A Prescription for Change

The underutilised profession of pharmacy has become the sleeping beauty of our health services but not for much longer. 

Historic changes are underway that promise to awaken a new dynamic in pharmacy practice in Ireland, enabling pharmacists to reach their full potential in delivering an enhanced range of services to patients as part of inter-professional multi-disciplinary healthcare teams.

New legislation has provided scaffolding around which the profession recently commenced a major restructuring of pharmacy education and training in Ireland, which will lead to a significant and major expansion of the role of pharmacy practice.

The scope of untapped potential in the profession is extensive, ranging from health screening and vaccinations to pharmacist prescribing and clinical specialisation.

And pharmacists around the country are keen to embrace this new direction, according to the Pharmaceutical Society of Ireland (PSI), the pharmacy regulator. A recent PSI Study of Community Pharmacy Practice in Ireland that found most pharmacists want to provide new and enhanced services, such as lung capacity screening, sexual health services and structured medicine use reviews. They told researchers that they feel pharmacy is under-valued and under appreciated in current healthcare structures.

The springboard from which the profession is launching itself into a bright new future is the Pharmacy Act 2007. Replacing legislation more than 130 years old, the new Pharmacy Act provides modern and robust regulations that will make the profession more transparent, patient-centred, and focused on patient safety.

A key aspect is the introduction of mandatory continuing professional development (CPD) for pharmacists in Ireland. Currently, in order to be accepted for continued registration, all pharmacists now sign a declaration on an annual basis that they will maintain competency and continue to bring new knowledge and skills to their practice.

In line with the recommendations contained in its Review of International CPD models, the PSI is currently implementing a new system of mandatory CPD for pharmacists.

Kate O’Flaherty, PSI Acting Head of Pharmacy Practice Development, explained that this new CPD system is not based on a traditional points system or accumulation of contact hours. Instead all pharmacists will be encouraged to adopt a more reflective approach to learning and to identify their own learning and development needs based on the skills and competencies required for their particular professional practice.

“Our new CPD model is largely based on a model that has been in place for the last 13 years in Ontario, Canada, for pharmacists. Patient safety is at its core, and it’s a self-reflective peer-supported model. We are currently developing a CPD portfolio, which will be most likely an online portfolio that will serve as a template for pharmacists to help them assess their learning needs and enable them to record, evaluate and demonstrate their professional development.”

The new CPD system will also take into account the many types of learning in which pharmacists can engage in order to progress their professional development. These range from Informal Learning, such as practical, “on-the-job” learning from experience that traditionally does not lead to certification but enhances the individual’s professional knowledge and skills; through to Formal Learning by participation in quality-assured, structured programmes of education training.

“We’re also developing a competency framework for pharmacists which will help with, for example, communication and consultation skills. There are patient consultation areas in all pharmacies now, so possibly many pharmacists will feel they need to develop their communication and consultation skills to maximise the benefits to patients of consultations, and learn how to deal with new and challenging scenarios. They may need new skills or to develop the skills that they already have,” said Kate.

“Another aspect of our CPD model is the peer support and peer review system. Pulling this all together is the imminent establishment of the first Institute of Pharmacy in Ireland. The various medical specialties all have their own colleges or institutes, such as the ICGP or the College of Obstetrics and Gynaecology. Similarly, the Institute of Pharmacy will manage our new CPD system,  a quality assurance process and an assessment process that would be based for the most part on peer assessment.

“The exciting potential of this new Institute is that it will also offer a platform for the development of specialisation in pharmacy. For example, in other countries where this has been developed you would have consultant pharmacists in oncology or cardiology, and they would be part of a wider multi disciplinary healthcare team. Many of those pharmacists would also have specialist prescriptive authority.”

This is a ground-up restructuring initiative for the PSI, starting with an overhaul of the current undergraduate programme, which has long been a four-year pharmacy degree with a further one-year pre-registration training period. The new education model that will replace the old system, possibly as early as 2012, is a five-year integrated Masters programme, which allows pharmacy students to contextualise theory and knowledge in structured placements in a variety of pharmacy fields.

“The students will be regularly placed on work experience in pharmacies, whether it’s in the community or hospital or pharmaceutical industry, which will make what they’re learning in the lecture or the lab more relevant to them. It’s much more integrated and they get to experience what it’s like to work with real patients and as part of a multi-professional healthcare team.

