issn 2052-6415 (online) issn 1354-0912 (print) journal of … · 2020-01-17 · 2 journal of...

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IN THIS ISSUE:l General Practitioners’ views ondeprescribing in the hospital setting

l Experiential learning opportunities forundergraduate pharmacy students incommunity pharmacies in the UnitedKingdom

l Equipping pharmacists for the modernNHS; how can we achieve ‘EducationOptimisation’?

l Primary Care Cluster Pharmacist

l Whither should I go in my career?

l Prioritise as a Leader – email triage tips

Note: page 19 amendments made on140120.

20JanVolume Thirty-six

Number One

ISSN 2052-6415 (Online)ISSN 1354-0912 (Print)

Journal of Pharmacy Management

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Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020

www.pharman.co.uk

General Practitioners’ views on deprescribing in the hospital setting

Michael Wilcock and Marco Motta

Experiential learning opportunities for undergraduate pharmacy students

in community pharmacies in the United Kingdom

Amardeep Singh, Dr Hana Morrissey and Professor Patrick Ball

CLARION CALLEquipping pharmacists for the modern NHS; how can we achieve

‘Education Optimisation’?

Dr Julie Sowter, Sandra Martin and Diane Webb

FACE2FACEPrimary Care Cluster Pharmacist

Lloyd Hambridge

MANAGEMENT CONUNDRUMWhither should I go in my career?

LEADERSHIP Prioritise as a Leader – email triage tips

5

12

21

25

28

32

CONTENTS

BEST PRACTICE IN PHARMACY MANAGEMENT

1



BEST PRACTICE

General Practitioners’ views ondeprescribing in the hospital setting

The reasons why many patients end up

taking many drugs, perhaps ten or more, is

complex. It would be good to address the

factors at an early stage to minimise this

occurring but the reality is that a specific

focus on deprescribing is often required.

Who, however, should take the lead or be

involved in deprescribing the drugs that

patients no longer need? An article in this

edition looks at the issue of polypharmacy

and overprescribing and reports the results

of a survey amongst GPs with a lead

prescribing role within their individual

practices. The GPs acknowledged that

polypharmacy could be problematic and

that deprescribing in such circumstances

was necessary. The perception was that

deprescribing by secondary care colleagues

was not as extensive as it could be and

that this task should be undertaken by a

GP or practice pharmacist. The top four

classes of medicine that should be targeted

were seen to be opioids, anticholinergics,

NSAIDs and hypnotics. This helpful survey

shows the potential for improved

communication between primary and

secondary care with regard to deprescribing

and provides a basis for targeting the

approach to specific drug groups.

Experiential learning opportunitiesfor undergraduate pharmacystudents in community pharmaciesin the United Kingdom

‘The recent development of pharmacists

employed in general practice has

broadened possible career pathways.

Preparing pharmacy graduates to develop

smoothly into these roles requires

pharmacy education to adapt and evolve.’

That is the view outlined in this paper, which

then goes on to develop an approach by

which this could be done by introducing

experiential learning modules into the

curriculum, similar to that provided to

other healthcare professionals. The article

then examines the willingness of the

community pharmacy sector in providing

workplace-based learning opportunities

and it is encouraging to note the general

support for this concept. It is clearly

important that the profession carefully

considers the implications of the changes

that are occurring, particularly in the

development of the patient-facing roles

that are developing for pharmacists in GP

practices, and ensures that education and

training meets future needs.

CLARION CALLEquipping pharmacists for themodern NHS; how can we achieve‘Education Optimisation’?

Continuing the theme of the need to

reflect on the changing roles of

pharmacists and ensure that educational

and training provision is appropriately

developed in response, a passionate plea is

made to ‘integrate soft skills development

and opportunities for interprofessional

learning to equip pharmacists for

extended patient-facing roles as integral

members of the multi-professional care

team’. The call here is for ‘collaboration

between education providers and the

evolving integrated care systems (ICSs) to

predict and provide tailored educational

support for local service innovations and to

evaluate their effectiveness’. The concept

is one of ‘educational optimisation’, which

will underpin the future development of

the profession. It is hoped that it is a call

that will be heard and that new

pharmacists of the future will experience

changes in their education and training

that will give them further confidence to

work in multi-disciplinary teams and

develop patient-facing roles.

FACE2FACEPrimary Care Cluster Pharmacist

Primary Care Networks are a relatively

new concept, as is the role of a Primary

Care Network Pharmacist – but what do

such colleagues actually do? This is

outlined in the Face2Face article where

it is explained that the role can broadly

be categorised as embracing clinical

patient facing activity in GP practices,

process/system redesign or development

(e.g. repeat ordering/dispensing processes)

and population engagement/health

education programmes. Some of the

challenges and successes of the role are

outlined in the article.


There are more opportunities and

branches within the profession than

previously. What does this mean for

someone setting out on their career?

Should they favour a certain branch and,

if they do, what are the support and

networks available that will sustain them,

particularly with the newer roles (e.g.

Primary Care Cluster Pharmacist as

outlined above, GP Practice Pharmacist).

Indeed, to what extent will such networks

even be appropriate to those working in

some multidisciplinary environments?

Our commentators give some views.

LEADERSHIPPrioritise as a Leader – email triage

Have you ever despaired at the number of

emails reaching your inbox? No problem

– read this section for top tips on how to

manage the situation and tame the flow!

EDITORIAL

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Your feedback is always welcome. Please click here to complete our

Reader Survey for this issue.

Subscribe now!Our journals are available free of

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working for the NHS.

To obtain your own

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3

WOULD YOU LIKE TO PUBLISH YOUR WORK IN THE JoPM?

The JoPM aims to disseminate good practice about service developments andprocesses involved in the management of medicines to senior pharmacists

in primary and secondary care.

Guidance for authors is available at:https://www.pharman.co.uk/uploads/imagelib/pdfs/PM%20Journals%20Guidance_for_Authors.pdf .

All material should be sent electronically to the Editor-in-Chief ([email protected]).

Journal of Pharmacy Management

Journal of Medicines Optimisation



https://www.pharman.co.uk/uploads/imagelib/pdfs/PM%20Journals%20Guidance_for_Authors.pdf


WRITE UP YOUR GOOD WORKAND SPREAD IT TO YOUR

COLLEAGUES

Is it about managerial good practice, service developments and processesinvolved in the management of medicines?

THINK JOURNAL OF PHARMACY MANAGEMENT (JoPM)!This is distributed quarterly throughout the UK to senior pharmacists in primaryand secondary care.

Is it about good practice in medicines optimisation with a focus on ‘optimisation’,which relates to quality and improving patient care, rather than cost aspects?

THINK JOURNAL OF MEDICINES OPTIMISATION (JoMO)!This is distributed biannually throughout the UK to clinical pharmacists, doctors,nurses and other healthcare professionals.

Why not write an article that addresses the medicines optimisation initiative for specific therapeutic areas?

Sharing such targeted work will hopefully facilitate discussion and the implementation of best practice within specialisms.

If you have something to say to readers, we will help you say it!About 3,000 words is good but full Guidance for Authors is available on the PharmacyManagement website under the Journals tab at https://www.pharman.co.uk/ .


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5

BEST PRACTICE IN PHARMACY MANAGEMENT

General Practitioners’ views ondeprescribing in the hospital setting Michael Wilcock, Head of Prescribing Support Unit, Pharmacy Department, Royal

Cornwall Hospitals NHS Trust, Truro and Marco Motta, Pharmaceutical Adviser, NHS

Kernow Clinical Commissioning Group Medicines Optimisation Team, St Austell.

Correspondence to: [email protected]

Background

Polypharmacy and inappropriate

medication use contribute to adverse drug

reactions and patient harm. One Scottish

study showed that between 1995 and

2010 the number of people on ten or

more medicines had increased from

1.9% to 5.6%, and a third of people

aged 75 years and over were taking at

least six medicines.1 Rather than use a

threshold number of drugs to define

polypharmacy, definitions of appropriate

and problematic polypharmacy have been

proposed.2,3 Managing polypharmacy

through deprescribing is a global

initiative.4 Although there is a lack of

consensus on defining deprescribing, a

working definition has been suggested as:

“deprescribing is the process of

withdrawal of an inappropriate

medication, supervised by a healthcare

professional with the goal of managing

polypharmacy and improving outcomes”.5

A range of barriers and facilitators to

managing polypharmacy and implementing

deprescribing have been identified within

the domains of the system, culture,

professional and patient.6,7,8 Examples of

such barriers are shown in Box 1.9

The ideal setting (e.g. primary care,

secondary care) for deprescribing to

occur is something that has not been

confirmed, although once a potentially

inappropriate medicine is identified,

arguably it should be actioned at that

point.10 In the context of multimorbidity

and frailty, National Institute for Health

and Care Excellence (NICE) guidance

identifies primary care and community care

settings, and hospital outpatient settings,

as opportunities to adopt an approach to

care that takes account of multimorbidity

(and managing polypharmacy).11 This

guidance also notes that comprehensive

assessment of older people with

complex needs should occur at the point

of admission to hospital. An acute

inpatient admission therefore presents a

unique opportunity for physicians and

Abstract

Title

General Practitioners’ views on deprescribing in the hospital

setting.

Author List

Wilcock M, Motta M.

Introduction

The management of polypharmacy and overprescribing is a

national and global work stream. It is currently uncertain how

best to implement an approach to carrying out routine

deprescribing activity. The aim of this study was to assess

the views of general practitioners (GPs) in one Clinical

Commissioning Group towards the role of the hospital team

in deprescribing.

Method

A survey was undertaken using a questionnaire delivered to a

convenience sample of GPs identified as having a prescribing

lead role within their practice.

Results

Across three CCG-organised medicines optimisation meetings,

41 (91%) of 45 GPs completed the survey. Respondents

considered tackling problematic polypharmacy to be relatively

Abstract

important (mean score of 4.2 out of a maximum of 5). GPs

perceived that they or a practice based pharmacist should have

control of any actual deprescribing actions, though there was a

recognition of the potential role for the senior hospital doctor

and senior hospital pharmacist. Just under one-third of GPs

responded that they had not seen hospital doctors tackling

problematic polypharmacy, and approximately only 10%

perceived that senior hospital doctors (other than Care of the

Elderly) had an approach to deprescribing that was reasonable.

Conclusion

In this study, we found that GPs were supportive of

deprescribing activities in the hospital setting and suggested

that the top four classes of medicine that should be targeted

are opioids, anticholinergics, NSAIDs and hypnotics. It was

perceived that there is an opportunity to undertake more

hospital deprescribing than currently occurs. Communication

and collaboration between GPs, hospital doctors and

pharmacists are potential means of improving patient

outcomes through sharing deprescribing responsibilities.

Keywords: deprescribing, polypharmacy, hospital doctor.

Marco MottaMichael Wilcock



pharmacists to collaboratively review

medications that can be safely

deprescribed, although acute care stays

are typically short and focused on the

reason for admission. One barrier to

deprescribing, as perceived by GPs, is that

patients sometimes believe that

specialists have more authority than GPs

over medication changes.12,13 In tandem

with this perception, one of the factors

that is reported to facilitate

implementation of deprescribing efforts

includes collaboration and communication

within and across professional and

practice disciplines.6 Hence the act of

ceasing the medication whilst in hospital

should overcome any concerns possibly

held by the patient or the patient’s GP.

Aim

To understand GPs’ perceptions and

views on managing problematic

polypharmacy and the role of the hospital

team in tackling polypharmacy.

Method

Across Cornwall, locality-based prescribing

meetings are held four times a year. These

meetings, organised by NHS Kernow CCG

medicines optimisation team, are

intended to have a focus on clinical

prescribing and medicines optimisation. A

GP prescribing lead from each surgery is

invited to attend these meetings and

disseminate the learning within their own

practice. A brief anonymous survey was

delivered to GPs at three meetings for

practice prescribing leads early in 2019,

with the attendees asked to complete the

survey having been advised that it was

anonymous and would take only a few

minutes to complete. The survey had

previously been piloted with three GPs

and minor amendments made. The

introduction to the survey described, in

general terms, the ongoing worldwide

and national focus on polypharmacy and

deprescribing in the context of

multimorbidity. The survey consisted of

six questions (five of which had

predetermined answers from which to

choose), plus one question that allowed

respondents to make free-text comments.


