SECTION 1: INTRODUCTION
1. 0. Background
The role of pharmacists has evolved continuously through time. This can be traced back to the pre-NHS era(1948), when visits to a doctor were very expensive for patients, thus making the pharmacists the first point of call for most patients in need of healthcare advice and treatment (RPSGB, 2008a). Consequently, pharmacists spent most of their time preparing a wide range of products from raw ingredients, leaving very little time to spend with patient for the briefest of clinical assessments. With the introduction of the NHS, visits to the doctors (termed GPs) became much cheaper, and the responsibility for clinical assessment of patients shifted wholly to the GPs.
The move of medical assessment services wholly to GPs came at a price, which was an increasing pressure on GPs that could hardly be met, thus reducing the quality of health service provided to patients. To address this issue, all health professionals are currently involved in sharing responsibilities to provide safer and better health care (RPSGB, 2008b). Amongst these health professionals, pharmacists are in the most suitable position to reduce the pressure on GP’s by providing appropriate health services that go beyond the traditional pharmaceutical dispensing service. In recognition of this fact, the role of the pharmacist in all sectors has constantly expanded since 1948.
This development has seen pharmacists taking more clinical roles at the front-line of public healthcare, instead of keeping themselves in the dispensary mixing medicines. It is in recognition of this trend that Steve Churton, president of pharmacist society, noted that:
“ The profession is unrecognisable from 60 years ago and continues to experience a phase of profound change and development. The opportunities open to the profession are far-reaching and pharmacists are being increasingly recognised for their clinical skill and the contribution they makes to the national’s health” (RPSGB, 2008c).
It can be argued that various factors account for the current face of Pharmacy practice, however the singular most powerful forces have been the deliberate policies put in place to guide the expanded role of pharmacist in the delivery of efficient health care services. These are majorly the previous contract dating back to 1987 and the new contract introduced in 2005 which culminated in the Pharmacy White Paper of 2008 (PSNC, 2009a). These contracts are further discussed in the section on literature review; what is worth mentioning here is that of these policies, the White Paper of 2008 sets out the most ambitious role for pharmacists to rise up to. At the time of its publication, the then chief pharmaceutical officer for England, Keith Ridge, described it as being about ‘ ambition, consolidation, and leadership’ (PJ, 2007).
The White Paper sets out a vision for building on the strengths of pharmacy. It outlines the use of the capacity and capabilities of pharmacists to deliver further improvements in pharmaceutical services over the coming years as part of an overall strategy to ensure safer, more effective, fairer and more personalised patient care. A further key initiative of the paper is to make health services more accessible and help reduce health inequalities (DoH 2008)
The aspirations of the paper called for a major shift in pharmaceutical culture which will see more community pharmacists offer advanced service to enhance their clinical roles (Goundery-Smith, 2008). The key advanced services identified by the paper are Medicine Use Review (MUR) and Prescription Intervention Service (PSNC, 2009c). Besides the advanced services, the paper also outlines essential and enhanced services to be offered by community pharmacist, these are further discussed in the section on literature review.
In as much as these objectives are very laudable, they brought to the fore the need to scrutinise the capability of community pharmacist to effectively carry out this functions. There was also the question of community pharmacist not being at same skill level with their clinical colleagues. This led the paper to call for accreditation of both the pharmacist and the premise from which advanced services are offered (RPSGB, 2008c), thus constituting the first time such accreditation and specified skill set was required from pharmacist (Alexander, 2006).
The fallout of the above mandate for accreditation and specific skill set required by pharmacists intending to offer advanced service was the need to indentify the authority or professional body to offer the accreditation, the training needed by pharmacists, the institutions to provide such training, the content of such trainings and the assessment of the efficiency of the training provided in meeting the goals (RPSGB, 2008c).
It is against this backdrop that this study sets out to investigate the educational needs of community pharmacists to deliver the aspirations set out by the White Paper. The study concentrates on MUR as a pointer to the overall picture for achieving the provision of advanced services in the new contract. It investigates what MUR services are available to patients, the training received to get accreditation, the adequacy of such training received and the quality of services provided to patients.
