Pharmacists in Scotland - five-year integrated education programme: scoping report

Discussion

The Advisory Group has previously agreed to reject the status quo option (whilst also recognising that nothing actually stays the same) and this narrowed the choice down to two proposals: an enhanced 4+1 or a five-year integrated programme. Whilst funding and student intake numbers were critical the principle decision for the group was with regards determining a high level strategic position. Aspects of the detail could be addressed as part of any implementation programme. In addition there were areas, such as the admission process and the modular pre-registration programme, which had been identified during the course of the discussions that could progress regardless of any national position.

• The Problem

Throughout the stakeholder events concerns had been expressed regarding both the confidence and competence of current newly registered pharmacists to deliver future practice models and the mismatch of numbers between MPharm graduates from the two Schools of Pharmacy and funded PRPS training places and the consequent risk to programme standardisation.

• The Student Perspective

Undergraduate students and pre-registration pharmacists supported the idea of either a linked 4+1 qualification or an integrated five-year qualification, acknowledging that change from the status quo was needed. International students, in particular, saw an integrated five-year model not as a barrier but an opportunity to gain coterminus graduation and registration as a pharmacist. However, all of them stated a preference for the five-year integrated model as long as progression was based on performance as a way of maintaining motivation and focus. All groups also were prepared to accept a reduced wage or bursary during the equivalent of any pre-registration training as long as it was enough to live on and that the money saved was used to fund additional student places as a result. Importantly they all highlighted that there required to be sufficient Student Awards Agency for Scotland ( SAAS) funding to support students for five years (including travel and accommodation for placements). Again students valued increased experiential learning which they believed would increase confidence and competency, and also allow students to relate theory to practice. However some had reservations about whether a 6-month block at the end of university, as opposed to 12-months, would mean they were ready for practice although they conceded that it was difficult to judge. There was consensus that increased experiential learning provided more options to work in different sectors and opportunities to contextualise their learning and apply it in practice. Both undergraduate students and pre-registration pharmacists agreed having an interview process at the point of entry to a School of Pharmacy was appropriate. The pre-registration pharmacists requested that the MPharm be re-classed as a 'clinical' degree, thus allowing access to clinical funding streams. They were also keen to see an equivalent of ACT funding for pharmacy allowing training providers to be remunerated and ensuring standards of quality.

• The Training Provider Perspective

Both Schools of Pharmacy expressed a desire to ensure that they provided students with enhanced experiential learning in clinical practice throughout their period of learning accepting the value of workplace learning for reinforcing confidence and competence. They also acknowledged the challenges and difficulties when almost all their current placement provision was delivered on goodwill. There was a view from one of the Schools that as they implemented their redesigned course that it was too early to be having a discussion about future changes and that there was little 'give' in the current programme for any more experiential learning. From a NES perspective one of the key challenges is that the student/trainee numbers registered for the MPharm degree programmes do not match the current pre-registration training places available within the service. Both NES and the two Schools expressed a shared interest in ensuring that the competencies and qualities of future pharmacy graduates meet the workforce demands in Scotland, albeit that pharmacy workforce planning is at a very early stage. They also have a common goal to ensure that all changes are developed within a robust clinical and educational governance framework. There was also consensus on the value of earlier development and assessment of professionalism, holistic clinical decision-making and consultation and clinical assessment skills for future pharmacists

• The Service Provider Perspective

The focus of the service was on ensuring that the competencies and qualities of future graduates met the workforce demands in Scotland: newly qualified pharmacists practicing at the top of their licence. Service providers articulated that a 'day one' pharmacist should be: capable; confident; comfortable; independent / autonomous; able to deliver services; able to recognise their limitations; and be able to work with and in the multidisciplinary team, as well as their own team. Whilst recognising that the undergraduate MPharm courses were continually changing and improving service providers felt progress to date wasn't enough to drive the step change required to build capacity and support the cultural shift required to move the profession forward. They saw designing and delivering a new model of enhanced experiential learning in clinical practice throughout a five-year model as vital to supporting competence and confidence of early career pharmacists. They were looking for all pharmacy graduates to be closer to an Agenda for Change (AfC) hospital band 6 than they currently were with an early career educational pathway to provide the skills and knowledge to be competent prescribers by early to mid-band 7.

• The Regulator Perspective

The GPhC remit was driven by the regulatory standards and not workforce planning or salary scales (although they remained mindful to the impact of the standards on those areas). The GPhC's focus was currently on integration of science and practice and the benefits of this have been evidenced in the student experience. An area for future focus will be on interprofessionalism. Currently the GPhC accredit both 4+1 and integrated five-year courses. There was a clear message that the integrated five-year course was here to stay, despite the tensions with the international market and associated implications for capacity. The GPhC confirmed that as long as the learning outcomes were met and the final six-month period of learning in practice was maintained then there would not be a problem with any of the proposed options from their perspective. The GPhC also indicated their willingness to support any transitional programme structure.

