Neil Howie 1
1MSc, SFHEA, PA-R, Principal Research Fellow, Physician Associates for Healthcare Improvement, Wolverhampton, United Kingdom
ABSTRACT
Background: As the Physician Associate (PA) profession in the UK moves towards statutory regulation with the General Medical Council (GMC), consideration is being given to which, if any, mechanism of prescribing should be granted to PAs. This study examines the alignment between the PA educational curriculum and two pathways to prescribing authority: independent prescribing (IP) from qualification and the non-medical prescribing course. The aim is to determine whether PA education equips graduates for independent prescribing, potentially reducing the need for post-qualification training. Methods: A comparative curriculum analysis was conducted by mapping the pre-2023 PA curriculum against the General Pharmaceutical Council (GPhC) standards for pharmacist independent prescribers and the GMC outcomes for newly qualified doctors. The curriculum mapping was performed using an Excel-based comparison tool, identifying areas of direct and oblique alignment between the PA curriculum and the master curricula. Results: The analysis revealed comprehensive alignment between the PA curriculum and the competencies required for independent prescribing by pharmacists and newly qualified doctors. Key areas of alignment include patient-centred care, professional knowledge and skills, and professionalism. However, gaps were identified in the PA curriculum regarding the use of technology in prescribing and the clinical governance of prescribing. Discussion: The findings suggest that the PA curriculum provides a strong foundation for many aspects of prescribing education, supporting the idea that PAs should be granted the use of a mechanism of prescribing. Addressing identified gaps, particularly in technology use and clinical governance, could further enhance PA preparedness for prescribing roles. This could reduce the extent of any post-qualification training. Future research should explore variations in clinical experience and individual readiness for independent prescribing among PAs. Collaborative efforts and ongoing curriculum refinement are essential to integrate PAs into prescribing roles while ensuring patient safety in the UK healthcare system.
Keywords: Physician associate, Physician assistant, Prescribing education, Independent prescribing, Curriculum mapping, Health professions education
Date submitted: 19-May-2024
Email: Neil Howie (neilhowie@pafhi.org)
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Citation: Howie N. A Comparative Analysis of the UK Physician Associate Curriculum Against the Prescriber Curricula for Pharmacists and Doctors. Educ Health 2024;37:357-366
Online access: www.educationforhealthjournal.org
DOI: 10.62694/efh.2024.91
Published by The Network: Towards Unity for Health
As the Physician Associate (PA) profession prepares for statutory regulation under the General Medical Council (GMC), there is increasing recognition of the need for PAs to have prescribing authority. 1 Currently, PAs are unable to prescribe prescription-only medications (POMs), which limits their ability to independently manage patient care. With over 4,000 qualified PAs in the UK, the lack of prescribing authority is seen as a barrier to the profession’s full integration into clinical practice. Independent prescribing (IP) has been identified as the most appropriate mechanism to overcome this limitation and enable PAs to work to the fullest capacity of their training.
Independent prescribing (IP) refers to the ability of healthcare professionals to prescribe medicines, including POMs, without needing direct supervision from another clinician. The prescriber takes full responsibility for assessing the patient, making a diagnosis, deciding on the necessary treatment, and prescribing the appropriate medication. This role is typically associated with a high level of professional autonomy and clinical responsibility. In the UK, there are two main routes to becoming an independent prescriber:
In contrast to independent prescribing, Patient Group Directions (PGDs) offer a more limited form of prescribing autonomy. Under PGDs, clinicians can only supply or administer POMs to patients who fit specific criteria outlined in a written direction. The criteria are pre-determined, and the clinician must be signed off as competent to administer each specific POM. This restricts flexibility in clinical decision-making, as the clinician is bound by the PGD’s instructions rather than making a case-by-case assessment of the patient’s needs.
The introduction of statutory regulation for PAs presents an opportunity to reconsider their role within healthcare systems, particularly in prescribing. The debate now focuses on whether PAs should be granted prescribing authority from qualification or follow the post-registration route used by other healthcare professionals.
This study builds upon previous research, which identified independent prescribing as the most suitable mechanism for PAs. 3 It aims to map the pre-2023 UK PA curriculum against the prescribing curricula for doctors and pharmacists, assessing whether PAs are already equipped for prescribing roles and determining whether additional post-qualification training is necessary. The findings will contribute to ongoing discussions about PA prescribing authority and guide future policy on prescribing pathways for PAs in the UK.