Box 1: Barriers to medicines optimisation or deprescribing

Concern from clinicians to discontinue medications started by another provider

Time expenditure

Fear of drug-withdrawal side effects

Lack of resources

Resistance from patients or family members

Fear of losing patient-provider relationship

Can any of these be safely deprescribed?

iStock.com/AnuchaCheechang


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7

Results

The three meetings were attended by a

total of 45 GPs, with completed

questionnaires returned from 41 (91%).

No other GP characteristics were

recorded.

The respondents’ mean rating on the

importance of tackling problematic

polypharmacy on a scale of 1 (not

important) to 5 (very important) was

4.2. When asked an introductory

question about the NICE clinical guideline

on ‘Multimorbidity: clinical assessment

and management’, 17 (42%) recollected

having scanned relevant sections but

had not really acted on the advice, 12

(29%) had read the guideline and were

trying to implement the advice, and 12

(29%) had not read nor seen any

summary of it. As regards who should be

undertaking polypharmacy reviews

(respondents could tick any of the eight

choices listed, see Table 1), the two

most frequently chosen options were -

the patient’s GP who can enact changes

(33 responses) and the practice-based

pharmacist who can enact changes (33).

When asked if they had seen hospital

doctors tackling problematic polypharmacy

such as stopping medicines that appear

to have no indication, attempting to

reduce the treatment burden for the

patient, ceasing preventative medicines in

the very old or at end of life, 12 (29.3%)

indicated they had seen this especially in

the ‘older’ patient, 16 (39%) had seen

this in patients in general some of the

time, and 13 (32%) had not seen this

happening at all. When questioned to

what extent do they think senior hospital

doctors in specialties other than Care of

the Elderly should have more of a focus

on tackling problematic polypharmacy,

20 (49%) answered they could do a lot

better at engaging with the deprescribing

movement, 10 (24%) answered they

could do a little better at engagement, 4

(10%) answered that their approach to

deprescribing seems reasonable, and 7

(17%) were concerned there is no

View Number

The patient’s GP who can then enact changes 33 (80%)

Practice-based pharmacist who can then enact changes 33 (80%)

When the patient is in hospital, a senior hospital doctor who can make suggestions to the GP 26 (63%)

When the patient is in hospital, a senior hospital pharmacist who can make suggestions to the GP 25 (61%)

When the patient is in hospital, a senior hospital doctor who can enact changes 25 (61%)

Practice support pharmacist from the CCG Prescribing Team who can make suggestions to the GP 25 (61%)

Community pharmacist who can make suggestions to the GP 17 (41%)

Nurse practitioner in the surgery who can make suggestions to the GP 12 (29%)

Table 1. GPs’ views on who should be undertaking reviews of patients with polypharmacy

Box 2: Examples of themes from free text comments

Supportive

“Being in hospital in a 24 hr monitored environment is an opportunity to deprescribe.”

“Great to have hosp doctor initiate change which helps with GP continuing plan of deprescribing.”

Cautionary

“If stopped in hospital and patient only has short stay then effects of deprescribing might only appear afterdischarge and may mean starting again.”

“Involve the patient, not just stopping without consultation. Communicating this with GPs. If drugs getstopped on discharge without any mention of why they probably get restarted.”

Not supportive

“Due to specialised areas of expertise hosp drs are not in a good position to make an overall judgement ofwhat is a good mix of medication. Stable polypharmacy is often better than destabilising the patient in a shortadmission.”

“During short admission there is likely to be too little time and too little knowledge of the patient to achievedeprescribing.”



thought given to opportunities for

deprescribing for hospital inpatients.

From the list of 11 medicines or

classes of medicines that senior hospital

doctors should target when considering

deprescribing (selecting all that apply),

the top four were opioids with the

hospital commencing the withdrawal

and the GP continuing the reduction (36

responses), anticholinergics with the

hospital ceasing the drug (35), NSAIDs

with the hospital ceasing the drug, and

benzodiazepines and related drugs with

the hospital advising the GP to

commence withdrawing the drug (33

responses each).

Sixteen respondents provided free text

comments (examples in Box 2). These

were categorised into themes of

supportive of deprescribing occurring in

hospital (8 respondents), cautionary

comments (3), not supportive (3), and

comments not specifically related to

hospital deprescribing (2).

Discussion

Polypharmacy has been described as a

‘wicked’ problem comprising a complex

tangle of the biological, behavioural,

technological, cultural, and socio-political,

with the authors commenting that it is

unlikely that GPs can address the

challenge singlehandedly, because the

solutions to some of these factors lie in

higher-order structural, economic, and

sociopolitical change.14

It is reassuring that GPs responding to

our short survey rated the importance of

tackling problematic polypharmacy as 4.2

out of a maximum importance of 5.2

Just under one-third of respondents

(29%) claimed to have read the NICE

multimorbidity guideline and were trying

to implement the advice, though a similar

proportion acknowledged that they

were not aware of this guideline. The

other respondents (42%), though aware,

had not acted on the advice. Studies have

found that GPs were generally supportive

of deprescribing but were infrequently

able to incorporate deprescribing into

regular practice.15,16 These barriers to

deprescribing include patient expectations,

the medical culture of prescribing, fear of

bad outcomes such as patient harm and

any subsequent reputational damage, and

various organizational factors (e.g. time

required to implement deprescribing).

Our small sample of GPs appeared to

have a preference that polypharmacy

reviews be undertaken either by the GP

or by practice based pharmacists. This

primary care setting does indeed provide

access to prescription history, medical

records and the environment for ongoing

monitoring after discontinuation. However,

deprescribing by GPs may be hindered by

time limitations and professional barriers

with specialists (i.e. not wanting to alter

medications started by a specialist).17 Our

GPs did welcome deprescribing input

from secondary care, with the role of the

senior hospital doctor in enacting

iStock.com/Jae Young Ju

“It is reassuring that GPs responding to our short survey rated the

importance of tackling problematic polypharmacy as

4 out of a maximum importance of 5.”

Polypharmacy reviews can be undertaken by the GP or by practice based pharmacists.


www.pharman.co.uk

9

changes whilst the patient is in hospital

acknowledged by 61% of respondents.

Some GPs did provide answers

(including free text responses) welcoming

greater deprescribing activity from the

hospital. Hospitalisation provides an

opportunity to review medicines and

conduct deprescribing; however, studies

show that levels of problematic

deprescribing activity is minimal.18

Barriers to deprescribing whilst the

patient is an inpatient include the

focus on acute medical problems, and

limited time for follow-up.19 These are

reflected in the free text comments

from our survey. In another qualitative

study, hospital-based health care

professionals cited time constraints and

reluctance to assume responsibility as key

factors and concluded that primary care is

the most appropriate setting to evaluate

treatment plans and patient adherence.20

Geriatricians felt their role was more to

support GPs’ optimisation of care, and

that potential input to ongoing care

coordination was limited due to the

short duration of their interaction with

these patients. Others though take the

opposing stance and argue that the

hospital stay affords the time for in-depth

interviews with patients necessary to

overcome deprescribing barriers, and

align medication therapies with patients’

goals of care.21

A Canadian report looking into

deprescribing for elderly patients identified

five priority drug classes for which expert

clinicians felt guidance is needed for

deprescribing. The classes of drugs that

emerged strongly from the rankings were

benzodiazepines, atypical antipsychotics,

statins, tricyclic antidepressants, and

proton pump inhibitors.22 These results

may well be different to our survey (with

the top four being opioids,

anticholinergics, NSAIDs and hypnotics)

due to the nature of the investigation.

Farrell and colleagues, the authors of the

report, set about engaging physicians,

pharmacists and nurses in identifying and

prioritising medication classes where

evidence-based deprescribing guidelines

would be of benefit to clinicians, whereas

we asked respondents a somewhat

different question and included drugs that

could be ceased abruptly in hospital as

well as drugs that need to be tapered off

over a period of time. There is a range of

criteria that can be utilised when reviewing

medication in older adults e.g. Beers

Criteria23, STOPP/START24, as well as a

number of process models and tools

describing the steps necessary for

successful deprescribing.25 However, the

evidence as to how such criteria and tools

should be applied in the inpatient care

setting is limited.26,27,28

The limitations of this survey are

recognised. This was a small study

undertaken in just one CCG and results

may not be generalisable to the overall

population of GPs in Cornwall or

elsewhere. Also, all data were self-

reported and therefore subject to bias. In

addition, only GP opinions are described

here and ideally the views of practice

nurses and practice pharmacists should

also be sought.

Conclusions

The results of the small survey

demonstrated that GPs perceived a role for

the hospital in deprescribing problematic

pharmacy. In the context of managing

patients with multimorbidity, they

considered the top four classes of

medicine that should be targeted as

opioids, anticholinergics, NSAIDs and

hypnotics. This choice is to be expected as

three of these classes are acknowledged as

high risk medicines, and the fourth class

(anticholinergics) features in recognised

guides and tools for deprescribing.

However, GPs also see themselves, and

practice based pharmacists, as being key

to conducting polypharmacy reviews.

Communication and collaboration

between GPs and specialist and hospital

pharmacist will be critical for providing

the best outcome for patient safety if

deprescribing of problematic polypharmacy

in a hospital setting is to become routine

accepted practice.

Declaration of interests

Mike Wilcock is undertaking a NICE

Scholarship into polypharmacy and

deprescribing during 2019/20. Marco

Motta has nothing to declare.


Journal of Pharmacy Management • Volume 35 • Issue 4 • October 201910

“. . . GPs perceived a role for the hospital in deprescribingproblematic pharmacy. In the context of managing

patients with multimorbidity, they considered the top fourclasses of medicine that should be targeted as opioids,

anticholinergics, NSAIDs and hypnotics.”

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2. The King’s Fund 2013. Polypharmacy and medicines optimisation: making itsafe and sound. Available at:http://www.kingsfund.org.uk/publications/polypha+rmacy-and-medicines-optimisation

3. National Institute for Health and Care Excellence, 2015. Medicinesoptimisation: the safe and effective use of medicines to enable the bestpossible outcomes (NG5). Available at: http://www.nice.org.uk/guidance/ng5

4. Medication Safety in Polypharmacy. Geneva: World Health Organization;2019 (WHO/UHC/SDS/2019.11). Available at:https://apps.who.int/iris/bitstream/handle/10665/325454/WHO-UHC-SDS-2019.11-eng.pdf?ua=1

5. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emergingdefinition of ‘deprescribing’ with network analysis: implications for futureresearch and clinical practice. Br J Clin Pharmacol 2015;80:1254-68 Availableat: https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.12732

6. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers toand enablers of deprescribing: a systematic review. Drugs Aging 2013; 30:793–807. Available from:https://link.springer.com/article/10.1007%2Fs40266-013-0106-8

7. Conklin J, Farrell B, Suleman S. Implementing deprescribing guidelines intofrontline practice: Barriers and facilitators. Res Soc Admin Pharm2019;15:796-800. Available at:https://www.sciencedirect.com/science/article/pii/S1551741118307526?via%3Dihub

8. Reeve E, Moriarty F, Nahas R, Turner JP, Kouladjian O'Donnell L, Hilmer SN. Anarrative review of the safety concerns of deprescribing in older adults andstrategies to mitigate potential harms. Expert Opin Drug Saf 2018;17:39–49Available from:https://www.tandfonline.com/doi/abs/10.1080/14740338.2018.1397625?af=R&journalCode=ieds20

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12. Anderson K, Foster M, Freeman C, Luetsch K, Scott I. Negotiating“unmeasurable harm and benefit” perspectives of general practitioners andconsultant pharmacists on deprescribing in the primary care setting. QualHealth Res 2017;27:1936-1947. Available at:https://journals.sagepub.com/doi/pdf/10.1177/1049732316687732

13. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. Challenges and Enablers ofDeprescribing: A General Practitioner Perspective. PLoS ONE 2016;11(4):e0151066. Available at:https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0151066&type=printable

14. Swinglehurst D, Fudge N.The polypharmacy challenge: time for a new script?Br J Gen Pract 2017;67:388-389. Available at:https://bjgp.org/content/67/662/388/tab-pdf

