SECTION 1: INTRODUCTION
The role of pharmacists has evolved continuously through time. This can be traced back to the pre-NHS era(1948), when visits to a doctor were very expensive for patients, thus making the pharmacists the first point of call for most patients in need of healthcare advice and treatment (RPSGB, 2008a). Consequently, pharmacists spent most of their time preparing a wide range of products from raw ingredients, leaving very little time to spend with patient for the briefest of clinical assessments. With the introduction of the NHS, visits to the doctors (termed GPs) became much cheaper, and the responsibility for clinical assessment of patients shifted wholly to the GPs.
The move of medical assessment services wholly to GPs came at a price, which was an increasing pressure on GPs that could hardly be met, thus reducing the quality of health service provided to patients. To address this issue, all health professionals are currently involved in sharing responsibilities to provide safer and better health care (RPSGB, 2008b). Amongst these health professionals, pharmacists are in the most suitable position to reduce the pressure on GP's by providing appropriate health services that go beyond the traditional pharmaceutical dispensing service. In recognition of this fact, the role of the pharmacist in all sectors has constantly expanded since 1948.
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This development has seen pharmacists taking more clinical roles at the front-line of public healthcare, instead of keeping themselves in the dispensary mixing medicines. It is in recognition of this trend that Steve Churton, president of pharmacist society, noted that:
"The profession is unrecognisable from 60 years ago and continues to experience a phase of profound change and development. The opportunities open to the profession are far-reaching and pharmacists are being increasingly recognised for their clinical skill and the contribution they makes to the national's health" (RPSGB, 2008c).
It can be argued that various factors account for the current face of Pharmacy practice, however the singular most powerful forces have been the deliberate policies put in place to guide the expanded role of pharmacist in the delivery of efficient health care services. These are majorly the previous contract dating back to 1987 and the new contract introduced in 2005 which culminated in the Pharmacy White Paper of 2008 (PSNC, 2009a). These contracts are further discussed in the section on literature review; what is worth mentioning here is that of these policies, the White Paper of 2008 sets out the most ambitious role for pharmacists to rise up to. At the time of its publication, the then chief pharmaceutical officer for England, Keith Ridge, described it as being about 'ambition, consolidation, and leadership' (PJ, 2007).
The White Paper sets out a vision for building on the strengths of pharmacy. It outlines the use of the capacity and capabilities of pharmacists to deliver further improvements in pharmaceutical services over the coming years as part of an overall strategy to ensure safer, more effective, fairer and more personalised patient care. A further key initiative of the paper is to make health services more accessible and help reduce health inequalities (DoH 2008)
The aspirations of the paper called for a major shift in pharmaceutical culture which will see more community pharmacists offer advanced service to enhance their clinical roles (Goundery-Smith, 2008). The key advanced services identified by the paper are Medicine Use Review (MUR) and Prescription Intervention Service (PSNC, 2009c). Besides the advanced services, the paper also outlines essential and enhanced services to be offered by community pharmacist, these are further discussed in the section on literature review.
In as much as these objectives are very laudable, they brought to the fore the need to scrutinise the capability of community pharmacist to effectively carry out this functions. There was also the question of community pharmacist not being at same skill level with their clinical colleagues. This led the paper to call for accreditation of both the pharmacist and the premise from which advanced services are offered (RPSGB, 2008c), thus constituting the first time such accreditation and specified skill set was required from pharmacist (Alexander, 2006).
The fallout of the above mandate for accreditation and specific skill set required by pharmacists intending to offer advanced service was the need to indentify the authority or professional body to offer the accreditation, the training needed by pharmacists, the institutions to provide such training, the content of such trainings and the assessment of the efficiency of the training provided in meeting the goals (RPSGB, 2008c).
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It is against this backdrop that this study sets out to investigate the educational needs of community pharmacists to deliver the aspirations set out by the White Paper. The study concentrates on MUR as a pointer to the overall picture for achieving the provision of advanced services in the new contract. It investigates what MUR services are available to patients, the training received to get accreditation, the adequacy of such training received and the quality of services provided to patients.
Section one of this work presents a review of the previous contract in comparison to new contract; the aspirations of the White Paper are discussed, the skill gap between community and clinical pharmacists is highlighted, MUR is discussed in detail, highlighting its benefits, set targets and the challenges to meet these targets. Section two dwells on the methods applied for the study, the results are presented in section three, while section four discusses them and section gives the conclusion drawn from the findings of the study.
1.1 The Pharmacy Contracts
It has already been mentioned that the pharmacy profession is going through a rapid phase of change that has seen its image transformed immensely from what it was twenty years ago. This change will be discussed in terms of the previous contract and the new contract which define the scope of the pharmacy practice.
1.1.1 Previous Contract
The previous contract dated back to 1987 and was focused on the throughput of a high volume of prescriptions (PSNC, 2009a). Bellingham (2004) summarised the key points of the contact as:
- The service was highly focused on dispensing. The volume and throughput of prescription were emphasised, rather than the quality and accessibility of service.
- All pharmacies were treated as the same irrespective of the range and quality of services that they offered.
- A perception that dispensing as many prescriptions as possible was a hallmark of a successful community pharmacy was reinforced, and did not support pharmacists' role in reducing the number of unnecessary prescriptions.
The clinical importance of patient's pharmaceutical service was largely ignored in this contract. This shortfall led to the development of a new contract in which the Department of Health (DOH) shifted focus to an integrated role of community pharmacist within the NHS. The new contract shifted priority to the provision of better, safer and cost effective pharmaceutical services to the public.