Section one of this work presents a review of the previous contract in comparison to new contract; the aspirations of the White Paper are discussed, the skill gap between community and clinical pharmacists is highlighted, MUR is discussed in detail, highlighting its benefits, set targets and the challenges to meet these targets. Section two dwells on the methods applied for the study, the results are presented in section three, while section four discusses them and section gives the conclusion drawn from the findings of the study.
1. 1 The Pharmacy Contracts
It has already been mentioned that the pharmacy profession is going through a rapid phase of change that has seen its image transformed immensely from what it was twenty years ago. This change will be discussed in terms of the previous contract and the new contract which define the scope of the pharmacy practice.
1. 1. 1 Previous Contract
The previous contract dated back to 1987 and was focused on the throughput of a high volume of prescriptions (PSNC, 2009a). Bellingham (2004) summarised the key points of the contact as:
- The service was highly focused on dispensing. The volume and throughput of prescription were emphasised, rather than the quality and accessibility of service.
- All pharmacies were treated as the same irrespective of the range and quality of services that they offered.
- A perception that dispensing as many prescriptions as possible was a hallmark of a successful community pharmacy was reinforced, and did not support pharmacists’ role in reducing the number of unnecessary prescriptions.
The clinical importance of patient’s pharmaceutical service was largely ignored in this contract. This shortfall led to the development of a new contract in which the Department of Health (DOH) shifted focus to an integrated role of community pharmacist within the NHS. The new contract shifted priority to the provision of better, safer and cost effective pharmaceutical services to the public.
1. 1. 2 The New Pharmacy Contract: Promoting Safe, Better and Effective Service
The new community pharmacy contract was introduced by the Department of Health (DoH) and agreed by the Pharmaceutical Services Negotiating Committee (PSNC) and the NHS Confederation (NHS Employers) (PSNC, 2009a). It was accepted by pharmacy contractors in different ballots and came into force in April 2005 (PSNC, 2009a). The new contract differed from the previous contract, as its aim was shifted to the provision of a wider range of more clinical services, as well as driving the focus of the profession to clinical service from dispensing. It recognises pharmacy as an integral part of NHS, thus utilising skills and knowledge of pharmacists. There are three tiers in the new pharmacy contract – essential services, advanced services, and enhanced services. Each of these is further discussed below:
- Essential Services:
All pharmacy contractors must provide the seven services mentioned under this tier. The services are: dispensing medicines, repeat dispensing, waste management, public health, signposting, support for self care, and clinical governance (PSNC, 2009b). These are nationally agreed services and are not open to local arrangement.
- Advanced Services:
Contractors can offer one service under the new arrangement in this tier. Both pharmacist and pharmacy premises need accreditation to provide a Medicine Use Review (MUR) and Prescription Intervention Service as advanced services (PSNC, 2009c). This service is nationally specified.
- Enhanced Services:
Enhanced services are from the third tier of services in the contractual framework, and are commissioned and funded by Local Health Boards (PSNC, 2009d). The requirements for these services are currently set out in “ The Pharmaceutical Services (Advanced and Enhanced Services) Directions 2005” (PSNC, 2009d). Contractors and Local Pharmaceutical Committee (LPC) negotiate to provide services in accordance with these specifications where a local need for the service is determined.
1. 2 Aspirations set-up by the Pharmacy White Paper 2008
Pharmacists are a vastly underused resource, even with the new contract introduced. The DOH published the White Paper ‘ Pharmacy in England – Building on Strengths, ‘ Delivering the Future’ on April 2008, in which it offers many proposals to expand the role of community pharmacy. Some of these roles are discussed below:
1. 2. 1 Promoting better Sexual Health
The treatment of damaged reproductive organs due to untreated infections caused by unprotected sex is costing the NHS a lot of money. Chlamydia is one of the most common sexually transmitted infections in the young population (Department of Health, 2008). Pharmacists are raising awareness of Chlamydia, HIV and other STDs by helping the National Chlamydia Screening Programme. The burden of STDs such as Chlamydia can be easily reduced by pharmacists, who serve as the main point of call for using the non-invasive test kit (DOH, 2008). Pharmacists can also contribute their expertise to reducing unintended pregnancy, especially in teenagers by providing contraceptives support and advice (Department of Health, 2008). EHC is most effective if used during
the first 72 hours after unprotected sex, but getting a doctor’s appointment or finding a convenient family planning clinic surgery time was often a barrier to women getting the help they needed to avoid a termination. Pharmacies are the ideal places to offer this service as not only is they in the fortunate position of
having a healthcare professional on hand at all times, they are open evenings and weekends with no appointment needed. (Ref: http://www. rpsgb. org. uk/pdfs/pharmcasestudyeht. pdf).
