of training across
Britain? In some courses, the trainees are being taught what drugs to
prescribe in heart failure, when their area of practice might be quite
different. Therefore, Mr McRobbie asked whether students are being taught
the process of prescribing, or are they being taught underpinning knowledge
which should be assessed before the prescribing course? He suggested
that pharmacists need to develop a robust process for prescribing, in
the way that medics have, and document a process for diagnosis. It is
this prescribing process that should be taught on the supplementary prescribing
courses.
One of the key concerns of the participants was what exactly is a clinical
management plan (CMP). The law is grey about what detail is needed when
they are written. Mr McRobbie believes that there is concern among pharmacists
that they may face legal action if the clinical management plan is not
detailed enough to cover what they are doing legally. Will a reference
to hospital policy be enough for a CMP, and what if some hospitals do
not have descriptive policies on managing particular groups of patients.
Spending time every week working in primary care, Mr McRobbie asked also
how a CMP could be imported into a GP’s database?
Mr McRobbie also questioned the transferability of the supplementary
prescribing qualification. He called on the Royal Pharmaceutical Society
to create a national assessment programme, to ensure that the level of
competence can be proven to be the same wherever the course takes place.
He thought that if he moved hospitals, a new institution may think that
his qualification was not at the required standard and therefore he would
need to re-train. There needs to be consistency in both the training
and the assessment. The medical training system has a consistent process
for demonstrating competence. It is widely known what the minimum qualifications
are for a medical consultant, for example, and this may be missing from
the supplementary prescribing qualification.
There is a lack of clarity within the pharmacy profession about where
prescribing is taking practitioners. Mr McRobbie is concerned that prescribing
will be taught on the undergraduate course, and new graduates will therefore
be in a position to prescribe. There is clear evidence to show that newly
qualified pharmacists are not effective at safe use of medicines. Asking
them to prescribe as well maybe slightly optimistic. The people who do
most of the prescribing in hospitals are junior medical staff, who are
not good at it. Should we be replacing them with junior pharmacy staff,
who will not be good either? There are some real risks in this
strategy.
There is also concern that some people are being sent on supplementary
prescribing course to meet government targets. There have been disappointing
results with nurse prescribers, with only half those that have undertaken
the independent prescriber training using their skills in their jobs,
he said.
There are plenty of positive points to come out of the training. Pharmacists
who are training as supplementary prescribers are excited to be part
of something new. The people who have put themselves forward to be at
the forefront of this development in pharmacy practice are leaders within
the profession. They see the opportunity to shape the training and what
comes next in terms of setting some of the standards for clinical management
plans.
They have received a tremendous amount of support from designated medical
practitioners (DMPs). The DMPs recognise the responsibility of signing
someone off as a prescriber, and have consequently provided a lot of
support to help participants achieve the required standard.
A further benefit of undertaking the training is the rare opportunity
to have contact with pharmacists working in
different hospitals and in different specialities and nurses.
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