Use of practice frameworks

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Chapter: Hospital pharmacy : Consultant pharmacists

Despite the exciting advances in hospital pharmacy practice, recruitment to junior posts remained challenging, not helped by the salary differential between hospital and community pharmacy.

Use of practice frameworks


Early years


Despite the exciting advances in hospital pharmacy practice, recruitment to junior posts remained challenging, not helped by the salary differential between hospital and community pharmacy. This was addressed by the intro-duction of work-based formal clinical training programmes to attract and then retain junior pharmacists. In the south-east, this was known as the Structured Training and Experience for Pharmacists (STEPS) project – a focused development programme with staged objectives. This was a London-based project, with Southampton as a control site. Junior pharma-cists were given a structured rotation through London hospitals with defined achievements at each clinical rotation. The project showed that pharmacists developed competencies that could be defined and assessed in order to achieve performance targets. This progression was achieved more rapidly when the targets were described at the beginning of the programme and the Competency Development and Education Group (CoDEG) used this to pro-duce the evidence-based, validated general-level competency framework, which emerged in 2003.


Higher-level and advanced practice


Senior clinical pharmacists who had not moved into a management position, including those who had taught on postgraduate or training programmes, expressed their desire for recognition of their higher-level/advanced prac-tice. At the time, there was no method of defining higher-level/advanced practice in pharmacy and reputation relied on recognition by peers and medical colleagues. Some practitioners working at higher-level specialist practice aligned themselves more closely with the medical team than the pharmacy team, making it difficult to identify the pharmacy level at which they practised.


Hospital-based practice


In the late 1980s US pharmacy practice began to move away from the tradi-tional pyramid structure of hospital pharmacy where promotion to a higher level relied on managerial responsibility. The parallel career ladders describe a more rectangular model where those with relevant clinical competencies can be promoted to the same level as their manager, who deals with human resources issues – akin to models in business. Promotion was linked to a review board considering a variety of documentation (evidence) and port-folios now included self-evaluation against competencies, peer evaluations, letters of recommendation, records of teaching and supervision of juniors.


This was a way of rewarding mentorship and supervision of junior pharma-cists and allowed practice to develop where supply activities were delegated to technicians. Promotion might require delivery of a practice development project or new service such as pharmacokinetic support or nutrition.


The Americans struggled with the classification of young pharmacists. Their pathway was the generation of evidence, which consisted of interven-tion log, descriptions of projects, research published papers, case reviews, contributions to hospital committees and mentor recommendations – much like portfolios of practice today.


The top of these parallel career ladders was occupied by an associate director who was managed by the pharmacy director. The pharmacy director was generally supported by a top-level team, each contributing to the external perception of the pharmacy contribution to hospital care. There might be an operational manager below the director, mirrored by a clinical pharmacy manager in the UK.


In the UK, many clinical pharmacists had developed in the single ladder of clinical practice with the additional skill of building strong working relationships with other clinical specialities and good communication skills. Pharmacy was lacking capacity in practice research. The question that followed was: could multidimensional practitioners be created with not just the ladder of expert practice and education but also research and leadership capabilities?


Consultant pharmacists


The answer to clinical leadership for patient-facing clinical roles came in the late 1990s with the emergence of the consultant nurse role, as Project 2000 moved nursing into a degree-based profession. Later the consultant allied health professional (AHP) role was developed, paving the way for consultant pharmacists, for which Department of Health guidance was published in 2005.


Suggestions of the consultant pharmacist role had been developed in the UK in the early 2000s.


Following the success of the general-level competency framework, CoDEG set up a PhD project to look at a framework for advanced practice. The College of Pharmacy Practice faculty groups and UKCPA were asked to nominate ‘experts’ to participate in the research, which would attempt to determine competencies of advanced practice and the levels of practice. This research demonstrated that there were at least 50 practitioners in the UK working at a very high (‘consultant’) level and led to the development of the advanced-level framework. This information contributed to the Department of Health working party on consultant pharmacists, with a wider reference group as part of the Department of Health consultant pharmacist project in 2004. The Department of Health utilised the framework in its 2005 guidance, renamed as the advanced and consultant level framework (ACLF).


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