1. 2. 2 Promoting Healthy Living
Obesity is a growing issue in the UK population as it increases the risks of life threatening conditions like heart disease, cancer, diabetes etc. Given that the public value community pharmacists as local leaders in health matters (Department of Health, 2008), pharmacists can contribute to improve individual BMI scores by operating weight management clinics in pharmacies and prescribing weight reduction medicines, which all have the potential to improve overall health.
1. 2. 3 Smoking Cessation
Smoking causes 87, 000 premature deaths each year in England (Department of Health, 2008) and still remains the principal avoidable cause of premature death and ill health today. More people are thus quitting smoking with NHS support. In this vein, opportunistic and brief advice/interventions from pharmacists have been helping smokers to quit easily and successfully (DoH, 2008).
1. 2. 4 Support for Alcohol Abusers
Excessive alcohol consumption can cause life threatening and life-long problems such as liver cirrhosis and alcohol abuse is causing more premature death than breast cancer, cervical cancer and MRSA infection combined (DOH, 2008). Pharmacists can reduce alcohol related health burden by promoting healthy life advice aimed at raising awareness of the effects of excess alcohol.
1. 2. 5 Helping aging population and MUR (medicine use review)
MURs help to improve patients’ medicine use knowledge, reduce medicine wastage, improve patient’s health and reduce unnecessary hospital admissions (DoH, 2008). An MUR is the best way that pharmacists can have one-to-one conversation with patient. It enables pharmacists to identify problems patients are experiencing regarding their medication. If necessary pharmacists can make recommendations to patients, helping them to get more benefits from their medication. They can also make recommendations to the patient’s prescriber to change medication.
By February 2008, pharmacists conducted 1. 25 million MURs, which cost NHS £30million (DoH, 2008). The impact of MURs on improved compliance with prescribe medicines is not assessed. According to the white paper (DoH, 2008) the government wants PCTs to prioritise MURs to meet their health improvement targets and to make the service more effective. The number of long-term condition (LTC) sufferers is increasing as proportion of elderly is increasing. By age 60, over half the population have at least one LTC (DoH, 2008). A high number of hospital admissions result from people not taking medicine as intended, and this most true for elderly people (DoH, 2008). To check this trend, pharmacists can provide support for staying healthy and healthy lifestyle advice as part of NHS team. The most valuable advice in this area is by carrying out targeted and appropriate MURs which will make NHS service more cost effective.
1. 3 Education and Training available to Pharmacists.
Different higher education institutions and professional development organisations have developed postgraduate programmes to support pharmacists to be up-to-date with necessary skills and training to enable them provide pharmaceutical services competently. Medway School of Pharmacy already provides a range of training for primary care pharmacists, including a Postgraduate Certificate and Diploma in General Pharmacy Practice (PgCert/DipGPP) which is a two year part-time programme. The (PgCert/DipGPP) programme at Medway School of Pharmacy is designed to equip general level pharmacy practitioners with the core skills and competencies they require to provide a holistic pharmaceutical care in practice setting. Several of the postgraduate programmes are briefly discussed below:
1. 3. 1 The STEP Scheme
The STEP (Structured Training and Experience for Pharmacist) was initially introduced to solve severe problems with recruiting and retaining junior pharmacists in South East London (DOH, 2001). The programme recruits basic grade pharmacists for a 3-year structured rotation (Andalo, 2002). It offers a wider range of training than the usual hospital basic grade rotation to newly qualified pharmacists. Trainees can develop skills from different areas of practice without changing employer each time. Entrants into the programme from other sectors can have their previous experience taken into account, and may not have to go through the full foundation training programme (Andalo, 2002). STEP pharmacists are employed by one of the four participating hospital trusts. The pharmacists can be attached to a clinical team in general medicine, diabetes or cardiology. A summary of the STEP programme (DoH, 2001) is given below:
- It is a three-year programme.
