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An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain
Research in Social and Administrative Pharmacy 9 (2013) 155–165
Original Research
An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain Samuel D. Jee, M.Res., Sally Jacobs, Ph.D., Ellen I. Schafheutle, Ph.D., M.Res., M.Sc., M.R.Pharm.S.*, Rebecca Elvey, Ph.D., Karen Hassell, Ph.D., Peter R. Noyce, C.B.E., Ph.D., F.R.Pharm.S. School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
Abstract Background: With revalidation in pharmacy in the United Kingdom fast approaching, appropriate systems of revalidation in community pharmacy are required. With little known about the potential use of appraisals for evaluating fitness to practice in pharmacy professionals (pharmacists and pharmacy technicians) in this sector, research was undertaken to explore their potential utility in a revalidation process. Objectives: To examine existing structures and processes in community pharmacy appraisals in Great Britain (ie, England, Scotland, and Wales) and consider the views of pharmacy stakeholders on if, and how, appraisals could contribute to revalidation of pharmacy professionals. Methods: Semi-structured telephone interviews were conducted with senior staff (eg, superintendents and professional development managers) from chain community pharmacies as well as pharmacy managers/ owners from independent pharmacies. Senior staff from locum agencies and pharmacy technician stakeholders were also interviewed. Results: Appraisals were in place for pharmacists in most chain pharmacies but not in independent pharmacies. Locum pharmacists were not appraised, either by the companies they worked for or by the locum agencies. Pharmacy managers/owners working in independent pharmacies were also not appraised. Pharmacy technicians were appraised in most chain pharmacies but only in some independent pharmacies. Where appraisals were in operation, they were carried out by line managers who may or may not be a pharmacist. Appraisals did not seem to cover areas relevant to fitness to practice but instead focused more on performance related to business targets. This was particularly true for those in more senior positions within the organization such as area managers and superintendent pharmacists. Conclusions: Existing systems of appraisal, on their own, do not seem to be suitable for revalidating a pharmacy professional. Considerable changes to the existing appraisal systems in community pharmacy and employer engagement may be necessary if they are to play a role in revalidation. Ó 2013 Elsevier Inc. All rights reserved. * Corresponding author. Tel.: þ44 161 275 7493; fax: þ44 161 275 2416. E-mail address: [email protected] (E.I. Schafheutle). 1551-7411/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2012.07.004
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Keywords: Revalidation; Community pharmacy; Appraisals; Great Britain; United Kingdom
Introduction The pharmacy profession in the United Kingdom (UK)a is anticipating a process of revalidation to be rolled out across all sectors over the coming years.1 Pharmacy professionals, comprising both pharmacists and pharmacy technicians, are regulated by the General Pharmaceutical Council (GPhC) and must be on the GPhC register to practice. Whilst pharmacists are an established profession, pharmacy technicians only recently became a regulated profession in England, Scotland, and Wales (ie, Great Britain [GB]). This became mandatory in July 2011, although pharmacy technicians have been able to register on a voluntary basis since 2005.2 As a regulatory body, the GPhC lays out clear standards for conduct, ethics, and performance of pharmacy professionals3 (previously the Code of Ethics for Pharmacists and Pharmacy Technicians4). It sets out the values, attitudes, and behaviors expected of pharmacy professionals and outlines the minimum standards that pharmacy professionals must adhere to. As a regulator, the GPhC would oversee the process of revalidation, described as a mechanism that allows health professionals to demonstrate that they remain up-to-date and fit to practice,5 for pharmacy professionals practicing in all sectors including community pharmacy. The GPhC has defined fitness to practice as “a person’s suitability to be on the register without restrictions,” in which admission to the register requires that a registrant has “the skills, knowledge, character and health required to do their job safely and effectively.”6 It is likely that pharmacy professionals will have to demonstrate their fitness to practice to maintain their right to practice in the future, but the process is yet to be determined. Most pharmacy professionals practicing in GB work within community pharmacy, often alongside pharmacy support staff, which include counter assistants and dispensing assistants. According to the last pharmacy census conducted in 2008, just over 70% of practicing pharmacists in GB work a
within this sector.7 A recent census of pharmacy technicians showed that a similar proportion of pharmacy technicians (67%) work in the community pharmacy as well.8 Community pharmacies operate in a variety of locations from shopping areas in large cities and small communities, in or near health centers, and in supermarkets. Pharmacy organizations that have a large number of stores are typically referred to as multiple or “chain” pharmacies, whereas pharmacies that are owned by individual (independent) pharmacists, typically having only 1 store, are referred to as independent pharmacies. Chain pharmacies employ a large number of pharmacy staff who are managed by a pharmacy branch manager, a pharmacist in charge of an individual pharmacy. Pharmacy branch managers are often managed by an area manager who oversees the operations of a number of pharmacies. Superintendent pharmacists are the most senior members of pharmacy staff within a pharmacy organization, and they have overall responsibility for the pharmaceutical part of the business. They oversee and govern pharmacy operations in the company through, for example, devising and implementing standard operating procedures.9 In smaller independent pharmacies, there is typically 1 pharmacy branch manager who takes responsibility for the running of the pharmacy. They may or may not be the owner of the pharmacy who, such as superintendents in chain pharmacies, should ensure that the standards of running a retail pharmacy business are being met.9 Some pharmacy professionals are selfemployed and may work in a number of community pharmacies rather than being employed by a single company. These “locum” pharmacy professionals comprise a large number of the community pharmacy workforce: In the 2008 census of pharmacists,7 37% of pharmacists working in community pharmacy classified themselves as locum pharmacists. No data exist on the number of locum pharmacy technicians, but the figure is not thought to be large. Locums can work with agencies that
The United Kingdom comprises England, Scotland, Wales, and Northern Ireland (Ulster). Uniquely, among UK health care professions, there are 2 UK pharmacy regulators; the GPhC regulates pharmacists and pharmacy technicians practicing in England, Scotland, and Wales (GB); in Northern Ireland, only pharmacists are regulated, by the Pharmaceutical Society of Northern Ireland.
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provide help in finding them work, but they can also make their own arrangements, often returning to certain pharmacies on a regular basis.10 The role of appraisals in revalidation In medicine, a profession ahead of pharmacy in terms of implementing revalidation in the UK,11 there are systems already in place that have been designated as suitable sources of evidence for revalidation. Annual appraisals are a key element of medical revalidation and were introduced for all doctors working within the National Health Service (NHS), the tax-funded health service available to all UK residents, in 2001.12 An NHS Revalidation Support team was established, which worked toward “strengthening NHS medical appraisal to support revalidation in England.”11,13 For doctors, appraisals have been defined as “. a professional process of constructive dialogue in which the doctor being appraised has a formal structured opportunity to reflect on their work and to consider how their effectiveness might be improved.”14
It has been noted that the appraisal should aim to bridge experience and reflection, which can encourage learning and precipitate behavior change to improve practice.15 During annual appraisals, typically conducted by medical line managers, doctors will discuss their practice and performance with the appraiser and demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice.16,17 They can demonstrate their adherence to these through, for example, providing evidence of continuing professional development (CPD) and feedback from colleagues and patients where appropriate (ie, for those doctors who have direct patient contact), with portfolios of evidence.18 Every 5 years, responsible officers,19 who are typically experienced senior doctors in NHS organizations,20 will then make recommendations to the General Medical Council (GMC) about a doctor’s fitness to practice. Responsible officers will base their recommendation on the appraisals that were conducted by the appraiser over the 5-year revalidation cycle and other information stemming from clinical governance systems at the organization.21 The GMC will then decide whether to revalidate a licensed doctor. Implementing such a system can, b
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however, be expensive, with first-year costs of rolling out the legislation of responsible officers amounting to £26 million and subsequent annual costs averaging £21.9 million.22 Fortunately, investing in this system can improve health care outcomes, which can save the health care system money, estimated at £16.4 millionb annually.22 The medical profession thus has a framework in place, which will facilitate the process of revalidation to be introduced in late 2012, and this includes the use of appraisals.11 The process and arrangements for the revalidation of pharmacy professionals have yet to be determined. Currently, pharmacy professionals must complete 9 records of CPD each year to maintain their registration.23 Although CPD may have its place within a framework for revalidation, for example, in contributing to portfolios, this form of self-assessment/reflection may not be sufficient to reassure patients and the public that pharmacy professionals are fit to practice. The use of appraisals has been proposed by the Royal Pharmaceutical Society of GB (RPSGB)c Revalidation Advisory Group’s report to the Department of Health24 as 1 possible model for revalidation in pharmacy. Appraisals in pharmacy may be carried out under the Knowledge and Skills Framework,5,25,26 a clear and comprehensive appraisal system that can be used for staff review and development, which pharmacy professionals working in NHS organizations (eg, hospitals) may already participate in. However, the community pharmacy sector does not have a comparable framework in place. No published studies are available for the content, structure, and the utility of appraisal systems in community pharmacy in GB for the revalidation of pharmacy professionals, and international evidence is limited.27 The present study The research presented here is part of a larger program of work,28,29 which aimed to evaluate the use of appraisals and alternative sources of evidence for the purpose of revalidation in pharmacy in GB. More specifically, the objectives were to gather information on existing structures, processes, and items covered in appraisals implemented in the main sectors in pharmacy and explore the views of pharmacy employers on
Exchange rate as of July 2012 was USD 1.55 (EUR 1.26) to GBP (£) 1 (www.xe.com). The RPSGB was the former regulatory body for pharmacy in GB. Since September 2010, the Royal Pharmaceutical Society has become the professional body for pharmacists in GB. c
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if, and how, appraisals could feed into revalidation in future explore other possible sources and structures for gathering evidence for the purpose of revalidation, which already exist in pharmacy examine the views of practicing pharmacists and registered pharmacy technicians working in all sectors on assessment methods and processes for the purpose of revalidation, in England, Scotland, and Wales. This program of work explored employer/ management perspectives from different pharmacy sectors, such as academia and industry,30 NHS organizations (ie, hospitals and primary care),31 external monitoring and inspections of community pharmacies,32 and the views of pharmacy professionals on revalidation.33 The aim of the present article is to focus on community pharmacy, from the employer perspective, and explore current arrangements with regard to the use of appraisals and their potential relevance or utility for the purpose of revalidation in pharmacy in GB. The objectives were to investigate existing structures, processes, and items covered in appraisals implemented in the community pharmacy sector in GB explore the views of pharmacy employers on if, and how, appraisals could contribute to the revalidation of pharmacy professionals in the future and where the responsibility of fitness to practice lies