1.1.2 The New Pharmacy Contract: Promoting Safe, Better and Effective Service
The new community pharmacy contract was introduced by the Department of Health (DoH) and agreed by the Pharmaceutical Services Negotiating Committee (PSNC) and the NHS Confederation (NHS Employers) (PSNC, 2009a). It was accepted by pharmacy contractors in different ballots and came into force in April 2005 (PSNC, 2009a). The new contract differed from the previous contract, as its aim was shifted to the provision of a wider range of more clinical services, as well as driving the focus of the profession to clinical service from dispensing. It recognises pharmacy as an integral part of NHS, thus utilising skills and knowledge of pharmacists. There are three tiers in the new pharmacy contract - essential services, advanced services, and enhanced services. Each of these is further discussed below:
- Essential Services:
- Advanced Services:
- Enhanced Services:
All pharmacy contractors must provide the seven services mentioned under this tier. The services are: dispensing medicines, repeat dispensing, waste management, public health, signposting, support for self care, and clinical governance (PSNC, 2009b). These are nationally agreed services and are not open to local arrangement.
Contractors can offer one service under the new arrangement in this tier. Both pharmacist and pharmacy premises need accreditation to provide a Medicine Use Review (MUR) and Prescription Intervention Service as advanced services (PSNC, 2009c). This service is nationally specified.
Enhanced services are from the third tier of services in the contractual framework, and are commissioned and funded by Local Health Boards (PSNC, 2009d).The requirements for these services are currently set out in "The Pharmaceutical Services (Advanced and Enhanced Services) Directions 2005" (PSNC, 2009d). Contractors and Local Pharmaceutical Committee (LPC) negotiate to provide services in accordance with these specifications where a local need for the service is determined.
1.2 Aspirations set-up by the Pharmacy White Paper 2008
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Pharmacists are a vastly underused resource, even with the new contract introduced. The DOH published the White Paper 'Pharmacy in England - Building on Strengths, 'Delivering the Future' on April 2008, in which it offers many proposals to expand the role of community pharmacy. Some of these roles are discussed below:
1.2.1 Promoting better Sexual Health
The treatment of damaged reproductive organs due to untreated infections caused by unprotected sex is costing the NHS a lot of money. Chlamydia is one of the most common sexually transmitted infections in the young population (Department of Health, 2008). Pharmacists are raising awareness of Chlamydia, HIV and other STDs by helping the National Chlamydia Screening Programme. The burden of STDs such as Chlamydia can be easily reduced by pharmacists, who serve as the main point of call for using the non-invasive test kit (DOH, 2008). Pharmacists can also contribute their expertise to reducing unintended pregnancy, especially in teenagers by providing contraceptives support and advice (Department of Health, 2008). EHC is most effective if used during the first 72 hours after unprotected sex, but getting a doctor's appointment or finding a convenient family planning clinic surgery time was often a barrier to women getting the help they needed to avoid a termination. Pharmacies are the ideal places to offer this service as not only is they in the fortunate position of having a healthcare professional on hand at all times, they are open evenings and weekends with no appointment needed. (Ref: http://www.rpsgb.org.uk/pdfs/pharmcasestudyeht.pdf).
1.2.2 Promoting Healthy Living
Obesity is a growing issue in the UK population as it increases the risks of life threatening conditions like heart disease, cancer, diabetes etc. Given that the public value community pharmacists as local leaders in health matters (Department of Health, 2008), pharmacists can contribute to improve individual BMI scores by operating weight management clinics in pharmacies and prescribing weight reduction medicines, which all have the potential to improve overall health.
1.2.3 Smoking Cessation
Smoking causes 87,000 premature deaths each year in England (Department of Health, 2008) and still remains the principal avoidable cause of premature death and ill health today. More people are thus quitting smoking with NHS support. In this vein, opportunistic and brief advice/interventions from pharmacists have been helping smokers to quit easily and successfully (DoH, 2008).
1.2.4 Support for Alcohol Abusers
Excessive alcohol consumption can cause life threatening and life-long problems such as liver cirrhosis and alcohol abuse is causing more premature death than breast cancer, cervical cancer and MRSA infection combined (DOH, 2008). Pharmacists can reduce alcohol related health burden by promoting healthy life advice aimed at raising awareness of the effects of excess alcohol.
1.2.5 Helping aging population and MUR (medicine use review)
MURs help to improve patients' medicine use knowledge, reduce medicine wastage, improve patient's health and reduce unnecessary hospital admissions (DoH, 2008). An MUR is the best way that pharmacists can have one-to-one conversation with patient. It enables pharmacists to identify problems patients are experiencing regarding their medication. If necessary pharmacists can make recommendations to patients, helping them to get more benefits from their medication. They can also make recommendations to the patient's prescriber to change medication.
By February 2008, pharmacists conducted 1.25 million MURs, which cost NHS £30million (DoH, 2008). The impact of MURs on improved compliance with prescribe medicines is not assessed. According to the white paper (DoH, 2008) the government wants PCTs to prioritise MURs to meet their health improvement targets and to make the service more effective. The number of long-term condition (LTC) sufferers is increasing as proportion of elderly is increasing. By age 60, over half the population have at least one LTC (DoH, 2008). A high number of hospital admissions result from people not taking medicine as intended, and this most true for elderly people (DoH, 2008). To check this trend, pharmacists can provide support for staying healthy and healthy lifestyle advice as part of NHS team. The most valuable advice in this area is by carrying out targeted and appropriate MURs which will make NHS service more cost effective.
1.3 Education and Training available to Pharmacists.
Different higher education institutions and professional development organisations have developed postgraduate programmes to support pharmacists to be up-to-date with necessary skills and training to enable them provide pharmaceutical services competently. Medway School of Pharmacy already provides a range of training for primary care pharmacists, including a Postgraduate Certificate and Diploma in General Pharmacy Practice (PgCert/DipGPP) which is a two year part-time programme. The (PgCert/DipGPP) programme at Medway School of Pharmacy is designed to equip general level pharmacy practitioners with the core skills and competencies they require to provide a holistic pharmaceutical care in practice setting. Several of the postgraduate programmes are briefly discussed below:
1.3.1 The STEP Scheme
The STEP (Structured Training and Experience for Pharmacist) was initially introduced to solve severe problems with recruiting and retaining junior pharmacists in South East London (DOH, 2001). The programme recruits basic grade pharmacists for a 3-year structured rotation (Andalo, 2002). It offers a wider range of training than the usual hospital basic grade rotation to newly qualified pharmacists. Trainees can develop skills from different areas of practice without changing employer each time. Entrants into the programme from other sectors can have their previous experience taken into account, and may not have to go through the full foundation training programme (Andalo, 2002). STEP pharmacists are employed by one of the four participating hospital trusts. The pharmacists can be attached to a clinical team in general medicine, diabetes or cardiology. A summary of the STEP programme (DoH, 2001) is given below:
- It is a three-year programme.
