24 ❚ Prescriber May 2019 prescriber.co.uk

■ EDUCATION

Prescribing skill and accuracy is essen-tial if patients are to be given the

correct medication at the right dosage, and not to be harmed by pharmaceuti-cals. There are an estimated 66 million potentially clinically significant medica-tion errors in England per year, 71% of these in primary care.1 Globally, the cost

of medication errors has been estimated at US $42 billion annually or almost 1% of total global health expenditure.2 Little wonder then that the World Health Organization’s (WHO’s) third global patient safety challenge is “medication without harm” – the aim of which is to reduce by 50% the level of severe, avoid-

Introducing the Prescribing Skills Assessment box setsANGELA DOWDEN

All recently-qualified medics will be familiar with the Prescribing Safety Assessment (PSA), an examination that must be passed before doctors can move on to their F2 foundation year. Now, the British Pharmacological Society, which co-created the PSA, is championing wider use of its Prescribing Skills Assessment – the cloud-based learning platform that underpins the PSA – and is introducing a series of ‘box sets’ to test prescribers in various areas of prescribing.

Figure 1. How a Prescribing Skills Assessment box set is created

Initiation/defining scopeFollowing topic agreement, consideration of the target audience (eg

doctors, non-medical prescribers, specialists). Identification of what is relevant to include, and at what level of difficulty

Matrix mappingCreation of a matrix that highlights the various types of drugs and

scenarios that should be included. Mapping of these to one of the 8 item styles (detailed in the main text)

Interrogation of the BPSA item bankIdentifying what questions are already held in the relevant area and

inserting suitable items into the matrix

Writing of new materialA team of expert authors commissioned to write specific items, in the

relevant item styles, where gaps in the matrix are identified

Quality assuranceAn intensive period of further editing and peer review as required

External validationExtra checks by the external specialist groups where necessary, and by the client to ensure the questions fit the local formulary, guidelines and practice

Release to marketStandard access is via a portal linked to the institution offering the

assessment

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Prescribing skills assessment l EDUCATION ■

able harm related to medications – in the five years up to 2022. The ongoing education of prescribers is crucial if this goal is to be achieved, and it is in this space that the British Pharmacological Society has set its sights on becoming a world-leading pro-vider. To this end, the charity’s skills and assessment arm, BPS Assessment Ltd (BPSA), has begun piloting a series of ‘box sets’, which are online interactive tests designed to hone a prescriber’s skills in specific areas.

A track history of educating prescribers These box sets could be seen as a logical development given the British Pharmacological Society has amassed a huge wealth of experience and informa-tion in its work on the Prescribing Safety Assessment (PSA) examination. The exam, taken by all UK trainee doctors, was devised jointly by the charity and the Medical Schools Council and became mandatory in 2016. The British Pharmacological Society also has parallel experience in creating e-learning programmes – specifically the Prescribe programme, which helps trainee prescribers develop a firm grounding in the principles of clinical pharmacology and use of medicines more generally, and the Prescribing Simulator, available since March 2019, which presents prescribers with clinical scenarios in a hospital set-ting that require a medicine to be pre-scribed using an electronic prescription form. Both were created with funding from Health Education England, and are availa-ble on their e-Learning for Healthcare hub.

A 21st century digital interface What’s different about the box sets is the delivery: they don’t piggy back on other online teaching platforms, but instead use the BPSA’s own platform – which they’ve coined the Prescribing Skills Assessment – originally developed by technologists and clinical pharmacolo-gists to underpin the PSA exam. Simon Maxwell, Professor of Student Learning and Clinical Pharmacology at the University of Edinburgh and BPSA’s Medical Director, says the interactive sys-tem uses technology in a way that hasn’t

been seen before in this branch of medi-cal education. The key is the provision of instantaneous feedback. He explains: “It allow individuals to write prescriptions into a digital interface, which then provides an efficient auto-mated marking scheme, with targeted feedback. It can be done rapidly and at volume. The system is structured in a log-ical way that reflects clinical practice. It is attractive to both teachers and learners, and it can be delivered at a distance.” Having a slick platform is one thing but it’s also important to target the areas that prescribers will engage with, and the topics they feel will benefit them. One of the first box sets being launched into the UK market is for CCGs, consisting of two 15-question sets on clinical topics relevant to prescribing in primary care. A second box set is aimed at prescrib-ing for hypertension, and a third covers antibiotic prescribing and antimicrobial resistance (AMR). Figure 1 gives an over-view of how the box sets are created. All box sets are at various stages of development – the one for prescribers in primary care is currently being piloted among GPs at Wandsworth CCG, while the AMR one is a little further behind as it is awaiting expert review. For the hyperten-sion box set there’s a full rollout planned in collaboration with the British and Irish

Hypertension Society (BIHS) from June 2019, coinciding with the launch of the new NICE guideline in this area.

Prescribing education that benefits patient and public healthBPS Assessment Managing Director, Jono Bruun, says a driving factor behind the three box sets is benefit to patients, as well as to public health more widely. “For example, we have prioritised the development of our AMR-focused box sets, because we hope they will play a part in addressing the global antimicro-bial resistance issue, by ensuring the considered and thoughtful prescribing of antibiotics by all prescribers across med-ical professions. “[With the GP pilot] we recognised that there was significant scope for sup-porting and engaging with primary care at grassroots level; in particular, to help early-career GPs who may have limited experience of practical prescribing. Wandsworth CCG has been a fantastic partner, being both innovative in its think-ing and appreciating the critical impor-tance of safe prescribing.” According to Professor Maxwell, the hypertension box set addresses another high-impact area, not because prescrib-ing for the condition is particularly tricky, but because it’s the largest area of long-

Figure 2. Demonstration box set screenshot showing an example of a question fitting the prescribing style

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26 ❚ Prescriber May 2019 prescriber.co.uk

term prescribing in primary care and a major resource investment, meaning that getting it right is vital. “Hypertension prescribing is very guideline-driven with plenty of supporting evidence, so we need to encourage those guidelines to be followed and the evidence implemented for the benefit of patients,” he says.