Table 1 professions that can undertake post-registration independent prescribing qualifications and time of registration required to commence a course
This curriculum mapping seeks to determine whether PA education currently equips graduates to undertake either of the existing methods of independent prescribing. If it does, this could significantly reduce or eliminate the need for additional prescribing training post-qualification, potentially recognising prior learning to expedite the process. Moreover, the findings could guide future development of the model of prescribing mechanisms that PAs could utilise.
The objective is to map the pre-2023 national PA curriculum against the prescribing curricula of doctors and pharmacist independent prescribers (PIPs).
Some literature exists on the teaching of pharmacology to PA students. It has been reported that the nature of pharmacology teaching on UK PA courses varied. 4 Two other pieces of work have explored, to some degree, the views of PAs on different mechanisms of prescribing. 5,6 Another study has compared the scope of practice of PAs to that of three healthcare roles and indicates IP as the most appropriate mechanism for providing POM. 3 However, none directly maps the PA national curriculum to that of either a post-registration IP course, or the prescribing competences set out by the GMC for doctors.
Curriculum mapping refers to the comparison of two or more curricula, producing an illustration, often in the form of a grid. The resulting illustration can then be reviewed to identify areas of commonality and difference between the curricula in question and highlight gaps between them. The data being compared is in the form of the documents that comprise the curricula. These can be written by different organisations, using different terminology, structures, and formats, which can make direct comparison difficult. The curriculum map seeks to overcome these institute-level disparities to provide a meaningful comparison. The approach to mapping that has been used here follows the principles for curriculum mapping set out by Greatorex et al. 7
To select the appropriate curricula for comparison it was first necessary to define the level of the curricula to ensure that these are all at the same level of influence in the respective professions. This was done in line with the concept of macro, meso, and micro level curriculum, as defined in general approaches to education. 8 In this context, the individual modules and classes that comprise the course are the micro-level curriculum. The overall programme specification or syllabus is the meso-level, and the macro-level are those national-level documents which define the requirements of the meso-level.
For this comparison, the PA national curriculum is The Competence and Curriculum Framework for the Physician Assistant (CCF). 9 The CCF is one of two macro-level documents that govern the education of PAs. The other is the Matrix of Core Clinical Conditions, 10 which specifies clinical conditions that PAs are expected to assess, and the level of competence expected to assess and manage these conditions. In contrast, the CCF sets out general competencies, educational outcomes, and core syllabus for PA education. This is set out across the document in different sections:
These five subsections represent the curriculum for PA education that will be compared separately against each of the two master curricula.
The curriculum mapping in this study followed the structured approach outlined by Gretorex et al., 7 which provides a systematic method for comparing curricula by identifying areas of direct and oblique alignment. This stepwise process ensured that the Physician Associate (PA) curriculum was rigorously compared to the independent prescribing curricula of pharmacists and doctors.
The master curriculum for non-medical prescribing is the General Pharmaceutical Council’s (GPhC) Standards for the Education and Training of Pharmacist Independent Prescribers. 11 This was selected as it specifies a curriculum for all PIP courses that includes competencies, as well as the overall standards of the course being undertaken. This aligns well with the equivalent physician associate curriculum document, as both can be defined as macro-level curricula. Equivalent documents for other NMP professions do not necessarily combine these features. For example, the Nursing and Midwifery Council (NMC) Standards for Prescribing Programmes12 sets overall standards for programmes (e.g. the entry criteria to programmes, practice learning and assessment) but for specific prescribing competencies, refers to another document, the Royal Pharmaceutical Society’s (RPS) A Competency Framework for All Prescribers. 13
For the curriculum for independent prescribing from qualification, the GMC’s Outcomes for Graduates 14 was selected. The outcomes are those listed in section 18: Prescribing Medications Safely, and these set the standards expected for new doctors. This aligned well to the CCF, which sets the standards for newly qualified PAs. Outcomes for Graduates is also a macro-level curriculum.
The comparison was conducted at the macro level, focusing on national-level standards that define competencies across the professions:
An Excel-based tool was created for curriculum mapping:
The author conducted the curriculum mapping independently. Each section of the CCF was reviewed and compared to the relevant sections of the GPhC and GMC curricula. Focus was placed on competencies such as clinical decision-making, pharmacology knowledge, and legal/ethical responsibilities related to prescribing.