- Option opens to both junior and more experienced pharmacists.
- Placement available across 15 different trusts, including 6 PCTs and two mental health trusts.
- One of the four trusts employs pharmacists for three years regardless of where elective placements are based.
- First year foundation in standard hospital pharmacy at employing trust.
- Six-month clinical and patient-centred elective at employing trust.
- Three six-month placements at any trust within the district.
- Placements fill pharmacy vacancies where appropriate.
The STEP programme helped hospitals to solve issues regarding lack of skills in junior pharmacists. A modified programme, which may be similar to STEP, could be developed for community to increase clinical skills of community pharmacists.
1. 3. 2 The Continuing Professional Development Portfolio
The Continuing Professional Development (CPD) scheme is aimed at developing the concept of lifelong learning and of using that learning for continuous professional development. It is expected to show changes in the profession of pharmacy and methods of working in health care provision. According to the RPSGB (2009), the portfolio will enable pharmacists to:
- Identify present knowledge and skills and also the knowledge and skills which is necessary to develop;
- Recognise workplace training;
- Record and plan their professional development;
- Set up professional aspirations;
- Develop analytical and evaluative practice skills; and
- Gain the maximum benefit from their training and education.
Presently, CPD is a mandatory requirement for practising pharmacists. It is helping pharmacists to identify and develop their skills to provide safer and better NHS services.
1. 3. 3 CPPE (Centre for Pharmacy Postgraduate Education)
The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the Department of Health to provide continuing education for registered, practising pharmacists and pharmacy technicians providing NHS services in all sectors of practice, including community, hospital, prison and primary care pharmacies in England (CPPE, 2009). Its mission statement in 2006 is stated as “ Provider of educational solutions for NHS pharmacy workforce across England to maximise their contribution to patient care.” It is mainly based at The University of Manchester but provides support by local tutor networks. Besides supporting professional CPD needs, CPPE helps pharmacists and pharmacy technicians to embrace service re-design and modernisation in NHS services (CPPE, 2009).
1. 3. 4 Reading University’s Certificate in Competence in MUR (MUR Assessment only)
The University of Reading’s School of Pharmacy plays host to The Centre for Inter-Professional Postgraduate Education and Training (CIPPET) which supports the achievement of an objective of the Department of Health in training the pharmaceutical workforce to attain flexible and appropriate skills that will enable them cope with the ever-changing services offered by pharmacists both in the hospital and in the community (CIPPET, 2009; DoH, 2002). Within the CIPPET, the University offers the Certificate of Competence in Medicines Use Review (MUR) which is an assessment only process for pharmacists to get accredited to offer MUR services.
The accreditation process, which was setup in conjunction with the NPA, involves the submission of a portfolio of evidence to demonstrate all the competencies the DoH health guide. The University’s official website state that:
The portfolio comprises:
- Response to one case study – answers to all questions and a completed NHS MUR form
- A minimum of two MURs with reflective reports and anonymous supporting evidence e. g. a copy of the patient’s prescription or PMR (University of Reading, 2009).
It is worth noting that although the accreditation was established in conjunction with the NPA, pharmacists are not required to be members of the NPA in order to get accredited, however, they must be registered pharmacist before certification can be handed over to them.
1. 3. 5 Medway School of Pharmacy’s Skills for the Future (MUR Teaching and Assessment).
This PSNC endorsed course, which has been renamed – Skills for MUR, offers a comprehensive package that combines an online assessment module with a series of learning materials (PSNC, 2009f). It is a distance learning course offered by the Medway School of Pharmacy in conjunction with Chemist+Druggist and benefits from educational grant by GSK plus. The Skills for the Future course has been running since 2004 accrediting over 12, 000 community pharmacists to provide MUR services to date (PSNC, op cit.).