• The model

The Advisory Group reflected on the purpose of any change. They agreed it was to: further enhance the initial education and training of pharmacists to meet the developing role of the profession and the needs of the NHS in Scotland; and provide better management of pharmacy trainee numbers to meet workforce demands balance the numbers in order not to over-produce pharmacy graduates. At the NHS stakeholder event there had been a clear statement about it being unethical to produce more students than could be accommodated in Scotland and the Advisory group agreed that they wanted to address the inequity in access to pre-registration places in Scotland. Advisory Group members agreed that the pharmacy workforce planning piece of work was at a relatively early stage but there was an opportunity to start to address this going forward.

The GPhC had evidence that the new graduates coming through recently reaccredited MPharm courses were seen to be more competent but there was a view from the service that further progress was required. When GPhC specifically asked the service if enough had been done the answer was no, although they acknowledged that they had seen an improvement. The Group heard that the GPhC would be rewriting the draft initial education outcomes document that they had consulted on in 2013 and that the new outcomes would be a significant step-on from the existing ones. As a result, the Group had the opportunity to reflect on the current and future needs of the service by considering which model could best accommodate the rapidly changing landscape and assist in ensuring future pharmacists were equipped with prescribing and clinical skills. Members acknowledged the importance of experiential learning and wanted to ensure it was of sufficient quality and was provided at appropriate points in the MPharm programme.

Following on from this, a view was expressed that a commitment to educating the future workforce didn't come though as being part of the professional culture in pharmacy. The problem might be that the conversation continually focused on the model and not the outcomes. Group members agreed that focusing on achieving the outcomes would help the Schools and the service to share ownership of the solution.

Members agreed that student feedback from the events seemed to indicate that being a student for five years was not an issue as far as they were concerned as long as there was sufficient funding. They were also struck by the comments from students at SIPBS who were in favour of the five-year integrated model but concerned about losing their motivation and wanted some process to keep them to account (so in one way competition was valued by them). Therefore, there needed to be some form of incentive for them to progress.

The Group discussed the risks and benefits of the different options that had been presented. Representatives from the service were concerned about whether an enhanced 4+1 model put enough stretch in the system to generate improvement or would it ultimately deliver more of the same. There was agreement from a pedagogic perspective that all the evidence indicated that a five-year integrated model would be the best educational option. This being the case then the next issue was to agree where the experiential learning should be provided.

At the outset of the work the Group had been presented with three options: option one which was to maintain separate qualifications (4-year MPharm followed by application for 1-year pre-registration training); option two which was to move to a linked qualification (4-year MPharm progressing to 1-year pre-registration training); and option three which was to introduce an integrated qualification (five-year programme with coterminus graduation and registration). Option one had been rejected at an earlier stage. The Group considered if there was any mileage in now modifying option two to badge it as a five-year integrated MPharm which was delivered through an enhanced 4+1 model. In other words, keep the traditional concept of a final year at the end of the undergraduate course but introduce a linked qualification with coterminous registration and graduation allowing better control of the numbers and providing a simple solution to the international student dilemma. Consideration would need to be given to a student's status if they exited after four years but that was a conversation that needed to a happen anyway. The advantage of this approach was that it forced both the Schools and the service to make the links between the undergraduate course and the pre-registration year which would continue to move the current Scottish model forward.

In essence this suggested a five-year integrated model which could be delivered in one of three ways: a 12 month block of experiential learning year five; two six month blocks of experiential learning the first block to be delivered prior to year five and the second in the final six months of year five; or dispersed blocks across the first four years and a final six month block at the end of the fifth year. Pharmacy students must undertake the final six months in practice as a result of a European Directive.

The Group had considered the risks and benefits of the different model options across the course of their four meetings and had taken evidence from a wide range of stakeholders including students and staff. Key themes from the events included: ensuring equality; being ambitious; delivering what was needed for the future; better mobilising capacity; and supporting culture change. It appeared that the majority of group members were aiming for a five-year integrated MPharm. Members agreed that an integrated degree would force the service and the Schools to think about the links and bind them together in a shared sense of ownership on delivering the outcomes. However in agreeing this, they acknowledged that further work was required to bottom out the detail of how experiential learning should be delivered, the financing arrangements and how that linked to the admission process, including the numbers. There was also a need to ensure stability moving forward so a robust implementation plan and a clear transition pathway were seen as critical. It was about ensuring the appropriate balance between being ambitious and mitigating against risk and ensuring traction versus defining an appropriate pace. This was best achieved through a robust transition pathway with incremental steps. The Group acknowledged the importance of taking the time needed to prepare the ground for any changes, however, if the pace needed to quicken then that was always an option. The Group had also identified a number of key building blocks such as the current NES modular PRPS pilot, the existing quality management system and existing interprofessional learning activities.

• Transitional arrangements

Advisory group members felt that it was important to be clear about the impact of any changes. There was a view employers may be reticent to move straight to a five-year integrated model. On the other hand perhaps the profession needed to challenge itself. It was clear that both the service and students wanted change. By identifying areas that would challenge the system and mitigation arrangements to ensure against any unintended consequences of change the Group felt robust transitional pathway could be put in place to support a decision to move to an integrated five-year model.