15. Carrier H, Zaytseva A, Bocquier A, Villani P, Verdoux H, Fortin M, et al. GPs'management of polypharmacy and therapeutic dilemma in patients withmultimorbidity: a cross-sectional survey of GPs in France. Br J Gen Pract2019;69:e270-8. Available from: https://bjgp.org/content/69/681/e270.long

16. Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: PrimaryCare Physicians' Views on Deprescribing in Everyday Practice. Ann Fam Med2017;15:341-346. Available at:http://www.annfammed.org/content/15/4/341.long

17. Anderson K, Freeman C, Stowasser D, Scott I. Prescriber barriers and enablersto minimising potentially inappropriate medications in adults: a systematicreview and thematic synthesis. BMJ Open 2014;4:e006544 Available at:https://bmjopen.bmj.com/content/bmjopen/4/12/e006544.full.pdf

18. Scott S, Clark A, Farrow C, May H, Patel M, Twigg MJ, Wright DJ,Bhattacharya D. Deprescribing admission medication at a UK teachinghospital; a report on quantity and nature of activity. Int J Clin Pharm2018;40:991-996.Available from:https://link.springer.com/article/10.1007%2Fs11096-018-0673-1

19. Cullinan S, Fleming A, O'Mahony D, Ryan C, O'Sullivan D, Gallagher P, et al.Doctors' perspectives on the barriers to appropriate prescribing in olderhospitalized patients: a qualitative study. Br J Clin Pharmacol 2014;79:860–9.Available at:https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.12555

20. McNamara KP, Breken BD, Alzubaidi HT, Bell JS, Dunbar JA, Walker C, HernanA. Health professional perspectives on the management of multimorbidityand polypharmacy for older patients in Australia. Age Ageing 2017;46:291-299. Available at: https://academic.oup.com/ageing/article/46/2/291/2498696

21. Petersen AW, Shah AS, Simmons SF, Shotwell MS, Jacobsen JML, Myers AP,Mixon AS, Bell SP, Kripalani S, Schnelle JF, Vasilevskis EE. Shed-MEDS: pilot ofa patient-centered deprescribing framework reduces medications inhospitalized older adults being transferred to inpatient postacute care. TherAdv DrugSafety 2018;9:523–533. Available at:https://journals.sagepub.com/doi/pdf/10.1177/2042098618781524

22. Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What ArePriorities for Deprescribing for Elderly Patients? Capturing the Voice ofPractitioners: A Modified Delphi Process. PLoS ONE 2015;10(4): e0122246.Available at:https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0122246&type=printable

23. The 2019 American Geriatrics Society Beers Criteria® Update Expert Panel.American Geriatrics Society 2019 Updated AGS Beers Criteria® for PotentiallyInappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67:674-694. Available from:https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767

24. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P.STOPP/START criteria for potentially inappropriate prescribing in older people:version 2. Age Ageing 2015; 44:213-8. Available at:https://academic.oup.com/ageing/article/44/2/213/2812233

25. Linsky A, Gellad WF, Linder JA, Friedberg MW. Advancing the Science ofDeprescribing: A Novel Comprehensive Conceptual Framework. J Am GeriatrSoc. 2019 Aug 20. doi: 10.1111/jgs.16136. [Epub ahead of print]. Availablefrom: https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16136

26. Gallagher PF, O'Connor MN, O'Mahony D. Prevention of potentiallyinappropriate prescribing for elderly patients: a randomized controlled trialusing STOPP/START criteria, Clin Pharmacol Ther 2011;89:845-54. Availablefrom: https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1038/clpt.2011.44

27. McKean M, Pillans P, Scott IA. A medication review and deprescribing methodfor hospitalised older patients receiving multiple medications. Intern Med J2016;46:35–42. Available from:https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.12906

28. Cheong ST, Ng TM, Tan KT. Pharmacist-initiated deprescribing in hospitalisedelderly: prevalence and acceptance by physicians. Eur J Hosp Pharm.2018;25(e1):e35-e39. Available from: https://ejhp.bmj.com/content/25/e1/e35

https://bmcmedicine.biomedcentral.com/track/pdf/10.1186/s12916-015-0322-7

http://www.kingsfund.org.uk/publications/polypha+rmacy-and-medicines-optimisation3

http://www.nice.org.uk/guidance/ng5

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https://apps.who.int/iris/bitstream/handle/10665/325454/WHO-UHC-SDS-2019.11-eng.pdf?ua=1

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https://www.mdpi.com/2226-4787/6/4/112/htm

https://www.nice.org.uk/guidance/ng56

https://journals.sagepub.com/doi/pdf/10.1177/1049732316687732

https://bjgp.org/content/67/662/388/tab-pdf

https://bjgp.org/content/69/681/e270.long

http://www.annfammed.org/content/15/4/341.long

https://bmjopen.bmj.com/content/bmjopen/4/12/e006544.full.pdf

https://link.springer.com/article/10.1007%2Fs11096-018-0673-1

https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.12555

https://academic.oup.com/ageing/article/46/2/291/2498696

https://journals.sagepub.com/doi/pdf/10.1177/2042098618781524

https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767

https://academic.oup.com/ageing/article/44/2/213/2812233

https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16136

https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1038/clpt.2011.44

https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.12906

https://ejhp.bmj.com/content/25/e1/e35

http://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation

https://www.sciencedirect.com/science/article/pii/S1551741118307526?via%3Dihub

https://www.tandfonline.com/doi/abs/10.1080/14740338.2018.1397625?af=R&journalCode=ieds20

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0151066&type=printable

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0122246&type=printable

Diary Dates with Pharmacy Management in 2020

JoMO-UKCPA Respiratory WorkshopDate: Thursday 12 March 2020Venue: The MacDonald Burlington Hotel, Burlington Arcade, 126 New Street,

Birmingham B2 4JQ

PM Celtic ConferenceDate: Thursday 26 March 2020Venue: Mercure Cardiff Holland House Hotel, 24 - 26 Newport Rd, Cardiff CF24 0DD

JoMO-UKCPA Diabetes WorkshopDate: Tuesday 12 May 2020Venue: Amba Marble Arch Hotel, Bryanston St, Marylebone, London W1H 7EH

Pharmacy Management National Forum for ScotlandDate: Thursday 27 August 2020Venue: DoubleTree by Hilton Glasgow Central Hotel, 36 Cambridge St,

Glasgow G2 3HN

JoMO-UKCPA Cardiovascular WorkshopDate: Wednesday 30 September 2020Venue: Amba Marble Arch Hotel, Bryanston St, Marylebone, London W1H 7EH

Pharmacy Together ConferenceDate: November 2020Venue: London

Pharmacy Management National Forum for WalesDate: Autumn 2020Venue: Cardiff

Pharmacy Management National Forum for Northern IrelandDate: Autumn 2020Venue: Belfast


Experiential learning opportunities for undergraduatepharmacy students in community pharmacies in the United Kingdom Amardeep Singh, Pharmacist Independent Prescriber and PhD

Candidate; Dr Hana Morrissey, Reader in Clinical Pharmacy;

Professor Patrick Ball, Professor of Pharmacy Practice: School of

Pharmacy, Faculty of Science and Engineering, University of

Wolverhampton, United Kingdom.


Abstract

Title

Experiential learning opportunities for undergraduate

pharmacy students in community pharmacies in the United

Kingdom.

Author List

Singh A, Morrisey H, Ball P.

Summary

Pharmacists in the UK are a resource at many levels of patient

care, regularly providing expert clinical advice with and without

appointment or signposting to appropriate help or support.

The NHS is under increasing pressure to deliver services and

pharmacists play an increasing role in helping people

understand how to use their medication, along with providing

healthy living advice.

The recent development of pharmacists employed in general

practice has broadened possible career pathways. Preparing

pharmacy graduates to develop smoothly into these roles

requires pharmacy education to adapt and evolve. One

possible innovation is the introduction of experiential learning

modules in the curriculum, similar to that provided to other

healthcare professionals such as doctors, nurses, physician

associates, etc. Workplace-based learning would align the

attainment of professional competencies during the

undergraduate course to reflect the future role.

Abstract

The paper examines the inclination of community sector

pharmacists to provide experiential learning through a survey

of stakeholders and pharmacists. It was found that

pharmacists value workplace experiential learning

opportunities and liked the concept of students arriving

trained and validated in certain services prior to placement.

Placement students would have the opportunity to contribute

something back to their placement site. The survey underpins

the need to examine current gaps of pharmacy education

curriculum, why the change is required, and the models that

could possibly be used to deliver that change.

Keywords: GPCP, inhaler, adherence, monitoring, coding,

holistic, self-management.

Author Contributions• Conceptualisation, methodology, validation of the analysis,

investigation: Amardeep Singh, Hana Morrissey, Patrick Ball

• Writing - original draft preparation: Amardeep Singh

• Writing - review and editing: Hana Morrissey, Patrick Ball

• Supervision: Hana Morrissey, Patrick Ball

• Project Administration: Hana Morrissey.

Introduction

Pharmacy practice has evolved and

continues to do so. The only constant is

change but, as practice changes,

education and training must at least keep

pace, or better still attempt to anticipate

some of the directions of change and

position the profession. We have evolved

from ‘chemists and druggists’ to

pharmacists and we are increasingly

being asked to take on further patient-

facing roles. An historical perspective can

inform our perception of the evolution in

the profession and how it has adapted to

changing societal needs.1

From Asclepius until the 18th century,

the exclusive entry to the pharmacy

profession was as an apprentice

apothecary where the aspiring pharmacist

or aspiring apothecary, would work side-

by-side with the established practitioner,

learning the skills of compounding and

extracting of drugs by shadowing and

practising medication-related activities

under supervision. This may be the origin

of a recent proposal that training could

return to an apprenticeship model, but

this is unlikely to be accepted by the

profession. In the UK until middle of the

18th century anyone could earn the title

‘chemist and druggist’. It was this lack of

regulation that, eventually, led to the

establishment of the Pharmaceutical

Society as a professional body.2

Despite the profession’s extensive and

growing patient-facing role, pharmacy

training in the UK is still classified as a

science degree and therefore attracts no

funding for experiential clinical

Patrick BallHana MorrisseyAmardeep Singh



www.pharman.co.uk

13

placement. The undergraduate pharmacy

curriculum has a strong science base,

which is unique amongst the frontline

health professions, and this is considered

by many to be essential to retain. In this

context, adding in the required clinical

modules and experiential placements

without funding support poses a

challenge.3,4

Pharmacy education in

the UK and globally

Globally, the pharmacy education

curriculum is based upon pillars of

professionalism, clinical knowledge,

pharmaceutical chemistry and their

practical application. As the profession

adapts to the changing needs and

requirements of society, so ideally the

training program should also adapt to

prepare the entrants to our profession for

the roles they will be expected to fulfil.

Globally, pharmacy schools follow a

curriculum that includes a foundation of

pharmacy science, pharmacokinetics,

pharmacology, medicinal chemistry, and

pharmacotherapy in addition to medication

safety, pharmacy law and ethics,

biostatistics, toxicology, epidemiology,

hands-on skill-based practical classes,

evidence-based practice, innovation and

business management. While all schools

aim to meet the same outcomes and

educational goals and objectives, the way

in which they do so varies considerably

across the countries and is linked to

specific local needs and availability of

resources. In the US, Canada and

Australia, for example, most schools

emphasise more clinical coursework in

later years of course.3 In Europe,

institutions follow the Quality Assurance

in European Pharmacy Education and

Training (PHAR-QA) consortium, which is

a complex curriculum of competency

attainment.5

Disparity in the design ofUK undergraduatepharmacy courses

In comparison to other European

pharmacy programs, the UK programs

stand out in that they provide the

underlying scientific and theoretical

knowledge alongside experimental and

clinical expertise. Therefore, at the end of

the 4-year program, the graduate is

expected to be fully equipped to enter

the clinical/practice environment. This

contrasts with other European programs

where the university component of the

education concentrates purely on the

scientific aspects before the students

graduate and enter the pharmacy

practice training arena leading to 6 years

total training. Examining the UK

expectations of uniform and advanced

healthcare provision to all patients, it

appears that the pharmacist of the future

has a greater clinical role within the

multidisciplinary team of doctors, nurses

and other health care professionals.