For example, the GPhC standards for safe prescribing were directly compared with PA competencies in pharmacology and patient care, identifying where the PA curriculum aligned or diverged from the prescribing curricula of other professions.
The curriculum mapping was performed by a single researcher, following the guidelines provided by Gretorex et al. 7 No formal consensus-building or statistical measures (e.g., kappa statistics) were used, but the structured approach ensured that judgments of alignment were rigorously applied.
The curriculum mapping analysis revealed a comprehensive alignment between the Competence and Curriculum Framework (CCF) for Physician Associates and the master curricula outlined by the GPhC and the GMC. Specifically, the CCF mapped entirely to the GPhC standards for pharmacist independent prescribers, encompassing all learning outcomes across the five sections of the CCF. This alignment indicates a strong correlation between the educational objectives of the Physician Associate curriculum and the competencies required for independent prescribing by pharmacists.
Furthermore, the CCF demonstrated a robust alignment with the GMC outcomes for newly qualified doctors, particularly in the domain of prescribing medications safely. All competencies specified by the GMC were found to correspond to elements within the CCF, highlighting the consistency between the educational requirements for Physician Associates and those for medical practitioners.
In addition to the direct alignment observed between the curricula, several areas of oblique alignment were identified during the mapping process. These instances signify overlapping themes or concepts between the curricula, albeit with nuanced differences in terminology or emphasis. For instance, both the GPhC and GMC curricula emphasised the importance of utilising technology in prescribing practices, a concept implicitly echoed in the CCF’s focus on adapting to different healthcare settings and technological advancements.
Table 2 (Direct alignment – green; Oblique alignment – yellow; No alignment - red)
Table 3 (Direct alignment – green; Oblique alignment – yellow; No alignment - red)
Overall, the results of the curriculum mapping analysis indicate a strong foundation within the Physician Associate curriculum that aligns closely with the educational standards set forth by regulatory bodies for prescribing professions. This alignment suggests that Physician Associate education adequately prepares graduates for the responsibilities associated with independent prescribing, and so lays a solid groundwork for the potential future integration of prescribing authority within the profession.
This study identified several areas of alignment and divergence between the PA curriculum and independent prescribing (IP) curricula. Notably, there was comprehensive alignment with the GPhC standards for pharmacist independent prescribers and the GMC outcomes for newly qualified doctors, indicating a strong foundation within the Physician Associate curriculum. However, areas of oblique alignment underscore the need for refinement to ensure comprehensive coverage of prescribing competencies.
The mapping process found three areas of oblique alignment between the CCF and each of the two master curricula. In each case, the outcome used very specific language that did not have a direct equivalent in the CCF.
The areas of oblique alignment are generally specific to one of the curricula or another. However, there is one common area in both the GMC (GMC – n) and GPhC (GPhC – 22 & 23) curricula: the use of technology in prescribing. Both specifically acknowledge that technology will impact prescribing, either through electronic prescribing systems or through the limitations that remote consultation places on responding to patient needs. Although the PA curriculum does not have a direct equivalent, it does refer to preparing prescriptions in different settings, including primary care (2.3.8), and to becoming adept at the use of information technology (3.4). This suggests a potential link between the two learning outcomes (LOs), but such a link should not be assumed. The latter PA LO suggests that a PA should adapt to new technology regardless of its purpose. This corresponds to the gap between the declared and taught curriculum, as set out by Harden 15, where in this case, the PA curriculum does not explicitly state that electronic prescribing systems should be taught but might be discussed with students depending on the PA course.
Similarly, the GMC curriculum specifies a learning outcome for respecting patient use of complementary therapies. There is no equivalent LO for PAs under prescribing, but there is a LO (2.3.2) in which PAs must respect and foster patient choice in planning and deciding on their own treatment decisions.
GPhC outcome 14 refers to the clinical governance of the prescriber, noting that they may also be able to supply medicines. There is no equivalent in the GMC outcomes, nor in the RPS competencies on prescribing. Instead, the CCF had a broad equivalent that aligns with the general principle of the corresponding outcome, but there is potential for a curriculum gap to form due to interpretation of that outcome.
