Empowering future pharmacists - Embedding prescribing in the United Kingdom pharmacy undergraduate degree.

INTRODUCTION: Pharmacy education within the United Kingdom (UK) is on the cusp of a major change with the integration of pharmacist independent prescribing into the undergraduate Master of Pharmacy (MPharm) degree and foundation year. This presents an opportunity for schools of pharmacy to completely review and redesign the MPharm degree in order to embed prescribing. This commentary details what needs to change within the MPharm degree and how these changes can be enacted. COMMENTARY: The learning outcomes for the new degree place greater emphasis on diagnostic and consultation skills, risk management, professional judgement, and leadership. Course content needs to be sequenced so that complexity builds throughout the programme and clinical skills are taught and practised within the context of prescribing. There will be more emphasis on higher-order cognitive skills, such as collaborative clinical decision-making, considering potential risks and benefits. Teaching will need to align with learning on placements and time needs built into the curriculum for preparation and debrief sessions following placements and simulation scenarios. The increased responsibility that comes with prescribing rights will require review of how professional identity is formed and professionalism skills are taught and assessed. IMPLICATIONS: Pharmacists' expertise in medicines means that they are well-placed to be prescribers, which will help meet health service demands. Long-term funding will be required for placements in community, general practice, and hospital settings, including the provision of training and support to pharmacists mentoring students on placements. In spite of the challenges of curriculum redesign, this opportunity is wholeheartedly welcomed.

Development of a core set of clinical skills for pharmacist prescribers working in general practice: A Delphi study.

BACKGROUND: With increasing numbers of pharmacists working in general practices and undertaking patient-facing roles, it has been recognised that they must have the necessary clinical skills. However, previous studies have highlighted that practice-based pharmacists (PBPs) do not feel confident regarding their clinical skills, and it is unclear what skills are needed. OBJECTIVE: To develop a core set of clinical skills (CSs) required for pharmacists who intend to practise as independent prescribers working in general practice/family medicine. METHODS: Based on a previous study, 18 CSs were selected for inclusion in a three-round Delphi consensus questionnaire. These skills were rated by a Delphi panel on a 9-point Likert scale (ranging from 1 = limited importance to 9 = critical). The Delphi panel comprised designated leads of pharmacist independent prescribing programmes in each United Kingdom educational provider listed on the General Pharmaceutical Council website. A CS was included in the core set if 80% or more of participants scored between 7 and 9, and 15% or less scored between 1 and 3. RESULTS: Following Round 1, seven CSs met the criteria for inclusion: 'Measuring heart rate (radial pulse)', 'Assessing respiratory rate', 'Measuring blood pressure (manual, e.g. with aneroid sphygmomanometer)', 'Measuring blood pressure (automated, i.e. electronic blood pressure monitor)', 'Measuring peripheral oxygen saturation (using pulse oximeter)', 'Measuring temperature', 'Measuring Peak Expiratory Flow Rate'. After two further rounds, a further four CSs were included consisting of 'Undertaking a urinalysis', 'Respiratory examination (includes inspection, palpation, percussion and listening to breath sounds)', 'Screening for/assessment of depression and anxiety using a validated questionnaire (e.g. Patient Health Questionnaire-9 [PHQ-9] scoring)', and 'Patient assessment via National Early Warning Score (NEWS)'. No consensus was reached on nine CSs. CONCLUSION: This study has produced a core set of CSs for prescribing pharmacists. This study may contribute to standardisation of training and assessment for pharmacist prescribers working in general practice/family medicine.

The cardiology training needs of general practice-based pharmacists.

OBJECTIVES: As the role of the general practice clinical pharmacist (GPCP) evolves, there has been a shift towards patient-facing roles across multiple conditions. This study aimed to measure the self-reported cardiology training needs of GPCPs. METHODS: An online survey was developed. Participants were shown a list of statements on cardiac conditions and medication across seven sub-domains. Participants self-reported their knowledge against each statement using a Likert Scale. Participants were considered to require training in that topic where they had 'disagreed', 'strongly disagreed' or expressed a 'neutral' rating in ≥3/7 areas. Participants were shown a list of single statements around cardiology test result knowledge and clinical assessment skills. Respondents who 'disagreed', 'strongly disagreed' or declared a 'neutral' position with the statement were judged to need training in that topic. KEY FINDINGS: Seventy-three out of 135 (54%) GPCPs responded. Acute coronary syndrome had the highest training requirement (38/73, 52%) within conditions. Fifty-nine out of 73 (81%) required training on sacubitril/valsartan and 57/73 (78%) with ivabradine. Fifty-four out of 73 (74%) and 44/73 (60%) required training on how to interpret natriuretic peptides and troponin, respectively. Fifty-nine out of 73 (81%), 48/73 (66%) and 55/73 (75%) required training on interpreting ECG, echocardiogram and coronary angiography, respectively. Reduced length of experience in general practice (<2 years) was commonly associated with increased training needs. CONCLUSIONS: There are areas of unmet cardiology training needs within GPCPs that require further support. As the GPCP role evolves, discussion is needed with national pharmacy stakeholders to decide how to incorporate this learning into routine training programmes.

