Three models of clinical supervision were explored at the Royal Pharmaceutical Society (RPS) conference earlier this month, in a session chaired by Susan Roberts, the associate director for pharmacy at NHS Education for Scotland.
The session was badged as ‘The great prescribing debate’ and heard about approaches being used to support pharmacists to develop into confident and safe prescribers.
Could clinical supervision for all replace designated prescribing practitioners?
Cara Mackenzie, head of pharmacy at NHS Fife suggested that all pharmacists – including non-prescribers – should have clinical supervision and protected learning time.
‘It’s common practice in other professions such as medics and nursing, but less so within pharmacy at the moment,’ Ms Mackenzie told RPS conference delegates.
‘As the role of the pharmacist develops, it’s important to ensure that individuals are enabled and empowered to practice within their competence, expand their competence and maintain their competence.’
She suggested that a clinical supervisor could guide an individual through training and credentialing, day to day reflections on routine practice, as well as providing encouragement, motivation, and support in times of stress.
Clinical supervision should not be seen as therapy, mentoring or coaching, but rather a time for ‘the individual [to] consider their scope of practice and identify areas for growth or any goals that they have, supported by their supervisor’.
‘It can and should evolve in line with the individual’s needs and take them through early career to experienced clinical practice,’ Ms Mackenzie said.
‘It can be both formal and informal, but importantly, it’s about being flexible to suit the individual and their needs, and it can complement existing and other arrangements too.’
‘It does provide practitioners with a space to reflect on their practice, explore new approaches and decide courses of action, helping to build their personal and professional resilience,’ she added.
She highlighted that this was of particular importance with around 86% of pharmacists at high risk of burnout and 61% of pharmacists not being offered sufficient protected learning time.
‘Ultimately, the benefits that clinical supervision bring can contribute to improved patient care and enhancement of staff morale,’ Ms Mackenzie said.
Though identifying a supervisor could be ‘tricky’, she noted, ‘especially in the first instances of rolling it out, perhaps in settings where there’s no resemblance right now to clinical supervision’.
And she suggested that if adequate clinical supervision were in place ‘as standard’, the designated DPP role may not be needed.
‘That’s maybe a step too far for some of you right now that are just getting to grips with the DPP [role], but I think that it’s important to consider that for the future, and not rule it out – clinical supervision would be able to fulfil the DPP requirements,’ Ms Mackenzie said.
Could pharmacist prescribers support DPPs in a lighter-touch role?
Lloyd Kennett, senior education and training pharmacist at NHS Lanarkshire, shared how a ‘prescribing supervisor’ role could bridge the gap between prescribing pharmacists and DPPs.
When changes to pharmacist training and the need for DPPs were announced, Mr Kennett said there was ‘almost a fear or anxiety’ among pharmacists about becoming DPPs, as well as ‘a pressure down the road to deliver this’ in time for 2025/26.
In response, a prescribing supervisor role was implemented in Scotland, based on a model developed by the University of the West of England.
This new role was recommended for pharmacists who lacked the confidence or competencies to become a fully-fledged DPP, Mr Kennett said. But he highlighted that there was ‘quite a lot of overlap’ between the role of a prescribing supervisor and a DPP.
‘They’re both role models. They’re both responsible for supervision. They both facilitate the MDT integration. They’re responsible for identifying and planning their opportunities. They create a supportive environment for the prescribing trainee to learn. They review evidence, and they also undertake formative assessment and give constructive feedback,’ he said.
Prescribing supervisors were also supported with at least five hours of learning time, training for clinical and physical assessment skills, and were able to refer any issues to the DPP to be escalated to the university, rather than having to deal with it themselves.
They also needed just six months of prescribing experience, rather than the three years required at that time for a DPP.
‘We wanted to encourage those in early careers to develop these skills and capabilities for supporting others,’ Mr Kennett said.
The role helped people ‘to build confidence, build either perceived capability or capability, and also, ultimately, by feeling more confident, more capable and having the opportunity, they were more motivated, and they demonstrated these behaviours in terms of eligibility to be a prescribing supervisor’, he added.