Medical education has long

incorporated extensive integration of

workplace experience alongside learning

modules. Workplace learning plays a

crucial role in the development of

learners’ attitudes, behaviours and skills

as they are socialised into the profession.6

A number of factors contribute to this

form of learning and development

including supervision, feedback, the work

iStock.com/AndreyPopov

The pharmacist of the future will have a greater clinical role within the multidisciplinary healthcare team.


environment and culture and, perhaps

most importantly, exposure to patients.

Patient contact within a multidisciplinary

team early in training can serve to

develop the communication skills and

empathy necessary in frontline healthcare

professionals.7

Whilst maintaining its strong science

foundation, pharmacy is an increasingly

clinical, patient-focussed profession, yet

education and training has traditionally

been very different from medical

education, and pharmacy students mostly

graduate lacking first-hand experience in

one-on-one patient communication and

in delivery of professional services.8 The

GPhC is currently considering changing

the pharmacy degree to incorporate the

pre-registration component within the

undergraduate training allowing workplace

integration to equip students with

necessary skills for the changing role of

the pharmacist within the healthcare

platform. A similar approach was tested

and evaluated in Scotland; however, this

did not include students from all years

of education nor the training and

certification on patient life-style

modification advice.9

Is change required?

United Kingdom government reports

have described multiple challenges in

health care, including the increasing

prevalence of non-communicable

diseases, sub-optimal treatment outcomes

and spiralling costs.10 To address the

challenges, the reports call for a changed

model of healthcare, focussed on

promoting healthy lifestyles and team-

based delivery of health care including

professionals from different disciplines

where pharmacists share responsibility

with other team members for patients’

health outcomes. These principles have

been incorporated into accreditation

standards for the MPharm degree. The

underpinning philosophy is that the best

way to train pharmacists to accept

responsibility for patients’ health

outcomes is to include supervised

workplace-based patient care experiences

into the MPharm curriculum from the

first-year with steadily increasing patient

care responsibilities.11 The time devoted

to workplace-based learning would

increase throughout the remainder of the

MPharm programme. Academic and

practice-based educators have the

responsibility of ensuring that MPharm

graduates have gained the skill-sets called

for in the accreditation standards and the

published government reports.12 The

Scotland National Pharmacy Board has

adopted experiential learning and

embraced the concept of task

performance on placement place rather

than just observing.13

Challenges caused by the

current model

There are no formal requirements for

experiential education or clinical

placements within the UK MPharm

program, but it has become an

expectation.12 The placements are not

funded as for medical and other health

professional students, so most universities

offer just one week of experiential

learning in community pharmacy for each

year with most clinical education focused

on classroom simulation and role play

with teacher practitioners. This is a long

way far from real practice, which can only

be best delivered when students are

placed in clinical environments.14 The

short duration of experiential rotations is

the major criticism of the current

curriculum; an observational placement at

a single site without any rotations leaves

students with an unimaginable gap of

clinical practice experience. Additionally,

the lack of national guidelines means

students have minimal opportunities to

assume any clinical responsibility or

accountability for patient care. With this

high degree of dependency on

preceptors, many employers view taking

on experiential students as a burden,

rather than as contributing members of

the health care team.15

Assessment within UK pharmacy

schools relies predominantly on

performance in written, theory

examinations. Invariably there is also a

contribution from coursework exercises

requiring the writing of reports and

interpretation of data. The research

project falls within this latter category

and usually contributes approximately

15%-20% to the final award but

universities have been moving away from

this practice because of plagiarism.

Increasing use is being made of

competency-based assessments with

pass/fail criteria including history taking,

vital investigations, observations of signs

and symptoms, graded by means of

objective structured clinical examination.

This again involves classroom role plays

and emphasis on the satisfactory grades

for moving to the next level. Patient

involvement is zero.14

The GPhC highlighted the ‘integration

ladder’ developed by the medical

curriculum and assessment expert

Professor Ronald Harden.16 The three

models of integration that meet the

expectations of future pharmacists are

14 Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020

“The underpinning philosophy is that the best way to train pharmaciststo accept responsibility for patients’ health outcomes is

to include supervised workplace-based patient care

experiences into the MPharm curriculum . . .”

15Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020

www.pharman.co.uk

Question Strongly Agree Disagree Stronglyagree disagree

Would you support the initiative of developing a work-based 64.81% 24.07% 7.41% 3.70%learning for Pharmacy undergraduate students through placementin community pharmacy sector?

Do you think that one-year pharmacy pre-registration placement 18.52% 44.44% 33.33% 3.70%is enough to achieve required competence knowledge forpharmacist role?

Do you think that one week of placement of undergraduate 22.22% 42.59% 31.48% 3.70%pharmacy student in community pharmacy will be beneficialto both employer and students?

Would you be happy to take 1st, 2nd and 3rd year pharmacy 35.19% 51.85% 11.11% 1.85%students at your workplace?

If students are trained to provide a certified service at your 22.22% 59.26% 14.81% 3.705%pharmacy, would you have confidence to allow them toprovide that service?

Table 1: Questions required Yes/No answers

‘trans-disciplinary’, ‘inter-disciplinary’ and

‘multi-disciplinary’. Another approach

could be a six-step approach:17

• Identify the students’ knowledge or

skill gap or new knowledge and skill

required.

• Assess students’ general needs and

learning in the identified topic.

• Target assess to the competencies

where learning is a lifelong, professional

requirement.

• Set clear learning aim and objectives.

• Establish clear educational strategies

and framework.

• Implement the learning experience,

monitor its performance and evaluate

its outcomes.

How could the newpharmacy educationmodel be delivered?

Careful consideration of the above led to

the design of a survey to be delivered

through SurveyMonkey to gauge the

effect of ‘workplace-based training’, ‘small

group discussion’ and ‘reflective writing’ in

enhancing student learning in the MPharm

at the University of Wolverhampton.

Employers in the community pharmacy

sector were asked to respond to ten

questions based on workplace-based

learning for 1st, 2nd and 3rd year students

studying the MPharm degree course.

Results and discussion

In the survey, six questions were based

on ‘agree’ or ‘disagree’ responses to

questions (Table 1). Out of 54 responses, in

the survey, six questions were based on

‘agree’ or ‘disagree’ responses to questions

(Table 1). Out of 54 responses, 42.59%

(median) community pharmacists selected

‘strongly agree’ or ‘agree’ to all six

questions and 7.41% (median) of

respondents selected ‘disagree’ or ‘strongly

disagree’. This suggests that employers

appreciate the importance of experiential

learning for pharmacy undergraduates in a

similar way as the early training of

dispensers, healthcare assistants and

technicians but this learning should be

considered as reflection on concepts from a

taught course and not as the only means to

train pharmacists. selected ‘strongly

agree’ or ‘agree’ to all six questions and

7.41% (median) of respondents selected

‘disagree’ or ‘strongly disagree’. This

suggests that employers appreciate the

importance of experiential learning for

pharmacy undergraduates in a similar

way as the early training of dispensers,

healthcare assistants and technicians but

this learning should be considered as

reflection on concepts from a taught

course and not as the only means to train

pharmacists.

With a response of 87% of employers

willing to take students (Figure 1) and

with 73.5% who would like to see some

government funding (Figure 2), it appears

there will not be a shortage of places if

payments were offered by a new training

scheme. However, a paradigm shift is

required to change the culture of

placement being a burden to an

additional of free labour performed by

students trained in the university settings

in certain activities and deemed to be

competent in performing them before

placement. They are still students and

would require oversight by their mentor

during the initial real life application, but

they could deliver certain tasks

unsupported and gain a valuable patient-

facing experience.

Task consideredappropriate for thestudent in communitypharmacy placements

When pharmacists were asked what jobs

the students could do, they selected



those activities which clearly consume the

most of community pharmacy workload.

Shelf filling, stock management,

prescription reception and fridge

temperature reading accounted for over

80%of responses (Table 2).

Advice provided topatients

Mixed responses were found on patient

advice with employers’ biggest

confidence of 95.83% in General Sales

List (GSL) goods advice followed by a

75% response to over-the-counter (OTC)

counselling to patients. More specialised

advice services like telephone advice,

prescription medicine and medication

reviews had lower confidence but

depend on the students’ level of progress

within their MPharm degree.

Other clinical services

provided in community

pharmacy

Among clinical services responses, blood

pressure check, lifestyle advice and safe

handling of medicine waste were the

highest, but all other clinical services

routinely undertaken were considered as

suitable with the lowest being cholesterol

checking (39.58%) and controlled drugs

disposal entries (41.67%).

While profession-specific training is

essential, application of this training in

interdisciplinary simulation training,

provides a valuable level of peer review

(medical, nursing, assistant physicians

and pharmacy) and assessment of

competencies by trainers from other

professions. However, interdisciplinary

activities are underdeveloped and

underutilised, partly because in practice

they pose major timetabling issues for

institutions. Students are exposed to real-

life scenarios during their pre-registration

placement and the current shadowing

placements do not prepare them, in

knowledge or confidence, for this

exposure. Additionally, regardless of

whether they will be placed in community

or in hospital, they will always have to

communicate with other health care

providers to gather or pass information.

If undergraduate practice-based

placements are considered in the future

and valued as a labour force, they must

be designed based on the preferences of

the largest employment sector for

pharmacists, which is for community

pharmacists. If this is to occur at

undergraduate level, community pharmacy

pre-registration placements will be

regarded as a favourable clinical

development pathway - not only hospital

pharmacy placements.18 Pharmacy

practice training cannot be separated

from service provision and has to be a

fundamental part of the design and

delivery of patient care following the

same concept of nursing and medical

education. It is recognised that anFigure 2: Employers preference for funding placements

Figure 1: Employers’ willingness to host

undergraduate students during placements

www.pharman.co.uk

Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020 17

institution that trains well delivers high

quality care.

For this to happen, pharmacy students

need to be aware of the changing role of

the pharmacist within NHS and diversity

of roles in community, hospital, general

practice, management and specialist

clinical roles.19 Designing placements and

objectives that fit into normal routines and

work patterns are more likely to be

accepted in the community. As workplace

learning is considered as an essential part

of the culture of quality training, the role

of the facilitator and educational supervisor

will require further development.

Moreover, it is crucial that pharmacy

employers’ value and develop

infrastructure that encourages best and

imaginative use of workplace-based

learning methods, and a risk-free

opportunity for students to develop the

best possible clinical and professional skills

and knowledge. Knowledge creation and

the deployment of new knowledge in the

workplace have given rise to the

workplace itself being recognised as a site

of learning and knowledge production.20 If

health education is to continue to make a

contribution to the knowledge economy,

collaborative activities based in and around

the workplace should be considered.

Students will explore the changing

employment patterns and how it has

impacted on the demand for higher level

skills, more flexibility, reflection and

career planning. Graduate level skills and

qualifications are seen as being

increasingly important in the changing

workplace.21

ANSWER CHOICES RESPONSES

Dispensary 59.18% 29

OTC 67.35% 33

Shelf Filling 89.80% 44

Stock and date check 89.80% 44

Prescription reception 81.63% 40

Prescription hand out 71.43% 35

Cash handling/Till service 67.35% 33

Fridge temp check 83.67% 41

Telephone answering 63.27% 31

Telephone queries 34.69% 17

Medication assembling 61.22% 30

Labelling 55.10% 27

Dispensing 46.94% 23

Other (please specify) 8.16% 4

Total Respondents: 49

Table 2: Tasks suggested by community pharmacist


Prescription queries patients 56.25% 27

Telephone advice 31.25% 15

Prescription queries/clinicians 33.33% 16

General sale list advice 95.83% 46

Prescription medicine advice 33.33% 16

Prescription only medicine advice 27.08% 13

Counselling OTC 75.00% 36

Medication review 12.50% 6



Table 3: Advice in community pharmacy


18 Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020

It is recognised that an institution that

trains well also delivers high quality care.

Like medicine, pharmacy training

struggles with limited time to spend on

educational activities during the taught

course so it becomes even more

important that training programs deliver

real value for organisations.22

Who will benefit?