An evaluation of virtual ethics discussion groups as a method of learning on a pharmacist Independent Prescribing (IP) programme.

BACKGROUND AND PURPOSE: A postgraduate body within Queen's University Belfast (QUB) has offered a pharmacist Independent Prescribing (IP) programme to pharmacists living locally in Northern Ireland (NI) since 2006. In 2016, this course was modified and delivered by the School of Pharmacy within QUB for a non-local population of pharmacists from Great Britain (GB). In order to substitute face-to-face, live training in NI, distance learning methods were employed for one of the modules that involved studying ethical dilemmas. The purpose of this study was to assess participant acceptance and perceived effectiveness of the utilized distance learning methods. EDUCATIONAL ACTIVITY AND SETTING: All participants within Cohort 2 of the IP programme offered to GB pharmacists viewed an online recorded lecture on dealing with ethical dilemmas. This involved being taught about a professional decision-making model. Participants then applied this model to four ethical case studies via virtual discussion groups and were invited to complete a questionnaire regarding their views on these teaching methods. FINDINGS: Twenty participants viewed the online recorded lecture, and 19 attended the virtual discussion groups. Eighteen participants (90%) responded to the survey. Participants reacted positively to the e-learning format. Following the training, all participants felt confident applying the professional decision-making model and only one did not intend to apply the model to their practice. SUMMARY: The utilized e-learning format was well received and effective in producing pharmacists who felt confident approaching and resolving ethical dilemmas in their new roles as pharmacist prescribers.

Comparison of the effects of a 7-day period of non-compliance on blood pressure control using three different antihypertensive agents.

OBJECTIVES: To compare blood pressure control during 7 days of drug omission in patients taking bendroflumethiazide 2.5 mg, nifedipine LA 30 mg or enalapril 20 mg once daily and, secondarily, to measure patient compliance. METHODS: Twenty-four patients with hypertension were assigned, in a random crossover fashion, to a sequence of bendroflumethiazide, nifedipine LA and enalapril, each for 4 weeks, followed by a 1-week period of dose omission. The patients measured their own blood pressure daily using an Omron 705CP monitor. Differences in blood pressure from baseline (mean blood pressure during week 4 on treatment) and the week of dose omission were compared between the three drugs. Patient compliance was measured using pill counts and the Medication Event Monitoring System. RESULTS: Bendroflumethiazide maintained blood pressure control during drug omission for longer than enalapril or nifedipine LA. The magnitudes of the increase in systolic blood pressure (SBP) between baseline and day 7 off treatment were 7.0, 12.2 and 9.7 mmHg for bendroflumethiazide, nifedipine LA and enalapril, respectively. For diastolic blood pressure (DBP), the values were 2.9, 5.3 and 7.3 mmHg for bendroflumethiazide, nifedipine LA and enalapril, respectively. Differences in SBP between bendroflumethiazide and the comparator drugs occurred at day 2 off treatment. Differences in DBP between bendroflumethiazide and nifedipine were apparent on days 2 and 3 off treatment. Differences in DBP between bendroflumethiazide and enalapril were apparent on days 2, 3, 4 and 5 off treatment. Patient compliance throughout the study was high in terms of both taking the medication when required and omitting the medication when required. CONCLUSIONS: Bendroflumethiazide maintained blood pressure control during a period of drug omission better than nifedipine or enalapril.

Uptake of COX-2 selective inhibitors and influence on NSAID prescribing in Northern Ireland.

PURPOSE: Rofecoxib and celecoxib have been recently introduced and promoted as 'safer' non-steroidal anti-inflammatory drugs (NSAIDs) regarding gastric toxicity. The primary aim was to measure their uptake and any impact on conventional NSAID prescribing. A secondary aim was to assess any change in proton pump inhibitor (PPI) prescribing. METHODS: Prescribing data in terms of defined daily doses (DDDs) were pooled from 1997 onwards. Linear trends in the data were tested for using regression analyses. Direct comparisons were made between the April-June quarter of the year 1999 (i.e. before the introduction of rofecoxib and celecoxib) and the same quarter 3 years later. RESULTS: Overall NSAID prescribing in Northern Ireland was found to be increasing linearly at an estimated rate of 154,000 DDDs per quarter since the introduction of celecoxib and rofecoxib. The rate of increase in the volume of prescribing of the two new drugs was found to be four times the rate of decrease in prescribing of the 'older' NSAIDs. Overall prescribing of anti-inflammatory agents had increased from 37.8 to 47.7 DDDs/1000 patients/day over 3 years with no effect on the upward trend in PPI prescribing. CONCLUSIONS: The introduction of rofecoxib and celecoxib has increased prescribing volume of anti-inflammatory agents by 26% in Northern Ireland over the 3-year period. This could pose safety problems in the future as more people are being prescribed anti-inflammatory agents.