- Option opens to both junior and more experienced pharmacists.
- Placement available across 15 different trusts, including 6 PCTs and two mental health trusts.
- One of the four trusts employs pharmacists for three years regardless of where elective placements are based.
- First year foundation in standard hospital pharmacy at employing trust.
- Six-month clinical and patient-centred elective at employing trust.
- Three six-month placements at any trust within the district.
- Placements fill pharmacy vacancies where appropriate.
The STEP programme helped hospitals to solve issues regarding lack of skills in junior pharmacists. A modified programme, which may be similar to STEP, could be developed for community to increase clinical skills of community pharmacists.
1.3.2 The Continuing Professional Development Portfolio
The Continuing Professional Development (CPD) scheme is aimed at developing the concept of lifelong learning and of using that learning for continuous professional development. It is expected to show changes in the profession of pharmacy and methods of working in health care provision. According to the RPSGB (2009), the portfolio will enable pharmacists to:
- Identify present knowledge and skills and also the knowledge and skills which is necessary to develop;
- Recognise workplace training;
- Record and plan their professional development;
- Set up professional aspirations;
- Develop analytical and evaluative practice skills; and
- Gain the maximum benefit from their training and education.
Presently, CPD is a mandatory requirement for practising pharmacists. It is helping pharmacists to identify and develop their skills to provide safer and better NHS services.
1.3.3 CPPE (Centre for Pharmacy Postgraduate Education)
The Centre for Pharmacy Postgraduate Education (CPPE) is funded by the Department of Health to provide continuing education for registered, practising pharmacists and pharmacy technicians providing NHS services in all sectors of practice, including community, hospital, prison and primary care pharmacies in England (CPPE, 2009). Its mission statement in 2006 is stated as "Provider of educational solutions for NHS pharmacy workforce across England to maximise their contribution to patient care." It is mainly based at The University of Manchester but provides support by local tutor networks. Besides supporting professional CPD needs, CPPE helps pharmacists and pharmacy technicians to embrace service re-design and modernisation in NHS services (CPPE, 2009).
1.3.4 Reading University's Certificate in Competence in MUR (MUR Assessment only)
The University of Reading's School of Pharmacy plays host to The Centre for Inter-Professional Postgraduate Education and Training (CIPPET) which supports the achievement of an objective of the Department of Health in training the pharmaceutical workforce to attain flexible and appropriate skills that will enable them cope with the ever-changing services offered by pharmacists both in the hospital and in the community (CIPPET, 2009; DoH, 2002). Within the CIPPET, the University offers the Certificate of Competence in Medicines Use Review (MUR) which is an assessment only process for pharmacists to get accredited to offer MUR services.
The accreditation process, which was setup in conjunction with the NPA, involves the submission of a portfolio of evidence to demonstrate all the competencies the DoH health guide. The University's official website state that:
The portfolio comprises:
- Response to one case study - answers to all questions and a completed NHS MUR form
- A minimum of two MURs with reflective reports and anonymous supporting evidence e.g. a copy of the patient's prescription or PMR (University of Reading, 2009).
It is worth noting that although the accreditation was established in conjunction with the NPA, pharmacists are not required to be members of the NPA in order to get accredited, however, they must be registered pharmacist before certification can be handed over to them.
1.3.5 Medway School of Pharmacy's Skills for the Future (MUR Teaching and Assessment).
This PSNC endorsed course, which has been renamed - Skills for MUR, offers a comprehensive package that combines an online assessment module with a series of learning materials (PSNC, 2009f). It is a distance learning course offered by the Medway School of Pharmacy in conjunction with Chemist+Druggist and benefits from educational grant by GSK plus. The Skills for the Future course has been running since 2004 accrediting over 12, 000 community pharmacists to provide MUR services to date (PSNC, op cit.).
The course materials provided for training include the MUR Handbook which details the requirements and procedures for MUR services as well as practical advice for not only conducting interviews and liaising with GPs but also for identifying patients who need MUR services; and 12 clinical modules which outline the recommended guidelines and treatments for the most frequently encountered conditions.
In order to get accredited, pharmacists are required to get registered, complete an online assessment, and successfully complete three cases in which they are asked to review a patient's PMR, watch a short MUR interview session and correctly complete an MUR.
1.3.6 Cardiff University's Practice Certificate in MUR and Prescription Intervention.
The Practice Certificate in MUR and Prescription Intervention is an assessment programme developed by the Welsh School of Pharmacy (WSP) and WCPPE at Cardiff University to prepare and accredit pharmacists for MUR. The assessment which is hosted in Cardiff University was developed in collaboration with 5 other schools of Pharmacy (Universities of Brighton, East Anglia, Hertfordshire, London and Portsmouth) and is designed to tests pharmacists knowledge of both the theory and practice of MUR (WCPPE, 2009). This is done through a portfolio which consists of two parts - the first part is designed to help the pharmacist gain the key knowledge and skills required to competently carry out MUR while the second part is entails the completion of two case studies.
1.4 The Current State of MUR
In the preceding sections, it has been established that MUR is one of the advanced service for community pharmacist since April 2005 in the new pharmacy contract Overtime, it has evolved to become a major tool in accessing the achievements of the new contract as it gives the opportunity to develop the added value they give to the communities they serve (Alexander, 2006). Consequently, a lot of research has been devoted to this area especially in terms of assessing the impact of the MUR on communities and measuring the efficiency with which the services are offered. This section is thus aimed at giving a synopsis of current literature on this subject.
