Hospital Pharmacist
Vol 11 No 5 p195-197
May 2004

DPharm Degree — why a doctorate degree for pharmacists is needed

By Peter Taylor, MRPharmS

Significant challenges face the pharmacy profession both now and over the coming years. Not only do we have a shortage of pharmacists but there are also significant shortages in appropriately trained senior pharmacists applying for specialist posts.

There is, therefore, a need to extend workforce planning and to develop a more integrated approach to the development of our pharmacists, particularly in the middle and more senior grades. To achieve this we must identify the needs of the profession and match these with appropriate training and succession planning.

The working environment is changing rapidly. Boundaries previously clearly defined and thought to be relatively safe are now disappearing. The emerging primary care organisations and development of a primary care-centred service delivery model may mean that the traditional roles in hospital pharmacy will change as well. Extending the roles of our technicians has allowed pharmacists to concentrate on their particular specialist roles but has also made others feel less comfortable in their existing roles. The role of non-medical consultants is also emerging.

What does that mean for pharmacists? Can we demonstrate that we have a robust model for pharmacists that can stand alongside any other established consultant role?

As hospital environments are driven to more specialised roles, pharmacists need to respond with their own specialties to support and enhance patient care. The current arrangements do not seem to develop middle grade pharmacists in a structured way, nor are they linked to the needs of the future service and workforce development. Where will our future consultant pharmacists and leaders come from? Are we addressing succession planning?

Clinical governance requires our professionals to be fit for purpose and to demonstrate that they are continuously improving their services to patients. These services should be supported by evidence of effectiveness and so a research base for our practice is needed.

This article looks at the role of a professional doctorate in supporting these workforce development issues. The University of Bradford is one of the UK institutions offering the doctorate, and the course structure of this programme will be discussed (for details of the other institutions offering this degree, see Panel 1 below, p197).

Clinical diploma

The ubiquitous clinical diploma, used by many as the natural progression from registration, has been effective in providing structured development in the formative years of practice. In some cases, the emphasis on clinical pharmacy may have narrowed the horizons of pharmacists leaving a shortfall of pharmacists interested in the more technical aspects of our work.

The current postgraduate diplomas have without doubt improved the ability of our junior staff to offer more and more complex pharmaceutical care in a confident manner. As a means of developing newly registered pharmacists, and for helping those returning to practice or changing sectors, the diplomas are excellent. They offer structured development and supervision in the working environment. In my own experience, an appropriately structured scheme will also help develop more senior staff as they contribute to the running, teaching and supervision of the course and recognise the need to keep on top of their own subjects to help them act as role models.

For pharmacy managers, diplomas provide significant advantages. Delivering the service as the individuals are being trained gives us a degree of sustainability. They can also regularise recruitment and workforce planning. Starting dates are matched to preregistration training completion dates. Numbers of staff in training with a known outcome becomes an important piece of information for future planning.

However, at the end of this period of training, pharmacists are not specialists. They are competent practitioners with excellent problem solving and interpersonal skills, and the ability to apply their pharmaceutical knowledge. The limitation of time spent in each of their rotations inevitably limits the development of specialised knowledge that will take practice and health care forward.

To take us on from the diplomas, can a structured career development programme meet the needs of both individuals and the service?

Doctorate degree

Hospital pharmacists within Yorkshire, working with the University of Bradford, have developed a doctorate programme which supports pharmacists in middle and senior grade posts. A clinical diploma or masters degree is the usual entry requirement, but for those with a significant career history, credit can be given under the prior experiential or certificated learning rules.

Currently our scheme is in two parts, the first being a series of three practice units, each usually of a year’s duration. This is followed by a two-year placement in a post offering both leading edge practice and a significant research project, in the student’s chosen specialist area.

Practice units

Using our experience of diploma training, the first practice units were set up to give the practitioner challenging objectives to meet. These were based on existing posts, modified in such a way as to provide two or three specialist pharmaceutical areas that would be complementary. So, for instance, our first post used as a pilot site consisted of a main specialty, oncology, with two supplementary specialities, aseptic dispensing services (particularly the professional input into this process) and quality assurance (QA). This allowed the student to develop some technical skills and knowledge while undertaking a specialist clinical post.