Methods Data collection Given its exploratory nature, a qualitative approach was adopted for this research. A purposive sample of participants representing the community pharmacy sector was approached through professional networks known to the research team. The researchers sought to target a diverse sample of participants from a range of community pharmacy stakeholders who could offer insight into the current methods of appraisals for pharmacists and pharmacy technicians in a wide range of organizations such as chain and independent pharmacies and also locum agencies. Topic guides were developed based on the existing knowledge from the research and professional and policy literature and also guided by the objectives of the research commissioners. The areas covered in the topic guide included the
existence and structure of appraisals for pharmacists and pharmacy technicians, who was responsible for conducting appraisals, the potential use of appraisals for revalidation, where the responsibility lies for ensuring a community pharmacy professional’s fitness to practice, and the difficulties associated with assessing a pharmacy professional’s fitness to practice. The topic guides were used by the interviewers to conduct semi-structured interviews with probes used where necessary. Informed consent was sought from interviewees in writing before the interviews took place. All interviews were conducted over the telephone and digitally recorded by 1 of the 3 interviewers, including 2 authors (S.D.J. and S.J.). While maintaining the anonymity of participants, recordings of the interviews were transcribed verbatim by an agency contracted to the host university. This study was classified as “service evaluation and development” by the UK National Research Ethics Service, a view subsequently endorsed by the University of Manchester Research Ethics Committee. Formal research ethics approval was therefore not required. Data were also collected as part of another study34 that investigated issues surrounding poor performance of pharmacists, including insight into the use of appraisals to identify performance concerns. This research was commissioned by the National Clinical Assessment Service (NCAS) and was carried out by fellow researchers at the University of Manchester. Data analysis The interview transcripts were analyzed by the first author (S.D.J.). An iterative process of analysis was undertaken, supported by monthly meetings with the coauthors to discuss the transcripts and emergent themes stemming from the data that were analyzed using the framework technique,35 a form of thematic analysis that has 5 key stages. The first stage is “data familiarization,” whereby the analyst listens to and reads through the data gathered and can begin considering and noting key ideas and recurrent themes. The second stage is “identifying a thematic framework,” which involves going through any notes and emergent themes from the data familiarization stage to create a framework from which data can be thematically organized. The analyst can draw on a priori issues, informed by research aims and interview topic guides, and emergent themes derived directly from the data. The third stage is “indexing” in
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which the analyst applies the thematic framework to the data and can annotate or code the data, for example, using qualitative software packages (QSR International NVIVO 10 in this study). The fourth stage is “charting” in which the analyst begins to organize and synthesize the annotations or coding into overarching themes, which allow comparison between subthemes and interviewees. The fifth and final stage of the framework technique is “mapping and interpretation” in which the analyst pulls all the key concepts and characteristics of the data together to provide a clear interpretation of the key findings.
Results A total of 33 interviews were conducted from May to September 2009 and from February to April 2010. Interviews lasted between 15 and 25 minutes. Seventeen interviews were conducted with 14 senior staff (eg, superintendents and professional development managers) from 9 chain community pharmacies (some individuals were interviewed twice, once for the NCAS study34 and again for this research to obtain more detail about appraisal systems). Nine interviews were conducted with pharmacy branch managers/ owners from 9 independent pharmacies. Three interviews were conducted with senior management staff from 3 locum agencies. A final 4 interviews were conducted with pharmacy technician representatives, 2 with senior technicians in hospitals and 2 with members of the Association of Pharmacy Technicians UK. Appraisal structure Eight of the 9 chain pharmacies participating in this study had appraisal systems in place for both pharmacy technicians and pharmacists, and the ninth was developing a system of appraisals but for pharmacy branch managers only. None of the 9 independent pharmacies had any formal appraisal system for pharmacists (pharmacy branch managers/owners and other pharmacists), although 4 had them in place for pharmacy technicians. Pharmacy owners, despite sometimes conducting appraisals with their staff, did not undergo any formal appraisal procedures themselves. Appraisals in community pharmacies were generally conducted by an individual’s line manager (who may or may not be a pharmacist); for example, pharmacy technicians were often appraised by pharmacy branch managers. Pharmacists in
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managerial (eg, pharmacy branch manager and area manager) or superintendent positions were commonly found to be appraised by nonpharmacists. In organizations that had appraisals in place, these were typically carried out on an annual basis, sometimes with quarterly or 6 monthly reviews. Content of appraisals Appraisals for both pharmacists and pharmacy technicians, where they were conducted, had a strong focus on business-related performance and were not generally used to assess clinical skills or professional performance. This was particularly the case for more senior pharmacy staff with management responsibilities (such as area managers or superintendents) in the larger organizations who were usually appraised by non-pharmacists and where the focus of appraisals was oriented around business targets (eg, the number of medicine use reviews carried out and sales made). The following quotes from 2 chain pharmacy interviewees illustrate this point: “[.] with it being the area manager role it’s very business focussed [.] and basically justifying what I’ve done over the past quarter, reviewing the targets that [the line manager] set me the previous quarter.” (Chain pharmacy 9) “[the appraisal] wouldn’t be a [.] it’s not a conversation about clinical capability [.] or professional capability it would be a, it would be a conversation that’s probably more, more easily associated with a business context.” (Chain pharmacy 6)
Concerns with clinical and/or professional underperformance were more commonly picked up through customer complaints or peer reporting and occasionally through routine monitoring processes. Performance concerns were often thought to be issues that should be picked up as they occurred and not left for an appraisal, as demonstrated by the following view from a chain pharmacy representative: “[.] [errors] would be picked up in appraisal but I would hope they wouldn’t be, we wouldn’t wait until the appraisal came round. So by that I mean that if we’ve got concerns throughout the year, that we’re picking them up throughout the year and at the appraisal we’re telling them whether we’ve got concerns that are ongoing or whether they’ve improved or not. The appraisals only happen once a year you see, so they’re really quite a one off event. If we had concerns on a clinical
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Jee et al. / Research in Social and Administrative Pharmacy 9 (2013) 155–165 basis, we certainly wouldn’t be waiting until the appraisal before we raised them.” (Chain pharmacy 7)
As with the appraisals of pharmacists, pharmacy technician appraisals did not cover fitness to practice concerns. Some interviewees noted that the appraisals of pharmacy technicians were not as thorough as those of pharmacistsdwho generally have more overall responsibility in the pharmacyd and simply about how they could improve on any of their weaknesses in contributing to the organization and about future objectives such as career progression. It seemed that pharmacy technicians were appraised in a similar fashion to other (nonpharmacist) employees, such as counter assistants, exemplified by the following interviewee: “[Pharmacy technicians] get a very basic appraisal along with other colleagues but not a thorough one like pharmacists get. [Their appraisal is] still very much as any other colleague in the store as opposed to a pharmacist. I think once they become registered and we see them in the same way, then they will get different appraisals which will be more closely aligned to pharmacists than to normal colleagues. But currently our view is that they’re more like colleagues than pharmacists.” (Chain pharmacy 1)
One pharmacy technician stakeholder who was interviewed highlighted what is examined in the annual appraisal within the community pharmacy they work in: “They look at [.] how you’re performing within the business, they look at career progression, they sort of talk of your weaknesses and your strengths [.] ask if there’s anything that they can do to help improve your performance if you weren’t performing as they want you to [.]” (Pharmacy Technician stakeholder 2)
Locums Locum pharmacists were not covered by any system of appraisal in the pharmacy organizations where they worked nor by locum agencies. According to 1 community pharmacy interviewee, the reason behind this was that locum pharmacists are not classed as employees. “The locum ones, you’re not allowed to appraise locums because that classes them down for employee and gives you a tax and [national insurance] issue.” (Chain pharmacy 7a)
Interviewees from locum agencies explained that they normally undertake background checks
of those who register with them and ensure that their clients are up-to-date with professional registration. However, appraisals were not part of their remit and they had no systematic measures in place to appraise locum pharmacists (or pharmacy technicians) on any issues concerning fitness to practice and revalidation. Although locum pharmacists were not covered by formal appraisals, they may face informal scrutiny from those they work with in some places, and this may prevent them from returning to these organizations in the future as 1 interviewee pointed out: “.locum pharmacists are probably best reviewed by the people that work with them or tend to be reviewed by the people that work with them which tends to be the dispensers and the technicians within the pharmacy. And I think they, they sort of ultimately will say, ‘Yes we’ll have that one back’ or, ‘No we won’t have that one back’ you know so, so it’s not you know it’s not the best way but no they don’t . we don’t do anything with locum pharmacists at all.” (Chain pharmacy 4)
Locum pharmacists may perform poorly within some organizations and lose the option of returning there if, for example, support staff give negative feedback about them to senior management. However, they still have the freedom to work elsewhere, and the options include smaller independent pharmacies, where pharmacists, such as pharmacy branch managers, owners, and locum pharmacists, typically go unmonitored: “.the pharmacists don’t have line managers as such because they work in a shop by themselves so no one is sort of sitting, watching them.” (Independent 3)
Locum agencies confirmed that they also had no formal systems to share information about locums where concerns about their performance or fitness to practice may have been raised. Utility of appraisals for revalidation Interviewees were asked about the extent to which their organization’s appraisal system was currently suitable as a potential source of evidence for the revalidation of pharmacy professionals or could be developed to become so. It was clear that the appraisals were considered, at best, a framework from which to build on for revalidation but that many believed appraisals were currently unsuitable for this purpose. For independent pharmacies with no appraisal systems in place,
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particular difficulties were envisaged in implementing an appraisal-based system of revalidation: “I think if we go down the revalidation route it’ll have to be by peer review . I don’t think we can cope with that as well. Well I think we’d have to, we’d have to get somebody external to, to help us out with that sort of stuff.” (Independent 8)