The course materials provided for training include the MUR Handbook which details the requirements and procedures for MUR services as well as practical advice for not only conducting interviews and liaising with GPs but also for identifying patients who need MUR services; and 12 clinical modules which outline the recommended guidelines and treatments for the most frequently encountered conditions.
In order to get accredited, pharmacists are required to get registered, complete an online assessment, and successfully complete three cases in which they are asked to review a patient’s PMR, watch a short MUR interview session and correctly complete an MUR.
1. 3. 6 Cardiff University’s Practice Certificate in MUR and Prescription Intervention.
The Practice Certificate in MUR and Prescription Intervention is an assessment programme developed by the Welsh School of Pharmacy (WSP) and WCPPE at Cardiff University to prepare and accredit pharmacists for MUR. The assessment which is hosted in Cardiff University was developed in collaboration with 5 other schools of Pharmacy (Universities of Brighton, East Anglia, Hertfordshire, London and Portsmouth) and is designed to tests pharmacists knowledge of both the theory and practice of MUR (WCPPE, 2009). This is done through a portfolio which consists of two parts – the first part is designed to help the pharmacist gain the key knowledge and skills required to competently carry out MUR while the second part is entails the completion of two case studies.
1. 4 The Current State of MUR
In the preceding sections, it has been established that MUR is one of the advanced service for community pharmacist since April 2005 in the new pharmacy contract Overtime, it has evolved to become a major tool in accessing the achievements of the new contract as it gives the opportunity to develop the added value they give to the communities they serve (Alexander, 2006). Consequently, a lot of research has been devoted to this area especially in terms of assessing the impact of the MUR on communities and measuring the efficiency with which the services are offered. This section is thus aimed at giving a synopsis of current literature on this subject.
1. 4. 1 MUR – Meaning and Process
A medicine use review is a routine structured review. It can be prompted proactively by identification of certain patient group e. g. older people on multiple medicines, people with diabetes or asthma that subsequently leads to an invitation for MUR. The White Paper puts it as:
“ MURs are one-to-one conversations between people and pharmacists that are designed to identify any problems a person is experiencing with their medicines e. g. remembering which medicines to take when and in what order or any difficulty with swallowing pills” (DoH, 2008)
On the surface, MUR can easily be mixed with Prescription Intervention Service (PIS); PSNC (op cit) differentiates between the services by highlighting that while the MUR is carried out periodically, once a year for example, the PIS is a form of MUR carried out on an ad hoc basis to highlight any considerable issues observed in the process dispensing prescribed drugs. Though this information is currently captured on paper and passed to the GP when deemed necessary, one of the aspiration of the White Paper is that it will eventually be captured electronically, a proposal that some authors have criticised the government for a slow implementation (Goundery-Smith, 2008).
The DoH (2005) summarised the aims of MUR as follows: to work in conjunction with the patient in order to:
- improve the patient’s knowledge and use of the drug;
- Establish the patient’s actual use, understanding and experience of taking drugs,;
- Identifying, discussing and resolving poor or ineffective use of drugs by the patient;
- Identifying side effects and drug interactions that may affect the patient’s compliance with instructions given by a health care professional for taking of drugs; and
- Improving the clinical and cost effectiveness of drugs prescribed to patients thereby reducing the wastage of such drugs (DoH, 2005)
1. 4. 2 Benefits of MUR
There are various benefits that can be derived from the participation of pharmacist in MUR. The key areas where such benefits can be felt include helping the ageing population, long-term conditions (LTCs), adverse drug reaction (ADR); and medicine wastage. The reporting of ADR can easily be seen as most prominent of these benefits because it not only constitute a target for NHS but the also a goal vigorously pursued by the international community through the WHO (van Grootheest et al, 2003).
NPCI (2008) summarises the benefits of MUR into four broad categories, these are benefits to the patient, the pharmacist, the GPs and the PCFs. The benefits to the patients include an appreciation of the time spent with the pharmacists, enhanced outcome of treatments, and important information gained about the drugs they are taking. On the part of the pharmacists, the benefits include the effective use of their in a broader perspective, an improved status with the hierarchy of health professionals, and a better integration into the main stream of healthcare provision. The GPs stand to benefit as they will see a reduced workload both directly and in terms of a healthier community which reduces visits to the GP. Finally, the PCT strongly see benefits manifested in reduced drug expenditure as patients cut down on waste by better complying with prescriptions.