As this is a training post, the support and participation of other members of the clinical team — pharmacy, medical and nursing — is essential. Not only are they involved in the development of the pharmacist, but they need to be aware that at the end of each year the pharmacist moves on and a new one begins. This is further complicated by the rotation systems, as the pharmacist coming to this post could be in their first, second or third year of the programme. The practice units are therefore designed to build on previous experience and to use transferable skills. Senior staff in that specialty support the new student and ensure that the developing service does not suffer from the rotational nature of the training. Enhanced supervision, objective setting and feedback create an environment that should develop the participant irrespective of their previous experience.

Other rotations in the scheme cover a wide range of specialties including medicines information with neurosciences, paediatric oncology, diabetes with cardiology, surgery with nutrition, vascular surgery with cardiology, and respiratory medicine.

Other hospital specialties are being developed to offer pharmacists some choice in their progression. However, there should be some consideration given to service needs for the future so that we can offer to develop people in shortage specialties.

A key area for hospital pharmacists outside the more traditional professional role is that of management development and succession planning for future chief pharmacists. The apparent reluctance of middle grade staff to apply for chief pharmacist posts is disconcerting. One reason given is that there is little perceived benefit from taking on the extra responsibilities and pressure. There may also be a lack of coaching and supervision earlier in pharmacists’ careers to expose them to appropriate management activity. Providing a rotation for a middle grade pharmacist to undertake a significant, but supported, management role would have the advantage of involving pharmacists in a high level of management at an earlier stage of their careers, without giving up their career development in professional activities. This may also encourage some of them into pharmacy management as a specialty in its own right.

It was never our intention to restrict placements to hospital specialties. As more of our pharmacists begin to develop services in primary care then rotations offering opportunities to develop those new skills are required. Roles such as public health pharmacists, primary care trust pharmaceutical advisors and GP practice pharmacists come to mind and would sit comfortably with our current model of training.

Manufacturing and QA roles in hospitals could link well to an industrial placement and similarly a clinical rotation might benefit an industrial pharmacist’s rotation scheme. Community pharmacists are now taking part in clinical postgraduate diploma training schemes and the next logical step could be the development of more specialist roles, with supporting rotations both within primary care but also between primary and secondary care.

Employment problems may well provide significant barriers to these rotations. In the hospital rotations now under way, chief pharmacists have continued to employ their staff even though the pharmacist may be working for another organisation, provided they receive a pharmacist undertaking the training scheme in return, working for their organisation under an honorary contract. This approach clearly has its limitations and problems but has allowed the scheme to develop in a more corporate way. One way forward for the NHS would be to develop a “deanery system” to employ and manage the rotations of all the participants, along with the accreditation of all training posts.

Rotations outside the NHS would need further thought on how they can be managed. We are, however, already seeing progress in some of the preregistration placements, and this should not be an insurmountable problem for our doctorate rotations, should the will be there to make it happen.

Throughout these rotations the university supports the scheme. This support is not so much by providing pharmaceutical knowledge, but by teaching systems that will allow self-development such as reflective practice, evidence based health care and research methods and skills. The university also plays a key role in developing and approving appropriate assessment methods and maintaining a momentum for the development of individuals.

Reflective practice plays a significant part in the ethos of the scheme. Future leaders of our practices must continuously review their own performance and ensure that they take responsibility for their own development and direction as well as that of others. Participants keep a reflective diary and submit a reflective journal at the end of each practice unit. Case studies submitted as evidence of the standard of work undertaken also have a reflective element. Both the reflective journal and the case studies are reviewed by a panel of senior tutors as part of the process of establishing progress and are undertaken between practice units.

The involvement of the university also ensures that appropriate rigour is applied to the scheme. This should allow any future employer of pharmacists undertaking the programme to understand what they can expect of the pharmacists in terms of knowledge and skills. This could also allow standards to be similar across different schemes if this approach were to be developed elsewhere in the country.

At the end of the three practice units participants can leave the scheme with an academic award. This is a master degree reflecting their ability as advanced practitioners. This is not the consultant level that the scheme aspires to produce, but is perhaps more equivalent to the associate specialist grade used in medicine.

