The White Paper “Pharmacy in England” set out the Government’s aspirations for an expanded pharmacist role in delivering clinical services to patients. To achieve this, changes are needed to education and training, underpinned by sound quality assurance.
Traditionally, QA of NHS-funded pharmacy programmes has been underdeveloped. To employ a preregistration trainee pharmacist, employers need to register their premises as a training site and provide a named preregistration pharmacy tutor. The requirements to be a tutor stipulated by the Royal Pharmaceutical Society are basic, taking into account the hours of work and length of time the prospective tutor has been on the register.
Substantial regulatory changes are under way in pharmacy for 2010, including the launch of the new General Pharmaceutical Council and creation of a new professional body. Part of the regulator’s remit will be to set standards for education and competencies for practice. It is clear that QA and quality management (QM) systems will need to develop in postgraduate pharmacy education to meet this challenge, but there is no clear direction on how these should be shaped or managed.
The Society recently consulted on its proposed principles for pharmacy education and training. These included a section (section 7) on quality principles (Box 1), and these have been broadly accepted. The Society has also published a study that it commissioned in 2007 to scope provision tor QA for the preregistration scheme under the Pharmacists and Pharmacy Technicians Order 2007. Keele University undertook the research with input from the Society and the West Midlands workforce deanery. The study made several recommendations, with the underlying theme that there is a lack of QM infrastructure in all sectors of pharmacy practice, and this lack prevents a common approach to preregistration training.
Currently the Society does not offer a quality management strategy for preregistration training sites, tutors and programmes.
This article describes a novel and cost effective way of quality managing preregistration trainee pharmacist education within the NHS-managed sector.
Preregistration trainee pharmacist training in NHS South East Coast
Within NHS South East Coast, NHS preregistration training is managed by South East Medicines Management Education and Development (SEMMED), a division of the Kent, Surrey and Sussex Postgraduate Deanery (KSS). SEMMED was integrated into KSS in 2008 in line with national support for multiprofessional workforce deaneries.
The SEMMED team includes pharmacists, pharmacy technicians, and business sup port and administration personnel. SEMMED’s responsibilities include:
- Advising on capacity and commissioning of NHS-funded preregistration trainee pharmacist places
- Marketing and recruitment into NHS-employed preregistration trainee pharmacist placements
- Preregistration trainee tutor training and support
- Managing trainees in difficulty
- Providing a supplementary programme of study days and learning resources
- Quality managing the preregistration pharmacist experience in NHS trusts
In the past the approach to QM in the south east has been one of “exception reporting” rather than a systematic review of processes. Annually there would be a review of a range of indirect quality indicators such as performance in. Society examinations, regional audit and OSCE assessments and end of-year feedback from students, including placements, study days and review of first destination data.
In 2006, SEMMED piloted che use of the Skills for Health Ongoing Quality Monitoring and Enhancement (OQME) tool. This has now been replaced by Enhancing Quality in Partnership (EQuIP) (www.skillsforhealth.org.uk). Feedback from trusts that used the tool suggested that it was a time-consuming and bureaucratic process, and labour-intensive for those being reviewed and for the reviewer.
Box 1: Society principles for pharmacy education training
7.1 Quality assurance processes must be rigorous, evidence based, both internal and external, to ensure that standards are being maintained, curricula are continually reviewed and good practice is being shared.
7.2 Processes must be valid (they should measure what they intend to measure) and reliable (they should produce consistent and accurate results).
7.3 There must be a clear statement of quality assurance responsibility and accountability for the different aspects of provision. Those responsible for quality assurance must demonstrate an appropriate range of expertise and knowledge. There must be separation of functions between providers and their external quality assurers.
7.4 External quality assurance should confirm the validity of processes and outcomes of internal quality assurance and build upon them.
7.5 Quality assurance should be transparent.
7.6 Quality assurance processes should be efficient, effective and proportional, taking account of the costs and the effectiveness of the programmes as well as the process itself.