• Experiential learning ( EL)

Advisory group members were struck by students' comments about the variability in the quality of undergraduate placements. They identified that ensuring all experiential learning, including interprofessional learning, was delivered to an excellent standard was an important priority by building on the existing NES PRPS quality management arrangements.

There was broad agreement that the modular pre-registration programme provided a useful building block for EL. However there were mixed views about the benefits of providing most of the EL in one year at the end, in two six month blocks or gradually dispersed across the course. One of the Schools was concerned about what would have to come out of the curriculum to accommodate EL however representatives from the service saw the opportunities already emerging from the elective options selected by students on the first cohort of the modular programme and that the matter of how to accommodate this across a five-year MPharm was a practical issue that should be addressed in the transition and implementation phases.

The educational argument reinforced the value of closely aligning learning with the placement experience. There was some discussion about using holiday periods for EL however this may disadvantage students if it was unpaid as it reduced students' ability to generate income to subsidise their study funding. There was some evidence from a five-year MPharm degree which included two six-months blocks of pre-registration training that demonstrated that the students tended to fare less well in the earlier block but much better in the second six-month block when they were much more confident and able. Members felt that this provided a helpful reassurance to proposed changes to the existing model.

There was a view from some members of the group that this might fundamentally change how pharmacists perceived placements provision as most wouldn't see themselves as academics or an extension of the university. This most likely would require a change in mindset. There were lessons to be learnt from the experience of existing integrated courses and the balance of education and the timing of experience in practice to contextualise learning. There was also evidence of pedagogic benefits when the educational outcomes and EL experience were properly aligned and delivered by training providers who were motivated and enthusiastic. This was supported by evidence from the initial pre-registration student survey which identified that pharmacists who had been tutors for less than ten years were more self-critical and more driven to improve the training they provided.

The Advisory Group heard evidence of the increase in preferences to cross-sector and portfolio working and agreed that this was likely to further accelerate. Overall there was agreement that a more dispersed model for EL allowed students to be exposed to different experiences across the time period and should be deliverable with the right planning and preparation.

• Quality management

All Advisory Group members agreed that the existing NES PRPS quality management system would be the obvious starting point for any new arrangements that may be required. A comprehensive network of accredited training sites and a cohort of experienced tutors were already in place across Scotland. The existing principles of the quality management system could easily be extended to cover either an enhanced 4+1-year model or an integrated five-year model. Work would be required to scope and agree how NES, the two Schools and the service worked together to deliver any new arrangements. In addition, there were other systems in NES such as the nursing system that the group had learnt about that could be adapted to underpin any new measures.

• Funding

At the outset of the work programme Advisory Group members had been informed that any recommendations needed to be implemented from within current available Scottish Government and Scottish Funding Council ( SFC) funding envelopes in order to remain cost neutral. The SFC provides funding for an MPharm undergraduate degree as a science/laboratory-based subject at price group 2 (£9,336 per FTE), unlike medicine and dentistry, who are funded for two years at price group 3 (£8,274 per FTE) and three years at price group 1 (£16,454 per FTE). Additional funding for experiential learning and placements for medical and dental undergraduate education comes through ACT funding. There is no equivalent for pharmacy meaning that opportunities for patient contact, placement and other forms of experiential learning are limited and rely on goodwill and personal relationships. Currently the NHS PRPS scheme resources are almost fully directed towards the employment of 170 pre-registration pharmacists who are employed in Scotland by their preferred NES approved training provider and their salary and associated costs are covered by a training grant paid to the employer by NES. Members agreed that, notwithstanding some concerns about the lack of any new funding, something significantly better could be done with the existing PRPS money. There was some discussion about moving from the traditional science funding.

• International students

The matter of international students had been raised on a number of occasions. Both GPhC and the two Schools advised that the pre-registration training requirements for international students varied: some wanted a UK pre-registration training post, others wanted to go home after they had completed the undergraduate MPharm course. The Group had heard evidence from international students about the appeal of a fully integrated five-year MPharm. They had also learnt about the charging system for international students used by medicine and dentistry and also in the five-year MPharm pilots in England. There was a view expressed about selling a future vision on the value and desirability of having a Scottish five-year integrated MPharm qualification.

• Admissions

The Advisory Group heard that it was likely that the GPhC's new initial education standards would include a requirement to interview prior to admission. Members agreed that values-based recruitment was used across the NHS and it would be a natural extension to introduce it at undergraduate level in both Schools. Members had heard about the use of multiple mini-interviews in medicine and in pharmacy and the evidence for such an approach. They acknowledged that including interviews in the admission process may require some alterations to UCAS deadlines however this wasn't seen as a problem. The issue of poorly performing students was discussed including strategies to identify and support them sooner in the process, alongside existing university exit strategies. It was agreed that an improved admissions process would help identify some potentially unsuitable students before entry to the course. Following on from the Once for Scotland approach, the Advisory Group supported a single overarching process that was institutionally determined in order to maintain the Schools' individual identities.