There is a need for research on how services can improve patient access to, and safety of, medicines. Poor medication practice causes injury and harm, and annually costs an estimated $42 billion USD globally. The WHO plans to reduce this by 50% by 2022 . While there is evidence of effectiveness of non-medical prescribing, there lack studies which have focused on prescribing errors and patient safety. There is a vast accumulation of evidence of widespread suboptimal prescribing by doctors that increases the risk of patient harm [2-5] with evidence of the costs of inappropriate prescribing in the UK .
Prescribing by non-medical health professionals has been adopted into the legislative frameworks of several countries including Canada, Ireland, New Zealand, the United States (US) and the United Kingdom  and a global survey, on advanced practice in the pharmacy workforce, has shown that nearly a fifth of the 48 countries responding had prescribing rights . While the specific models of practice vary, the stated aims are similar: improving patient care without compromising safety; enabling easier and quicker access to medicines; increasing patient choice; better using the skills of healthcare professionals; and contributing to more flexible team working . Non-medical prescribing is most advanced in the UK, with the introduction of supplementary prescribing in 2003  followed by independent prescribing in 2006 . Independent prescribers prescribe, within their competence, the same range of medicines as physicians. Evidence derived from systematic reviews confirms that non-medical prescribing is as effective as medical prescribing in a range of acute and chronic conditions [12-13], and well accepted by a diverse range of key stakeholders .
To improve prescribing competence and safety of medical graduates in the UK, a ‘Prescribing Safety Assessment’ (PSA) was developed by the British Pharmacological Society and the Medical Schools Council . The PSA is designed to be a valid and reliable assessment of prescribing skills based on competencies identified by the UK General Medical Council: writing new prescriptions; reviewing existing prescriptions; calculating drug doses; identifying and avoiding both adverse drug reactions and medication errors; and amending prescribing to suit individual patient circumstances . It is an open book, time-limited assessment, with questions across seven different clinical settings. The standard set is that expected of final year medical students, in the latter stages of their final exams, who are at the peak of their preparation for practice. All candidates sitting the PSA have access to an electronic British National Formulary (BNF) and a calculator inbuilt into the system. Following several years of piloting, the PSA was launched across the UK in 2014. Data from over seven thousand UK final year medical students across 31 medical schools who participated in the PSA in 2016 gave an overall pass rate of 95% of students, with marked variation between schools . In 2015, a pilot group of 59 pharmacist independent prescribers in Scotland participated in the PSA. The PSA in this study consisted of 30 questions which had been used in the 2014 assessments for final year medical students. The mean overall PSA scores (±SD) were 87.5%±8.7 (range 52-98) compared to 88.5% for medical students. Pharmacists performed equivalently to medical students in all assessment areas, with a slightly lower performance in the prescribing, drug monitoring and data interpretation questions offset by better performance in prescription review and adverse drug reactions .
While medical students will prescribe (under supervision) at the point of graduation on completion of a five-year undergraduate course, currently pharmacists must have at least two years of post-registration practice experience in a patient-facing role prior to enrolling on the prescribing training programme . Following completion of a four-year undergraduate Master of Pharmacy degree in the UK, graduates must complete an additional foundation year of experiential training and assessment (formerly called pre-registration training) before registering as pharmacists with the General Pharmaceutical Council (GPhC). So currently, the minimum time between graduation and commencing prescribing training is therefore three years.
However, revised standards for the Initial Education and Training of Pharmacists, published by the GPhC in January 2021, mean that courses will incorporate the skills, knowledge and attributes for prescribing, to enable pharmacists to independently prescribe from the point of registration .
Work has been undertaken into aspects of prescribing training, practice and competence from the perspectives of pharmacy students and graduates. A cross-sectional survey of UK pre-registration graduates identified that while most respondents expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Many cited the need to first increase their confidence through experience and to demonstrate competence as a pharmacist . A later qualitative study with Scottish pre-registration graduates reported that while most expressed a desire to train as prescribers, they acknowledged the need first to develop as pharmacists . A more recent study from England reported PSA performance of final year pharmacy students from four universities and local pharmacy pre-registration graduates. The mean scores for the graduates in community (n=27) and hospital (n=209) settings were 86.3% and 85.3%, respectively. For the 397 undergraduates, the mean score was 73% . The number of candidates passing the PSA was not reported.
The International Pharmaceutical Federation have published a framework for the quality assurance of pharmacy education with 5 ‘Pillars of Quality’. There are differences in the pillars of; context, structure and processes of undergraduate and foundation training in Scotland. There are two Schools of Pharmacy who work closely together and in collaboration with NHS Education for Scotland (NES). Significantly, the initial education has received Scottish Government funding to develop, implement and quality assure a comprehensive programme of experiential learning placements and interprofessional learning initiatives. In addition, the foundation training year is organised differently to other jurisdictions with NES co-ordinating all aspects. Given the policy direction of pharmacist prescribing in Scotland, there is also a justifiable need for further PSA based research in this context. In 2017 around 40% of pharmacists in Scotland had completed or were undertaking prescribing training. The policy direction of the Scottish Government is for patient-facing pharmacists to be independent prescribers managing caseloads of patients and for patients to increasingly access community pharmacies as a first port of call for healthcare . Furthermore, there has been significant investment to employ pharmacists within general medical practices to contribute to patient care through a range of activities, including prescribing .
So, to complement the previous PSA work in pharmacy student cohorts it is essential that similar confirmatory research is undertaken in different educational and practice contexts within different healthcare jurisdictions so we can better understand potential influences on student development and competence.
In this way it will be possible to continue the development of the PSA for it to be used internationally where non-medical prescribing is being integrated to healthcare education and practice.
Aims of the study
To determine PSA performance of final year undergraduate student pharmacists (year 4) and pre-registration pharmacy graduates (year 5) and explore their opinions on its suitability.
The study was approved by the management committee at NES and ethical review committees at each university. All participants registered on the PSA online system and were provided with full information about the PSA and the study. Consent was assumed by completion and submission of the survey.