It is crucial that pharmacy employers

value and develop infrastructure that

encourages best and imaginative use of

workplace based learning methods, and

a risk-free opportunity for students to

develop the best possible clinical and

professional skills and knowledge.

Knowledge creation and the

deployment of new knowledge in the

workplace have given rise to the

workplace itself being recognised as a site

of learning and knowledge production.23

If health education is to continue to make

a contribution to the knowledge

economy, collaborative activities based in

and around the workplace should be

considered.

This will help to uncover the hidden

potential of students to navigate

workload pressure, polarisation between

groups and their own biases are crucial to

learn in the workplace environment and

workplace-based experiential courses

present pharmacy educators with the

logistical challenge of finding sufficient

numbers of pharmacy practitioners to

host MPharm students.24 They also

provide academic challenges because

assessment of student performance

extends beyond areas amenable to

traditional assessment methods, such as

multiple-choice question examination, to

the assessment of higher cognitive

functions including communication,

critical-thinking, decision-making, problem-

solving and lifelong learning skills.

Small group discussion and reflective

writing are considered effective

educational methods for assessing higher

cognitive function in both formative and

summative form. Accordingly, it is

important to integrate practice-based

learning with small group discussion and

reflective writing in an iterative learning

cycle.25 They are particularly effective as

educational methods when students are

required to describe, analyse and answer

questions about their own workplace-

based activities.26 A focus on students’

workplace-based experiences promotes

students’ motivation to learn by

enhancing the relevance of small group

discussion and reflective writing. Kolb

described reflective practice as cycle

where clinical experience occur and

trigger lifelong practice behaviour of

reflection and ongoing self-evaluation.25

The cycle continue through sharing the

experience with others practitioners and

reviewing its learning outcomes, reflect

on how the experience made one feel,

reflect on the actions and consequences

and how they can be improved, and if it

can be applied to other scenarios and

then apply the learnt outcomes to new

experience and repeat the cycle again.


CD registry entry 54.17% 26

CD disposal entry 41.67% 20

Medication waste 79;17% 38

Smoking advice 47.92% 23

BP check 75.00% 36

Inhaler technique 56.25% 27

Weight management 58.33% 28

Diabetes check 41.67% 20

Cholesterol check 39.58% 19

Lifestyle advice 75.00% 36



Table 4: other clinical services in community pharmacy

“It is crucial that pharmacy employers value and developinfrastructure that encourages best and imaginative

use of workplace based learning methods . . .”


www.pharman.co.uk

19

Conclusion

Globally, pharmacists are trained within

an educational framework that is built

upon a foundation of a strong curriculum.

There are identified gaps that are being

addressed to enhance experiential

learning but, to date, there is no solid

framework universally applied as seen

in undergraduate courses for other

professions. In the UK particularly, where

the community has accepted pharmacists

as first-line professionals for routine

medical problems, and not just suppliers

of medication, this represents an

enormous shift in roles. The NHS and

Public Health England (PHE) strongly

promote the multidisciplinary approach

to patient care and considers vital the role

of pharmacists at each level of patient

care. There is a need of an introduction of

compulsory experiential learning in the

pharmacy undergraduate course to equip

the modern pharmacy workforce for the

future.

Funding

This project received no external funding.


All authors declare no conflict of interest

professionally or financially.

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2. Zebroski B. A brief history of pharmacy: Humanity’s search for wellness. NewYork, Routledge 2016. pp260. ISBN-13: 978-0415537841

3. Karimi R, Arendt C, Cawley P, Buhler A, Elbarbry F, Roberts S. LearningBridge: Curricular Integration of Didactic and Experiential Education. Am JPharm Educ.2010;74(3):Article 48. Available from:https://www.ajpe.org/content/74/3/48

4. Anon Pharmacy in England. Building on strengths – delivering the future.London, HM Government Department of Health. 2008. Available atwww.gov.uk/government/uploads/system/uploads/attachment_data/file/228858/7341.pdf

5. Atkinson J, Rombaut B, Pozo A, Rekkas D, Veski P, Hirvonen J et al. ADescription of the European Pharmacy Education and Training QualityAssurance Project. Pharmacy. 2013;1(1):3-7. Available at:https://www.mdpi.com/2226-4787/1/1/3/htm

6. Helyer R. Learning through reflection: the critical role of reflection in work-based learning (WBL). Journal of Work-Applied Management, [online]2015;7(1):15-27. Available at:http://www.emeraldinsight.com/doi/full/10.1108/JWAM-10-2015-003[Accessed 2 Jan. 2019].

7. Croker A, Smith T, Fisher K, Littlejohns S. Educators’ InterprofessionalCollaborative Relationships: Helping Pharmacy Students Learn to Work withOther Professions. Pharmacy. 2016;4(2):17. doi: 10.3390/pharmacy4020017.Available at: https://www.mdpi.com/2226-4787/4/2/17

8. Smithson J, Bellingan M, Glass B, Mills J. Standardized patients in pharmacyeducation: An integrative literature review. Curr Pharm Teach Learn.2015;7(6):851-863. Available at:https://www.sciencedirect.com/science/article/pii/S1877129715000842

9. Andalo D. Scottish government backs new integrated five-year pharmacydegree for 2020. [online] Pharm J. 2017[online] Available at:https://www.pharmaceutical-journal.com/news-and-analysis/news/scottish-government-backs-new-integrated-five-year-pharmacy-degree-for-2020/20202712.article [Accessed 10 Jan. 2019].

10. Anon. The Right Medicine: A Strategy for Pharmaceutical Care in Scotland.Edinburgh: Scottish Executive Health Department. Astron. 2002. Available at:http://www.scotland.gov.uk/Resource/Doc/158742/0043086.pdf

11. Flynn AA, MacKinnon GE. Assessing capacity of hospitals to partner withacademic programs for experiential education. Am J Pharm Educ. 2008;72(5):Article 116. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2630141/

12. General Pharmaceutical Council. Future pharmacists: standards for the initialeducation and training of pharmacists. May 2019.

13. Hendry G, Winn P, Wiggins S, Turner CJ. Qualitative evaluation of a practice-based experience pilot program for Master of Pharmacy students in Scotland.Am J Pharm Educ. 2016;80 (10), Article 165. Available at:https://www.ajpe.org/content/80/10/165

14. Sosabowski M, Gard P. Pharmacy Education in the United Kingdom. Am JPharm Educ. 2008;72(6):Article 130. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661171/

15. Duggan C. Reforming educational career development for practitioners in theUK, presented at Trends in Pharmacy Education, European Association ofFaculties of Pharmacy Meeting, September 20-22, 2007

16. Harden RM. The integration ladder: a tool for curriculum planning andevaluation. Med Educ. 2000;34:551-557. Available at:http://medsci.indiana.edu/c602web/tbl/reading/The_Integration_Ladder_Harden_Med_Educ_2.pdf

17. Thomas A, Kern E, Hughes T, Chen Y. Curriculum Development for MedicalEducation: A Six-Step Approach. Baltimore: Johns Hopkins University Press,2015. Project MUSE,

18. Academy of Medical Royal Colleges Improving Assessment: Further Guidanceand Recommendations. 2016[online] Available at: http://aomrc.org.uk/wp-content/uploads/2016/06/Improving_assessment_Further_GR_0616-1.pdf[Accessed 12 Mar. 2019].

19. Thornley T, Wright D, Kirkdale C. Demonstrating the patient benefit andvalue for the NHS of community pharmacy: insight from the CommunityPharmacy Future model. Clin Pharm. 2017;9(4):[online] Available at:https://www.pharmaceutical-journal.com/research/demonstrating-the-patient-benefit-and-value-for-the-nhs-of-community-pharmacy-insight-from-the-community-pharmacy-future-model/20202334.article [Accessed 11 Mar.2019].

20. Burke L, Marks‐Maran D, Ooms A, Webb M, Cooper D. Towards a pedagogyof work‐based learning: perceptions of work‐based learning in foundationdegrees. J Vocat Educ Train. 2009;61(1):15-33. Available from:http://heer.qaa.ac.uk/SearchForSummaries/Summaries/Pages/LTA231.aspx

21. Saunders V, Zuzel K. Evaluating Employability Skills: Employer and StudentPerceptions. Biosci Educ. 2010;15(1):1-15. Available from:https://www.researchgate.net/publication/228846598_Evaluating_Employability_Skills_Employer_and_Student_Perceptions

22. Winn P, Turner CJ. Description and evaluation of an MPharm practice-basedexperience pilot program. Am J Pharm Educ. 2016;80(9): Article 151.Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221833/

23. Graudins L, Dooley M. Medication Safety: Experiential Learning for PharmacyStudents and Staff in a Hospital Setting. Pharmacy. 2016;4(4):38. Availableat: https://www.mdpi.com/2226-4787/4/4/38/htm

24. Epstein RM, Hundert EM. Defining and assessing professional competence.JAMA. 2008; 287:226-235. Available athttp://acmd615.pbworks.com/w/file/fetch/46353210/epstein_JAMA.pdf

25. Kolb DA. Experiential learning. Experience as the source of learning indevelopment. Prentice Hall, 2nd edition. Pearson Education, Inc. UpperSaddle River, New Jersey, USA. 2014.

26. Smith A, Darracott R. Modernizing pharmacy careers programme: review ofpharmacist undergraduate training and proposals for reform. London, HealthEducation England. 2011.

NOTE: hyperlinks to refs 3,11,13,14,22 amended on 140120.

“. . . the community has accepted pharmacists as first-lineprofessionals for routine medical problems,

and not just suppliers of medication . . .”


https://academic.oup.com/ajhp/article-abstract/64/14/1541/5134905?redirectedFrom=fulltext




http://www.emeraldinsight.com/doi/full/10.1108/JWAM-10-2015-003

https://www.mdpi.com/2226-4787/4/2/17

https://www.sciencedirect.com/science/article/pii/S1877129715000842

https://www.pharmaceutical-journal.com/news-and-analysis/news/scottish-government-backs-new-integrated-five-year-pharmacy-degree-for-2020/20202712.article




http://aomrc.org.uk/wp-content/uploads/2016/06/Improving_assessment_Further_GR_0616-1.pdf



https://www.pharmaceutical-journal.com/research/demonstrating-the-patient-benefit-and-value-for-the-nhs-of-community-pharmacy-insight-from-the-community-pharmacy-future-model/20202334.article





https://www.researchgate.net/publication/228846598_Evaluating_Employabili


http://acmd615.pbworks.com/w/file/fetch/46353210/epstein_JAMA.pdf

www.gov.uk/government/uploads/system/uploads/attachment_data/file/228858/7341.pdf

http://www.scotland.gov.uk/Resource/Doc/158742/0043086.pdf

http://medsci.indiana.edu/c602web/tbl/reading/The_Integration_Ladder_Harden_Med_Educ_2.pdf

https://www.ajpe.org/doi/full/10.5688/aj740348

https://www.ajpe.org/content/80/10/165

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661171/



http://heer.qaa.ac.uk/SearchForSummaries/Summaries/Pages/LTA231.aspx


www.pharman.co.uk

21

CLARION CALLA section for passionate calls for action to further develop the contribution that

pharmacy can make to healthcare

Equipping pharmacists for the modern NHS; how can weachieve ‘Education Optimisation’? Dr Julie Sowter, Senior Lecturer; Mrs Sandra

Martin, Lecturer; Dr Gemma Quinn, Senior

Lecturer and Mrs Diane Webb, Lecturer:

School of Pharmacy and Medical Sciences,

University of Bradford.

Correspondence to:

[email protected]

Abstract

Title

Equipping pharmacists for the modern NHS; how can we

achieve ‘Education Optimisation’?

Author List

Sowter J, Martin S, Quinn G, Webb D.

Summary

This article recognises the need to respond to increasing

demand for pharmacy services, particularly in primary care,

and make greater use of pharmacists in patient-facing roles.

Work with stakeholders highlighted the need to integrate soft

skills development and opportunities for interprofessional

learning to equip pharmacists for extended patient-facing

roles as integral members of the multi-professional care team.

