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Prescribing assessment could become requirement for new doctors

By Catherine Reilly - 13th Jan 2025

Prescribing assessment

The HSE National Medication Safety Programme has advocated for the introduction of a prescribing competence assessment for doctors entering practice in Ireland. Catherine Reilly reports

The HSE National Medication Safety Programme has asked the Medical Council to consider requiring medical students and/or interns to pass the prescribing safety assessment (PSA), the Medical Independent (MI) has learned. It would also need to be available or required at other points to ensure full coverage.

The PSA was established by the British Pharmacological Society (BPS) and the UK Medical Schools Council (MSC) to improve prescribing quality and enhance patient safety.

The impetus for the exam was the 2009 EQUIP study, which was conducted in 19 NHS Hospital Trusts. It found that 8.9 per cent of hospital prescriptions contained errors. The error rate among doctors in foundation year 1 (FY1) and FY2 was 8.4 per cent and 10.3 per cent respectively, compared with 5.9 per cent for consultants.

The PSA has been adopted by all UK medical schools, although many do not use it as a summative assessment. However, all FY1 doctors must pass the PSA to progress to FY2.

In 2022 the BPS and MSC commissioned an independent review to support national decision-making about the future of the PSA. This review, chaired by Prof Jane Dacre, was initiated in the context of the imminent introduction of the medical licensing assessment (MLA), which will test the core knowledge, skills, and behaviours of doctors new to medical practice in the UK.

The Dacre review noted that the PSA is a robust and well-validated standalone test, with good overall reliability. Evidence of prescribing competence was “highly desirable for new UK doctors, and those entering the UK from overseas”. It recommended the continuation of the PSA (potentially including it within an extended MLA) and a requirement to take the assessment before entering clinical practice. It also advised that the General Medical Council should have regulatory oversight of the exam.

In September 2024 the Irish Medical Council’s education and training committee (ETC) discussed correspondence it received from the Clinical Lead of the HSE National Medication Safety Programme, Ms Ciara Kirke.

The ETC was asked to consider making the PSA a mandatory requirement for the award of a certificate of experience (which the Council issues to doctors who complete the intern year), according to meeting minutes.

The PSA was also discussed at the previous ETC meeting in the context of undergraduate training. The minutes, obtained under Freedom of Information law, noted that the matter would be raised with the Irish Medical Schools Council.

HSE

The HSE’s understanding was that the PSA assessment and associated teaching and resources are available within the six Irish medical schools. However, it indicated that in most cases the PSA had not been implemented as a mandatory requirement contributing to final marks.

According to the HSE, there are three points where the PSA could potentially be made available, or required, within the Irish healthcare setting: Undergraduate level; during the intern year and prior to registration to practice in Ireland; and for entrants to basic specialist training, including international medical graduates.

“The undergraduate curriculum would provide the best preparedness for practice, however, offering it during the intern year initially may bridge a gap while all colleges can integrate it into the curriculum. Providing an opportunity for completion of the assessment to doctors wishing to enter the Irish health system would also be necessary if full coverage of prescribers is to be achieved,” a HSE spokesperson told MI.

The HSE stated there are several measures in place to a “varying extent” nationally to improve prescribing quality. These measures include high-quality and standardised clinical pharmacology training, prescribing training scheme modules or elements, and ad hoc training provided by doctors and pharmacists in health settings, particularly hospitals.

“Interns and all NCHDs are supervised in their practice, working with a team of more senior doctors including a consultant. Multidisciplinary teams and particularly clinical pharmacists work collaboratively with prescribers with a strong safety focus. Medicines information resources, electronic prescribing systems and resources promoting safer practice are becoming more commonly available.”

The HSE said it welcomed the ETC’s consideration of whether the PSA may become a requirement at stages of training.

In the future, the HSE could consider making the assessment a requirement for recruitment or for completion following commencement in post.

Council response

In December, a Medical Council spokesperson informed MI the ETC was “considering the options”.

The Council inspects medicine degree programmes using standards from the World Federation for Medical Education. Prescribing is covered under ‘clinical sciences and skills’.

Formal training for interns must include instruction in the development of clinical judgement and elements of safe practice, including considerations around prescribing.

Prescribing safety is one of eight ‘entrustable professional activities’ in the intern curriculum framework developed by the medical intern unit at National Doctors Training and Planning and overseen by the medical intern board. This curriculum has not yet been formally operationalised, it is understood.

Prescribing safety is a component of the Council’s forthcoming new standards and guidance for education and training. The area will also be considered as part of its national graduate outcomes project, which aims to clarify the learning outcomes expected of doctors entering the intern year.

Position of medical schools on PSA

MI contacted the six medical schools in relation to the PSA.

A University of Galway spokesperson said the PSA resources are available to its medical students.

While not a mandatory component of the programme, 80 per cent of final-year students will take the assessment this year.  There is a therapeutics and prescribing programme, which is a mandatory curricular component subject to assessments and mapped to graduate learning outcomes.

A University of Limerick spokesperson said the PSA has been mandatory for all of its final-year medicine students for several years. It contributes to the final summative marks and grade for the final-year professional competencies module.

Trinity College Dublin has offered the PSA to final-year medical students since 2013. “It is mandatory for the 2024/2025 final medical year cohort. The PSA does not currently contribute to the final-year mark.”

Prof Paula O’Leary, Dean and Head, University College Cork (UCC) School of Medicine, said its medicine curriculum includes formal teaching in therapeutics through structured lectures, tutorials, and workshops.

The assessment of knowledge and application of safe prescribing skill is incorporated into written and clinical assessments.

Prof O’Leary said the PSA is available to UCC medicine students to sit on a voluntary basis.

The UCC School of Medicine is undertaking a major review of the curriculum at present. Prescribing competencies and their assessments is an important element of this review.

After the PSA’s quality and validity was established in the UK in 2015, University College Dublin’s (UCD) School of Medicine adopted it as a mandatory component of its professional completion module.

“Within a few years of introducing it, we decided to award students module credit for the PSA. As anticipated, this increased student engagement with learning resources and improved overall cohort performance, ergo the benchmarked prescribing skills of our graduates,” stated Associate Prof Helen Gallagher, Head of Clinical Pharmacology and Therapeutics.

“Two years ago, we introduced the PSA for doctors in our intern network who had not already attained PSA certification (eg, graduates of other medical schools) and have now established the PSA as a requirement for all interns in the UCD Intern Training Network.”

Comment was awaited from the RCSI.

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