In many organizations, appraisals acted more as formative assessment and a review of progress as opposed to being a summative assessment. Evidence of this was found in both chain and independent pharmacies: “[.] so it’s [the appraisal] really a summary of . you were set objectives for 2009, have you met those objectives? Have you exceeded them? And what development do you need going forward . it’s a very positive process our appraisal process.” (Chain pharmacy 7b) “It’s [the appraisal] specific to the person’s role and it’s what they do and, you know, are they doing what we want or could we improve what they’re doing. It’s more, it’s a two-way process, how does the person feel about how they’re doing and then if we wanted them to do something a little different, maybe make a few suggestions.” (Independent 3)
Some of the difficulties in considering whether appraisals were suitable for, or could contribute toward, revalidation were because of the ambiguity surrounding revalidation. Without clearer guidelines on what revalidation in pharmacy would involve, and what standards a revalidation assessment would be made against, interviewees found it very difficult to cast judgment on the usefulness of appraisals for this purpose. This uncertainty about revalidation was highlighted by 1 interviewee who commented about what pharmacy professionals should be expected to achieve: “[.] I think it’s a little bit about the fact that you know what can you say . you know what are you validating to?” (Chain pharmacy 2)
Where responsibility for fitness to practice lies The responsibility for ensuring a pharmacy professional’s fitness to practice was often seen by interviewees in chain pharmacies as a joint responsibility, with the individual having responsibility for their own professional practice and the organization having responsibility for the provision of services. This was illustrated by a superintendent pharmacist:
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“I mean ultimately I’ve, I’ve obviously got the accountability for the quality of the service [.] I think there’s a shared responsibility with the individual practitioner because we obviously employ pharmacists to be competent in the role that they undertake and clearly Code of Ethics obligations means that they should not be practicing in an area that they do not feel that they’re competent.” (Chain pharmacy 6)
In a small number of chain pharmacies, it appeared that the individual pharmacist’s professional and clinical performance was seen as entirely their own responsibility and therefore not something addressed much during an appraisal: “If we’re looking at number targets in terms of clinical issues we, we don’t measure very much because we tend to assume that every pharmacist comes as a fully trained pharmacist already and doesn’t need any more support from us on that.” (Chain pharmacy 1)
Similarly, 1 interviewee from an independent pharmacy, without formal appraisals in place for pharmacists, suggested the main responsibility of the fitness to practice of pharmacists tended to lie with the individual and the regulator: “[.] well I suppose you know . the ultimate, the ultimate sort of responsibility for their fitness to practice lies, lies with them and [the General Pharmaceutical Council].” (Independent 9)
Difficulties associated with assessing a pharmacy professional’s fitness to practice There may be difficulties with assessing another pharmacy professional’s fitness to practice in an appraisal. This issue was explored with interviewees to consider their views on this. Some believed that assessing another pharmacy professional in an appraisal could be done if the assessor was trained appropriately to do this: “I think peer evaluation can be quite good as long as the appraiser is, you know, has the right skills to do it.” (Chain pharmacy 2)
Although there was some consensus with the view that a trained assessor could appraise a pharmacy professional’s fitness to practice, there was evidence that some individuals may feel uncomfortable with the notion of assessing someone who is qualified to do the job: I’m employing a professional to do a professional job, you know, if they’re qualified and competent, you know, qualified then who am I to sort of question that. (Independent 3)
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Discussion This study offers novel insights into the existing structures and processes in community pharmacy appraisals in GB and considered how appraisals could contribute to the revalidation of pharmacy professionals. The focus of the research was on the employer perspective of existing appraisal systems in community pharmacy in GB, with the views of senior staff being sought. It is important to gain the views of other pharmacy stakeholders in various positions and from different sectors before decisions on the process of revalidation are made. Insight into the employee perspective is explored in another article33 as are views from stakeholders in academia and the pharmaceutical industry,30 as well as pharmacy professionals working in NHS organizations.31 Finally, a critical discussion article appraises the various strands and implications for pharmacy revalidation.36 Qualitative methodology was adopted for this research because it can provide detailed insights into areas that have not been explored in depth,37 which was well suited for this research. The nature of such methodology does, however, limit the generalizability of the findings to all community pharmacies in GB because the sample sizes are relatively small. Nevertheless, the relevant stakeholders providing a management/employer perspective were involved, and data saturation was achieved, with no new themes emerging. As an exploratory study, the findings do provide important and detailed insights, which can inform the development of a new system of revalidation for pharmacy professionals in GB. Chain pharmacies The existing structures and processes involved in appraisals in community pharmacy and the views on if, and how, they could contribute to the revalidation of pharmacy professionals in GB were explored. At the time of interview, most chain community pharmacies had an appraisal system in place for employed pharmacists and pharmacy technicians, but locum pharmacists were not included in appraisals. Appraisals were typically carried out by line managers, who were not always pharmacists themselves. Pharmacists in senior positions, such as superintendents and area managers, in chain pharmacies were appraised in a number of companies, although appraisals appeared to be oriented more toward the business and operational side of the
organization, perhaps because of their appraisers often being non-pharmacists. With a number of pharmacists being assessed by non-pharmacists, having an appraisal about fitness to practice will prove difficult if the assessor has no background experience in this area. It may, therefore, be necessary for pharmacists to assess each other in the form of peer review, which has been proposed by the medical profession.38 Alternative methods of demonstrating one’s fitness to practice to external bodies such as the GPhC Inspectorate39 may also be considered (presented in another article32), particularly for those working in isolation, such as pharmacy owners or locums, where peer review may not be feasible.32 Although this research found that some may feel uncomfortable questioning another professional’s fitness to practice, this may be mitigated by having appropriate training in place for assessors. Literature from the medical profession has highlighted the importance of supporting a more structured, objective, and evidence-based approach to appraisals by having assessors trained to a high standard.40,41 Overall, appraisals were geared more toward business targets than fitness to practice. This “business” focus of appraisals for pharmacy professionals, which appears to be prevalent in community pharmacy, does not appear to lend itself well to a process of revalidation, which is intended to assert one’s fitness to practice.5 This research highlighted an issue in community pharmacy as to where responsibility for pharmacists’dand now pharmacy technicians’2dfitness to practice should lie. Some interviewees suggested that much of the responsibility lies with the individual who is practicing and also with the regulator, and how employing organizations do or should feed into this is less clear. Further work would need to be carried out on the content covered in pharmacists’ (and pharmacy technicians’) appraisals in community pharmacy, which are business focused, so that they could be used to inform fitness to practice and revalidation. Such work would also need to explore the extent to which community pharmacy employers would be willing and able to engage in supporting or contributing to a system of revalidation, how independence would be ensured, and how the process could be quality assured. Pharmacy technicians were assessed more in line with counter assistants than as a pharmacy professional (similar to a pharmacist), probably because at the time the research was conducted
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registration of pharmacy technicians was not mandatory as it is now.2 With pharmacy technicians now required to be registered and thus revalidated, more work is needed to determine how best this could be undertaken, building on the limited available studies.27 Independent pharmacies In the 9 independent pharmacies, appraisal systems were not in place for pharmacists. Pharmacy technicians were appraised in 4 of these pharmacies, but these appraisals were not an assessment of fitness to practice. Pharmacy managers/owners in charge of the pharmacy were not appraised because they were effectively the most senior in the organization and therefore had no superior to conduct an appraisal for them. Implementing a system of revalidation for these senior pharmacists would be difficult if appraisals are to play a key part. Other sources of evidence, such as that collected during inspection or contract monitoring visits (discussed in another article32), may be useful, and external bodies such as the inspectorate or the GPhC may have a more direct role to play here. This research demonstrates the absence of systems of appraisal in place for locum pharmacists, which may be a cause of concern, given their prevalence in community pharmacies.7 Representatives from the locum agencies that were interviewed also felt unable to assess the locums they placed. This meant that not only did locums not come under any management structures but also there were currently no systems in place to (formally) share information about performance concerns, which could then inform applicability to revalidation.42 Locums typically work in a number of sites; therefore, allocating an assessor would be difficult. As with senior pharmacists such as pharmacy owners and superintendents, other sources of evidence may be most appropriate.32 In some organizations, appraisals, when in place, acted more as a formative process and a review of progress rather than a summative assessment. In medicine, it has been noted that the appraisal should aim to establish a link between experience and reflection, thus encouraging learning, with the ultimate aim of changing behavior to improve practice.15 Some studies have identified clear benefits of such a purely formative approach,43,44 including enhanced learning and improved practice.45 However, if appraisals are to be used as a method of revalidation, they will have to
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take on a summative element. The White Paper published by the Department of Health noted that the appraisal procedure “should be both formative and summative, to ensure objectively that required standards are met” (2009:7),5 so some form of assessment in, for example, clinical competence or patient counseling may need to be incorporated into appraisals if they are to lend themselves to revalidation. This research suggests that to make appraisals useful in supporting a system of revalidation, they would need to undergo major revision. Clear guidance would need to come from the regulator, and companies and individuals employing pharmacy professionals would need to actively engage in the development and implementation of such a system. Representatives from most organizations who were interviewed acknowledged the limitations of their current appraisals for assessing fitness to practice issues. Although the appraisal system may provide a foundation from which to build for revalidation purposes, the content of appraisals does not appear conducive to revalidation in their present state. As noted by some interviewees in this study and another study,33 there is a strong need to have clear standards for the assessment of pharmacy professionals and deciding who will be an appropriate assessor.