“This model will also create new roles for a lot of established pharmacists who, under the new system, will become teacher practitioners. As well as running a pharmacy and looking after patients, their pharmacy will become a teaching pharmacy; they will take on student pharmacists for on-the-job learning,” said Kate.

A new Tutor Training and Accreditation Programme (TTAP) was developed in 2010 by the Royal College of Surgeons in Ireland (RCSI) on behalf of the PSI to train and accredit tutor pharmacists who oversee the workplace training of pharmacy interns.

November of the same year saw the first cohort of 139 students graduate from the inaugural Masters-level MPharm programme, delivered by the RCSI, marking the first significant milestone of the education reform agenda.

“What’s exciting is that this initial masters programme gave us a start on developing the curriculum for the new integrated five-year masters so that it incorporates new emerging trends and the expanding role in pharmacy. It brings Irish pharmacy in line with international best practice.

“For example, all of the new Masters’ graduates are trained in vaccination skills and they all participated in an inter professional prescribing sciences module alongside medical students, which was not on the curriculum previously.”

Pharmacists are playing an increasing role in direct patient care

The PSI, through its Pharmacy Ireland 2020 initiative, is also encouraging and facilitating greater involvement of pharmacists in the delivery of integrated health services in the community and has established an expert National Pharmacy Reference Group to progress this agenda. A key initiative is to support pharmacy engagement in the work of the HSE Clinical Stategies and Programmes Directorate on implementing new clinical and disease management programmes in pharmacy.

This desire to actively engage more with local multi-professional groups in the care of patients was voiced by 94.6% of pharmacists who responded to the PSI Study of Community Pharmacy Practice in Ireland.

Many respondents felt that the pharmacist is currently underutilised and that there is potential to expand the role of pharmacy in healthcare services to patients. Screening and diagnostic services, medicine use reviews, minor ailment schemes, and vaccinations, were some of the suggestions for the pharmacist to contribute more to patient care.

“For a lot of people, the first contact they have with the health service per se is when they walk into their local pharmacy looking for advice and information. It’s very important that pharmacy is linked with the rest of the health service, fully participating in national public health initiatives, and maintaining close links with multidisciplinary care teams,” observed Kate.

Arising from the recent reclassification by the Irish Medicines of the formerly prescription-only emergency contraceptive pill which is now available directly from pharmacists without a prescription, she envisaged the potentially more medicines could be considered for switching from prescription control so they can be accessed from a pharmacist.

“In other countries there are more nedicines available through pharmacists, essentially the patient will be getting their medication from a different healthcare professional who is perfectly competent, and has the appropriate consultation environment and training,” she pointed out.

In the UK and other countries, medicines such as oral fluconazole for thrush in women; some of the triptans for migraine; statins; low dose aspirin, and certain antibiotics are available from pharmacists.

In addition, more than 50 Boots pharmacies nationwide provided a flu vaccination service last winter, with other pharmacies expected to follow in the coming year. In countries where seasonal flu vaccinations are available in pharmacies, uptake levels have increased by up to 50%.

“Why stop with the flu vaccination? Pharmacy could link in with other public health vaccinations, such as the cervical cancer vaccine. Pharmacists need to be integrated more into the greater wider health service. It’s not the pharmacist or the GP working in isolation, we should be working together to capture all patients who need vaccinations.”

And Kate added: “Up to 2007, when the new pharmacy Act was introduced, the argument against pharmacists vaccinating or making the morning after pill available in pharmacies, or pharmacist prescribing was that we didn’t have the regulatory framework to protect the public. There was no fitness to practise if anything went wrong; you didn’t have robust regulations that would give guidance to pharmacies; and we didn’t have mandatory CPD so there was no way of assuring that pharmacists were continually ensuring their skills were up to date.

“But now we have all of those requirements and safeguards in place or imminent, those arguments against expanding the role of pharmacists are essentially gone. Our future pharmacy graduates are going to be trained to the highest international standards. All of the markers are in place - the regulatory framework, new education and training initiatives, and the appetite to expand our role in the community - the catalyst for this development to take off in a big way is here and ultimately patients and the health system will benefit.”