Department of Pharmacy

Independent Prescribing Course

Additional Information

To apply: Please complete all sections of the formelectronically, ensuring where signatures are required that these pages are scanned. Please upload this to your Kings application via the portal. The course fee for the 2016-17 academic year is £2,400.

Closing date: The closing date for the applications is5pm Monday 14th November for entry to the January 2017 course. Please bear in mind that applications will be reviewed after the deadline with applicants being informed within the next two weekswhether they have been successful.

Provide evidence below of relevant ‘patient orientated practice’ in hospital / community / primary care

1 Employment Details

Name and address of current employer(s)PositionDate

2 Pharmacy Regulator Details

Name as it appear on General Pharmaceutical Council / PSNI Register
General Pharmaceutical Council (GPhC) or Pharmaceutical Society of Northern Ireland (PSNI) registration number on practicing register
Date of registration GPhC/PSNI

3Medical Practitioner Details

Competency Statement Medical Practitioner
A Medical Practitionerwith whom you work with as a pharmacist providing 'patient orientated services' should sign the following
Outline of service provide by the applicant:
I confirm that (insert pharmacist’s name) provides the above service and that they have relevant patient oriented practice to develop the independent service outlined below in section 4.
Signed …………………………………………………………. Date……………………
Name in block capitals
Work Address

4 Outlining the independent service you want to offer, developing your scope of practice

Outline your intended prescribing scope of practice linked to your relevant ‘patient orientated practice in hospital / community / primary care’. Initially, you will be a NOVICE prescriber. It may therefore not appropriate to align your prescribing scope of practice to your broad scope of practice as an experienced pharmacist. For example, it would not normally be acceptable to include the treatment of a complex medical condition AND to include all supporting medications for that conditionwithin your scope of practice when completing this course.
Please describe below which groups of patients and diseases states you are planning to prescribe for and in what setting
Group(s) of patients:
Disease state(s):
Setting:
Outline the class(es) of drugs (we recommend no more than three) that you will use to demonstrate competence and to support the development of your portfolio linked to your scope of practice for the purpose of this course. Please contact the course leaders for clarification if required.
1
2.
3.
Other
Applicant’s declaration
I understand the GPhC’s requirement to attend all taught sessions throughout this course, and that I have the appropriate level of professional indemnity insurance.
Signed …………………………………………………………. Date

Please provide information about the organisation for whose patients you intend to prescribe

5 Supporting Organisation Details

About your ‘Supporting Organisation’
Your supporting organisation is the organisation whose patients you will prescribe for. For NHS patients this could be a primary care organisation,hospital trust or GP practice. For private patients this could be a private hospital or clinic.
Name of organisation
Address
NB If prescribing in primary care to NHS patients it is strongly recommended that you have the support of your local primary care organisation as they will be able to request NHS prescription forms for you.
The name and address of a senior manager or practitioner in your supporting organisation who can confirm
  • You have at least two years of appropriate patient orientated experience in a hospital, community or primary care setting after your pre-registration year
  • You have up-to-date clinical, pharmacology and pharmaceutical knowledge relevant to this identified area of prescribing practice
  • You will be able to adhere to the organisation’s non-medical prescribing policy
Name
Job title
Supporting organisation:
Address
Signature……………………………………………………………..

The Information required for section 6& 7, are entry requirements for the prescribing course as stipulated by the General Pharmaceutical Council6 CPD details

Description of on-going CPD
Briefly describe below how you have reflected on your own performance as a pharmacist providing patient orientated services and taken responsibility for your own CPD. This should be associated with your proposed scope of practice. In addition to the descriptions below please submit two CPD records of events and reflective accounts completed relating to your proposed scope of prescribing (you should attached these as PDFs using the recognised GPhC CPD format)

7Prescribing Network Details

Development of your prescribing network
Describe below how you will develop your own networks for support, reflection and learning, including prescribers from other professions

Confirmation of Information required for application to the Practice Certificate in Independent Prescribing