Conclusion There is no simple solution for implementing a system of revalidation in the community pharmacy, and different approaches will need to be considered. Existing systems of appraisal may have their uses, if they were to change their current focus, but in their current form, and on their own, they would not be sufficient. At present, community pharmacy employers are not engaged routinely in assessing the fitness to practice of their pharmacy professional staff, and at least some have considered the responsibility for fitness to practice lies entirely with the individual practitioner and the regulator. Community pharmacies undergo contract monitoring visits from NHS primary care organizations and inspections from the regulatory body, and there may be some scope for these to play a part in the revalidation procedure.32 This may be able to serve as part of the summative assessment that is desirable as part of revalidation. Future research could investigate the use of other approaches to revalidation, which may include the use of colleague and patient feedback
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and portfolios, such as those to be used by doctors,11 to show evidence that individuals maintain principles and values of the profession, and demonstrate fitness to practice; this may not, however, be an option for pharmacists working alone, lacking the option for peer assessment. Acknowledgments The research team would firstly like to thank the individuals who agreed to be interviewed and were willing to share their experiences and views, which formed the basis of the analysis and the article. Thanks also to Helen Potter who conducted some of the earlier interviews, which were part funded by the NCAS, whose contribution the authors hereby acknowledge. This work was undertaken by the authors at the University of Manchester with funding from the RPSGB (and now the GPhC), who commissioned this study on behalf of the Department of Health. The views expressed in the publication are those of the authors and not necessarily those of the GPhC. References 1. Hasman A. Get ready for revalidation in pharmacy. Pharm J 2009;283:485. 2. Registration, General Pharmaceutical Council. Available at: www.pharmacyregulation.org/registration. Accessed 13.03.12. 3. General Pharmaceutical Council. Standards of Conduct, Ethics and Performance. London, UK: GPhC; 2010. 4. Royal Pharmaceutical Society of Great Britain. Code of Ethics for Pharmacists and Pharmacy Technicians. London, UK: Royal Pharmaceutical Society of Great Britain; 2007. 5. Department of Health. Trust, Assurance and Safetyd The Regulation of Health Professionals in the 21st Century. London, UK: Stationery Office; 2007. 6. What is ‘fitness to practise’?, General Pharmaceutical Council, GPhC. Available at: www.pharmacy regulation.org/raising-concerns/raising-concerns-aboutpharmacy-professional/what-fitness-practise. Accessed 06.07.12. 7. Seston L, Hassell K. Pharmacy Workforce Census 2008: Main Findings. London, UK: RPSGB; 2009. 8. Seston L, Hassell K. First census of pharmacy technicians: 1. demographics and working patterns. Pharm J 2012;288:140. 9. General Pharmaceutical Council. Standards for Pharmacy Owners and Superintendent Pharmacists of Retail Pharmacy Businesses. London, UK: GPhC; 2010.
10. Shann P, Hassell K. Flexible working: understanding the locum pharmacist in Great Britain. Res Social Adm Pharm 2006;2:388–407. 11. Revalidation, General Medical Council, GMC. Available at: http://www.gmc-uk.org/doctors/revalidation. asp. Accessed 10.07.12. 12. Department of Health. Supporting Doctors, Protecting Patients: A Consultation Paper. London, UK: Crown Copyright; 1999. 13. NHS Revalidation Support Team. Strengthening NHS Medical Appraisal to Support Revalidation in England. A Proposal Paper for Piloting from the NHS Revalidation Support Team. 2009. London. Available at: www.revalidationsupport.nhs.uk. Accessed 16.08.12. 14. Department of Health. Guidance on Appraisal for General Practitioners Working in the NHS. London, UK: Department of Health; 2002. 15. Law S, Haman H, Cameron N, Staples I. GP peer appraisal in Scotland: an ongoing and developing exercise in quality. Educ Prim Care 2009;20:99–103. 16. General Medical Council. Good Medical Practice. London, UK: General Medical Council; 2009. 17. RevalidationdGMP framework for appraisal and assessment, General Medical Council, GMC. Available at: www.gmc-uk.org/doctors/revalidation/revalidation_ gmp_framework.asp. Accessed 18.05.12. 18. General Medical Council. Supporting Information for Appraisal and Revalidation. London, UK: GMC; 2011. 19. Responsible Officers, General Medical Council. Available at: www.gmc-uk.org/doctors/revalidation/ faq_revalidation_p5.asp. Accessed 13.03.12. 20. The Role of Responsible Officer. Response to the Consultation on Responsible Officers and Their Duties Relating to the Medical Profession. London, UK: Department of Health; 2009. 21. My revalidation, General Medical Council, GMC. Available at: http://www.gmc-uk.org/doctors/reva lidation/12388.asp. Accessed 06.07.12. 22. The Medical Profession (Responsible Officers) Regulations 2010-Impact Assessment. 2010. 23. Continuing professional development, General Pharmaceutical Council. Available at: www.pharmacy regulation.org/regulatingpharmacy/educationand professionaldevelopment/continuingprofessional developmentcpd/index.aspx. Accessed 06.07.12. 24. Royal Pharmaceutical Society of Great Britain. A Draft Model for Revalidation in Pharmacy. Report to the Department of Health. London, UK: RPSGB; 2009. 25. Department of Health. The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London, UK: Department of Health; 2004. 26. Department of Health. The Regulation of the Nonmedical Healthcare Professionals. A Review by the Department of Health, Chaired by Andrew Foster. London, UK: Department of Health; 2006.
Jee et al. / Research in Social and Administrative Pharmacy 9 (2013) 155–165 27. Desselle SP, Vaughan M, Faria T. Creating a performance appraisal template for pharmacy technicians using the method of equal-appearing intervals. J Am Pharm Assoc (Wash) 2002;42:768–777. 28. Schafheutle EI, Jacobs S, Jee SD, Elvey R, Hassell K, Noyce PR. Revalidation in Pharmacy: Evaluation of Appraisal and Alternative Sources of Evidence, Vol 1: Main report. University of Manchester & General Pharmaceutical Council; 2010. 29. Schafheutle EI, Jacobs S, Jee SD, Elvey R, Hassell K, Noyce PR. Revalidation in Pharmacy: Evaluation of Appraisal and Alternative Sources of Evidence, Vol 2: Supporting evidence. University of Manchester & General Pharmaceutical Council; 2010. 30. Elvey R, Schafheutle EI, Jacobs S, Jee SD, Hassell K, Noyce PR. Revalidation arrangements for pharmacy professionals in industry and academia in Great Britain: a qualitative study. Res Soc Admin Pharm 2013; 9:178–187. 31. Schafheutle EI, Jee SJ, Hassell K, Noyce PR. What could the NHS appraisal system contribute to revalidation in pharmacy? Pharm J 2011;286:82. 32. Jacobs S, Schafheutle EI, Jee SD, Elvey R, Hassell K, Noyce PR. Existing arrangements for monitoring community pharmacies in England: can they have a role in the revalidation of pharmacists? Res Soc Admin Pharm 2013;9:166–177. 33. Potter H, Hassell K, Noyce PR. Pharmacists’ and pharmacy technicians’ views on a process of revalidation of pharmacy professionals in Great Britain. Res Soc Admin Pharm 2013;9:142–154. 34. Hassell K, Jacobs S, Potter H, Prescott J, Schafheutle E, Seston L. Managing Performance Concerns about Pharmacists. A Report for the National Clinical Assessment Service. NCAS, London & CPWSdUniversity of Manchester; 2010. 35. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, ed. Analyzing
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
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Qualitative Data. London, UK: Routledge; 1994. p. 173–194. Schafheutle EI, Hassell K, Noyce PR. Ensuring continuing fitness to practice in the pharmacy workforce: Understanding the challenges of revalidation. Res Soc Admin Pharm 2013;9:199–214. Berg BL. Qualitative Research Methods for the Social Sciences. 4th ed. Boston, MA: Allyn and Bacon; 2001. Conlon M, Lyons N, Warner L, et al. Using appraisal as the vehicle for revalidation: squeezing a quart into a pint pot? Educ Prim Care 2009;20:77–80. The Inspectorate, General Pharmaceutical Council, GPhC. Available at: www.pharmacyregulation.org/ raising-concerns/inspectorate. Accessed 06.07.12. Wall D, Conlon M, Cullen R, Halligan A. Learning by doing: training general practitioners to be appraisers. Br J Clin Govern 2002;7:294–298. NHS Clinical Governance Support Team. Assuring the Quality of Medical Appraisal. London, UK: NHS CGST; 2005. Jacobs S, Hassell K, Seston EM, Potter H, Schafheutle EI. Identifying and managing performance concerns in UK community pharmacists. J Health Serv Res Policy 2013; in press. Zolle O, Rickenbach M, Gorrod E. The formative impact of general practice appraisals: a post-appraisal questionnaire survey. Educ Prim Care 2009;20: 445–454. Conlon M, Sweeney G, Lyons N, Shelly M. Appraisal: experiences, attitudes and impact. An evaluation of the appraisal process for general practitioners in England. Clinician Manag 2006;14:5–22. Finlay K, McLaren S. Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners’ experiences of appraisal. Qual Prim Care 2009;17:387–395.