The user experienceSo if you are a prescriber sitting down to tackle one of the box set assessments, what can you expect to encounter? Typically, you’d have a log in and pass-word attached to an institution where the box set is available, allowing access from anywhere at any time via their browser. You’d then be presented with 15 prescrib-ing questions per box set, which might take 30–40 mins to complete. With the feedback available, it offers around an hour of reflection and learning. The test questions fall into one of eight item styles, which mirror those used in the official PSA exam (see Figures 2–4), and are as follows:• Prescribing – Writing a safe, effective and legal prescription for a single med-icine using the documentation provided, to tackle a specific indication highlighted by the question• Prescription review – Identifying prescrip-tions (drugs, doses or routes) that are inappropriate, unsafe or ineffective from a current list of prescribed medicines• Planning management – Deciding which treatment would be most appropriate to manage a particular clinical situation• Providing important information to patients – Deciding what is the most important piece of information that should be provided to patients to allow them to choose whether to take a medicine, and to enhance its safety and effectiveness• Drug calculation skills – Making an accu-rate drug dosage calculation based on numerical information and recording the answer accurately with appropriate units of measurement• Adverse drug reactions – Identifying likely adverse reactions of specific drugs, selecting drugs to discontinue as likely causes of specific reactions, avoiding potential drug interactions, and providing appropriate treatment for patients suffer-ing an adverse event

• Monitoring therapy – Identifying the appropriate methods of assessing the success or failure of a therapeutic inter-vention• Data interpretation – Deciding on the meaning of the results of investigations as they relate to decisions about ongoing drug therapy and making an appropriate change to a prescription based on those data.

Dr Farah Jamil, who has evaluated the assessment platform as part of the Wandsworth CCG pilot for primary care prescribers, believes it is an exciting way to learn very quickly because all ques-tions are case based. She says: “What I’ve seen so far is really exciting. When you first come to primary care, you’re making clinical and treatment decisions in your own room, every 10 minutes, so you need to be able to make decisions very quickly. Questions are varied and close to real-life scenarios, so they’re very relevant for junior doctors to see. Having this alongside them at the early stages will really soar their confidence.”

How the costings workThe box sets are a commercial venture, worked up with partner institutions, so what’s the cost and who pays? BPSA responded by saying they couldn’t give Prescriber specific numbers, but that they talked about pricing with each organ-isation, taking into account the type of agreement they’re looking for and the stage the project is at, ie whether it’s a pilot scheme or full roll-out. “The hypertension box set will be for sale at tiered pricing levels for BIHS members, non-members and institutions, eg training organisations and university faculties,” BPSA told us. “If in the future a partner wanted to fund or sponsor the development of a new box set, we would again be looking at tiered pricing, plus the opportunity to make that box set available as a member benefit for the partner.”

Areas to address and future directionsUl t imate ly, the success o f the Prescribing Skills Assessment venture

Figure 3. Demonstration box set screenshot showing an example of a question fitting the prescription review style

Figure 4. Demonstration box set screenshot showing an example of a question fitting the adverse drug reaction style

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will be measured in terms of the num-bers of clinicians who engage with the assessments and improve their pre-scribing as a result. BPSA acknowledges that this may be an issue in the GP set-ting, where voluntary uptake of the cur-rent pilot has been low. One solution might be gaining Continuing Professional Development (CPD) accreditation for specific box sets, which the BPSA says it is actively pur-suing. Given that UK GPs must amass around 50 CPD credit units each year over a variety of topics to keep their reg-istration, it might be a strong incentive. But future direction is more than just UK based, and BPSA is increasingly linking up with partner institutions over-seas. A flagship five-year collaboration between the Royal College of Physicians and Surgeons of Canada and BPSA has recently been agreed, giving practising Canadian physicians access to online prescribing modules tailored to their healthcare context, in both English and

French. Local experts will be able to con-tribute to the question-writing process for the modules, which will help to continu-ally update and customise the platform for the Canadian medical community. Assessments on the Prescribing Skills Assessment platform are now used by customers in Italy, Denmark and Turkey, and there is also collaboration with the Middle East and Malaysia, as well as exploratory talks with China. In Australasia, in 2019, 13 medical schools will be sitting an exam based on the structure of the PSA exam taken here, but tailored to their market. “It’s a fantastically flexible tool, which enables educators to collaborate with and peer review each other and our own prescribing experts,” says Jono Bruun. “It allows each assessment to be cus-tomised for each region’s own medical community and formulary. We believe this puts us in a unique position to share our expertise, which we’d like to do as widely possible.”

If it helps even just a small bit toward the WHO goal to reduce avoidable harm related to medications on a global scale, it’s a laudable achievement.

References1. Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU). Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the preva-lence and burden of medication error in the UK. February 2018. Available from: http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf2. World Health Organization. Medication with-out harm. WHO global patient safety challenge. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/255263/WHO-HIS-SDS-2017.6-eng.pdf?sequence=1

Declaration of interestsNone to declare.

Angela Dowden is a freelance journalist and registered nutritionist