However, there is still a lack of awareness of the optimal use

Abstract

of pharmacists’ knowledge and skills in these roles. In

addition, timescales for responding to workforce development

tenders to get pharmacy staff trained up and ready for

proposed new services are often short. The pharmacy

workforce needs access to flexible educational pathways to

tailor their professional development and education providers

need to be responsive, adaptable and nimble. Therefore, this

call is for collaboration between education providers and the

evolving integrated care systems (ICSs) to predict and provide

tailored educational support for local service innovations and

to evaluate their effectiveness. It stems from the personal

experiences of four academics involved in developing

innovative professional postgraduate taught programmes.

Keywords: workforce development, education, interprofessional,

patient-facing, collaboration, commissioning

Mrs Diane WebbDr Gemma QuinnMrs Sandra MartinDr Julie Sowter

Background

The School of Pharmacy and Medical

Sciences, within the University of

Bradford provides post registration

professional taught programmes for

pharmacists at different stages of their

career and across sectors of practice to

address pharmacy workforce needs. We

aim to facilitate professional networking

and learning communities for

pharmacists on our courses and to

support the provision of a pipeline of

competent staff for the NHS.

This ‘Clarion Call’ was catalysed by

one from Sally Bower in a previous

edition of this journal,1 which aimed to

encourage the pharmacy profession to

consider and extend their leadership

role, particularly into the new integrated

care systems (ICSs). In order to achieve

this goal, she urged pharmacists to

review their skills and knowledge,

particularly the need for softer skills such

as group dynamics and self-awareness.

She also indicated that, for her, “better

understanding of how to handle change

and uncertainty meant this was less

challenging than it might have been”.

This advice chimed with what we, as

academics supporting the continuing

professional development of registered

pharmacists, had identified during

discussions with service providers and

students. Her article also made us reflect

on our own leadership role in the

changing landscape of healthcare

education brought about by the

publication of the NHS Long Term Plan.2

NHS England is working closely with

Health Education England (HEE) to ensure

workforce development meets service

demands at a national level. Alongside this,

the evolving ICSs will be implementing the

NHS Long Term Plan in accordance with

local service priorities. It is widely

accepted that the NHS Long Term Plan

will require national, regional and local

organisations to work more effectively

together to support the NHS. One of the

ways that we as educators can manage

change and uncertainty is to work closely

with service providers and commissioners




to mitigate against some of the

challenges that uncertainty brings and

optimise the opportunities that change

can offer.

This call is therefore an invitation for

closer collaboration between education

providers and the evolving ICSs to predict

and provide tailored educational support

for local service innovations and to

evaluate their effectiveness.

‘Education optimisation’ in

the NHS – is a ‘concordant’

approach needed?

Healthcare professionals are familiar with

the concept of ‘medicines optimisation’3

and we believe that similar guiding

principles will achieve ‘education

optimisation’ for our pharmacy workforce.

Medicines optimisation aims to help

patients make the most of their

medicines to improve patient outcomes.

The principles underpinning medicines

optimisation are about understanding the

experience of those that the medicines

impact upon, making sure that we

consider the evidence for and safety of

these interventions and making this part

of our routine practice.

From an educational perspective, we

already evaluate and gain an insight into

the students’ experience of our

educational interventions but we also

need to understand the needs of other

stakeholders with a vested interest,

including the new ICSs responsible for

meeting the health needs of local

populations. We want to ensure that our

educational approaches enable the

pharmacy workforce to work in new and

evolving roles as safe and effective

practitioners. By building close working

relationships between educators and ICSs

there is an opportunity to gain an

understanding about the impact

educational interventions are having and

optimise education so that it is

responsive, adaptable and nimble in

meeting workforce development needs.

All of this indicates the need for an

ongoing partnership approach; making

this part of our routine practice.

As advocated in the principles of

medicines optimisation, it is important to

consider the evidence that underpins our

educational interventions, although the

type of evidence may be different from

that used to guide treatment choices and

primarily stems from the evaluation of

our programmes. Evaluation can range

from seeking feedback about learners’

reactions to our teaching through to

measuring outcomes, such as change in

organisational practice and benefits to

patients as advocated by Barr et al.4 It is

important that evaluation is based on

meaningful outcome measures that are

agreed and valued by stakeholders. In

education, as with medicine, there is

often a tension between achieving

benefits to populations and benefits to

individuals. Educators and ICSs could,

therefore, usefully work together in

collaboration with our students and local

communities to agree on meaningful

outcomes for education.

iStock.com/cnythzl

There needs to be closer collaboration between education providers and the evolving Integrated Care Systems.


www.pharman.co.uk

23

We have recently introduced team-

based learning (TBL) into our

postgraduate programmes. An analysis of

the TBL literature shows that there is

evidence that this method improves

learning outcomes in several different

domains including student engagement,

team working and critical thinking and

there is some evidence of the transfer of

knowledge to practice environments.5

This teaching method incorporates a

flipped classroom approach, which

requires students to prepare prior to

attending a study day, at which point

their knowledge is tested. Following this

initial test of underpinning knowledge,

multiple small teams work on the same

application exercises within in a larger group

setting with subsequent discussions

between teams facilitated by a tutor. In

these discussions, teams explain and

justify their decisions. This is a teaching

method in which our School has

extensive experience at undergraduate

level and initial feedback from the

postgraduates has been positive.

However, this is an example of where we

still need to evaluate its effectiveness in

changing students’ practice. Similarly, we

have worked with patients to introduce

patient-led teaching about cross sector

medicines optimisation.6 Yet again, this

evaluated well with students and we

now need to explore the impact on

organisational practice and benefits to

patients.

We are constantly gathering

feedback through study day evaluation,

postgraduate taught experience surveys,

student-staff liaison committees and

continuous informal feedback from

students. We have also talked to a

variety of other stakeholders, including

Chief Pharmacists, Education & Training

pharmacists, Community Pharmacy West

Yorkshire, superintendents, Clinical

Commissioning Groups (CCGs), General

Practitioners (GPs), teacher-practitioners,

Health Education England (HEE) and

other Universities.

Alongside these ongoing initiatives

we have held two stakeholder events in

recent years. Our first event, which

focussed on primary care and how to

support the General Practice workforce,

included representation from pharmacists

in all sectors of clinical practice, pharmacy

technicians, GPs, CCGs, HEE and the

Royal Pharmaceutical Society (RPS). This

highlighted the need to integrate soft

skills development and opportunities for

interprofessional learning to equip

pharmacists for extended patient-facing

roles as integral members of the multi-

professional care team.7 These softer skills

are considered essential to enable

patients, their carers and other members

of the multi-professional team to gain full

benefit from pharmacists as medicines

specialists, as well as enabling

pharmacists to fulfil their leadership

potential as highlighted by Sally Bower.1

In addition, we identified that there was

still a lack of awareness about how to use

the knowledge and skills of the pharmacy

workforce to best effect in new and

evolving roles, particularly in primary care.

Through this event we were able to

develop our relationships with primary

care colleagues. As highlighted by the

Kings Fund in their interpretation of the

NHS Long Term Plan, collaboration in

primary care takes time, strong

relationships, a shared vision and

effective leadership.8 Our experience has

been that developing these relationships,

although challenging when all parties

have a demanding workload, has been

essential in enabling us to plan for

workforce development needs and offer

our expertise as educationalists for

learning support and assessment.

Our most recent stakeholder event in

July 2019, focussed on how we can best

prepare for what the future holds in

terms of the NHS Long Term Plan.2 The

pharmacy workforce will need to be

prepared for a future when patients are

not managed by sector. Alongside a

sound grounding in clinical topics, the

pharmacy workforce will need to have a

good understanding of different sectors

of practice and the ability to collaborate

as well as be flexible and resilient.

Stakeholders from all sectors of practice

attended, as did service users, which

made for rich and interesting discussions.

These discussions enabled us to test our

ideas about two new cross sector

programmes to support newly registered

pharmacists at ‘Foundation level’, and for

those with more experience at ‘Advanced

level’.

So, what’s next?

We need to engage in these types of

conversations with the evolving ICSs.

Concordance in the context of patient

consultations, advocates a sharing of power

in the professional-patient interaction. It

values the patient’s perspective,

acknowledging that the patient has

expertise in his or her body’s experience

of illness and response to treatment.9 We

can use this as an analogy for what we

want to achieve in the relationship

between education providers and those

developing new and innovative services,

such as the ICSs.

Now that the NHS Long Term Plan has

set strategy at a national level, the ICSs

will be tasked with the implementation at

a local level; by having regular

conversations to share expertise and plan

“. . . we identified that there was still a lack of awareness about howto use the knowledge and skills of the pharmacy workforce to best

effect in new and evolving roles, particularly in primary care.”



towards mutually agreed goals, we

should be able to achieve 'education

optimisation'. Timescales for responding

to workforce development tenders to get

pharmacy staff trained up and ready for

proposed new services are often short,

which highlights the importance of

strong ongoing partnerships between

ICSs and local education providers to be

able to quickly respond to invitations to

tender and optimise the educational

support offered to the workforce.

Working with the ICSs we can involve our

students in quality and service

improvement initiatives to provide

evidence for return on investment.

Ultimately, we need to evaluate the

impact of our education provision in

enabling students to take on new and

innovative roles, as well as researching

the impact of the pharmacists in these

roles.

We strongly believe that by

developing partnerships and employing a

concordant approach, ICSs and local

education providers can achieve

education optimisation for the local

workforce.


The authors have nothing to declare.

REFERENCES

1. Bower S. The Pharmacy Profession and Integrated Care Systems: Are YourSoft Skills Up To The Mark? Journal of Pharmacy Management.2018;34(4)138-140. Available from: https://www.pharman.co.uk/journals/the-journal-archive. [Accessed 22nd August 2019]

2. NHS England. The NHS Long Term Plan. 2019. Available from:https://www.england.nhs.uk/long-term-plan/. [Accessed 3rd July 2019]

3. NICE. Medicines optimisation: the safe and effective use of medicines toenable the best possible outcomes. 2015. Available from:https://www.nice.org.uk/guidance/ng5. [Accessed 28th August 2019]

4. Barr H, Freeth D, Hammick M, Koppel, Reeves S. Evaluations ofinterprofessional education: a United Kingdom review of health and socialcare.2000. London: CAIPE/BERA. Available from:https://www.caipe.org/resources/publications/barr-h-freethd-hammick-m-koppel-i-reeves-s-2000-evaluations-of-interprofessional-education. [Accessed28th August 2019]

5. Haidet P, Kubitz K, and McCormack WT. Analysis of the Team-Based LearningLiterature: TBL Comes of Age. J Excell Coll Teach. 2014;25(3-4)303–333.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4643940/.[Accessed 28th August 2019]

6. Martin SJ, Sowter J, Quinn G, Petty DP. Teaching cross-sector medicinesoptimisation to primary care pharmacists using an expert patient. PharmacyEducation. 2019;19(1)231-232. Pharmacy Education Conference -Manchester 2019. 52. Attended Electronic Poster Presentations.

7. Sowter J, Petty DP, Martin SJ, Quinn G. Using stakeholder engagement todevelop postgraduate taught programmes for primary care pharmacists.Pharmacy Education. 2019;19(1)232. Pharmacy Education Conference -Manchester 2019. 52. Attended Electronic Poster Presentations.

8. The King’s Fund. The NHS Long-Term Plan Explained.2019. Available from:https://www.kingsfund.org.uk/publications/nhs-long-term-plan-explained#implementation. [Accessed 21st August 2019]

9. NICE. Medicines adherence: involving patients in decisions about prescribedmedicines and supporting adherence. 2009. Available from:https://www.nice.org.uk/Guidance/CG76. [Accessed 22nd August 2019]

“. . . by having regular conversations to share expertise and plan

towards mutually agreed goals, we should be ableto achieve education optimisation.”

https://www.pharman.co.uk/journals/the-journal-archive



https://www.england.nhs.uk/long-term-plan/

https://www.nice.org.uk/guidance/ng5

https://www.caipe.org/resources/publications/barr-h-freethd-hammick-m-koppel-i-reeves-s-2000-evaluations-of-interprofessional-education




https://www.kingsfund.org.uk/publications/nhs-long-term-plan-explained#implementation



https://www.nice.org.uk/Guidance/CG76


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25

Question:

What is your job title?