7.7 Where appropriate, approved quality assurance systems operated by other bodies should be recognised.
7.8 Quality assurance systems should be reflexive and responsive to feedback.
7.9 Those undergoing education must be able to provide feedback on their education for it to be improved.
7.10 The outcomes of quality assurance should be made available to allow the sharing of good practice.
The process was specific to pharmacy and, therefore, it was the respqnsibility of the chief pharmacist and preregistration· pharmacist training manager to agree an action plan, with no trust executive involvement.
The move to multiprofessional deaneries and SEMMED’s integration into KSS in 2008 has provided many opportunities for shared learning between professions and improved economies of scale. As part of this united approach, in 2009 pharmacy will be included for the first time in the KSS quality management of NHS trust training placements of doctors, dentists and now preregistration trainee pharmacists: This KSS process is called “centre review” (see below).
The national quality system for postgraduate medical education is quality assured by the Postgraduate Medical Education and Training Board and the General Medical Council.
Centre review is an annual KSS Deanery process that aims to audit and develop NHS trusts’ capacity for educational management. The purpose is to ensure NHS resources are used cost-effectively to provide high quality training.
Every year, each education centre in KSS produces:
- A quality manual, showing how the centre complies with national and regional statutory and regulatory requirements, including those of KSS and national regulatory and professional bodies (The quality manual describes required specifications, procedures and documentation. There are three sections to the manual: education programmes and resources, human resources, and finance.)
- An education strategy, showing how the centre proposes to develop to meet the changing needs of the NHS (It includes: information about the background, strategic purposes and organisation of the centre and the NHS trust; a review of the previous year’s education action plan; and planning information specified in key areas.)
- An action plan, which arises out of discussion of the quality manual and the education strategy between the NHS trust chief executive, the clinical tutor, the medical education manager and KSS
In the KSS approach to centre review, there is a clear distinction between quality as compliance and quality as change. Quality as compliance is measured against standards expressed in the quality manual, whereas quality as responsiveness to change is expressed through the education strategy. The distinction is helpful in supporting new developments through the stages of innovation and implementation (via the education strategy) and then into custom and practice (via the quality manual).
The purpose of centre review is to support local creativity and diversity within national and regional guidelines. This is, therefore, a developmental inspection, rather than a grad ing and ranking inspection.
There is a particular, high participative process for developing the regional specifica tions for the quality manual and the educa tion strategy:
- The first draft of the overarching specifications is produced by the head of education. These are taken separately to KSS business managers and to NHS trust med ical education manager and clinical tutors for feedback. A partnership of SEMMED with a working group of NHS pharmacy managers and preregistration trainee pharmacist tutors tailored the specifications into supplementary guidance for pharmacy as shown in Box 2.
- A series of drafts of the supplementary guidance were produced by the pharmacy working group and ultimately approved by both preregistration trainee pharmacist tu tors and chief pharmacists.
- The final draft is appended to the quality manual. The final specifications for the manual and specifications for the education strategy are taken to a regional launch and after further corrections or modifications have been made, the new specifications are circulated and form the basis for that year’s exercise.
Each year, that three-month period of participative development is repeated to produce updated documentation. A major benefit from this process is the smooth implementation of visits and inspections, since participation in its development produces a high degree of confidence and personal investment, by chief pharmacists and preregistration pharmacist tutors. The quality manual specification and the education strategy specification form part of the detail of the education contract signed between the KSS dean director and the chief executives of KSS NHS trusts, so that they are an integral part of the financial and contractual relationships within NHS South East Coast.
Centre review visits
Each centre is visited twice a year. The first visit is carried out by a pair of trained verifiers, to verify that the centre’s quality manual is complete. The medical education manager oversees the verification process on the NHS trust’s behalf and the preregistration training manager’s role is to ensure all of the relevant pharmacy information is available in the pharmacy portfolio, (derived from the pharmacy supplementary guidance document) to be able to complete the pharmacy aspects of the trust·-quality manual.