1.4.1 MUR - Meaning and Process
A medicine use review is a routine structured review. It can be prompted proactively by identification of certain patient group e.g. older people on multiple medicines, people with diabetes or asthma that subsequently leads to an invitation for MUR. The White Paper puts it as:
"MURs are one-to-one conversations between people and pharmacists that are designed to identify any problems a person is experiencing with their medicines e.g. remembering which medicines to take when and in what order or any difficulty with swallowing pills" (DoH, 2008)
On the surface, MUR can easily be mixed with Prescription Intervention Service (PIS); PSNC (op cit) differentiates between the services by highlighting that while the MUR is carried out periodically, once a year for example, the PIS is a form of MUR carried out on an ad hoc basis to highlight any considerable issues observed in the process dispensing prescribed drugs. Though this information is currently captured on paper and passed to the GP when deemed necessary, one of the aspiration of the White Paper is that it will eventually be captured electronically, a proposal that some authors have criticised the government for a slow implementation (Goundery-Smith, 2008).
The DoH (2005) summarised the aims of MUR as follows: to work in conjunction with the patient in order to:
- improve the patient's knowledge and use of the drug;
- Establish the patient's actual use, understanding and experience of taking drugs,;
- Identifying, discussing and resolving poor or ineffective use of drugs by the patient;
- Identifying side effects and drug interactions that may affect the patient's compliance with instructions given by a health care professional for taking of drugs; and
- Improving the clinical and cost effectiveness of drugs prescribed to patients thereby reducing the wastage of such drugs (DoH, 2005)
1.4.2 Benefits of MUR
There are various benefits that can be derived from the participation of pharmacist in MUR. The key areas where such benefits can be felt include helping the ageing population, long-term conditions (LTCs), adverse drug reaction (ADR); and medicine wastage. The reporting of ADR can easily be seen as most prominent of these benefits because it not only constitute a target for NHS but the also a goal vigorously pursued by the international community through the WHO (van Grootheest et al, 2003).
NPCI (2008) summarises the benefits of MUR into four broad categories, these are benefits to the patient, the pharmacist, the GPs and the PCFs. The benefits to the patients include an appreciation of the time spent with the pharmacists, enhanced outcome of treatments, and important information gained about the drugs they are taking. On the part of the pharmacists, the benefits include the effective use of their in a broader perspective, an improved status with the hierarchy of health professionals, and a better integration into the main stream of healthcare provision. The GPs stand to benefit as they will see a reduced workload both directly and in terms of a healthier community which reduces visits to the GP. Finally, the PCT strongly see benefits manifested in reduced drug expenditure as patients cut down on waste by better complying with prescriptions.
1.4.3 Areas could be reviewed by MUR
- Priority clinical areas identified by the practice
- Priority clinical areas identified by PbC (Practice Based Commissioning structure) Groups.
- Key objectives stated in PCT Commissioning strategic plan, for example, Chronic obstructive pulmonary disease, cardiovascular and diabetes patients on high risk medicines such as anticoagulants and methotraxate
- Patient taking anti inflammatory medicines.
- Patients with certain conditions that appear to be underutilising their maintenance.
- Preventative treatment(based on repeat prescription request data)
- Patients possibly using excessive quantities of medicines or devices that would benefit from additional education and support from a pharmacist
- Specific patients identified by a member of the practice or during a GP consultation as being confused or having concerns about their medicines.
- Patients on more than 'x' medicines as indicated by the PCT to fit with local guidance
- Where community pharmacists pick up adherence problems.(DoH 2008)
1.4.4 Limitations of MUR
There are several limitations of the MUR service:
- Time Constrain: As pharmacist might have other services to render in the pharmacy most of the time it is difficult to blend their time to conduct MURs as most patients comes in without booking any appointment.
- Access to patient's data: The pharmacists always have a limited view of the medication the patient is on or has been taken whereas the full drug schedule in the case notes is located in the wards hence making it difficult to make an appropriate treatment recommendation.
- Patients consistency - It is difficult for patients to be tracked down in terms of their medication in situations where patients tends to escape the appointments for MUR
1.4.4 MUR Accreditation
A key dynamic in the administration of MUR is that unlike over the counter dispensation, an MUR session entails the pharmacist and the patients to have a place quiet and confidential enough to discuss the patience's health issues. This requirement prompted the need for accreditation of not only the pharmacist but also the premise for which the MUR is to be carried out.
The accreditation of the pharmacist mandated to various tertiary educational institute (DoH, 2005). However, there is no clear cut methodology for the assessment of the pharmacists due primarily infeasibility of supervising each pharmacist for a test practical session. To this end various institute have come up with different competency assessment methods. Pharmacist accreditation for MUR can be undertaken at one of a number of higher education institutions in England and Wales. Although they all asses the same list of competencies, the methods (Alexander A 2006a) .In section 1.3.3 to 1.3.6 The Medway School of Pharmacy requires pharmacist to produce responses to videotaped MUR interviews. The University of Reading followed with a portfolio assessment requiring answers to the case study, the completion of two MURs and a reflective report. The Welsh school of Pharmacy (WSP) MUR assessment in at Cardiff University adopts a structured portfolio approach which candidates are recommended to complete over a period of 4-6 weeks. The portfolio was developed in collaboration with colleagues from six other Schools of Pharmacy (Brighton, East Anglia, Hertfordshire, King's college, London and Portsmouth and involves the completion of four paper based MURs plus two MURs with individual patients. Additionally pharmacists are required to reflect their consultation skills and their underpinning therapeutic knowledge of the patient's main condition using structured frameworks Abdel Tawab R et al (2008). The University of Manchester in collaboration with Centre of Pharmacy Postgraduate Education (CPPE) has produced an online assessment which combines multiple choice questions with case study responses and completion of and MUR document. Other higher education institutes providing postgraduate courses have incorporated MUR assessment into their modules.
On the other hand, the accreditation of the premises seems to have clearer cut rules, Alexander (2006) summarises the three key accreditation criteria for MUR premises as:
- Both the patient and pharmacist can be seated comfortably;
- Both parties can speak to each other at normal speaking level without being overheard by any third party such as other staff or customers; and
- The section assigned for MUR sessions must be clearly signed as a private consultation area.