The research placement

For those continuing with the scheme, one of the specialties undertaken in the earlier rotations is chosen as the specialist area for development. For those senior staff who may already hold a specialist post, and have been exempt from one or two practice units of part one, then the placement is already established.

For those rotating, sometimes between two or three hospitals, then this placement will need considerable planning. As described earlier, the practice units have generally been developed from existing posts. These were often high turnover positions, although, in many cases, without any predetermined start and finish dates. The placement for the research element may not currently exist or, if it does, is unlikely to become vacant at the right time, at least in the early years. This is further complicated by the student’s decision as to which specialty to pursue, which may not be made until well into the third practice unit.

A further complication arises from the need to find a position that can support leading edge practice in this particular field. There is also the need to support the running of a substantial research project. Even those with existing posts are unlikely to have 50 per cent of their job content devoted to research.

Extra funding will be necessary to create these posts along with the infrastructure to support the research. One source of funding will be successful research grant applications, again requiring considerable prior planning.

The programme requires the research to be substantial and, as it progresses, I would expect organisations involved with the scheme to develop a broader research base. Participants joining the unit for part two would then take a discrete piece of research from a much larger programme or theme of research. This would meet much more clearly the requirements of research governance in the NHS and would link to an existing and proven research team.

Support from a university is crucial for this part of the programme, particularly in the early stages. Help in formulating the research hypothesis, grant application and supervision of the research will be heavily dependent on university staff. Trust staff will still need to support the participant with the working environment for both the leading edge practice and the research, and provide for specialty supervision along with clinical supervision for the research.

Tutors

The role of placement tutors, whether in part one or two, developed on the basis that most middle grade pharmacists will have a line manager who leads in that specialist area. They should be providing some form of support and development as part of their role. However, as the scheme has progressed the need to develop the tutor has been clearly identified.

With new posts, or for existing posts that are developing beyond the skill or ability of the local tutors, then the concept of specialist tutors off-site acting in an advisory capacity has been adopted. Around the country there are specialist groups helping to develop the roles and standards for their own areas of activity and they may provide some support. Senior staff in other trusts providing leading edge services may also be a source of such support.

When piloting the scheme in my own hospital we engaged the services of a specialist pharmacist from the cancer centre in Leeds. He spent a few days working with my pharmacist directly, suggesting different approaches to treatments, setting new objectives for the pharmacist to meet and providing invaluable comments which moved the practice of our “guinea pig student” forward in a marked way. The review of case histories could then be done by correspondence so reducing the actual contact time to a minimum.

We are keen to develop this approach, as working collaboratively we can develop services in hospitals or in primary care where the willingness and need are there but the infrastructure may not be sufficiently developed. This might encourage units to develop an area-wide approach to training and development, using existing services but developing new and needed services using this scheme, supported by colleagues both from the same area and also from other centres.

Conclusion

The scheme now has participants in all practice units in part one, and one pharmacist who is completing part two. The scheme has developed slowly, perhaps more slowly than we had first envisaged. In some respects this has not been a bad thing as we are all trying to run the scheme and develop the new ways of working around our normal commitments.

The scheme seems to continue the rapid development of individuals seen with the clinical diplomas. Watching some of our students present at multidisciplinary meetings, I can see the emerging depth of knowledge and confidence in the use of research findings to support their presentations. Indeed, two of our students won the Pharmaceutical Care Award last year for a presentation on their work in the hypertension clinic at the Harrogate NHS Trust (Hospital Pharmacist 2004;10:278).

In meeting our objective of developing the consultant pharmacist of the future, I now have no doubts that this will be achieved. These people will be able to stand up to scrutiny and are already making an impact on services. I do not believe that it is acceptable to become a non-medical consultant by virtue of length of time in a role, but by demonstrating abilities in practice and bringing new thinking and direction to practice by research.

There is still a perception that this is a long course to embark on, and there is reluctance to commit to it particularly after an intensive two-year diploma. However, we should look at this as planned and effective career progression, fast tracking staff to the top positions. The scheme is more restrictive at the moment than it eventually will be, as there are only four trusts currently involved. As more come on board, so the opportunities for planning geographical location as well as specialty provides pharmacists more control over their lives. With a potential career of 40 or more years, planning some of the most important earlier years does not seem too great a burden.