A third of the RCGP membership examination is made up of workplace-based assessments. This portfolio of tools needs to reflect GMC requirements, the needs of future GPs and the RCGP curriculum.
Until now, GP trainees have not been assessed on their prescribing practice. However, in 2017 the GMC published a document describing generic professional competences and it decided that prescribing needed to be specifically assessed as part of the GP curriculum.
The RCGP has been piloting a new prescribing assessment for the past two years and all full-time trainees who started their ST3 year in August 2019 are required to complete this assessment by January 2020. These trainees will only be required to complete 10 case-based discussions in their ST3 year, as opposed to 12.
There is a hope to formally role out the assessment from August 2020 for all trainees. When the full package of assessments is changed in 2020 there will be an overall reduction in the assessments required.
What is the assessment?
The assessment is based on the PRACtICe and REVIST studies, which were GMC-led reviews by the University of Nottingham looking at the number of times errors were found in a prescription. The REVIST study found that 1 in 10 GP trainee prescription items contained some sort of error. The RCGP has worked with the Nottingham research team to create the assessment.
The assessment allows trainees to reflect on their prescribing by highlighting good practice but also identifying any errors or suboptimal prescribing and therefore formulating learning needs. It is not looking to set the expectation that all prescribing should be perfect and serves to help understand the competencies around prescribing safely.
A prescribing error has been defined as an intentional event that significantly reduces the probability of treatment being timely and effective or that might increase the risk of harm compared with generally accepted practice. Suboptimal prescribing is simply less than ideal practice that doesn’t fit the description of a prescribing error.
Prescribing errors and suboptimal prescribing
Six prescribing errors have been identified:
- Right drug – was the correct drug chosen?
- Right dose – was the correct dose chosen for the indication?
- Right dosage instructions – were the instructions correctly suggested in an understandable way?
- Right follow-up – was there a sensible follow up plan?
- Right documentation – has any appropriate documentation been provided?
- Right review – was a relevant review carried out before prescribing?
The GMC have stipulated that trainees should meet the ‘prescribing medicines safely’ competencies across a range of ages and clinical areas. In order to show this understanding, they should demonstrate an ability to:
- Adhere to local guidelines and evidence-based medicine
- Use antimicrobials appropriately
- Assess risks and benefits including those who have other medical conditions or an on other medications
- Identify when prescribing unlicensed medications and inform patients
- Counsel patients appropriately
- Review medications including their effects and monitor with blood tests when appropriate
What does the assessment involve?
Trainees need to retrospectively review prescriptions to include 60 items from a set date. Using the prescribing manual that can be found on the RCGP website (see below) trainees should map the prescriptions against potential prescribing errors.
This should be put onto an Excel spreadsheet (also available on the RCGP website) and then passed onto their trainer who should then review 20 of the items prescribed and map them against potential errors. The practice pharmacist could be involved in reviewing these prescriptions as well.
The trainee needs to complete a self-reflection within the learning log by commenting on their prescribing, any errors, the prescribing competences and generate a PDP if any learning needs are identified. The supervisor and trainee (and the practice pharmacist if they were involved) should have a tutorial to discuss the findings at which point the supervisor needs to complete an assessment form.
After this, the supervisor and trainee involved in this mandatory pilot should complete a questionnaire, which is being used to demonstrate that the assessment is reasonable and fair. Then the trainee needs to scan the spreadsheet into their learning log.
Ultimately, when this forms part of the workplace-based assessments, the summative assessment will be the information gathered from the trainer about the trainee’s prescribing. This will consist of a global judgement and be signed off within the educational supervisors report.
The RCGP says that it expects all trainees to have made some errors and have some suboptimal prescribing. The standards against which they are assessed are those set out in their training manual and local guidelines. Identifying errors is ultimately a positive thing and there is no 'right' or 'wrong' number of errors a trainee could or should have.
The process of reviewing 60 prescription items should take a trainee approximately 2-3 hours and then time needs to be given within a tutorial to discuss the findings with the supervisor. The trainer should be assessing prescribing habits within patient case reviews and prescribing meetings within the practice. It is important to make sure that prescriptions are reviewed from a wide range of areas including palliative care and controlled drugs as well as others.
It is highly recommended that the trainee and supervisor familiarise themselves with the documents on the RCGP website before starting the assessment (see below). There is a useful frequently asked questions sheet, which can be referred to for advice.
There is no doubt that this assessment is a valid tool to assess trainees prescribing patterns. This is an area of the curriculum that hasn’t historically been covered so obviously, but having a set way of identifying any errors of improvement will be beneficial for trainees and ultimately provide better and safer patient care.
Dr Kotecha is a GP trainer in Gwent, South Wales
Full advice on the prescribing assessment, including the spreadsheets , questionnaire and GP trainee manual, as well as a FAQ document can be found on the RCGP website here.