A five-year degree programme integrating the preregistration year was first proposed in 2011 by the discussion paper ‘Modernising Pharmacy Careers’ (MPC). It said the 12-month preregistration placement should be replaced by two six-month placements, at the beginning of year four and the end of year five, with a single application process for all practice placements, similar to the existing national recruitment scheme for NHS medical training posts.
The General Pharmaceutical Council (GPhC) is “convinced by the argument that the current MPharm degree and preregistration training should be brought together”, so it is likely to happen eventually, but what would the positives and negatives be for students, universities and employers?
Integration of the preregistration year has already happened on a small scale. There are currently three five-year pharmacy courses available in England which incorporate the preregistration year.
The University of Bradford in Yorkshire was the first university to run a five-year course. Its ethos was to offer students courses in which they went out on work experience — the sandwich course model. Since the 1970s pharmacy students at Bradford have had the option of one year’s work experience, first in a four-year course and then in a five-year course, as the core pharmacy degree moved from three to four years.
Until recently, on the five-year course, the preregistration year was split into two six-month placements – one in the final term of the third year, and another in the first term of the fifth year. However, four years ago the university adopted the model proposed by MPC and students now go on two six-month placements – one in the first term of their fourth year and another in the final term of their fifth year. Students will take their final exams in January, just before their final placement, and take the registration assessment before graduating in the summer.
The University of Nottingham is also offering a five-year MPharm degree in which the preregistration placement is fully integrated. The 11 students who enrolled in the first year of the restructured course are now in their fourth year and out on their first six-month placement. The University of East Anglia (UEA) is the latest to offer a five-year degree, which – like the Nottingham course – fully integrates the preregistration year.
The main difference between the models is that the Nottingham and UEA programmes are targeted primarily at non-EU residents. Changes to visa rules have made it more difficult for MPharm graduates from outside the EU to remain in the UK to undertake preregistration training. Joining a five-year programme that integrates preregistration training with academic study enables students to remain in the country on a student visa. However, students pay full university fees over the five years and, because they remain students, are not paid while undertaking their placements, making these two courses less attractive to UK students.
The Bradford course is geared towards UK students. Students on their preregistration year pay 20% of the university fee and are paid as employees during their placement, as they would be during the preregistration year that follows the standard four-year MPharm.
Splitting it up
What all three courses have in common is that the preregistration year is split into two six-month placements and most students will go to two different placements, often in different settings.
Source: University of Bradford
Marcus Rattray, head of the school of pharmacy and professor of pharmacology at the University of Bradford, says that the placement structure widens students’ experience, enabling them to compare one practice with another, ultimately allowing them to make informed career choices. He also says it has an impact on the pharmacy industry as a whole. “The number of graduates able to [train] in hospitals at the moment is about 25% nationally, you could theoretically double it to 50%,” he says. “It would be a good thing having graduates having experience of both sectors.” In the future, as opportunities in pharmacy widen, it may also be possible for students to mix placements in the general practice or even [the pharmaceutical] industry.
Aamna Khan and Hannah Maxted both chose the five-year Bradford course specifically because it gave them the opportunity to do split placements. Khan says that when she started the course she did not know what route she wanted to take. “It does help you decide which one you would prefer when you do get insights into working in both sectors,” she explains.
Maxted always knew that she wanted to work in hospital pharmacy, but she enjoyed her community placement and is glad she did it. “Even though I am in hospital now it means that if I ever want to locum I have got six months of experience behind me,” she adds. “I think if I had just been in hospital and never worked in community I would feel a little bit intimidated doing locum shifts.”
Source: University of Nottingham
However, Clive Roberts, head of the school of pharmacy and chair of pharmaceutical nanotechnology at the University of Nottingham, points out that split placements can have downsides for employers. “The employer needs to understand that they are getting someone who has not yet completed their academic education — so a lot of employer awareness and training needs to be done going forward,” he says.
Sheffield Teaching Hospitals Foundation Trust has been taking students from the Bradford sandwich course for more than a decade and currently has two six-month placement students and seven twelve-month preregistration trainees at any one time. Nicky Thomas, preregistration manager and tutor, says that some trusts opt to take only the fifth-year students because they are concerned about integrating third-year students into their training programme. However, she explains that they run exactly the same training programme for these students. “Certainly the students we take have always coped with it well and have been able to learn at the same pace. We don’t see a disadvantage in bringing them into the workplace earlier in their undergraduate training,” she adds.
Some employers may also fear that trainees are more likely to opt for their first post-qualification job in the sector where they did their most recent placement, Thomas notes. “Our experience is that if you give them a good strong preregistration experience, it doesn’t matter — it doesn’t affect your ability to still entice them to your organisation or back to that sector.”