Original Research
An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain Samuel D. Jee, M.Res., Sally Jacobs, Ph.D., Ellen I. Schafheutle, Ph.D., M.Res., M.Sc., M.R.Pharm.S.*, Rebecca Elvey, Ph.D., Karen Hassell, Ph.D., Peter R. Noyce, C.B.E., Ph.D., F.R.Pharm.S. School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK
Abstract Background: With revalidation in pharmacy in the United Kingdom fast approaching, appropriate systems of revalidation in community pharmacy are required. With little known about the potential use of appraisals for evaluating fitness to practice in pharmacy professionals (pharmacists and pharmacy technicians) in this sector, research was undertaken to explore their potential utility in a revalidation process. Objectives: To examine existing structures and processes in community pharmacy appraisals in Great Britain (ie, England, Scotland, and Wales) and consider the views of pharmacy stakeholders on if, and how, appraisals could contribute to revalidation of pharmacy professionals. Methods: Semi-structured telephone interviews were conducted with senior staff (eg, superintendents and professional development managers) from chain community pharmacies as well as pharmacy managers/ owners from independent pharmacies. Senior staff from locum agencies and pharmacy technician stakeholders were also interviewed. Results: Appraisals were in place for pharmacists in most chain pharmacies but not in independent pharmacies. Locum pharmacists were not appraised, either by the companies they worked for or by the locum agencies. Pharmacy managers/owners working in independent pharmacies were also not appraised. Pharmacy technicians were appraised in most chain pharmacies but only in some independent pharmacies. Where appraisals were in operation, they were carried out by line managers who may or may not be a pharmacist. Appraisals did not seem to cover areas relevant to fitness to practice but instead focused more on performance related to business targets. This was particularly true for those in more senior positions within the organization such as area managers and superintendent pharmacists. Conclusions: Existing systems of appraisal, on their own, do not seem to be suitable for revalidating a pharmacy professional. Considerable changes to the existing appraisal systems in community pharmacy and employer engagement may be necessary if they are to play a role in revalidation. Ó 2013 Elsevier Inc. All rights reserved. * Corresponding author. Tel.: þ44 161 275 7493; fax: þ44 161 275 2416. E-mail address: [email protected] (E.I. Schafheutle). 1551-7411/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2012.07.004
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Keywords: Revalidation; Community pharmacy; Appraisals; Great Britain; United Kingdom
Introduction The pharmacy profession in the United Kingdom (UK)a is anticipating a process of revalidation to be rolled out across all sectors over the coming years.1 Pharmacy professionals, comprising both pharmacists and pharmacy technicians, are regulated by the General Pharmaceutical Council (GPhC) and must be on the GPhC register to practice. Whilst pharmacists are an established profession, pharmacy technicians only recently became a regulated profession in England, Scotland, and Wales (ie, Great Britain [GB]). This became mandatory in July 2011, although pharmacy technicians have been able to register on a voluntary basis since 2005.2 As a regulatory body, the GPhC lays out clear standards for conduct, ethics, and performance of pharmacy professionals3 (previously the Code of Ethics for Pharmacists and Pharmacy Technicians4). It sets out the values, attitudes, and behaviors expected of pharmacy professionals and outlines the minimum standards that pharmacy professionals must adhere to. As a regulator, the GPhC would oversee the process of revalidation, described as a mechanism that allows health professionals to demonstrate that they remain up-to-date and fit to practice,5 for pharmacy professionals practicing in all sectors including community pharmacy. The GPhC has defined fitness to practice as “a person’s suitability to be on the register without restrictions,” in which admission to the register requires that a registrant has “the skills, knowledge, character and health required to do their job safely and effectively.”6 It is likely that pharmacy professionals will have to demonstrate their fitness to practice to maintain their right to practice in the future, but the process is yet to be determined. Most pharmacy professionals practicing in GB work within community pharmacy, often alongside pharmacy support staff, which include counter assistants and dispensing assistants. According to the last pharmacy census conducted in 2008, just over 70% of practicing pharmacists in GB work a
within this sector.7 A recent census of pharmacy technicians showed that a similar proportion of pharmacy technicians (67%) work in the community pharmacy as well.8 Community pharmacies operate in a variety of locations from shopping areas in large cities and small communities, in or near health centers, and in supermarkets. Pharmacy organizations that have a large number of stores are typically referred to as multiple or “chain” pharmacies, whereas pharmacies that are owned by individual (independent) pharmacists, typically having only 1 store, are referred to as independent pharmacies. Chain pharmacies employ a large number of pharmacy staff who are managed by a pharmacy branch manager, a pharmacist in charge of an individual pharmacy. Pharmacy branch managers are often managed by an area manager who oversees the operations of a number of pharmacies. Superintendent pharmacists are the most senior members of pharmacy staff within a pharmacy organization, and they have overall responsibility for the pharmaceutical part of the business. They oversee and govern pharmacy operations in the company through, for example, devising and implementing standard operating procedures.9 In smaller independent pharmacies, there is typically 1 pharmacy branch manager who takes responsibility for the running of the pharmacy. They may or may not be the owner of the pharmacy who, such as superintendents in chain pharmacies, should ensure that the standards of running a retail pharmacy business are being met.9 Some pharmacy professionals are selfemployed and may work in a number of community pharmacies rather than being employed by a single company. These “locum” pharmacy professionals comprise a large number of the community pharmacy workforce: In the 2008 census of pharmacists,7 37% of pharmacists working in community pharmacy classified themselves as locum pharmacists. No data exist on the number of locum pharmacy technicians, but the figure is not thought to be large. Locums can work with agencies that
The United Kingdom comprises England, Scotland, Wales, and Northern Ireland (Ulster). Uniquely, among UK health care professions, there are 2 UK pharmacy regulators; the GPhC regulates pharmacists and pharmacy technicians practicing in England, Scotland, and Wales (GB); in Northern Ireland, only pharmacists are regulated, by the Pharmaceutical Society of Northern Ireland.
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provide help in finding them work, but they can also make their own arrangements, often returning to certain pharmacies on a regular basis.10 The role of appraisals in revalidation In medicine, a profession ahead of pharmacy in terms of implementing revalidation in the UK,11 there are systems already in place that have been designated as suitable sources of evidence for revalidation. Annual appraisals are a key element of medical revalidation and were introduced for all doctors working within the National Health Service (NHS), the tax-funded health service available to all UK residents, in 2001.12 An NHS Revalidation Support team was established, which worked toward “strengthening NHS medical appraisal to support revalidation in England.”11,13 For doctors, appraisals have been defined as “. a professional process of constructive dialogue in which the doctor being appraised has a formal structured opportunity to reflect on their work and to consider how their effectiveness might be improved.”14
It has been noted that the appraisal should aim to bridge experience and reflection, which can encourage learning and precipitate behavior change to improve practice.15 During annual appraisals, typically conducted by medical line managers, doctors will discuss their practice and performance with the appraiser and demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice.16,17 They can demonstrate their adherence to these through, for example, providing evidence of continuing professional development (CPD) and feedback from colleagues and patients where appropriate (ie, for those doctors who have direct patient contact), with portfolios of evidence.18 Every 5 years, responsible officers,19 who are typically experienced senior doctors in NHS organizations,20 will then make recommendations to the General Medical Council (GMC) about a doctor’s fitness to practice. Responsible officers will base their recommendation on the appraisals that were conducted by the appraiser over the 5-year revalidation cycle and other information stemming from clinical governance systems at the organization.21 The GMC will then decide whether to revalidate a licensed doctor. Implementing such a system can, b
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however, be expensive, with first-year costs of rolling out the legislation of responsible officers amounting to £26 million and subsequent annual costs averaging £21.9 million.22 Fortunately, investing in this system can improve health care outcomes, which can save the health care system money, estimated at £16.4 millionb annually.22 The medical profession thus has a framework in place, which will facilitate the process of revalidation to be introduced in late 2012, and this includes the use of appraisals.11 The process and arrangements for the revalidation of pharmacy professionals have yet to be determined. Currently, pharmacy professionals must complete 9 records of CPD each year to maintain their registration.23 Although CPD may have its place within a framework for revalidation, for example, in contributing to portfolios, this form of self-assessment/reflection may not be sufficient to reassure patients and the public that pharmacy professionals are fit to practice. The use of appraisals has been proposed by the Royal Pharmaceutical Society of GB (RPSGB)c Revalidation Advisory Group’s report to the Department of Health24 as 1 possible model for revalidation in pharmacy. Appraisals in pharmacy may be carried out under the Knowledge and Skills Framework,5,25,26 a clear and comprehensive appraisal system that can be used for staff review and development, which pharmacy professionals working in NHS organizations (eg, hospitals) may already participate in. However, the community pharmacy sector does not have a comparable framework in place. No published studies are available for the content, structure, and the utility of appraisal systems in community pharmacy in GB for the revalidation of pharmacy professionals, and international evidence is limited.27 The present study The research presented here is part of a larger program of work,28,29 which aimed to evaluate the use of appraisals and alternative sources of evidence for the purpose of revalidation in pharmacy in GB. More specifically, the objectives were to gather information on existing structures, processes, and items covered in appraisals implemented in the main sectors in pharmacy and explore the views of pharmacy employers on
Exchange rate as of July 2012 was USD 1.55 (EUR 1.26) to GBP (£) 1 (www.xe.com). The RPSGB was the former regulatory body for pharmacy in GB. Since September 2010, the Royal Pharmaceutical Society has become the professional body for pharmacists in GB. c
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if, and how, appraisals could feed into revalidation in future explore other possible sources and structures for gathering evidence for the purpose of revalidation, which already exist in pharmacy examine the views of practicing pharmacists and registered pharmacy technicians working in all sectors on assessment methods and processes for the purpose of revalidation, in England, Scotland, and Wales. This program of work explored employer/ management perspectives from different pharmacy sectors, such as academia and industry,30 NHS organizations (ie, hospitals and primary care),31 external monitoring and inspections of community pharmacies,32 and the views of pharmacy professionals on revalidation.33 The aim of the present article is to focus on community pharmacy, from the employer perspective, and explore current arrangements with regard to the use of appraisals and their potential relevance or utility for the purpose of revalidation in pharmacy in GB. The objectives were to investigate existing structures, processes, and items covered in appraisals implemented in the community pharmacy sector in GB explore the views of pharmacy employers on if, and how, appraisals could contribute to the revalidation of pharmacy professionals in the future and where the responsibility of fitness to practice lies