The second visit, a fortnight later, is a formal meeting between the NHS trust chief executive, the director of medical education, the medical education manager, a dean and a deanery education adviser (plus any other NHS trust staff the chief executive wishes to invite, such as the medical director, chief pharmacist or finance director). That meeting discusses the results of the quality manual verification visit, the results of the previous year’s action plan and the education strategy for postgraduate medical, dental and preregistration trainee pharmacist education that has been prepared by the NHS trust. At the end of the meeting a draft action plan is agreed for the forthcoming year. The participants at the meeting then have a week in which to make any additions, changes or revisions to the draft action plan, after which it is attached to the education contract. Formal signing of the education contract takes place at the end of the deanery’s annual centre review process by the dean director and the chief executive of the NHS trust.
The inclusion of pharmacy in the KSS deanery quality management process will ensure that NHS preregistration training sites, tutor programmes and resources are standardised across the south east coast area.
It also raises the profile of pharmacy education in NHS trusts at an executive level ar should support chief pharmacists in soh r problems related to organisational training in frastructure. This model provides economics of scale as one deanery team is able to review the education of a number of professions at once rather than on separate visits for each professional group.
In the case of pharmacy this may have required a dedicated assessment for one or two trainees on some sites. The approach also encourages multiprofessional problem solving and shared learning.
Initial feedback from chief pharmacists has been positive. They can relate to the benefits of a multiprofessional approach and the collective identification of infrastructure issues and raise the profile of pharmacy education in their organisation.
Preregistration trainee pharmacist tutors were initially enthusiastic in compiling this guidance. However, they became apprehensive and less supportive when the schedule of verification and centre review visits was circulated. On investigation, the reasons for this included a fear of failure if they were unable to provide sufficient documentation to evidence their current practice or if they did not yet fulfil all the required standards. These fears were allayed following feedback that the view process is designed to be developmental and supportive with a focus on action planning rather than criticism. Tensions between professional groups were identified in some localities and part of the ongoing evaluation will be to consider the impact of this on the process.
Negative feedback from a small number of directors of medical education who thought that inclusion of pharmacy in centre review meant that they would be accountable for pharmacy education was overcome by a discussion to clarify governance arrangements for pharmacy education in NHS trusts.
It is recognised that not all deaneries are multiprofessional or operate a centre review quality management model. We do not propose that this model is applicable to other localities; instead we suggest that the principles of a multiprofessional approach with executive engagement is one which others may wish to aspire to.
SEMMED supports preregistration trainee pharmacist training in Hampshire and the Isle of Wight, where the Wessex deanery operates a different system of QA. Rolling out this model in this area is being explored but the plan is to pilot it this year on a uniprofessional basis with SEMMED taking on the verifier roles and feeding back to the chief pharmacist and preregistration training manager.
The inclusion of pharmacy in centre review focuses solely on preregistration pharmacy education. However, we believe there is scope to extend this to include other pharmacy placements, including postgraduate diploma and junior pharmacist training posts and student pharmacy technicians.
“Pharmacy in England” advocates that there should be increased clinical content and experience throughout the current MPharm undergraduate programme. The likelihood is that the preregistration year and undergraduate programme will become integrated in future, which may impact on funding to provide the quality management system described. However, we believe that the funda mental principles behind this approach are sound and should be given serious consider ation in the development of QA systems by the future regulator and professional body.
We propose that KSS’s centre review could be an effective quality management process which bridges the gap between internal quality control carried out by employers and overarching quality assurance which will be the role of the GPhC as a regulator similar to the medical education model.
Box 2: An example of a specification in the supplementary pharmacy guidance for the KSS quality manual
Introduction to the NHS trust: deanery requirement
Introduction to the NHS trust must be structured, effective and inclusive (e.g. late starters)
(a) A structured general induction programme is provided on joining the trust
(b) Preregistration trainee pharmacists will attend the trust induction programme at the earliest opportunity
Records kept In HR department. Proof upon request
Any peregistration trainee pharmacist who does not attend trust induction as scheduled will be required to
attend the next course at the earliest opportunity.