One downside of recruiting trainees who completed a six-month placement is that they will not have had the full breadth of experience of one who did 12 months of training there. “The main thing in our programme that differs is that in their second 6 months, our 12-month preregistration trainees work towards looking after a ward of patients on their own,” Thomas explains. “The pharmacist is still there supervising them but, instead of them observing the pharmacist, we gradually switch it so that the pharmacist is observing the trainee. The trainees are fully capable of taking responsibility for a ward, so that the day they qualify they know that they can hit the ground running.”
However, she emphasises that the extra investment needed “would never be a reason for us not to re-employ a preregistration trainee who had been with us just for six months”.
Better quality training
Integrating the preregistration training into the degree and offering students a combination of placements would boost the quality of the training that students were exposed to, Rattray points out. “We know that the overall quality of preregistration training is much higher in hospitals, so we have a large group of pharmacy graduates [in the community] who perhaps aren’t getting the best experience in their preregistration year.”
Community providers currently receive funding from NHS England to cover the cost of the preregistration trainee’s salary, and hospitals receive funding from Health Education England. However, because hospitals provide a wide range of training to other NHS staff, they have the foundations and funding mechanisms in place to train tutors and provide students with access to additional training. This is far more difficult for community providers to offer outside the major chains, Rattray says.
But the main driver for a national five-year programme is the opportunity to improve the quality of graduates by giving higher education institutions more control over the quality of the placement experiences, he adds.
Maxted says that Bradford vetted her placements well and asked for feedback, whereas many of her friends on the four-year course found their one-year preregistration placements were more “luck of the draw”.
Rattray acknowledges that under the five-year degree students would have to pay five years of university fees and would not be paid for their preregistration placements, although it is hoped that they would receive a bursary to help with living costs. However, the additional funding available to universities would enable them to drive up the overall standards and quality of preregistration training.
Five-year degree students at the University of Nottingham remain full-time students while they are undertaking preregistration placements, and therefore have tutors who are dedicated to looking after them while they are out on placement. “It’s quite a different relationship that we have compared with students who graduate and then do a preregistration placement,” Roberts says.
To ensure that sufficient preregistration places are available, Nottingham has negotiated contracts with employers for its five-year course placements, almost all of which are in the community. University staff use the academic performance of the students to identify which placements fit best. However, this approach means that both students and employers may not get matched with what they would have considered their first choices.
Better academic results
Historically, from 2002 to 2006, students on Bradford’s sandwich course have done better than the national average, Rattray says, whereas the four-year course students have done slightly worse. However from 2010 to 2014, this has changed. “Historically it has been the higher achieving students that have chosen the sandwich course and now the intake is much more mixed, and we have found that the five-year degree is less attractive than it used to be for students since university fees were introduced [and increased],” he says.
The four and five-year courses initially follow the same curriculum but, once the students have been out on their first placement, a difference in performance is evident. “Once students have the clinical experience they progress better in the course… and that is particularly so for the more average students. For high-achieving students there is little difference,” Rattray adds.
Data from Bradford show that the average mark in modules increased between year two and the final year by 5.8% (from 59.8% to 65.6%) for students doing the five-year course, compared with 0.7% (from 59.1% to 59.8%) for students doing the four-year course.
“The biggest difference we notice is [when we] put the five-year students against four-year students at same stage of the course. Then the difference in clinical knowledge becomes apparent in the way that they are able to tackle questions,” reports Rattray. “[Five-year students] have many more examples to draw on; they can put the teaching into a better context at an early stage and a later stage.”
“We are firmly of the view that a national five-year programme will help improve the quality of the average pharmacist on the first day at work after registration,” he adds.
Khan says that her third-year placement in hospital helped her put her university knowledge in context. “There are a lot of things that I had never come across in university that I came across in placement,” she explains. Working in the warfarin clinic helped her understanding of anticoagulants, for example. “You learn about it [at university], but you don’t learn about the practical aspects and how they can differ for different people,” she says.
The experience of Nottingham and Bradford indicates that there would be a lot of issues to address if the preregistration training were to be integrated into a five-year degree programme. Roberts says that training providers would need a lot of education and support, particularly in the community where he says there is a lack of awareness of what an integrated preregistration course might mean. There is also the issue of how preregistration placements would be awarded – would this remain a national competitive process and how would that be funded? There are also considerations for students in terms of additional costs and the potential difficulties of finding accommodation for six-month placements.
Thomas says that if all preregistration placements were six months it would have some disadvantages for individual employees; if trainees are allocated in a similar way to foundation year doctors, tutors could have less say over the trainees they get. If students were not of the calibre the employer would have chosen, not well suited to the organisation, or choose to work for their other preregistration training employer, this could impact on an organisation’s recruitment pipeline, she warns.
Having trainees for only six months will also place a far greater training burden on an organisation. Not only will there be more individual trainees, but trainees give back more to the employer in their second six months. “They’ve had all their basic training, we are just smoothing out the edges… We can put them in any department to do any role,” Thomas explains. “We start getting some reward for that investment in training whereas, with the new proposed model, we will just get them to that level and then they will go.”