Methods Data collection Given its exploratory nature, a qualitative approach was adopted for this research. A purposive sample of participants representing the community pharmacy sector was approached through professional networks known to the research team. The researchers sought to target a diverse sample of participants from a range of community pharmacy stakeholders who could offer insight into the current methods of appraisals for pharmacists and pharmacy technicians in a wide range of organizations such as chain and independent pharmacies and also locum agencies. Topic guides were developed based on the existing knowledge from the research and professional and policy literature and also guided by the objectives of the research commissioners. The areas covered in the topic guide included the
existence and structure of appraisals for pharmacists and pharmacy technicians, who was responsible for conducting appraisals, the potential use of appraisals for revalidation, where the responsibility lies for ensuring a community pharmacy professional’s fitness to practice, and the difficulties associated with assessing a pharmacy professional’s fitness to practice. The topic guides were used by the interviewers to conduct semi-structured interviews with probes used where necessary. Informed consent was sought from interviewees in writing before the interviews took place. All interviews were conducted over the telephone and digitally recorded by 1 of the 3 interviewers, including 2 authors (S.D.J. and S.J.). While maintaining the anonymity of participants, recordings of the interviews were transcribed verbatim by an agency contracted to the host university. This study was classified as “service evaluation and development” by the UK National Research Ethics Service, a view subsequently endorsed by the University of Manchester Research Ethics Committee. Formal research ethics approval was therefore not required. Data were also collected as part of another study34 that investigated issues surrounding poor performance of pharmacists, including insight into the use of appraisals to identify performance concerns. This research was commissioned by the National Clinical Assessment Service (NCAS) and was carried out by fellow researchers at the University of Manchester. Data analysis The interview transcripts were analyzed by the first author (S.D.J.). An iterative process of analysis was undertaken, supported by monthly meetings with the coauthors to discuss the transcripts and emergent themes stemming from the data that were analyzed using the framework technique,35 a form of thematic analysis that has 5 key stages. The first stage is “data familiarization,” whereby the analyst listens to and reads through the data gathered and can begin considering and noting key ideas and recurrent themes. The second stage is “identifying a thematic framework,” which involves going through any notes and emergent themes from the data familiarization stage to create a framework from which data can be thematically organized. The analyst can draw on a priori issues, informed by research aims and interview topic guides, and emergent themes derived directly from the data. The third stage is “indexing” in
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which the analyst applies the thematic framework to the data and can annotate or code the data, for example, using qualitative software packages (QSR International NVIVO 10 in this study). The fourth stage is “charting” in which the analyst begins to organize and synthesize the annotations or coding into overarching themes, which allow comparison between subthemes and interviewees. The fifth and final stage of the framework technique is “mapping and interpretation” in which the analyst pulls all the key concepts and characteristics of the data together to provide a clear interpretation of the key findings.
Results A total of 33 interviews were conducted from May to September 2009 and from February to April 2010. Interviews lasted between 15 and 25 minutes. Seventeen interviews were conducted with 14 senior staff (eg, superintendents and professional development managers) from 9 chain community pharmacies (some individuals were interviewed twice, once for the NCAS study34 and again for this research to obtain more detail about appraisal systems). Nine interviews were conducted with pharmacy branch managers/ owners from 9 independent pharmacies. Three interviews were conducted with senior management staff from 3 locum agencies. A final 4 interviews were conducted with pharmacy technician representatives, 2 with senior technicians in hospitals and 2 with members of the Association of Pharmacy Technicians UK. Appraisal structure Eight of the 9 chain pharmacies participating in this study had appraisal systems in place for both pharmacy technicians and pharmacists, and the ninth was developing a system of appraisals but for pharmacy branch managers only. None of the 9 independent pharmacies had any formal appraisal system for pharmacists (pharmacy branch managers/owners and other pharmacists), although 4 had them in place for pharmacy technicians. Pharmacy owners, despite sometimes conducting appraisals with their staff, did not undergo any formal appraisal procedures themselves. Appraisals in community pharmacies were generally conducted by an individual’s line manager (who may or may not be a pharmacist); for example, pharmacy technicians were often appraised by pharmacy branch managers. Pharmacists in
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managerial (eg, pharmacy branch manager and area manager) or superintendent positions were commonly found to be appraised by nonpharmacists. In organizations that had appraisals in place, these were typically carried out on an annual basis, sometimes with quarterly or 6 monthly reviews. Content of appraisals Appraisals for both pharmacists and pharmacy technicians, where they were conducted, had a strong focus on business-related performance and were not generally used to assess clinical skills or professional performance. This was particularly the case for more senior pharmacy staff with management responsibilities (such as area managers or superintendents) in the larger organizations who were usually appraised by non-pharmacists and where the focus of appraisals was oriented around business targets (eg, the number of medicine use reviews carried out and sales made). The following quotes from 2 chain pharmacy interviewees illustrate this point: “[.] with it being the area manager role it’s very business focussed [.] and basically justifying what I’ve done over the past quarter, reviewing the targets that [the line manager] set me the previous quarter.” (Chain pharmacy 9) “[the appraisal] wouldn’t be a [.] it’s not a conversation about clinical capability [.] or professional capability it would be a, it would be a conversation that’s probably more, more easily associated with a business context.” (Chain pharmacy 6)
Concerns with clinical and/or professional underperformance were more commonly picked up through customer complaints or peer reporting and occasionally through routine monitoring processes. Performance concerns were often thought to be issues that should be picked up as they occurred and not left for an appraisal, as demonstrated by the following view from a chain pharmacy representative: “[.] [errors] would be picked up in appraisal but I would hope they wouldn’t be, we wouldn’t wait until the appraisal came round. So by that I mean that if we’ve got concerns throughout the year, that we’re picking them up throughout the year and at the appraisal we’re telling them whether we’ve got concerns that are ongoing or whether they’ve improved or not. The appraisals only happen once a year you see, so they’re really quite a one off event. If we had concerns on a clinical
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Jee et al. / Research in Social and Administrative Pharmacy 9 (2013) 155–165 basis, we certainly wouldn’t be waiting until the appraisal before we raised them.” (Chain pharmacy 7)
As with the appraisals of pharmacists, pharmacy technician appraisals did not cover fitness to practice concerns. Some interviewees noted that the appraisals of pharmacy technicians were not as thorough as those of pharmacistsdwho generally have more overall responsibility in the pharmacyd and simply about how they could improve on any of their weaknesses in contributing to the organization and about future objectives such as career progression. It seemed that pharmacy technicians were appraised in a similar fashion to other (nonpharmacist) employees, such as counter assistants, exemplified by the following interviewee: “[Pharmacy technicians] get a very basic appraisal along with other colleagues but not a thorough one like pharmacists get. [Their appraisal is] still very much as any other colleague in the store as opposed to a pharmacist. I think once they become registered and we see them in the same way, then they will get different appraisals which will be more closely aligned to pharmacists than to normal colleagues. But currently our view is that they’re more like colleagues than pharmacists.” (Chain pharmacy 1)
One pharmacy technician stakeholder who was interviewed highlighted what is examined in the annual appraisal within the community pharmacy they work in: “They look at [.] how you’re performing within the business, they look at career progression, they sort of talk of your weaknesses and your strengths [.] ask if there’s anything that they can do to help improve your performance if you weren’t performing as they want you to [.]” (Pharmacy Technician stakeholder 2)
Locums Locum pharmacists were not covered by any system of appraisal in the pharmacy organizations where they worked nor by locum agencies. According to 1 community pharmacy interviewee, the reason behind this was that locum pharmacists are not classed as employees. “The locum ones, you’re not allowed to appraise locums because that classes them down for employee and gives you a tax and [national insurance] issue.” (Chain pharmacy 7a)
Interviewees from locum agencies explained that they normally undertake background checks
of those who register with them and ensure that their clients are up-to-date with professional registration. However, appraisals were not part of their remit and they had no systematic measures in place to appraise locum pharmacists (or pharmacy technicians) on any issues concerning fitness to practice and revalidation. Although locum pharmacists were not covered by formal appraisals, they may face informal scrutiny from those they work with in some places, and this may prevent them from returning to these organizations in the future as 1 interviewee pointed out: “.locum pharmacists are probably best reviewed by the people that work with them or tend to be reviewed by the people that work with them which tends to be the dispensers and the technicians within the pharmacy. And I think they, they sort of ultimately will say, ‘Yes we’ll have that one back’ or, ‘No we won’t have that one back’ you know so, so it’s not you know it’s not the best way but no they don’t . we don’t do anything with locum pharmacists at all.” (Chain pharmacy 4)
Locum pharmacists may perform poorly within some organizations and lose the option of returning there if, for example, support staff give negative feedback about them to senior management. However, they still have the freedom to work elsewhere, and the options include smaller independent pharmacies, where pharmacists, such as pharmacy branch managers, owners, and locum pharmacists, typically go unmonitored: “.the pharmacists don’t have line managers as such because they work in a shop by themselves so no one is sort of sitting, watching them.” (Independent 3)
Locum agencies confirmed that they also had no formal systems to share information about locums where concerns about their performance or fitness to practice may have been raised. Utility of appraisals for revalidation Interviewees were asked about the extent to which their organization’s appraisal system was currently suitable as a potential source of evidence for the revalidation of pharmacy professionals or could be developed to become so. It was clear that the appraisals were considered, at best, a framework from which to build on for revalidation but that many believed appraisals were currently unsuitable for this purpose. For independent pharmacies with no appraisal systems in place,
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particular difficulties were envisaged in implementing an appraisal-based system of revalidation: “I think if we go down the revalidation route it’ll have to be by peer review . I don’t think we can cope with that as well. Well I think we’d have to, we’d have to get somebody external to, to help us out with that sort of stuff.” (Independent 8)