These areas of oblique alignment identified in this study underscore the importance of refining the PA curriculum to address specific language discrepancies and ensure comprehensive coverage of prescribing competencies. While the PA curriculum aligns with overarching principles of professionalism, person-centred care, and evidence-based practice, addressing the nuances highlighted by the GMC and GPhC curricula can enhance the preparedness of PAs for prescribing roles. Furthermore, future research should explore variations in clinical experience and individual readiness for independent prescribing to provide a more nuanced understanding of educational preparedness among PAs.
The findings from this curriculum comparison suggest several opportunities for enhancing the PA curriculum to better align with the competencies required for independent prescribing. While there is notable overlap between the existing PA curriculum and the prescribing curricula for doctors and pharmacists, some gaps in training were identified that could be addressed to ensure PAs are fully prepared for prescribing roles.
These targeted enhancements to the PA curriculum would not only better equip PAs for prescribing roles but also reduce the need for extensive post-qualification training. Implementing these changes would facilitate a smoother transition for PAs to be granted prescribing authority, whether upon qualification or through a tailored post-registration training programme.
The near-universal alignment of the PA curriculum to IP curricula supports earlier work on the potential use of IP by PAs. 3,16 It also reinforces the idea that IP is the appropriate mechanism for the provision of POMs by PAs. 3 Should prescribing authority be granted in the form of a post-registration IP course, existing PAs could apply for recognition of prior learning (RPL) for the equivalent outcomes of their PA course to an IP course. However, disparities may exist in how much RPL can be applied across different PA courses in the UK. Gaps will come, as highlighted in previous studies 4,17 particularly in pharmacology knowledge and other areas of oblique alignment identified by this research. Providers of IP courses must consider how to design flexibility into their curricula to accommodate these differences. A PA course provider could, for example, offer an IP course tailored specifically for graduates of their PA course.
A strength of this study is that all three of the curricula set out the expectations of a newly qualified practitioner in the respective professions, allowing a like for like comparison. This study is limited by being focused on macro-level curricula and not mapping micro-level curricula. It is not practical to map the curricula of all 35 current PA courses, and such a project would be limited to current course curricula and not consider older versions of a curriculum that have ceased to be used. Harden20, set out that curriculum gaps can exist between the ‘declared curriculum’ (the macro-level curriculum) and the taught curriculum (i.e. that at meso- and micro-level) that forms the basis of a course. Further research is required to map PA course curricula to the master curricula used in this study. A representative sample of 6–8 PA courses may be selected to give a national picture at the micro-level.
In conclusion, the comparative analysis between the PA curriculum and IP curricula primarily reveals areas of alignment. Although oblique alignments highlight language discrepancies that necessitate interpretation, the overall picture suggests that IP, in some form, would be an appropriate mechanism for providing POMs by PAs. Recognizing prior learning and refining the PA curriculum provide promising pathways for preparing PAs to undertake IP, should such a mechanism be provided. Moving forward, collaborative efforts and ongoing refinement of educational curricula are essential to ensure the effective integration of PAs into prescribing roles while upholding standards of patient care and safety in the UK healthcare system.
Nil.
There are no conflicts of interest.
I would like to thank colleagues at PAs for Healthcare Improvement for their contributions to the success of this research.
1. Howie N, Saunders J, Straughton K, Pooler A, Cadman-Davies L. The Proposed Journey to Prescribing for Physician Associates: Information for Educators [Internet]. Keele, U.K.: PA Educators Conference, Keele University, March 2021; 2021 [cited 2021 Apr 22]. Available from: https://www.researchgate.net/publication/350452034_The_Proposed_Journey_to_Prescribing_for_Physician_Associates_Information_for_Educators
