New research aims to investigate effective learning delivery methods for trainee prescribers. Dr Sofia Kitromili, TEL User Researcher, and Dr David James, Former Director of British Pharmacological Society explain the impact of training on healthcare delivery.
Prescribing medicines is the major tool used by the NHS to treat illness, alleviate symptoms, and prevent future disease. Medicines also represent a major investment, accounting for around 15% of total healthcare expenditure. For these reasons, rational and safe use of medicines is one of the most influential factors in the quality and cost-effectiveness of healthcare delivery. Unfortunately, previous studies have suggested that a significant minority (5–10%) of prescriptions written in hospital and primary care contain errors. Other research suggests that prescribing is one of the most challenging areas for recently graduating doctors and the part of their jobs that they feel most underprepared for.
Addressing this issue will involve a combination of improved systems of working alongside better training and preparation of the junior prescribers (medical or non-medical) who are responsible for much of the prescribing in NHS hospitals. This was a central motivation in developing the UK Prescribing Safety Assessment (PSA) as an assessment of basic competence to prescribe and supervise the use of medicines. This assessment has to be passed by all UK final-year medical students prior to beginning their careers as junior prescribers in the NHS. The need to review and improve prescribing training, grows with the extension of prescribing rights to other professionals, notably pharmacists, nurses, and physician associates, and the growing complexity of therapeutics.
All candidates who sit the PSA are offered practice assessments to undertake in preparation, where they are given automated feedback on their prescribing and other medicine-related decisions. The response to these materials has been very positive with many indicating how valuable they were in providing realistic case-based scenarios and targeted feedback, something that they wished they had been given access to earlier in their training. As a result, BPS Assessment, who provide the platform for delivering the PSA, have developed additional case-based materials in ‘box-sets’ of 15 cases covering specific aspects of clinical practice (e.g. hypertension, antimicrobials, diabetes). These box-sets are released on the purchase of licenses from the BPS, so that NHS trainee prescribers can practise their prescribing decisions with a variety of scenarios and obtain a generous feedback on their decision and the scenario at hand. NHS England has been funding trusts around the nation to obtain licenses for these practise sets, so that foundation doctors attached to the trusts can practise before taking the formal PSA Assessment. Our motivation behind setting the motion on this project was to investigate whether this approach of case-based practise scenarios is in fact a need for trainees and whether we should insist on funding it or whether we should be looking into a different solution.
NHS Trusts are all focused on the need to foster safe and effective practice in all aspects of healthcare, but medicines represent a particular challenge for all, given their high risk and the capacity for error (e.g. anticoagulants, opioid analgesics). Some have specific training sessions and posts dedicated to the topic and even local assessments, but these approaches are limited by finite and stretched resources. Therefore, the challenge or problem addressed here is:
How can frontline NHS prescribers be best equipped with ongoing training, development and assessment of their skills and knowledge, related to prescribing and supervising the use of medicines?
Our approach to this question has been focused on current education deliveries for NHS prescribers. We observed input from over 1000 foundation doctors (UK and overseas) who were asked to provide feedback on their experience when undertaking the PSA assessment and their training experience prior to taking the exam. The majority of doctors were stressing how unprepared they felt before taking the assessment, and a great need of preparing them better before having to take the exam. While this input is directly linked to the PSA, it still stands to be questioned on the evident unpreparedness that doctors feel when they must be examined on their prescribing skills. In a field where learning by making mistakes poses a real risk of somebody losing their lives, there is little room for error. When trainees state that they are not well equipped to take on an examination that will showcase their skills in the act of prescribing, then what does that say about their feelings when they are on the frontline faced with a patient who needs to be prescribed an ailment for their illness. We decided to investigate the actual training provided to NHS prescribers overall and exclude from our questioning a direct mention of the PSA. We wanted to understand how training is delivered in general and what seasoned prescribers and educators think about the methods utilised.
To do this we approached 10 NHS professionals who came from a range of pharmacological and medical backgrounds and were involved in some form of providing training for junior prescribers to interview them on their own education, current training methods, and the ways training delivery can be improved. Our data gathering and analysis is still underway though we have already identified common ground among the professionals and started to uncover more general prescribing concerns in the overall training provided nationwide. We hope that once our work is done and our results are shared with peers, more support will be put in place to assure that adequate and effective prescribing is available for all our prescribing trainees whether they are doctors, nurses, pharmacists, physician associates and any other role that is being trained to safely prescribe.