In many organizations, appraisals acted more as formative assessment and a review of progress as opposed to being a summative assessment. Evidence of this was found in both chain and independent pharmacies: “[.] so it’s [the appraisal] really a summary of . you were set objectives for 2009, have you met those objectives? Have you exceeded them? And what development do you need going forward . it’s a very positive process our appraisal process.” (Chain pharmacy 7b) “It’s [the appraisal] specific to the person’s role and it’s what they do and, you know, are they doing what we want or could we improve what they’re doing. It’s more, it’s a two-way process, how does the person feel about how they’re doing and then if we wanted them to do something a little different, maybe make a few suggestions.” (Independent 3)
Some of the difficulties in considering whether appraisals were suitable for, or could contribute toward, revalidation were because of the ambiguity surrounding revalidation. Without clearer guidelines on what revalidation in pharmacy would involve, and what standards a revalidation assessment would be made against, interviewees found it very difficult to cast judgment on the usefulness of appraisals for this purpose. This uncertainty about revalidation was highlighted by 1 interviewee who commented about what pharmacy professionals should be expected to achieve: “[.] I think it’s a little bit about the fact that you know what can you say . you know what are you validating to?” (Chain pharmacy 2)
Where responsibility for fitness to practice lies The responsibility for ensuring a pharmacy professional’s fitness to practice was often seen by interviewees in chain pharmacies as a joint responsibility, with the individual having responsibility for their own professional practice and the organization having responsibility for the provision of services. This was illustrated by a superintendent pharmacist:
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“I mean ultimately I’ve, I’ve obviously got the accountability for the quality of the service [.] I think there’s a shared responsibility with the individual practitioner because we obviously employ pharmacists to be competent in the role that they undertake and clearly Code of Ethics obligations means that they should not be practicing in an area that they do not feel that they’re competent.” (Chain pharmacy 6)
In a small number of chain pharmacies, it appeared that the individual pharmacist’s professional and clinical performance was seen as entirely their own responsibility and therefore not something addressed much during an appraisal: “If we’re looking at number targets in terms of clinical issues we, we don’t measure very much because we tend to assume that every pharmacist comes as a fully trained pharmacist already and doesn’t need any more support from us on that.” (Chain pharmacy 1)
Similarly, 1 interviewee from an independent pharmacy, without formal appraisals in place for pharmacists, suggested the main responsibility of the fitness to practice of pharmacists tended to lie with the individual and the regulator: “[.] well I suppose you know . the ultimate, the ultimate sort of responsibility for their fitness to practice lies, lies with them and [the General Pharmaceutical Council].” (Independent 9)
Difficulties associated with assessing a pharmacy professional’s fitness to practice There may be difficulties with assessing another pharmacy professional’s fitness to practice in an appraisal. This issue was explored with interviewees to consider their views on this. Some believed that assessing another pharmacy professional in an appraisal could be done if the assessor was trained appropriately to do this: “I think peer evaluation can be quite good as long as the appraiser is, you know, has the right skills to do it.” (Chain pharmacy 2)
Although there was some consensus with the view that a trained assessor could appraise a pharmacy professional’s fitness to practice, there was evidence that some individuals may feel uncomfortable with the notion of assessing someone who is qualified to do the job: I’m employing a professional to do a professional job, you know, if they’re qualified and competent, you know, qualified then who am I to sort of question that. (Independent 3)
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Discussion This study offers novel insights into the existing structures and processes in community pharmacy appraisals in GB and considered how appraisals could contribute to the revalidation of pharmacy professionals. The focus of the research was on the employer perspective of existing appraisal systems in community pharmacy in GB, with the views of senior staff being sought. It is important to gain the views of other pharmacy stakeholders in various positions and from different sectors before decisions on the process of revalidation are made. Insight into the employee perspective is explored in another article33 as are views from stakeholders in academia and the pharmaceutical industry,30 as well as pharmacy professionals working in NHS organizations.31 Finally, a critical discussion article appraises the various strands and implications for pharmacy revalidation.36 Qualitative methodology was adopted for this research because it can provide detailed insights into areas that have not been explored in depth,37 which was well suited for this research. The nature of such methodology does, however, limit the generalizability of the findings to all community pharmacies in GB because the sample sizes are relatively small. Nevertheless, the relevant stakeholders providing a management/employer perspective were involved, and data saturation was achieved, with no new themes emerging. As an exploratory study, the findings do provide important and detailed insights, which can inform the development of a new system of revalidation for pharmacy professionals in GB. Chain pharmacies The existing structures and processes involved in appraisals in community pharmacy and the views on if, and how, they could contribute to the revalidation of pharmacy professionals in GB were explored. At the time of interview, most chain community pharmacies had an appraisal system in place for employed pharmacists and pharmacy technicians, but locum pharmacists were not included in appraisals. Appraisals were typically carried out by line managers, who were not always pharmacists themselves. Pharmacists in senior positions, such as superintendents and area managers, in chain pharmacies were appraised in a number of companies, although appraisals appeared to be oriented more toward the business and operational side of the
organization, perhaps because of their appraisers often being non-pharmacists. With a number of pharmacists being assessed by non-pharmacists, having an appraisal about fitness to practice will prove difficult if the assessor has no background experience in this area. It may, therefore, be necessary for pharmacists to assess each other in the form of peer review, which has been proposed by the medical profession.38 Alternative methods of demonstrating one’s fitness to practice to external bodies such as the GPhC Inspectorate39 may also be considered (presented in another article32), particularly for those working in isolation, such as pharmacy owners or locums, where peer review may not be feasible.32 Although this research found that some may feel uncomfortable questioning another professional’s fitness to practice, this may be mitigated by having appropriate training in place for assessors. Literature from the medical profession has highlighted the importance of supporting a more structured, objective, and evidence-based approach to appraisals by having assessors trained to a high standard.40,41 Overall, appraisals were geared more toward business targets than fitness to practice. This “business” focus of appraisals for pharmacy professionals, which appears to be prevalent in community pharmacy, does not appear to lend itself well to a process of revalidation, which is intended to assert one’s fitness to practice.5 This research highlighted an issue in community pharmacy as to where responsibility for pharmacists’dand now pharmacy technicians’2dfitness to practice should lie. Some interviewees suggested that much of the responsibility lies with the individual who is practicing and also with the regulator, and how employing organizations do or should feed into this is less clear. Further work would need to be carried out on the content covered in pharmacists’ (and pharmacy technicians’) appraisals in community pharmacy, which are business focused, so that they could be used to inform fitness to practice and revalidation. Such work would also need to explore the extent to which community pharmacy employers would be willing and able to engage in supporting or contributing to a system of revalidation, how independence would be ensured, and how the process could be quality assured. Pharmacy technicians were assessed more in line with counter assistants than as a pharmacy professional (similar to a pharmacist), probably because at the time the research was conducted
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registration of pharmacy technicians was not mandatory as it is now.2 With pharmacy technicians now required to be registered and thus revalidated, more work is needed to determine how best this could be undertaken, building on the limited available studies.27 Independent pharmacies In the 9 independent pharmacies, appraisal systems were not in place for pharmacists. Pharmacy technicians were appraised in 4 of these pharmacies, but these appraisals were not an assessment of fitness to practice. Pharmacy managers/owners in charge of the pharmacy were not appraised because they were effectively the most senior in the organization and therefore had no superior to conduct an appraisal for them. Implementing a system of revalidation for these senior pharmacists would be difficult if appraisals are to play a key part. Other sources of evidence, such as that collected during inspection or contract monitoring visits (discussed in another article32), may be useful, and external bodies such as the inspectorate or the GPhC may have a more direct role to play here. This research demonstrates the absence of systems of appraisal in place for locum pharmacists, which may be a cause of concern, given their prevalence in community pharmacies.7 Representatives from the locum agencies that were interviewed also felt unable to assess the locums they placed. This meant that not only did locums not come under any management structures but also there were currently no systems in place to (formally) share information about performance concerns, which could then inform applicability to revalidation.42 Locums typically work in a number of sites; therefore, allocating an assessor would be difficult. As with senior pharmacists such as pharmacy owners and superintendents, other sources of evidence may be most appropriate.32 In some organizations, appraisals, when in place, acted more as a formative process and a review of progress rather than a summative assessment. In medicine, it has been noted that the appraisal should aim to establish a link between experience and reflection, thus encouraging learning, with the ultimate aim of changing behavior to improve practice.15 Some studies have identified clear benefits of such a purely formative approach,43,44 including enhanced learning and improved practice.45 However, if appraisals are to be used as a method of revalidation, they will have to
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take on a summative element. The White Paper published by the Department of Health noted that the appraisal procedure “should be both formative and summative, to ensure objectively that required standards are met” (2009:7),5 so some form of assessment in, for example, clinical competence or patient counseling may need to be incorporated into appraisals if they are to lend themselves to revalidation. This research suggests that to make appraisals useful in supporting a system of revalidation, they would need to undergo major revision. Clear guidance would need to come from the regulator, and companies and individuals employing pharmacy professionals would need to actively engage in the development and implementation of such a system. Representatives from most organizations who were interviewed acknowledged the limitations of their current appraisals for assessing fitness to practice issues. Although the appraisal system may provide a foundation from which to build for revalidation purposes, the content of appraisals does not appear conducive to revalidation in their present state. As noted by some interviewees in this study and another study,33 there is a strong need to have clear standards for the assessment of pharmacy professionals and deciding who will be an appropriate assessor.