It is worth mentioning however that despite the development of various accreditation methods, there still exist some cause for concern in terms of the efficiency of these methods to adequately access competencies without a direct practical test while the pharmacists are carrying out MUR (Steel, 2005).
The aim of this project is to explore the training and educational needs of community pharmacists to provide MUR services as outlined in the white paper.
The study has the following objectives:
- What are the educational developments pharmacists have completed to provide MUR services?
- What type of accreditation did pharmacists receive to perform MURs?
- Pharmacist's perception about the accreditation and training for the provision of MUR services.
- Investigate the requirement of further training and educational development to provide better MUR services?
Educational needs of Community Pharmacist for the future provision of MUR services under the aspirations of Pharmacy White Paper.
SECTION 2: METHODS
This project was a group project carried out by 5 fourth year MPharm students. Appendix 1 shows a general project plan, which outlines which activities, was done as a group and which were carried out individually.
2.1 Ethical Approval
Ethical approval is an independent review of the scientific merit and implications of study regarding the dignity, rights, and safety as well as the well being of the participants of this research however my research project did not require any ethical approval as my project did not involve any patients and NHS employee. The participants (Pharmacists) were private contractors to the Primary care trust (PCT). The ethical approval from the Medway school of Pharmacy was obtained.
A county survey was carried out by a group of 5 final years MPHARM students in the Kent area among 352 registered community pharmacies to sort their opinions on the required educational needs and training needed to enhance the aspirations set out in the new Pharmacy White Paper. The community Pharmacy profession in the Great Britain ( including Kent Area) have identified public health as one of its major hallmarks for the residence in these communities and hence will be a great challenge to knowhow and what extra education and training required to boost the services being rendered to the public as the Pharmacy White Paper aspires. The community Pharmacy also act as an ideal venue for this survey as it serves as the first line contact to the patient (Public) whenever ill-health is experienced. Finally, the community pharmacies are also major sites for Pharmacy and Pharmaceutical students or residency training of future pharmacists and pharmacy technicians hence there is a need to know their opinions on the facilities and training needed to meet the expectations of the Pharmacy White paper in this regard. Due to these essential factors considered, the methodology for this survey was carried out in the following systematic format:
2.3 Inclusion Criteria:
The research is focused on investigating the educational and training needs for pharmacists providing MURs, and thus the choice to use community pharmacists.
2.4 Exclusion Criteria:
Pre-registration pharmacists are not fully qualified pharmacist so they will be excluded in this research.
The aim of the study is to identify educational and training needs for community pharmacist providing MUR services. Hospital pharmacists are excluded as the research limited to community pharmacists.
2.5 Pharmacy address
A non-random sampling method was used in this study as questionnaires were sent to all of the pharmacies across Kent. Hence it was needed to begin with finding the locations of the premises. This was carried out by using a worldwide search engine such as Google as a major assistant tool in finding out all the post codes within the Kent metropolis.
In General, a total of 75 post codes were obtained in the Kent area with the aid of the Google search engine. These were then further sub-divided among the 3 research students in locating the different pharmacies that fall within these post codes. In order to carry out this to obtain the findings, 3 different methods/approach were utilised in finding the addresses of the local pharmacies under these post codes. These methods include;
- Online yellow pages
- NHS online system
- Royal Pharmaceutical Society of Great Britain (RPSGB) Website search
The different methods were reviewed in finding out which best suits the research in terms of validity and reliability. It was finally agreed and concluded on obtaining the addresses of the local pharmacy within Kent through the RPSGB website as it gives vivid and professional registered details of pharmacy premises.
2.6 Questionnaire Development
The development of the Questionnaire was a complex process however it was ensured to include all the necessary details especially on the front page as it acts as an "eye catching first impression" to the respondents. Due to this, the name of the Pharmacy School as well as the university carrying out the survey was outlined at the topmost section on the front page of the Questionnaire.
Underneath this was a clearly bolded Question under research. There was a need for such a bold font as it clearly summarises and emphasise on the main bulk of the entire survey. The group of researchers aimed to indicate the reason for choosing the question under study and the plans put in place to obtain the opinions required of the respondents. In addition to this, expected views and opinions of the questionnaire were categorised into 4 different sections. This was critically laid out in front of the questionnaire to give the respondent a specific idea of what to expect in the questionnaire. Section 2 contained 9 questions on Medicines Used Review (MUR) which was carried out with the main focus on the planning and procedure for the development of the questionnaire items consisted of different steps through brainstorm sessions by the group which was overseen by the supervisor for corrections and approval. The steps included the creation and compilation of the relevant variables included in the questionnaire that will one way or the other affect the results obtained.
Aside this, the instructions on how the questionnaires must be completed by the respondents were specified. Lastly but not the least, code number boxes were allocated on the bottom right on the front page of the questionnaire just to determine the number of returned questionnaires during the commencement of the data collection. Also by showing appreciation of questionnaire completion, a thank you statement was boldly expressed in small font to make the respondents feel appreciated of the information being passed on for the study.
There are several different ways of questionnaire construction however a conclusive decision was reached in creating a 6-page booklet questionnaire held together with a saddle stitch ( a staple in the spine of a booklet) to give it a professional look compared to the other questionnaire development methods. The next step regarding the production of the questionnaire and its design was the number of questionnaires to order taking into consideration the size of the sample (Selected Community pharmacies in Kent area), the number of follow-up mailings, and the number of discussion copies for other clinical pharmacy researchers as well as copies for inclusion as appendices in the research report. In respect to this, the number required for data collection was estimated to be 352 community pharmacies and this was multiplied by approximately a factor of 2 to determine the number of questionnaires to be ordered. This resulted in 650 orders thus almost doubling the number for the data collection. This was carried out considering the fact that the first mailing might not yield the expected response for data collected hence a back-up plan for constructing and developing excess questionnaires was taken into account to combat such a problem from developing by sending a participant or respondent a follow up mail as a reminder.
2.7 Questionnaire Design
The questionnaire was designed and developed in collaboration with clinical research students. In order to ensure that the questions asked meet the aims and objectives of this research study, the questions were analysed and critiqued for face and content validity.