1. 4. 3 Areas could be reviewed by MUR
- Priority clinical areas identified by the practice
- Priority clinical areas identified by PbC (Practice Based Commissioning structure) Groups.
- Key objectives stated in PCT Commissioning strategic plan, for example, Chronic obstructive pulmonary disease, cardiovascular and diabetes patients on high risk medicines such as anticoagulants and methotraxate
- Patient taking anti inflammatory medicines.
- Patients with certain conditions that appear to be underutilising their maintenance.
- Preventative treatment(based on repeat prescription request data)
- Patients possibly using excessive quantities of medicines or devices that would benefit from additional education and support from a pharmacist
- Specific patients identified by a member of the practice or during a GP consultation as being confused or having concerns about their medicines.
- Patients on more than ‘ x’ medicines as indicated by the PCT to fit with local guidance
- Where community pharmacists pick up adherence problems.(DoH 2008)
1. 4. 4 Limitations of MUR
There are several limitations of the MUR service:
- Time Constrain: As pharmacist might have other services to render in the pharmacy most of the time it is difficult to blend their time to conduct MURs as most patients comes in without booking any appointment.
- Access to patient’s data: The pharmacists always have a limited view of the medication the patient is on or has been taken whereas the full drug schedule in the case notes is located in the wards hence making it difficult to make an appropriate treatment recommendation.
- Patients consistency – It is difficult for patients to be tracked down in terms of their medication in situations where patients tends to escape the appointments for MUR
1. 4. 4 MUR Accreditation
A key dynamic in the administration of MUR is that unlike over the counter dispensation, an MUR session entails the pharmacist and the patients to have a place quiet and confidential enough to discuss the patience’s health issues. This requirement prompted the need for accreditation of not only the pharmacist but also the premise for which the MUR is to be carried out.
The accreditation of the pharmacist mandated to various tertiary educational institute (DoH, 2005). However, there is no clear cut methodology for the assessment of the pharmacists due primarily infeasibility of supervising each pharmacist for a test practical session. To this end various institute have come up with different competency assessment methods. Pharmacist accreditation for MUR can be undertaken at one of a number of higher education institutions in England and Wales. Although they all asses the same list of competencies, the methods (Alexander A 2006a) . In section 1. 3. 3 to 1. 3. 6 The Medway School of Pharmacy requires pharmacist to produce responses to videotaped MUR interviews. The University of Reading followed with a portfolio assessment requiring answers to the case study, the completion of two MURs and a reflective report. The Welsh school of Pharmacy (WSP) MUR assessment in at Cardiff University adopts a structured portfolio approach which candidates are recommended to complete over a period of 4-6 weeks. The portfolio was developed in collaboration with colleagues from six other Schools of Pharmacy (Brighton, East Anglia, Hertfordshire, King’s college, London and Portsmouth and involves the completion of four paper based MURs plus two MURs with individual patients. Additionally pharmacists are required to reflect their consultation skills and their underpinning therapeutic knowledge of the patient’s main condition using structured frameworks Abdel Tawab R et al (2008). The University of Manchester in collaboration with Centre of Pharmacy Postgraduate Education (CPPE) has produced an online assessment which combines multiple choice questions with case study responses and completion of and MUR document. Other higher education institutes providing postgraduate courses have incorporated MUR assessment into their modules.
On the other hand, the accreditation of the premises seems to have clearer cut rules, Alexander (2006) summarises the three key accreditation criteria for MUR premises as:
- Both the patient and pharmacist can be seated comfortably;
- Both parties can speak to each other at normal speaking level without being overheard by any third party such as other staff or customers; and
- The section assigned for MUR sessions must be clearly signed as a private consultation area.
It is worth mentioning however that despite the development of various accreditation methods, there still exist some cause for concern in terms of the efficiency of these methods to adequately access competencies without a direct practical test while the pharmacists are carrying out MUR (Steel, 2005).
1. 5 Aim
The aim of this project is to explore the training and educational needs of community pharmacists to provide MUR services as outlined in the white paper.
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