2. Department of Health and Social Security. Medicinal Products: Prescription by Nurses etc. Act 1992. 1992.
3. Howie N, Howie F, Seville P. Comparison of the scope of practice of physician associates with that of healthcare professions with prescribing responsibility from point of registration. Future Healthcare Journal. 2023;10(1):38–45. https://doi.org/10.7861/fhj.2022-0064
Crossref PubMed PMC
4. Guest BN, Chandrakanthan C, Bascombe K, Watkins J. Pharmacology for physician associate programmes: a collaborative, flexible and responsive approach to curriculum design. Future Healthcare Journal. 2021;8(3)–584. https://doi.org/10.7861/fhj.2021-0085
Crossref
5. Guest BN, Chandrakanthan AC, Bascombe K, Watkins J. Physician associate prescribing: perspectives, practices and pathways. Future Healthcare Journal. 2022;9:1–8. https://doi.org/10.7861/fhj.2022-0002
Crossref
6. Williams L, Adhiyaman V. What do physician associates think about independent prescribing? Future Healthcare Journal. 2022;9(3). 2022-0026. https://doi.org/10.7861/fhj.2022-0026
Crossref
7. Greatorex J, Rushton N, Coleman T, Darlington E, Elliott G. Towards a method for comparing curricula. 2019;(July). Available from: http://www.cambridgeassessment.org.uk
8. Boeren E. Understanding Sustainable Development Goal (SDG) 4 on “quality education” from micro, meso and macro perspectives. International Review of Education. 2019;65(2):277–294. https://doi.org/10.1007/s11159-019-09772-8
Crossref
9. Faculty of Physician Associates. Competence and Curriculum Framework for the Physician Assistant. Physician Assistant Managed Voluntary Register. 2012.
10. Department of Health. Matrix specification of Core Clinical Conditions for the Physician Assistant. 2006.
11. General Pharmaceutical Council. Standards for the education and training of pharmacist independent prescribers. General Pharmaceutical Council. 2019;(January). Available from: https://www.pharmacyregulation.org/education
12. Nursing and Midwifery Council. Part 3: Standards for prescribing programmes. 2018;(May):1–15. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-education-and-training/standards-for-prescribing-programmes.pdf
13. National Prescribing Centre. A single competency framework for all prescribers. NICE. 2012; (May):4,11–13. Available from: https://www.nice.org.uk
14. General Medical Council. Outcomes for graduates. General Medical Council Publications. 2018;1(1):8.
15. Harden RM. AMEE Guide No. 21: Curriculum mapping: A tool for transparent and authentic teaching and learning. Medical Teacher. 2001;23(2):123–137. https://doi.org/10.1080/01421590120036547
Crossref PubMed
16. Guest BN, Chandrakanthan C, Bascombe K, Watkins J. Preparing physician associates to prescribe: evidence, educational frameworks and pathways. Future Healthcare Journal. 2022;9(1):21–24. https://doi.org/10.7861/fhj.2022-0003
Crossref PubMed PMC
17. The Nursing and Midwifery Council. Changes to the requirements for entry to independent prescribing courses | General Pharmaceutical Council [Internet]. 2019 [cited 2022 Jul 4]. Available from: https://www.nmc.org.uk/education/becoming-a-nurse-midwife-nursing-associate/becoming-a-prescriber/
18. Harden RM. AMEE Guide No. 21: Curriculum mapping: A tool for transparent and authentic teaching and learning. Medical Teacher. 2001;23(2):123–137. https://doi.org/10.1080/01421590120036547
Crossref PubMed
19. Tan ACW, Emmerton LM, Hattingh HL. Prescribing and medication-initiation roles based on the perspectives of rural healthcare providers in a study community in Queensland. Australian Health Review. 2013;37(2):172–177. https://doi.org/10.1071/AH12144
Crossref PubMed
20. College of Paramedics, NHS England. Improving Patients’ Access to Medicines: A Guide to Implementing Paramedic Prescribing within the NHS in the UK. Reference COP-IP003.
21. General Pharmaceutical Council. GPhC accreditation criteria, learning outcomes and indicative content for pharmacist independent prescribing programmes. General Pharmaceutical Council. 2018. Available from: https://www.pharmacyregulation.org/education
22. Royal College of Podiatrists. Medicines: prescribing, sale, supply and administration of medicines by podiatrists [Internet]. [cited 2022 Jul 5]. Available from: https://rcpod.org.uk/the-college/medicines
23. Health and Care Professions Council. Standards for prescribing [Internet]. 2019 [cited 2022 Jul 5]. Available from: https://www.hcpc-uk.org/standards/standards-relevant-to-education-and-training/standards-for-prescribing/
24. The Nursing and Midwifery Council. Changes to the requirements for entry to independent prescribing courses | General Pharmaceutical Council [Internet]. 2019 [cited 2022 Jul 4]. Available from: https://www.nmc.org.uk/education/becoming-a-nurse-midwife-nursing-associate/becoming-a-prescriber/
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Education for Health | Volume 37, No. 4, October-December 2024