Answer:

Neighbourhood Care Network (NCN)/

Primary Care Cluster Pharmacist,

Caerphilly East, Aneurin Bevan University

Health Board.

What are your main

responsibilities/duties?

The role aims to improve the safe,

effective and prudent use of medicines

across the whole of the NCN/Primary

Care Cluster, with the NCN/Primary Care

Cluster-wide remit looking to address the

challenges posed by the inverse care law,

which states that the availability of good

medical or social care tends to vary

inversely with the need of the population

served. The main duties of the role are to

deliver the NCN/Primary Care Cluster’s

priorities, which are developed according

to the individual needs of the local

population, and provide pharmaceutical

expertise/support within the NCN/Primary

Care Cluster. The specific duties vary

according to population need but can be

broken down into a number of broad

themes including:

• clinical patient facing activity e.g.

clinics within GP practices on key

priority disease states

• process/system redesign or

development e.g. repeat ordering/

dispensing processes

• population engagement/health

education programmes.

To whom do you report and where

does the post fit in the management

structure?

NCN/Primary Care Cluster Pharmacists

report directly to the NCN/Cluster Leads.

In my particular circumstances the NCN

Lead provides direct line management

and professional support is provided by

the Primary Care Medicines Management

team within Aneurin Bevan University

Health Board.

How was/is the post funded? Is the

post funded on a non-recurring or

recurring basis?

The Welsh Government has allocated

funding for NCNs/Primary Care Clusters,

termed Cluster Development Monies

(CDM), for which funding for this post

has been obtained. The Cabinet

Secretary’s written evidence has

confirmed that this funding is recurrent

and will continue to support primary care

services in Wales.

When was the post first established?

The Welsh Government set out the

concept of primary care services being

co-ordinated on a ‘locality basis’ in its

primary and community services strategic

delivery programme termed ‘Setting

the Direction’ in 2010. It recognised the

fact that the vast majority of health and

care needs are met in local communities

by primary care and community services

and that patients want care to be local,

convenient and of consistently high

quality. The General Practitioners

Committee of BMA Wales agreed a

new contract deal with the Welsh

Government, effective April 2014, which

embedded this concept and resulted in

NCNs/Primary Care Clusters being

established.

Wales is split into 64 NCNs/Primary

Care Clusters, serving populations of

between 30,000 and 60,000 patients.

The geographical area that an

NCN/Primary Care Cluster covers is

determined by individual local Health

Boards. The intention is that

NCNs/Primary Care Clusters are used as

local planning mechanisms that promote

FACE2FACEPrimary Care Cluster PharmacistLloyd Hambridge, Neighbourhood Care Network (NCN)/Primary Care Cluster Pharmacist, Caerphilly East,

Aneurin Bevan University Health Board.


Lloyd Hambridge

“. . . the vast majority of health and care needs are met in localcommunities by primary care and community services . . .”




collaborative working across GP

practices, pharmacies, dental practices

and optometrists and also promote the

integration of primary care services with

key partners such as the Ambulance

Trust, Local Authority and Third Sector.

They provide a key role in supporting

local health needs assessments, allocating

appropriate resources and forecasting the

potential future demand on primary care.

The introduction of the NCN/Primary

Care Cluster Pharmacist role commenced

in 2015 following key policy drivers from

Welsh Government that built on ‘Setting

the Direction’ including ‘Together for

Health: five-year vision for the NHS in

Wales’, ‘Prudent Healthcare Principles’

and the ‘Plan for a Primary Care Service

for Wales up to March 2018’. These

documents clearly set out the intention to

see more pharmacists working in clinical

roles in general practice. This view was

driven further by a joint policy statement

by the Royal College of General

Practitioners and the Royal

Pharmaceutical Society that highlighted

the need for increased collaboration

between GPs and pharmacists to improve

the safe, effective and prudent use of

medicines in Wales.

Are you the first post holder? If not,

how long have you been in post?

I am the first post holder for Caerphilly

East NCN/Primary Care Cluster and was in

the first cohort of pharmacists across

Wales to start within this role during its

inception in 2015.

What have been the main difficulties

in establishing/developing the post

to its current level?

The main difficulties in establishing the

post to the current level have been

around the population size of the

NCN/Primary Care Cluster and the

number of partner organisations

encompassed within the NCN/Primary

Care Cluster. The Caerphilly East NCN has

a population nearing 60,000 patients,

with seven GP surgeries and several other

organisations making up the NCN. This

posed challenges around covering these

surgeries and the workload demand for

one pharmacist. The positive outcomes in

quality, safety, and consistency of patient

care as well as the improved access to

primary care services that was

demonstrated from role early on resulted

in further investment by the NCN into

pharmacist resource and, currently, two

pharmacists work within this role.

What have been the main

achievements/successes of the post?

The outcomes of the role have been

continually evaluated and reported to

Welsh Government since its inception

with clear benefits being seen with

quality, safety and consistency of patient

care, improved access to primary care

services and improved working experience

of primary care workforce as a result of

reduced workload demands.

Specifically, quality improvement work

was undertaken to improve patient safety

through undertaking an NCN wide

project to increase the reporting of

adverse drug reactions within the NCN

using the Yellow Card Scheme. The

Caerphilly East NCN had only reported

three incidents of adverse drug reactions

in 2015-16 and, following the completion

of the project, there was an 86% increase

in the number of reports in 2016-17 to

58 reports. This work was recognised in

the Royal Pharmaceutical Society Patient

Safety Conference, with the project

winning the patient safety award.

iStock.com/Hilch


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27

What are the main challenges/

priorities for future development

within the post which you currently

face?

The main challenges within the role are

around the management of workload

demands and the risk of ‘burnout’. This

risk was identified through work that was

undertaken by myself as part of a Masters

research project with Cardiff University

evaluating the role of NCN/Primary Care

Cluster Pharmacists across Wales. The

qualitative results of the project

highlighted that the ‘burnout’ risk that

has been evident with GPs for a number

of years was becoming a risk for

NCN/Primary Care Cluster Pharmacists.

The introduction of more pharmacists

into this role and other members of the

pharmacy team (e.g. pharmacy

technicians) is a big priority to help ensure

this risk is addressed.

What are the key competencies

required to do the post and what

options are available for training?

There are a number of key competencies

that are required for this role which

include:

• having an in depth understanding of

the primary care system

• excellent communication skills at a

number of levels including with

patients, clinicians and management

• experience of working within multi-

disciplinary teams

• up-to-date clinical skills and

knowledge. Pharmacists within this

role would typically have completed a

post-graduate diploma in

therapeutics and have completed a

non-medical prescribing training

programme.

A ‘Pharmacists in Practice Community

of Practice’ (PIPCOP) has been developed

within Wales that allows pharmacists to

share best practice and training as well as

educational support is provided through

both Health Education and Improvement

Wales (HEIW) and the NCN/Primary Care

Cluster Pharmacists local Health Board.

How does the post fit with general

career development opportunities

within the profession?

The role provides excellent opportunities

for all pharmacy professionals. In line with

the RPS roadmap for pharmacists the post

offers the opportunity for foundation

pharmacists to obtain experience and

develop skills within primary care setting

as well as opportunities for pharmacists to

become advanced within specific clinical

areas and service provision. The multi-

disciplinary nature of the role provides

further career development opportunities,

and this has provided opportunities for

pharmacy technicians also to develop

further patient focused skills and clinical

knowledge. The posts have provided

opportunities for pharmacists and

pharmacy technicians. Many have

changed roles to work directly for GP

surgeries, as partners within surgeries, as

NCN/Primary Care Cluster Leads or to

work for partner organisations that form

the NCN/Primary Care Cluster.

What messages would you give to

others who might be establishing/

developing a similar post?

Stakeholder engagement is key for the

success of a new post in an emerging area

such as described for this post.

Stakeholders need to fully understand the

role, the potential benefits and their own

requirements for the post to ensure they

are supportive and as a result that the role

will be accepted. Evaluation of the role is

vital to ensure the impact and outcomes

are seen as well as any issues are identified

which can as a result be addressed to

ensure the success of the post.

Do you have any Declarations of

Interest to make and, if so, what are

they?

No declarations of interests.

“Stakeholders need to fully understand the role, the potentialbenefits and their own requirements for the post . . .”




“It used to be so much more straightforward when we

set out on our career,” said Janet Donit, Chief Pharmacist

at Metropolis NHS Trust.

“Indeed,” replied Carey Whitecoat, Head of Medicines

Optimisation at Riverdale Primary Care Organisation.

“There was the hospital service, Community Pharmacy

or, for some, the pharmaceutical industry. The newly

qualifieds of today are spoiled for choice!”

“That’s just the problem”, said Janet. “One of my pre-reg

students asked me for some advice and I wasn’t sure

what to tell them. In a nutshell, she wanted to know

whether she should stay in the hospital service after her

training and perhaps develop as a specialist later on, go

into Community Pharmacy where new services seemed

to be developing all the time, work in a GP practice or

think of one of the new jobs in a Primary Care network!

Fortunately, we were interrupted so that has given me

some time before I resume our chat.”

“Wow,” exclaimed Carey. “I’m not sure I could be crystal

clear on the best way forward. I’d want to know a bit

about whether I would be employed in the NHS or some

other body and how my training and development

would unfurl. Even if you could be fairly clear about

things as they stand, you always need to bear in mind

that things can change. Just look at what we have seen.

Who would have imagined that pharmacists would be

prescribing and running patient-facing clinics when we

set out!”

“Would you mind if we used our coffee break to mull

this over so I can at least get a few points to get across

to my pre-reg?”

“Sounds OK to me. You find a seat and I’ll get the

coffees.”

What sort of comments do you think that Carey and Janet might come up with to

help the pre-registration pharmacy graduate clarify their next step?

Anthony Young, LeadPharmacist – Researchand WorkforceDevelopment,Northumberland Tyneand Wear NHS

Foundation Trust. Correspondence to:[email protected]

This is becoming more of a common issue

in practice these days as the choice of

sectors is growing, as detailed in the

conversation thread above. I think the

best advice to get across is that a

career in pharmacy is one that lasts for

many years so a decision made now

should not lock that individual into a

certain sector for ever! In my career thus

far I have come across many excellent

pharmacists who have worked across

multiple sectors and in some cases this

has made them a much more rounded

and effective pharmacist. Traditionally,

hospital pharmacy has focussed on

and delivered clinical training and

prescribing but other sectors are now

doing this also. This has partly been

brought about by the new NHS priorities

for Primary Care Networks (PCNs) and

Community Pharmacy so that clear

divide is becoming less so.

This seems a perfect opportunity for

Janet and Carey to discuss how they can

use their influence within the system

locally to think about the workforce in a

collaborative and innovative way. Could

they develop joint/shared posts to allow

this individual to work across sectors

simultaneously? Could they look to start

a conversation with Health Education

England (HEE) to consider whether

Foundation posts for all pharmacists

could be centrally funded, recruited to

and managed so that individual

employers have staff for rotations, similar

to medical training? This would give the

early year pharmacists time to understand

Commentaries



www.pharman.co.uk

29

each sector and decide what suits them

best and what they enjoy.

However, at the moment it still comes

down to the individual to decide where

they want to practice next. If I was Janet

I would also put the pre-reg in touch with

colleagues in other sectors so that the

pre-reg had an opportunity to see the

sector (usually incorporated into pre-reg

programmes) and also to discuss the roles

so they could make an educated choice.

Rena Amin, Joint

Assistant Director

Medicine Management,

NHS Greenwich

Clinical Commissioning

Group, London

Correspondence to:

[email protected]

The pharmacy profession has now

demonstrated that it is a workforce to be

reckoned with!

As a profession, positive impact on

patient care has been shown via working

more collaboratively as substantive

members of multi-disciplinary teams, by

improving clinical outcomes for patients

and by demonstrating value by various

initiatives. Programmes such as clinical

pharmacists in general practice, medicines

optimisation in care home, emergency

care, a variety of clinical services offered

via community pharmacies and hospital

services ranging from specialist to

consultant pharmacist offer a suite of

choices for the pre-registration graduate.

