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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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FACULTY
ROYA
L PH
ARMACEUTICAL SOC
IETY
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 20202
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.
MANAGEMENT CONUNDRUMWhither should I go in my career?
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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Reader Survey for this issue.
Subscribe now!Our journals are available free of
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To obtain your own
subscription please visit
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Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
www.pharman.co.uk
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 (alex.bower@pharman.co.uk).
Journal of Pharmacy Management
Journal of Medicines Optimisation
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/ .
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
www.pharman.co.uk
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: mike.wilcock@nhs.net
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.
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 20206
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
www.pharman.co.uk
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.”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 20208
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.
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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.”
REFERENCES
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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
9. The Hearing Aid Podcasts. 7.01- Polypharmacy. February 12 2019. Availableat: https://thehearingaidpodcasts.org.uk/7-01-polypharmacy/
10. Sadowski CA. Deprescribing—A Few Steps Further. Pharmacy 2018:6(4):112.Available at: https://www.mdpi.com/2226-4787/6/4/112/htm
11. National Institute for Health and Care Excellence, 2016. Multimorbidity:clinical assessment and management (NG56). Available at:https://www.nice.org.uk/guidance/ng56
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
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202012
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.
Correspondence to: hana.morrissey@wlv.ac.uk
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202016
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
ANSWER CHOICES RESPONSES
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
Other (please specify) 8.33% 4
Total Respondents: 48
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.
ANSWER CHOICES RESPONSES
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
Other (please specify) 2.08% 1
Total Respondents: 48
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 . . .”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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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.
Declaration of interests
All authors declare no conflict of interest
professionally or financially.
REFERENCES
1. Brock T, Franklin B. Differences in pharmacy terminology and practicebetween the United Kingdom and the United States. Am J Hlth-SystPharm;64(14):1541-1546. Available from:https://academic.oup.com/ajhp/article-abstract/64/14/1541/5134905?redirectedFrom=fulltext
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 . . .”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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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:
j.r.sowter@bradford.ac.uk
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
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202022
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.
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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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.”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202024
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.
Declaration of interests
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.”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 2020
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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.
Correspondence to: Lloyd.Hambridge2@wales.nhs.uk
Lloyd Hambridge
“. . . the vast majority of health and care needs are met in localcommunities by primary care and community services . . .”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202026
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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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 . . .”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202028
MANAGEMENT CONUNDRUMWhither should I go in my career?
“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:Anthony.young@ntw.nhs.uk
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
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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:
rena.amin@nhs.net
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.
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202030
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
Declaration of interests
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.”
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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’ . . .”
Journal of Pharmacy Management • Volume 36 • Issue 1 • January 202032
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
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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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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EDITORIAL BOARD FOR THE JOURNAL OF PHARMACY MANAGEMENT (JoPM)
Sarah Crotty Head of Pharmacy & MedicinesOptimisation, Herts Valleys ClinicalCommissioning Groupsarah.crotty@hertsvalleysccg.nhs.uk
Luke Groves Chief Pharmacist, Solent NHS Trust(Community & Mental Health) luke.groves@solent.nhs.uk
Gurpreet Virdi Pharmacy Lead South East (KentSurrey & Sussex), SpecialisedCommissioning,NHS England- South (South East) g.virdi@nhs.net
Jas Khambh Clinical Director and Chief Pharmacistat NHS London ProcurementPartnership (LPP)jas.khambh@lpp.nhs.uk
David Mehdizadeh Practice Pharmacist, The MayflowerMedical Practice, Doncasterdavid.mehdizadeh@nhs.net
Darshan Negandhi Pharmacist Proprietor/TeacherPractitioner/Preregistration Trainer/CPPE Tutor, Londondarshan.negandhi1@nhs.net
Anthony Young Lead Pharmacist – Research andWorkforce Development,Northumberland Tyne and Wear NHSFoundation Trust anthony.young@ntw.nhs.uk
SCOTLANDChristine Gilmour Director of Pharmacy, NHS Lanarkshirechristinegilmour746@ btinternet.com
Sharon Pfleger Consultant in Pharmaceutical PublicHealth, NHS Highlandsharon.pfleger@nhs.net
EditorAlex Bower Director of Publishing, Pharmacy Management alex.bower@pharman.co.uk
ENGLANDRena Amin Joint Assistant Director MedicineManagement, NHS Greenwich ClinicalCommissioning Group, Londonrena.amin@nhs.net
Graham Brack Head of Communications andIntegration, Pharmacy Managementgraham.brack@pharman.co.uk
Campbell Shimmins Community Pharmacist, Owner,Practitioner campbell.shimmins@me.com
David Thomson Lead Pharmacist, CommunityPharmacy Development &Governance, NHS Greater Glasgowand Clydedavid.thomson@ggc.scot.nhs.uk
NORTHERN IRELANDLindsay Gracey Community Pharmacistlindsaygracey@googlemail.com
Dr Ruth Miller Medicines Optimisation Project Lead,Department of Health, Northern Irelandruth.miller@health-ni.gov.uk
Professor Michael ScottHead of Pharmacy and Medicines Management,Northern Health and Social Care Trustdrmichael.scott@northerntrust.hscni.net
WALESJohn Terry Head of Pharmacy,Neath Port Talbot Hospitaljohn.terry@wales.nhs.uk
Judith VincentClinical Director, Pharmacy andMedicines Management, AbertaweBro Morgannwg University HealthBoard. judith.vincent@wales.nhs.uk
Roger WilliamsHead of Pharmacy Acute Services,Abertawe Bro Morgannwg UniversityHealth Boardroger.williams@btopenworld.com
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: pharm@pharman.co.uk
Jan 20