Involving pharmacists as prescribing supervisors as well as DPPs who might come from any profession gave trainees the support of someone who understood their course and professional practice, Mr Kennett said.
‘A multidisciplinary approach is critical to developing competent, safe prescribers,’ he added.
And it also developed supervisor capabilities within those who might not have otherwise taken it on.
Mr Kennett said he would like to develop the programme to ‘create a more structured outline of what a prescribing supervisor role is’, especially so as not to blur the boundaries with line managers and DPPs.
And he said that capacity to supervise others needed to be built into job plans. ‘It is a critical part of our role,’ Mr Kennett said.
Should trainee prescribers work towards a ‘level of practice’ rather than a ‘scope of practice’?
William Swain, associate director for clinical education at the UCL School of Pharmacy, shared his personal view that trainee pharmacists should have the option to learn transferable prescribing skills rather than specialise in a clinical area.
He noted that the General Pharmaceutical Council (GPhC)’s requirement for trainee prescribers to have an identified area of clinical practice was interpreted with ‘a more dynamic liberal view’ by some universities while ‘the vast majority’ expected a trainee prescriber to focus on a specific therapeutic area.
‘While I think that’s a really good idea for some pharmacists, it’s not necessarily a good idea perhaps for those at the beginning of their careers at foundation level,’ Mr Swain suggested, particularly if they were working rotationally in different areas.
He proposed that instead, training requirements could focus on ‘transferable prescribing skills that can be applied flexibly, rather than a regimented scope of therapeutic practice’.
Mr Swain suggested that having this option would help to better prepare pharmacists to deal with patients as they present to the pharmacy with overlapping and complex issues, as well as help pharmacists to broaden their scope of practice over time.
He suggested that since foundation level pharmacists would be learning to prescribe, there should be an agreed level of foundation practice that they could work at, with ‘support to be able to make a competent prescribing decision autonomously’, as F1 doctors have.
This would also reduce the ‘supervision burden’ on DPPs to have specialist knowledge in a specific therapeutic area.
Instead, they would be asked to support their trainee in ‘core foundational prescribing skills’, such as history taking, shared decision-making, basic physical examinations and documentation.
Removing the need for trainees to have a specific therapeutic area would also make prescribing courses ‘much more equitable for students’, Mr Swain suggested, because their opportunity to find support and practice with patients wouldn’t be limited by their chosen area of practice.
Mr Swain also said that such a change would ‘support flexibility in the workforce’, give trainees ‘the skills to know how to practice through this lens of collaboration’, and would remove any risk of them having ‘a false sense of security’ that might come from having specific knowledge in one therapeutic area but not in other comorbidities.
‘Having a flexible workforce that isn’t pigeon-holed in a specific scope of practice is really important if we’re looking at cross system working, working across boundaries and working across services,’ Mr Swain said.
‘It perhaps maps much better in terms of how we train as pharmacists, because ultimately I’m advocating for level of practice rather than scope of practice.’
Pharmacists would then be able to specialise or have special interests later on in their career, Mr Swain said.
‘Another potential benefit is perhaps transferable prescribing skills are less susceptible to change over time compared to scope-specific prescribing skills,’ he said.
‘Think about history taking, basic physical examination, documentation, communication… these things haven’t changed, really, for decades.
‘Whereas the evidence base for a particular therapeutic area, particularly in light of the changes of [artificial intelligence], where research is just going to accelerate, things are going to change so quickly that, actually, they’re far more susceptible to change,’ Mr Swain added.
A focus on transferrable skills rather than a specific scope of practice might also enable non-active prescribers, such as those that work in teaching, to act as DPPs, Mr Swain said.
And he said that if the GPhC were to ‘refresh the wording’ for prescribing training requirements, universities could begin to make this approach part of their courses.
A version of this article was originally published by our sister publication The Pharmacist.
Image: William Swain, Lloyd Kennett and Cara Mackenzie (L-R) speaking at the RPS Conference.