“This seems a perfect opportunity for Janet and Carey to

discuss how they can use their influence within the

system locally to think about the workforce in a

collaborative and innovative way.”

iStock.com/Mykyta Dolmatov

A decision made now should not lock that individual into a certain sector -

pharmacists can work across multiple sectors.




iStock.com/ EtiAmmos

Pre-registration pharmacy graduates

need to be assured that the future is

bright for the profession. The expanding

roles provide a plethora of options

depending on their interest, including an

opportunity to plan a more portfolio

based career akin to other healthcare

professionals in the NHS. The pre-

registration pharmacist should be

signposted to the Interim NHS People

Plan (June 2019),1 which sets out to

develop collaborative plans in liaison with

national leaders and partners to enable a

culture shift in how the NHS starts to

maximise the skills of various professional

to improve health outcomes. The NHS

needs the right staff with the right

competencies to meet future health

demands and pharmacists will be vital

to deliver this vision. The pharmacy

profession will spearhead programmes on

medicines safety, medicines optimisation,

reduction in wastage and promoting

self-care. It will be the pre-registration

trainees, if nurtured and supported, who

will provide sustainability and consistency

in the workforce capacity. Health

Education England (HEE) has also

reviewed education and training needs as

part of the Interim NHS People Plan.

These pre-registration trainees are in a

dynamic milieu and the onus is on them

to maximise their development. With

plans to introduce cross- sector pre-

registration and post graduate training,

the future pharmacy workforce is well

placed to harness these opportunities

and seek roles and jobs that really

interests them. Passionate and motivated

staff always improve productivity and

those qualities may also support their

career development. Additionally, high

quality foundation programmes for all

newly registered pharmacist will be

another training conduit that will help

these trainees to circumnavigate their

future roles whilst establishing their

credibility and enhancing their

competencies.

In a nutshell, both trainees and their

trainers have to be fully on-board with

the new roles established and

development of national educational and

training strategies to support their

development.

REFERENCES

1. NHS Employers. NHS Interim People Plan. June2019. Interim People Plan for the NHS. Availableat: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf


l The Commentators, who are

members of the Editorial Board for

Pharmacy Management, have been

offered a personal payment to write

the commentary.

“Pre-registration pharmacy graduates need to be assuredthat the future is bright for the profession.”

https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf





www.pharman.co.uk

31

In the time management workshops that

I run, leaders are often keen to find out

from each other how to manage their

email workload more effectively. They

point out that email is a tool to help you

do your work, and not the work itself.

Some leaders have brilliant and capable

administrative support that can handle all

of this, but most of us have to manage

our own emails. Do you feel at the mercy

of your emails, or are you an email

champion?

How can you become an

email champion?

The first step is to get yourself organised

and decide what you need and want

from your email management. Perversely,

this may feel like it takes more time when

you start, but it will save you time and

your team’s time in the long run.

To assist in my email management, Iresorted to my previous militaryexperience. In the RAF, I was taughtabout ‘service writing’ protocols at avery early stage in my career and I havefound the main principles of servicewriting very helpful throughout mycareer. The principles are:

1. Accuracy

2. Brevity

3. Clarity

4. Logic

5. Relevance

In all service correspondence, it is alsomade clear whether this is for ‘Action’ or‘Information’- a habit I continue today inemail headers when organising trainingprogrammes and events. These sameprinciples have been extremely helpful inmy email management.

Practical leadership tips

Handle emails once a day

Dipping into your inbox as emails arrive is

very tempting. You might be waiting for

some key information or expecting

somebody to have already replied to the

email you sent 10 minutes ago. Take a

quick ‘sense check’ to make sure it’s

nothing urgent, then only fully process

them at the beginning or end of the day.

Set aside a daily time slot and, if you

don’t finish, continue the next day.

Leaders I have talked to about email

management tell me that they ‘work late,

early’ – getting into work an hour before

everyone else to get on top of emails

before the day starts, but then leaving on

time so they can be with their family or

friends.

Prioritise as a Leader – email triage tipsBy Hilary Shields JP, Director of Ascensys Ltd.

Hilary's early career was in the Royal Air Force where she was commissioned as an Officer in the PersonnelBranch. These early leadership skills, earned in some very testing situations, have been an excellent base forthe career roles that followed.

With over 23 years of experience of the NHS and the Pharmaceutical Industry, Hilary regularly facilitatesgroups of Key Opinion Leaders (KOLs) and Multi-Disciplinary Teams (MDTs) in the NHS. She is also ABPIqualified, so understands the ethical requirements of the NHS and training delivery.

She has researched, developed and delivered training to a wide variety of organisations and individuals within the NHS, includingBoard Members of NHS Trusts. In July 2005, Hilary was appointed a Justice of the Peace for England and Wales and now sits as aPresiding Justice in the adult courts. This is an entirely voluntary role which is undertaken in addition to her training work.

For relaxation, Hilary is a keen gardener and enjoys baking.

Hilary Shields

LEADERSHIP

“In all service correspondence, it is also made clear whether this is for ‘Action’ or ‘Information’ . . .”



Focus on the 20% of emails that

matter – the Pareto 80/20 Principle

The Italian economist, Vilfredo Pareto

discovered in 1894 that 80% of the

wealth was owned by 20% of the

population. This 80/20 rule states that

80% of consequences come from 20%

of causes. In a sales environment, 80% of

sales come from 20% of the customers. If

we analyse our work, we may find that

80% of the work comes from 20% of the

patients. This principle applies to your

emails too – not all of your emails are the

same and you should focus on the 20%

of ‘high value’ emails that lead to

maximum output. What is a ‘high value’

email?

My ‘high value’ emails are the ones

that help me with my business or

personal goals. My 20% ‘high value’

emails include coaching clients, business

leads and correspondence with family

and friends. Everything else falls into the

80% bracket.

For the 20% emails I usually reply to

them immediately and certainly within 1-

2 days. For the 80% emails, I take a

longer time to reply, sometimes not even

replying at all. In the past I have spent

endless hours replying in depth to queries

and questions from some senders and

have not received any acknowledgement

or feedback that the extra information

was helpful. They lead busy lives, but so

do you.

I created a ‘REPLY BY…’ folder and file

emails that need a reply into this folder. I

set aside three days every week to reply

to emails – some weeks are different to

others because of work commitments,

but I aim for Monday, Wednesday and

Friday. That way I don’t feel pressured to

respond immediately and have time to

think it over before it’s time to reply.

You don’t need to reply to every

email

Shock! Horror! You don’t need to reply to

every email despite the temptation to do

so. We’re focussing on the 80% of emails

that fall into that ‘other’ category.

Leaders realise that it’s a lot more

effective to use your time on high value

tasks. They don’t worry too much about

replying to every single email. Reply if it

helps but, if the costs of replying are

greater than the benefits, perhaps it’s not

worth worrying about.

Structure emails into categories

Folders are there to help you organise

your time and emails. I subscribe to lots

of blogs and leadership updates. All of

these are sent straight into folders called

‘New Training Ideas‘ and ‘NHS Updates’. I

only read these folders when I want more

information on a topic. I also have what I

call main folders – for example, one

labelled ‘Accounts’ which then has sub

folders for ‘Expenses’, ‘VAT’, ‘Back-Up

Files’ and so on. I also have a ‘Follow Up’

folder in which I place emails from clients

who have changed jobs or moved to a

new company. This helps me to focus on

my 20% rule, which is to keep in touch

with business clients.

Use the ‘One Minute’ rule when

replying

If it only takes a minute to reply – do so

immediately and then file the email into

the appropriate folder. That will stop you

from allowing the email and its content

to block your leadership thought

processes. It is possible to clear out a lot

of emails in a short amount of time.

Do an audit of your inbox time

The next time you check your email

inbox, see how long it takes and time

yourself. How long does it take to absorb,

iStock.com/Alexey Bedrodny


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33

consider, read and reply to your emails?

Then do the 80/20 check – how much of

this was actually productive?

How to handle longemails – ACTION orINFORMATION?

What to do with long emails? Sometimes

an email can look like a series of journal

entries. Don’t reply in kind – follow the

one-minute rule above. If you do need to

respond, keep it brief. Is the email for

ACTION or INFORMATION? If it’s for

action, then use the rules above to deal

with it. If it’s for information, then file it in

the relevant folder.

When you are working with your team,

here’s what you can do as a leader to

improve this situation for everybody:

• Establish a new protocol with your

team for including ACTION or

INFORMATION in the email header

• Meet or phone individuals or team

members to discuss matters, rather

than engage in lengthy emails.

Then confirm action points in a

brief email.

Have an ‘Unsubscribathon’

During the course of a busy working

week I will have ordered things online,

subscribed to newsletters and had

another email from the gym to tell me

that there is a new Pilates teacher who

can stand on her head. I also don’t want

a Groupon voucher for £10 off a racing

car experience (how do they get this

stuff?).

Once a month, I have an

‘unsubscribathon’ to clear out the junk

mail that lands in my inbox and takes up

my time.

In summary, here are the top tips

for successful and efficient email

management:

1. Handle emails once a day

2. Focus on the 20% of emails that

matter

3. You don’t need to reply to every email

4. Structure emails into categories

5. Use the one-minute rule when

replying

6. Do an audit of your inbox time

7. How to handle long emails

8. Have an ‘unsubscribathon’

Emails are a necessary tool of

leadership, which should work for you,

rather than against you. If these

suggested changes seem overwhelming,

then pick one you prefer and make a

start. Good leaders make decisions and

take action.

“Emails are a necessary tool of leadership, which should work for you, rather than against you.”

iStock.com/frender



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35



www.pharman.co.uk

EDITORIAL BOARD FOR THE JOURNAL OF PHARMACY MANAGEMENT (JoPM)

Sarah Crotty Head of Pharmacy & MedicinesOptimisation, Herts Valleys ClinicalCommissioning [email protected]

Luke Groves Chief Pharmacist, Solent NHS Trust(Community & Mental Health) [email protected]

Gurpreet Virdi Pharmacy Lead South East (KentSurrey & Sussex), SpecialisedCommissioning,NHS England- South (South East) [email protected]

Jas Khambh Clinical Director and Chief Pharmacistat NHS London ProcurementPartnership (LPP)[email protected]

David Mehdizadeh Practice Pharmacist, The MayflowerMedical Practice, [email protected]

Darshan Negandhi Pharmacist Proprietor/TeacherPractitioner/Preregistration Trainer/CPPE Tutor, [email protected]

Anthony Young Lead Pharmacist – Research andWorkforce Development,Northumberland Tyne and Wear NHSFoundation Trust [email protected]

SCOTLANDChristine Gilmour Director of Pharmacy, NHS Lanarkshirechristinegilmour746@ btinternet.com

Sharon Pfleger Consultant in Pharmaceutical PublicHealth, NHS [email protected]

EditorAlex Bower Director of Publishing, Pharmacy Management [email protected]

ENGLANDRena Amin Joint Assistant Director MedicineManagement, NHS Greenwich ClinicalCommissioning Group, [email protected]

Graham Brack Head of Communications andIntegration, Pharmacy [email protected]

Campbell Shimmins Community Pharmacist, Owner,Practitioner [email protected]

David Thomson Lead Pharmacist, CommunityPharmacy Development &Governance, NHS Greater Glasgowand [email protected]

NORTHERN IRELANDLindsay Gracey Community [email protected]

Dr Ruth Miller Medicines Optimisation Project Lead,Department of Health, Northern [email protected]

Professor Michael ScottHead of Pharmacy and Medicines Management,Northern Health and Social Care [email protected]

WALESJohn Terry Head of Pharmacy,Neath Port Talbot [email protected]

Judith VincentClinical Director, Pharmacy andMedicines Management, AbertaweBro Morgannwg University HealthBoard. [email protected]

Roger WilliamsHead of Pharmacy Acute Services,Abertawe Bro Morgannwg UniversityHealth [email protected]

Membership of the Editorial Board is an honorary appointment but a personal fee is offered for writing a Management Conundrum commentary,which is then declared in the journal, or for conducting peer review.





















Published by Pharman Limited

PO Box 2378, 39 Ridgeway Road, Salisbury, SP2 2PH

Tel: 01371 874478 Homepage: www.pharman.co.uk Email: [email protected]

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