Furthermore, to be assured of reliable responses and avoid any form of bias results, the wording of the questions were selected carefully making it simple and easier to comprehend. In designing the questionnaire, a variety of questions were considered and the most appropriate ones to elicit the needed information were chosen for the section (Section 2 - Medicines Used Review) of the questionnaire. In General 2 major question formats were chosen in the name of "Closed Questions" and "Open Questions". The majority of the questions asked were closed due to the fact that they were quicker and straightforward to answer and hence making it easier to code and analyse the information given. In order to ensure content validity, a decision was reached to include all the possible options or answers to the closed questions. In this section of the questionnaire design, 3 different types of closed questions were adopted which include Dichotomous questions, Multiple choice questions and lastly Likert format questions as they were more preferable in a self-completed questionnaires. The Dichotomous questions were important inclusion as they allowed the respondents (Registered Community Pharmacists) only one of two possible responses/answers for instance "Yes or No" questions. This was also essential as it eliminates any fence-sitting responses which will have negative implications on the results. In the relation to the multiple choice questions, even though they were less straightforward when it comes to coding however it was clear to the respondents how the questions must be answered as there were more than one responses or answers to choose from. The Likert form of questions were also adopted as it was used as the main tool to assess the attitude of the respondents ( Pharmacists ) as these set of questions allowed the respondents to express their views on series of statements ranked in order of importance. This helped to clarify the values and experience of the respondents in terms of the questions being asked. In terms of "Open Questions" during the questionnaire design only a few were included to provide an opportunity for respondents to express themselves freely in their response. In addition to this, probing questions asking for respondent's opinions were also left open in order to provide pharmacists the opportunity to answer freely and to enhance the researcher's exploration of the respondent's views and opinions. Different sample questions from previous research studies were viewed and verified to obtain ideas and knowledge for the layout of the questionnaire design. Aside this, specific time was allocated to each questionnaire presentation which included 6 different drafts before reaching an agreeable conclusion of the final piece of questionnaire. It was ensured to use bold fonts to separate different sections of the questionnaire and the sections were limited to one double-sided piece of A4 sheet to maximise the aesthetic value of the questionnaire with the idea of increasing the rate of response.
2.8 Questionnaire Validity
The validity of a questionnaire relies first and foremost on reliability.Validity refers to whether the questionnaire or survey measures what it intends to measure
Before sending the questionnaireand cover letter to the pharmacists, it was checked with CHSS staff and other pharmacy students to check the validity which proved to be very helpful and essential.
2.9 Cover Letter
A covering letter was produced alongside the questionnaire on a signed Medway school of pharmacy letter head proving the authenticity and professionalism of the research study. The covering letter vividly outlined the aims and objectives of the research survey and the students as well as the supervision team responsible for the project. The aim was rephrased and emphasised on "the determination of the opinions of practicing community pharmacists about the type of education they required to help deliver the set out aspirations in the pharmacy white paper."
This was very essential as it eliminates any other opinions and ensure to lead the respondents into a more concise and accurate responses to the questions being asked with the motive of maximising the response rate. Secondly, in order to further boost the response rate, respondents were reassured that all the answers and any further information will be treated with strict confidentiality measures. Furthermore it was specified that any information passed on will be used for this research project as well as to inform future educational programmes at the Medway School of Pharmacy subject to their approval. In order to facilitate and enhance quick response, respondents were assured that the questionnaire wouldn't take more than 10 minutes to complete and a replied date for returning completed questionnaire were clearly stated. Lastly, respondents who by any circumstances decided to pull out of the survey study was asked to return the blank uncompleted questionnaire using the pre-paid envelope to halt the researchers from sending any follow up questionnaire an letter. However both the school and email address of the supervising committee were provided for respondents who required further information and findings of this research. ( Appendix 1)
2.10 Pre-Paid Envelope
The returned envelopes included in the questionnaire were smaller in size compared to the outer envelope and the questionnaire was folded in order not to be refolded to fit the return envelope. This was taken into account to make the study appear more professional.
2.11 First mailing
A questionnaire, covering letter and stamped addressed envelope were sent to 352 community pharmacies within the address data base. Pharmacists were given two weeks to reply. The date of the first mailing and the date of return were entered into the data base. 25% (88) responses were achieved in the first mailing. 16 questionnaires were returned uncompleted. 5 questionnaires came back as there was something wrong with the addresses. The low response could partly be attributed to the postal strike of the Royal mail that took place within that period.
2.12 Second cover letter and second mailing
Couple of weeks after the first cover letter a second cover letter was sent as a reminder to the participants (registered community pharmacists in Kent) who were yet to return their completed questionnaire This was carried out by sending the same questionnaire again or the second time emphasising on how important it is completed before the set deadline.Furhtermore, all the general information included in the first letter was also reemphasised in the second cover letter such as "keeping their information strictly confidential" and "the essence of the code in front of the questionnaire" as a reminder in case the previous mail has been misplaced. This was essential to help increase response rate and also to help minimise errors of participants completing their questionnaire anyhow. The contact details of the supervision team and the research students were listed. Incase any of the participants requires any further information.(Appendix 2)
Upon reaching the return deadline, pharmacists who had not responded were sent another questionnaire as a reminder. Another two weeks were allocated for reply. The respond rate increased up to 35% (n=130)
2.13 Data Analysis/Analysis Tool
The data analysis tools that was created and used to compare responses/results data to best practices and standards as well as identifying gaps in responses were Microsoft Excel software. This was essential as data and results obtained were automatically tallied up by this software to provide a rich graphical display and statistical analysis (Bar graphs and Pie charts) of the response data.
Since a huge number of response (352) were to be analysed, it was important to utilise such a tool as it effectively and accurately enhances identification of longer term strategic changes of the results and this tool (Microsoft Excel) proved to be very suitable as it automatically adjusted the graphs whenever new set of response are obtained and logged into it.
In summary, it provided a clear understanding of the data analysis and helped attest the opinions of the participants as well as reaching the main objective with greater efficiency and effectiveness. In addition, the data obtained from the qualitative questions was analysed as a group and common themes were adapted into the categories found within the results tables.
