Community pharmacy in Scotland has a record of pushing through schemes designed to get the most out of its pharmacists. So NHS Education Scotland’s (NES) announcement earlier this month that it will consider modernising its pharmacy degree has left England’s pharmacists once again wondering why those north of the border seem to be making greater strides towards progress.
NES, which currently oversees the country’s pre-registration placements and funding, said it plans “to explore options to develop an integrated five-year pharmacy programme with a view to further improving the current training arrangements”.
The announcement set out two benefits of the five-year degree approach, which will combine an academic degree with two phases of pre-reg training. Scotland’s chief pharmaceutical officer Rose Marie Parr claimed the switch would “better prepare new pharmacists for practice” and “improve [the] management of pharmacy trainee numbers to meet workforce demands”.
In some ways, the move has been a long time coming. Five years ago, a report for the Modernising Pharmacy Careers (MPC) programme proposed a similar change to English degrees. So if this move can solve those two pressing concerns in Scotland, why does it seem to have been kicked into the long grass in England?
The MPC’s proposal was for a five-year degree that incorporated two six-month pre-reg placements, taking place at the beginning of the fourth and the end of the fifth year. It was greeted enthusiastically by the Royal Pharmaceutical Society (RPS) at the time, despite warnings about the burden of administration that changing the degree structure would bring.
Five years later, there has been no progress on any national programme of change in England. On its website, Health Education England (HEE), the NHS training and development body which published the MPC report, maintains that it is still “considering the five-year degree”. HEE declined to speak to C+D for this article, but did say it would have “a bit more detail about… work-based assessment, tutor training and recruitment and selection” later in the year.
Meanwhile, the pharmacy schools at the University of Nottingham and the University of East Anglia have launched five-year programmes, while the University of Bradford has run once since 1970. These courses are largely populated by non-EU, fee-paying students, who may be unable to secure UK visas to complete a year-long post-graduation, pre‑reg placement.
The small numbers of UK and EU students on these courses is hardly surprising, as they would have to pay an extra year of tuition fees (currently totalling at least £45,000 for five years). As Clive Roberts, head of the University of Nottingham’s school of pharmacy, puts it: “Those students are making the decision to have a different educational experience, but they are paying quite a lot more for that.”
So what is so good about this “different educational experience” that it has been mooted as the future of pharmacy education, despite the steep financial disincentive?
Splitting a one-year placement into two six-month stints creates what Mr Roberts describes as a “reflective learning experience”. This is borne out by students in the University of Nottingham’s first five-year cohort, who have recently returned to their studies after completing their first six-month placement, says Nottingham professor of social pharmacy Claire Anderson.
“They are finding that they can bring [back] quite a lot from what they learned in that first six month placement,” she says. “I think they have been able to apply what they’ve learned.”
“That to me was the purpose of it,” she explains. “People would go out, gradually build up their experience and bring it back to their course, so it’s embedding their learning better.”
Mr Roberts also argues that five-year degrees improve the quality of pre-reg placements, which can be variable.
“There are very many, very high-quality pre‑reg placements,” he says. “But as soon as you’re in smaller providers, it becomes more variable. We do have concerns about that.”
London contractor and former RPS president Ash Soni agrees: “The benefit of a degree being integrated is that you’d get better quality control over the pre-reg year.”
If this is true, then pharmacy contractors and patients could also benefit from trainees having a more rounded learning experience.
Aamer Safdar, principal pharmacist lead for education and development at Guy’s and St Thomas’ NHS Foundation Trust, feels this could be a selling point for HEE when it decides whether to commit to the proposed five-year degree. Mr Safdar, who was a teacher on the University of Bradford’s five-year course for more than a decade, says: “Because you’re socialising [trainees] into the profession earlier you’re potentially producing more competent, work-ready pharmacists. That benefits you when they graduate and register [because] they’re more ready to practise.”
Producing more practice-ready pharmacists was the MPC’s goal in updating the MPharm degree. Its original report proposed creating “day-one pharmacists” who “from the point of registration” could “take professional responsibility for optimising medicines in use and for supporting wider public health”.
At the moment, some pharmacy graduates fall short of this ideal, according to Hertfordshire contractor Graham Phillips. He says it often takes another year of training his newly registered pharmacists, “to get them anywhere near where they need to be”.