Please tick the box to confirm the statements below / Tick if correct
I am currently registered with the GPhC / PSNI
I have at least two years of appropriate patient orientated experience in a hospital, community or primary care setting after my pre-registration year
I have up-to-date clinical, pharmacology and pharmaceutical knowledge relevant to the identified area of prescribing practice
The relevant independent prescriber(s) in my organisation have agreed to support the introduction of non medical independent prescribing
I have NOT previously been enrolled on a course at another institution leading to a Practice Certificate in independent Prescribing
I have an agreement with a Designated Medical Practitioner to supervise my time in practice – representing a total of 90 hours (equivalent to 12 days in practice)
I do not manage/supervise or have a close personal relationship with my Designated Medical Practitioner
A professional relationship must exist between the student and the DMP they should not be a close family member or someone that you supervise or manage.
I have secured funding for the course fees from my employer
If the applicant is being funded by an employer / sponsor please provide the following details*:
Funding Organisation:
Contact Name:
Contact Address:
Name of Senior Manager/Practitioner
Signature of Senior Manager/Practitioner……………………………….
*The invoice will be sent to the person and address provided above
I intend to pay my own course fees

8 Applicant’s Statement

I confirm that the information I have provided above in support of my application to the Independent Prescribing course is correct

Fitness to practice: False Declarations

Please note, the Pharmacy Department King’s College London would be obliged to pass on to the College Fitness to Practice Committee the names of applicants that have deliberately falsified information given above to support their application to the course

In addition, if you have been sponsored to undertake the Practice Certificate in Independent Prescribing, it is YOUR responsibility to disclose the result of the assessment to your sponsor.

Name in Full………………………………………………………………………………….

Signature…………………………………………………………………….Date………..

9 Designated Medical Practitioner’s StatementSection - To be completed by the Designated Medical Practitioner

Name (please print)......

Organisation (please print)......

Address (please print)......

Email address (please print)......

Phone number (please print)......

DMP training, you are encouraged to make every best effort to attend this training with the student. It is anticipated that you will clarify the learning contract and the scope of practice following this joint training session and gain a broader understanding of the programme and your role. Please indicate below whether you will attend the programmed session:

January 2017 Cohort
Tuesday 24th January 2017: - Training session / 16.00 to 17:15

Background experience

Please answer the following questions regarding your clinical experience and role as a DMP.

Job title (please state)......

Please indicate below if you have previously been a Designated Medical Prescriber (tick all those which apply)

Pharmacist on the King’s College London Practice Certificate in Independent prescribing
Pharmacist on the King’s College London Supplementary Prescribing Course (ended January 2008)
Pharmacist on the King’s College London Supplementary to Independent Prescribing Course
Nurse / midwife on the King’s College London Independent prescribing Course
Nurse / midwife on the King’s College London Supplementary Prescribing Course
Pharmacists / nurse / midwife on another Independent prescribing Course
Please state the university......

Please indicate below your current experience of supervision, support and assessment of trainees in practice (please tick all those which apply).

GP trainees / Nurses
Medical students / Pharmacists
Junior Doctors / Other health care professional
Please state…………………….

Please indicate below if you current hold the any of the following qualifications (please tick all those which apply).

Relevant qualification doctor/dentist to act as a Designated Medical Practitioner

Joint Committee for Post-graduate Training in General Practice Certificate
A specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer.
Other (please state)......

Does the practice environment provide sufficient opportunities to meet learning outcomes of a pharmacist to become a non medical prescriber within the stated scope of practice?

Yes No

Has protected time been allocated to allow you to regularly meet with the trainee pharmacist non medical prescriber to undertake days in practice and to review their progress?

Yes No

Please describe the opportunities available in the practice environment (please detail below)

I have agreed to act as (insert student’s name) …………………………………………………………….….. Designated Medical Practitioner (DMP) during the 90 hrs in practice that form part of the course for pharmacist independent prescribing

I can confirm that I meet the standards as required in NHS guidance for the role of DMP

Has normally had at least three years recent clinical experience for a group of patients / clients in the relevant field of practice.

Is within a GP practice and is either vocationally trained or is in possession of a certificate of equivalent experience from the Joint Committee for Post-graduate Training in General Practice or is a specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer.

Has the support of the employing organisation or GP practice to act as the DMP who will provide supervision, support and opportunities to develop competence in prescribing practice.

Has training and experience in the supervision, support and assessment of trainees in practice

Is willing to participate in the assessment process of the pharmacist independent prescriber

Full Name:

Signed …………………………………………………………….Dated……………………………

Application Form September 2016Page 1 of 9