Pharmacy Leaders Programme ……………………………………………………………………………………………………..

Application formThere are currently 4.6 million people living with diabetes in the UK. Our mission is focused on working together as a society to:

provide the best care and support for those who are living with diabetes Prevent Type 2 diabetes Fund diabetes research and ultimately find a cure.

The role of pharmacists in diabetes care is growing as a result of their unique position within the healthcare system to provide more personalised care to people living with diabetes. However, at the moment pharmacists are not consistently supported to become leaders in their field and drive change in diabetes care.

The Diabetes UK Pharmacy Leaders programme responds to these needs, enabling pharmacists to develop the skills needed to drive transformational change in diabetes care, and spread improvement. The programme will also be an opportunity to identify potential gaps in diabetes care in the pharmacy space, find both barriers and solutions to improving care, and network with colleagues from across the country.

This programme is aimed at experienced practicing pharmacists with the ambitions and ability to improve diabetes care and deliver evidence based change.

DatesModule 1 (days 1 and 2) - Thursday 4 to Friday 5 April 2019 Module 2 (day 3) - Thursday 23 May 2019Module 3 (day 4) - To be set after Module 1Module 4 (day 5) - Friday 11 October 2019

You must be able to attend all 4 days.Course VenueLeicester Diabetes CentreLeicester General HospitalLeicester LE5 4PW

Diabetes UK will provide accommodation for the Thursday night at:College CourtKnighton RdLeicester LE2 3UF

Module 3 will consist of Action Learning Sets with your colleagues. The Action Learning Set groups will be decided at the beginning of the programme and dates will be set following the first module.

Please email completed forms to leadership@diabetes.org.uk

Application deadline: 5pm, Wednesday 27 February 2019

Personal detailsName Click here to enter text.

Job title Click here to enter text.

Employing organisation Click here to enter text.

Address Click here to enter text.

Post code Click here to enter text.

Work phone Click here to enter text. Mobile phone Click here to enter text.

Email Click here to enter text.

What are your personal objectives for taking part in the Pharmacy Leaders Programme (maximum 100 words)?

Think about a current challenge to good diabetes care in your local area. Briefly outline the challenge and some ideas for how you could overcome this challenge. Bullet points are fine (maximum 300 words).

AccommodationThe programme will start at 11.30am on Thursday 4 April and finishes at 6.30pm followed by a dinner. The following day, the course starts at 8.30 am on Friday 5 April and will finish at 1pm.

Diabetes UK will provide accommodation for the Thursday night if needed. Please indicate if you would require accommodation on the Thursday 4 April 2019. ☐ I will require accommodation on Thursday 4 April.

How did you hear about the Pharmacy Leaders Programme?☐ Diabetes UK Professional Conference ☐ Diabetes UK E-newsletter☐ From a colleague who has attended another Diabetes UK Leadership programme☐ From a colleague☐ From a contact at Diabetes UK☐ In a professional publication☐ Other (please specify)

Line managerI understand that the course is designed to support pharmacists to become leaders in service improvement. I believe that the above staff member has the capacity to be a leader of positive improvements in diabetes care and I will support them to implement their learnings following the course.

Signed …………………………………..……………………………………….......

Date Click here to enter text.

Name Click here to enter text.

Job title Click here to enter text.

Employing organisation Click here to enter text.

Applicant declaration

I declare that, to the best of my knowledge, all the information provided on this form is accurate.

Signed ………….………………………………………..………………………………………..............

Date Click here to enter text.

Please email completed forms to: leadership@diabetes.org.uk *This is a Diabetes UK project in collaboration with Novo Nordisk who are providing support and funding

This programme is endorsed by UKCPA The United Kingdom Clinical Pharmacy Association (UKCPA) is a not-for-profit member organisation for the pharmacy workforce providing clinical pharmacy services to patients. We promote expert practice in medicines management and strive to foster and support excellence in clinical pharmacy practice in order for practitioners to provide outstanding patient care. Our communities of practice support each other through the dissemination of knowledge and expertise, and through teaching and mentoring. For more information and support, please visit https://www.ukclinicalpharmacy.org

Keeping in touchWe’d love to keep you updated about how we support people living with diabetes and how you can help by donating, volunteering and campaigning.

We’ll stay in touch with you by post and phone. It helps us to keep our costs down if we can email you but it’s entirely your choice. Please tick the box to tell us you are happy to receive emails ☐

We want to send you the most relevant information so might ask you for personal data, for example about your diabetes or ethnicity. We promise to store it securely and keep it confidential. Please tick the box to tell us you are happy for us to use this information ☐

Occasionally we may need to share personal data with our suppliers to process your orders and requests or to provide other services to us.

We promise:

Never to release your personal details to another company for their marketing purposes

To always respect your communication preferences

We only want to send you relevant information and requests to support us. To do this we may analyse the information you provide and gather extra data.

You can find out more about how we use your information at www.diabetes.org.uk/privacy

You can change how you hear from us or ask us to stop communicating with you at any time:

Visit us at https://forms.diabetes.org.uk/im-in-charge

Email us at helpline@diabetes.org.uk

Phone us on 0345 123 2399

This is a Diabetes UK project in collaboration with Novo Nordisk who are providing support and funding