Conclusion There is no simple solution for implementing a system of revalidation in the community pharmacy, and different approaches will need to be considered. Existing systems of appraisal may have their uses, if they were to change their current focus, but in their current form, and on their own, they would not be sufficient. At present, community pharmacy employers are not engaged routinely in assessing the fitness to practice of their pharmacy professional staff, and at least some have considered the responsibility for fitness to practice lies entirely with the individual practitioner and the regulator. Community pharmacies undergo contract monitoring visits from NHS primary care organizations and inspections from the regulatory body, and there may be some scope for these to play a part in the revalidation procedure.32 This may be able to serve as part of the summative assessment that is desirable as part of revalidation. Future research could investigate the use of other approaches to revalidation, which may include the use of colleague and patient feedback
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and portfolios, such as those to be used by doctors,11 to show evidence that individuals maintain principles and values of the profession, and demonstrate fitness to practice; this may not, however, be an option for pharmacists working alone, lacking the option for peer assessment. Acknowledgments The research team would firstly like to thank the individuals who agreed to be interviewed and were willing to share their experiences and views, which formed the basis of the analysis and the article. Thanks also to Helen Potter who conducted some of the earlier interviews, which were part funded by the NCAS, whose contribution the authors hereby acknowledge. This work was undertaken by the authors at the University of Manchester with funding from the RPSGB (and now the GPhC), who commissioned this study on behalf of the Department of Health. The views expressed in the publication are those of the authors and not necessarily those of the GPhC. References 1. Hasman A. Get ready for revalidation in pharmacy. Pharm J 2009;283:485. 2. Registration, General Pharmaceutical Council. Available at: www.pharmacyregulation.org/registration. Accessed 13.03.12. 3. General Pharmaceutical Council. Standards of Conduct, Ethics and Performance. London, UK: GPhC; 2010. 4. Royal Pharmaceutical Society of Great Britain. Code of Ethics for Pharmacists and Pharmacy Technicians. London, UK: Royal Pharmaceutical Society of Great Britain; 2007. 5. Department of Health. Trust, Assurance and Safetyd The Regulation of Health Professionals in the 21st Century. London, UK: Stationery Office; 2007. 6. What is ‘fitness to practise’?, General Pharmaceutical Council, GPhC. Available at: www.pharmacy regulation.org/raising-concerns/raising-concerns-aboutpharmacy-professional/what-fitness-practise. Accessed 06.07.12. 7. Seston L, Hassell K. Pharmacy Workforce Census 2008: Main Findings. London, UK: RPSGB; 2009. 8. Seston L, Hassell K. First census of pharmacy technicians: 1. demographics and working patterns. Pharm J 2012;288:140. 9. General Pharmaceutical Council. Standards for Pharmacy Owners and Superintendent Pharmacists of Retail Pharmacy Businesses. London, UK: GPhC; 2010.
10. Shann P, Hassell K. Flexible working: understanding the locum pharmacist in Great Britain. Res Social Adm Pharm 2006;2:388–407. 11. Revalidation, General Medical Council, GMC. Available at: http://www.gmc-uk.org/doctors/revalidation. asp. Accessed 10.07.12. 12. Department of Health. Supporting Doctors, Protecting Patients: A Consultation Paper. London, UK: Crown Copyright; 1999. 13. NHS Revalidation Support Team. Strengthening NHS Medical Appraisal to Support Revalidation in England. A Proposal Paper for Piloting from the NHS Revalidation Support Team. 2009. London. Available at: www.revalidationsupport.nhs.uk. Accessed 16.08.12. 14. Department of Health. Guidance on Appraisal for General Practitioners Working in the NHS. London, UK: Department of Health; 2002. 15. Law S, Haman H, Cameron N, Staples I. GP peer appraisal in Scotland: an ongoing and developing exercise in quality. Educ Prim Care 2009;20:99–103. 16. General Medical Council. Good Medical Practice. London, UK: General Medical Council; 2009. 17. RevalidationdGMP framework for appraisal and assessment, General Medical Council, GMC. Available at: www.gmc-uk.org/doctors/revalidation/revalidation_ gmp_framework.asp. Accessed 18.05.12. 18. General Medical Council. Supporting Information for Appraisal and Revalidation. London, UK: GMC; 2011. 19. Responsible Officers, General Medical Council. Available at: www.gmc-uk.org/doctors/revalidation/ faq_revalidation_p5.asp. Accessed 13.03.12. 20. The Role of Responsible Officer. Response to the Consultation on Responsible Officers and Their Duties Relating to the Medical Profession. London, UK: Department of Health; 2009. 21. My revalidation, General Medical Council, GMC. Available at: http://www.gmc-uk.org/doctors/reva lidation/12388.asp. Accessed 06.07.12. 22. The Medical Profession (Responsible Officers) Regulations 2010-Impact Assessment. 2010. 23. Continuing professional development, General Pharmaceutical Council. Available at: www.pharmacy regulation.org/regulatingpharmacy/educationand professionaldevelopment/continuingprofessional developmentcpd/index.aspx. Accessed 06.07.12. 24. Royal Pharmaceutical Society of Great Britain. A Draft Model for Revalidation in Pharmacy. Report to the Department of Health. London, UK: RPSGB; 2009. 25. Department of Health. The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London, UK: Department of Health; 2004. 26. Department of Health. The Regulation of the Nonmedical Healthcare Professionals. A Review by the Department of Health, Chaired by Andrew Foster. London, UK: Department of Health; 2006.
Jee et al. / Research in Social and Administrative Pharmacy 9 (2013) 155–165 27. Desselle SP, Vaughan M, Faria T. Creating a performance appraisal template for pharmacy technicians using the method of equal-appearing intervals. J Am Pharm Assoc (Wash) 2002;42:768–777. 28. Schafheutle EI, Jacobs S, Jee SD, Elvey R, Hassell K, Noyce PR. Revalidation in Pharmacy: Evaluation of Appraisal and Alternative Sources of Evidence, Vol 1: Main report. University of Manchester & General Pharmaceutical Council; 2010. 29. Schafheutle EI, Jacobs S, Jee SD, Elvey R, Hassell K, Noyce PR. Revalidation in Pharmacy: Evaluation of Appraisal and Alternative Sources of Evidence, Vol 2: Supporting evidence. University of Manchester & General Pharmaceutical Council; 2010. 30. Elvey R, Schafheutle EI, Jacobs S, Jee SD, Hassell K, Noyce PR. Revalidation arrangements for pharmacy professionals in industry and academia in Great Britain: a qualitative study. Res Soc Admin Pharm 2013; 9:178–187. 31. Schafheutle EI, Jee SJ, Hassell K, Noyce PR. What could the NHS appraisal system contribute to revalidation in pharmacy? Pharm J 2011;286:82. 32. Jacobs S, Schafheutle EI, Jee SD, Elvey R, Hassell K, Noyce PR. Existing arrangements for monitoring community pharmacies in England: can they have a role in the revalidation of pharmacists? Res Soc Admin Pharm 2013;9:166–177. 33. Potter H, Hassell K, Noyce PR. Pharmacists’ and pharmacy technicians’ views on a process of revalidation of pharmacy professionals in Great Britain. Res Soc Admin Pharm 2013;9:142–154. 34. Hassell K, Jacobs S, Potter H, Prescott J, Schafheutle E, Seston L. Managing Performance Concerns about Pharmacists. A Report for the National Clinical Assessment Service. NCAS, London & CPWSdUniversity of Manchester; 2010. 35. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, ed. Analyzing
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
165
Qualitative Data. London, UK: Routledge; 1994. p. 173–194. Schafheutle EI, Hassell K, Noyce PR. Ensuring continuing fitness to practice in the pharmacy workforce: Understanding the challenges of revalidation. Res Soc Admin Pharm 2013;9:199–214. Berg BL. Qualitative Research Methods for the Social Sciences. 4th ed. Boston, MA: Allyn and Bacon; 2001. Conlon M, Lyons N, Warner L, et al. Using appraisal as the vehicle for revalidation: squeezing a quart into a pint pot? Educ Prim Care 2009;20:77–80. The Inspectorate, General Pharmaceutical Council, GPhC. Available at: www.pharmacyregulation.org/ raising-concerns/inspectorate. Accessed 06.07.12. Wall D, Conlon M, Cullen R, Halligan A. Learning by doing: training general practitioners to be appraisers. Br J Clin Govern 2002;7:294–298. NHS Clinical Governance Support Team. Assuring the Quality of Medical Appraisal. London, UK: NHS CGST; 2005. Jacobs S, Hassell K, Seston EM, Potter H, Schafheutle EI. Identifying and managing performance concerns in UK community pharmacists. J Health Serv Res Policy 2013; in press. Zolle O, Rickenbach M, Gorrod E. The formative impact of general practice appraisals: a post-appraisal questionnaire survey. Educ Prim Care 2009;20: 445–454. Conlon M, Sweeney G, Lyons N, Shelly M. Appraisal: experiences, attitudes and impact. An evaluation of the appraisal process for general practitioners in England. Clinician Manag 2006;14:5–22. Finlay K, McLaren S. Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners’ experiences of appraisal. Qual Prim Care 2009;17:387–395.