2.14 Data Entry
All the results and data collected from the completed questionnaires were entered into the Microsoft Excel Spreadsheet to find out the trend of opinions of different participants. The data was coded and entered into the database. The data input was then cleaned as another of the participating students crosschecked the inputs.
2.15 Data Checking
In order to ensure reliability and the validity of the data collected, it was crosschecked by other participating students
2.16 Monitoring returns/results
Monitoring the returned questionnaires set as the baseline and the starting point of the analysis and this proved valuable to the research. As soon as the questionnaires were returned to the school office the responses were then logged onto the analysis tool software (Microsoft Excel Spreadsheet).
2.15 Sampling Frame
The questionnaire was sent out at the beginning of November. The responses were tracked using the codes on the return envelopes as explained before. Two weeks after the first mail out a second questionnaire was sent to non-respondents. Data collection stopped on the second week of December.
Educational needs of Community Pharmacist for the future provision of MUR services under the aspirations of Pharmacy White Paper.
SECTION 3: RESULT
This section presents the results obtained from the various analyses carried out in this study. The results are objectively evaluated and where possible are compared to relevant literature reviews. The implications of each findings area also highlighted in the light of future research.
3.1 Response Overview
Earlier in section 2.2, it was noted that 352 questionnaires were distributed for the purpose of this study. Of these numbers, 134 pharmacists responded by mailing back the questionnaires. Fig 1 illustrates the portion o completed and blank questionnaire for first and second mailing. From the first mailing 88 responses were received within which 21 were blank. 46 questionnaires were obtained in the second mailing, 3 of them were blank. This breakdown implies that while the overall response rate was 38% the response rate for valid questionnaire stands at 31%. Fig 1.
The results from the returned questionnaires were entered into the microsof excel spreadsheet as mentioned earlier in section 2.13. A printout of this data base can be seen in appendix 4. The data was then manipulated into tables and graphs.
3.1.1 Response Rate by Postal Areas
In order to get a clearer picture of the response, the respondents were further analysed at postal areas level by aggregating similar postcodes. The analysis was carried out at postal areas level in order to ensure confidentiality of the respondents, a strategy advocated by Armstrong et al (1999), Dunnill & Barham (2007). The result showed that Bromley area had the lowest response rate of 3 %(n=4); this was followed by Dartford with 16%(n=18),Tonbridge with 19%(n=21),Canterbury with 29%(n=32) while Medway had the highest response rate 31%(n=35). This information is further displayed in Table 1 below..
3.1.2 Respondents Demographic Breakdown
The breakdown shown in Figure 1 reveals gender composition of the respondents. It can be seen that the respondents were composed of a higher proportion of female pharmacists 52 %( n=57) than male pharmacists 48 %( n=53) .
3.1.3 Respondents Breakdown by Years spent as Registered Practicing Pharmacists time o accreditation
The respondents were further analysed in terms of the years they have been registered and practising pharmacists. The breakdown is shown in table 2.
The respondents were grouped into three categories (31->40, 11-30 and 5-10) on the basis of the years of registration for the convenience of presenting the data.
Data reflect that 57% (n= 63) out of 110 respondents were gained their accreditation 2-4 years ago. About 70.5% respondents (n=12) who registered 31-40 years ago as pharmacists were accredited to provide MURs. The majority of respondents 60.4% (n=26) was accredited 2-4 years ago in the category of those who registered 11-30 years ago as pharmacists. The analysis of data also revealed that out of least experience pharmacists (registered 5-10 years ago) 50% of them (n=50) were accredited 2-4 years ago. Amongst the respondents within third category (registered 5-10 years ago), 24% (n=12) were accredited less than one year ago. Amongst those that registered as pharmacists 11-10 years ago.19% (n=8) of the respondents were accredited to provide the service.
3.2 MUR Accreditation
A major objective of this study was to find the prevalence of MUR accreditation amongst practising pharmacists. To ascertain this, the respondents were asked if they had obtained to provide MUR services-of the 110 valid responses 91 %( n=99) pharmacists said they were accredited to provide MUR services and 9 %( n=10) said they were not accredited (See Fig 3). Although this may look fairly impressive on the surface, it does underscore an unpleasant trend when one considers the fact that 4 years after the introduction of new pharmacy contract for this Advance service, this results reveal that 1 in every 10 pharmacist are yet to come onboard the drive the expand role of provision of MURs by the community pharmacists. This troubling trend, which was also highlighted by Goundery- Smith (2008), is further discussed in the next session.
Besides the percentage of accredited pharmacists, this study further investigated the period at which time the accreditation was acquired. This was essentially to highlight the ease with which pharmacist moved to embrace the provision of new contract. The result revealed that 16 %( n=16) of the respondents obtained their accreditation in the last year, 9 %( n=9) been accredited for 1 to 2 years, 63 %( n=63) have been accredited for as long as 2-4 years while 15 %( n=15) have been accredited over 4 years. It is worth nothing at this point that since the MUR accreditation was introduced in 2005, the option of being accredited over 4 years ago was a potential source of error, and as such category is being treated with reservations. However, the key information noted here is that majority of the respondent 63% got accredited between 2-4 years ago which reflects an early effort to get accredited by these pharmacists.