Pharmacy Voice chief executive Rob Darracott, a co-author of the MPC report, says “something is not quite right if everyone has to do something with their ‘day-one pharmacists’ because they’re not quite right for the workforce”.
But adult critical care pharmacist Kevin Bazaz questions whether it is realistic to ever expect “day-one pharmacists”. He says he did not feel fully prepared for the reality of being a fully qualified pharmacist after his pre-reg year. “Why should you? Every day is a learning day – [we] need to adapt, reflect and amend.”
Financial barriers to progress
The biggest obstacle towards MPharm students being “day-one” ready on completing their course is money. As Mr Roberts points out: “There’s currently no national funding to support a five‑year course.”
This is set against a backdrop where pharmacy degrees – which are financed as science degrees – get a fraction of the funding of healthcare courses, such as medicine.
The Pharmacy Schools Council, which represents 27 UK schools of pharmacy, says that if five-year degrees are developed there need to be guarantees about “tuition, maintenance and teaching grant funding for the fifth year”.
Five-year courses are expensive for universities to run, so require more investment. How much is in question, as while Mr Safdar argues that “with increased placements comes increased costs”, Mr Roberts says, “there would be economies of scale if there was a big shift to many more courses of the five-year type”.
It would also be difficult to incentivise and reimburse pre-reg placement providers, who would face, according to Mr Roberts, “an enormous change [and] a lot more work”, as well as less control over the trainees they take on.
There is therefore a risk of provider dropout, warns Humber local pharmaceutical committee (LPC) officer Steve Mosely. “You’ll have more students to place and fewer reasons for employers to take them on. It needs a hard think about what the offer is to the organisation hosting,” he says.
There is also a concern about potential costs to the individuals taking part, Mr Darracott says: “Everybody has that front of mind – that this can be expensive for students.”
Is there room for more graduates?
In the minds of many pharmacists, it is difficult to disassociate many of the controversies about pharmacy degrees from the proposals for their modernisation, which makes reforming them even more tricky.
“There has been an awful lot of debate in the last couple of years, which has mixed up a lot of issues,” Mr Roberts explains. Top of the list, he says, is “the number of people studying pharmacy”, and whether the government’s 2014 decision not to cap pharmacy school intakes means there are simply too many students entering the profession.
This is something Ms Parr is wary of. When announcing NHS Education Scotland’s plans, she deliberately emphasised that the extended degree had the benefit of aligning trainee numbers with “workforce demands”.
Mr Safdar believes the integrated degree might require universities to reduce student numbers – which, for the supporters of a cap, would be an added benefit.
But not everyone is so sure. Mr Soni points out that, in medicine and nursing a cap on student numbers has left both professions “desperately short” of people. “It takes five years to turn that around,” he warns.
First steps towards change
In England, many of the principles of a five-year degree – which aim to equip graduates with advanced clinical skills – have begun to take root in the four-year degrees from which students graduated this summer.
Mr Darracott says, “a lot of the things that an integrated programme would have developed are being road-tested anyway,” such as small-scale placements.
HEE has also begun to try to tackle quality control of pre-reg placements, by announcing this month that it is “calling for expressions of interest from community pharmacy employers to participate in centralised pre-reg pharmacist recruitment” from 2017 onwards.
Mr Safdar says these are signs that universities are trying to mitigate the risk of HEE shelving its plans for five-year degrees. But do these kinds of changes mean that integrated courses are no longer needed?
One of the MPC report’s authors disagrees, as he believes this natural evolution may not go far enough.
“I still remain completely committed to seeing this five-year programme come off – it’s best for patients,” says Professor Anthony Smith, who is now vice-provost (education and student affairs) at University College London. “People have looked at it and tried to take on some of the ideas and concepts, and use them in the current framework. But despite the best efforts of the schools of pharmacy, the academic learning is all up front and clinical application comes at the end. Academically, that’s not the best way.”
But Mr Darracott, however, is open to other ways of creating ‘day-one’ pharmacists and says the MPC’s vision is just one of a number of paths for the future of education. This could mean a diverse system of several different course structures – until there’s evidence to show which one is superior.
Whether England can ever commit to an official five-year degree strategy or not, this latest debate is a timely reminder that pharmacy training must continue evolving to meet the needs of professional practice.