Another accreditation variable considered by this research was the path of the accreditation chosen by the respondent pharmacists. As noted in section 1.4.2 the accreditation of pharmacists where let for the institution of higher learning. Four higher education Institutes were identified for this study, of these, two carried out only assement, and these are Reading University's Certificate in Competence in MUR and Manchester University /Centre of Postgraduate Education MUR Assessment. The other two institutes provide both teaching and assessment; these are the Medway School of Pharmacy's Skills for the future and the Cardiff University's Practice Certificate in MUR review and Prescription Intervention (See Table. 4) These four universities targeted specifically for MUR while other institutes such as Universities of Bath, Bradford and Aston offer Postgraduate courses with MUR assessment accreditation embedded in them (PSNC 2009e). The results showed that 37% (n=34) pharmacists went for assessment only option and 62 %( n=57) went for teaching and assessment. The analysis showed that of the 91 accredited pharmacists 6 got accredited by Reading, 28 by CPPE, 57 by Medway while none was accredited by Cardiff. The fact that none of the respondent was accredited by Cardiff in most likely due to the fact that all of the respondents were form Kent and thus less likely travel to Cardiff for accreditation .9 pharmacists went for other accreditation option.n & where
Another accreditation variable considered by this research was the path the respondents chose to get accredited. As noted in Section 1.4.2, the accreditation of pharmacist was left for institutes of higher learning. Four key accreditation options were identified for this study, of these, two carried out only assessment, and these are: Reading University's Certificate in Competence in MUR and Manchester University/ Centre of Postgraduate Education Medicine Use Review Assessment. The other two institutes provide both teaching and assessment, these are: the Medway School of Pharmacy's Skills for the Future and the Cardiff University's Practice Certificate in Medicine Use Review and Prescription Intervention. These four were isolated for this study because their programs are targeted specifically for MUR while other institutes such as the Universities of Bath, Bradford and Aston offer postgraduate courses with MUR assessment accreditation embedded in them (PSNC, 2009e).
The analysis showed that of the 64 accredited respondents, 7 got accredited by Reading, 17 by Manchester, 40 by Medway while none was accredited by Cardiff. This result is shown in Figure 5. The fact that none of the respondent was accredited by Cardiff is most likely due to the fact that all respondents were from the Kent area and are thus less likely to travel to Cardiff for accreditation.
3.3 MUR Training
The survey also investigated the training received by the respondents to aid them get accredited. When asked if they received any training to help them get accredited, 39 (61%) responded 'Yes' while 25 (39%) responded 'No' (See Figure 6). Those that received training help for accreditation were further asked to specify where the training was received. 25 of the 39 respondents received their training from Medway while the remaining 14 received training from various other sources such as Online training programmes, Boots preregistration training, and from their employers. Figure 7 further displays this information.
3.4 Provision of MUR Services
Having investigated the variables in training and accreditation, the study moved a step further to analyse the provision of MUR services to the community following the training and accreditation process. Respondents were asked if they have been providing MUR services following their accreditation, 58 of the 64 (i.e. 91%) responded 'Yes' while 6 (i.e. 9%) of the accredited respondents said 'No'. See Figure 8. The immediate question that pops to mind here is what factors would prevent a fully MUR accredited pharmacist from providing the services they got specially assessed for? The possible reasons for this are explore in section four.
The period of time for which the respondents have been providing MUR services was also analysed. The results displayed in Figure 9 show that of the 58 respondents providing MUR services, 10 (17%) have been doing so for less than 1 year, 3 (5%) have been providing MUR services for between 1-2 years, 21 (36.2%) have been doing so for 2-3 years, while 24 (41.37%) of the respondents said they have been providing MUR service for more than 3 years. The high percentage of respondents that have been providing the services for more than 3 years reflect the large percentage that equally obtained their accreditation in that period as shown in Figure 4 of section 3.2.
Another service provision variable investigated is the number of MUR sessions carried out per month by the respondents. It is worth noting that due to financial rewards given to pharmacies per MUR session, the National Service placed a cap on the number of sessions each pharmacy is allowed to claim per year, this cap is currently placed at 400 sessions per year (NPCI, 2008). The analyses of the responses revealed that 16 (27.58%) of the respondents provided less than 60 MUR sessions per year, 11 (18.96%) provided between 60-108 sessions per year, 20 (34.48%) provided between 120-228 sessions per year, 10 (17.24%) respondents provided between 240-400 sessions per year while only 1(1.7%) respondents claimed to provide more than 400 sessions per year. The results shown in Figure 10 reflect these figures which were derived from the monthly average provided by the respondents. The general picture is that about 81% of the respondents were not fully utilising the 400 session's provision by the National Service. More discussion is provided on this in section four.
3.5 Pharmacist's Perception of the MUR Accreditation Process
A set of three questions was asked to measure the respondent's perception of the relevance of the MUR accreditation process. The responses are shown in Table 2 below:
The first question was targeted at measuring the sufficiency of the accreditation process in ensuring that the pharmacists provide efficient MUR services. The analyses showed that 61.9% of the respondents either strongly agreed or agreed that the accreditation process was sufficient to ensure quality service, 20.63% either disagreed or strongly disagreed while 17.46% of the respondents were undecided. A further breakdown of these results is shown in Figure 11.
The second question was aimed at assessing the relevance of training received to aid pharmacist get accredited and provide better MUR service. The analyses showed that 68.25% of the respondents either strongly agreed or agreed that the training received was helpful in getting them provide efficient MUR services. 3.17% disagreed with this statement while 28.75% were not sure the training received was of any help in their provision of MUR services. The responses are displayed in Figure 12.
The third question was targeted at measuring any perceived deficiencies in the MUR training received. 46% of the respondents felt the training received could have been better, 17.46% either disagreed or strongly disagreed with the notion that the training needed improvement while 38% were not sure if improvements were needed in the training provided. Figure 13 further depicts this breakdown.
Following the above analysis, respondents were further asked if they think they need further training to enable them provide better MUR services. 57% of the respondents felt that they needed further training to enable them provide them better MUR services while 43% felt they do no need further MUR training (see Figure 14).
Finally, the respondents were asked to express their preferred methods of obtaining training. A breakdown of the responses shown in Figure 15 revealed that workshops were most popular with a score of 45, this was closely followed by online course with a score of 41, lectures and distant learning were tied with a score of 40, and learning with colleagues had 38 responses. The lowest preference went to problem based learning which scored 24 and was followed by the option of working through clinical scenarios which had a score of 33.
The results presented so far in this section will now be further critically analysed in the next section on discussion of result.
Educational needs of Community Pharmacist for the future provision of MUR services under the aspirations of Pharmacy White Paper.
SECTION FOUR: DISCUSSION
This section presents a critical analyses of the results displayed in the proceeding section. The first issues worth mentioning at this point are those that have to deal with data used to arrive at the results. As noted in Sect