**3. Education**

In light of the changing roles of pharmacy technicians, education is pivotal, and a key point of interest is the level of the baseline pharmacy technician qualifications, which vary considerably from country to country.

In 2017, the European Association of Pharmacy Technicians (EAPT) undertook a European-wide survey of education and training programmes [23]. The results highlighted the variation in pharmacy technician education in Europe with levels of study required for practice, licensing, or registration ranging from post-secondary diplomas to bachelor's degrees. Interestingly, comparison between the level of initial education requirements and the role undertaken by community pharmacy technicians in the EAPT 2017 European Survey [23] shows a correlation between countries with higher level education requirements and pharmacy practice activities. The volume and complexity of the dispensing activities carried out and the application of problem-solving skills are specifically enhanced in Denmark and Portugal, where bachelor's degrees are in place as the baseline education. Interestingly, comparing the academic credits of these bachelor's degrees using the European Credit Transfer and Accumulation System (ECTS) shows a further di fferential between the countries, with Denmark accruing 180 ECTS credits and Portugal 240.

In Great Britain, trainee pharmacy technicians are known as preregistration trainee pharmacy technicians (PTPTs) and undertake their training over a two-year period. Trainees are employed, therefore much of their learning and competence is gained in the workplace as they complete a competence-based qualification. They are also required to complete an academic (theoretical knowledge) qualification, which is delivered either as study days away from the workplace or distance learning. The qualification standards set by the GB pharmacy regulator are currently the Level 3 Diploma in Pharmacy Service Skills (work-based) and Level 3 Diploma in Pharmaceutical Science (theory) [24] which predate mandatory registration of 2011. These standards are still in use up until August 2020.

As the pharmacy technician role has developed, the underpinning education model in GB has failed to keep up with the practice, which has caused considerable confusion for pharmacists and employers as pharmacy technician roles, boundaries, and accountability have been di fficult to define [25,26].

Role definition is also a challenge across the globe as both the EAPT survey 7 and the International Pharmaceutical Federation (FIP) 2017 [8] introductory global descriptive survey blend the pharmacy technician role with that of 'pharmacy support workforce cadres' who work with pharmacists. Vast global variation compounds the barriers to understanding the pharmacy technician role, the education and competencies needed to underpin their work, and ultimately the autotomy of their professional practice.

Across the USA and Australia, current rules and regulations concerning the education and training of pharmacy technicians varies from state to state, and applying a national certified educational programme is a source of much debate. In comparison however, mirroring GB, Canada's national model for the regulation of pharmacy technicians exists across 90% of its provinces, and the pharmacy technician title is restricted to those who meet the qualification requirements and are registered with their provincial regulatory body [27].

Acknowledging the changing healthcare landscape and the need to upskill the pharmacy technician workforce, in October 2017, the GB pharmacy regulator published the new Initial Education and Training Standards (IETS) [28]. The outcome-based standards now being introduced (2020) incorporate the shift in knowledge and skills required for patient/person-centred practice. This involves four domains of study: 1. Person-centred care; 2. Professionalism; 3. Professional knowledge and skills; 4. Collaboration. Using Miller's Pyramid (1990) [29] theory of assessment and competence, the new standards will require building from fundamental knowledge level of 'knows', to the application level of 'knows how', to measuring competence at the 'does' level and having to achieve and exceed at the lower level before moving on.

Whilst providing a broad base of knowledge and skills for work in a range of pharmacy settings across GB, the IETS have a strong emphasis on e ffective communication to support the clinical, operational, and scientific practices, procedures, and professionalism required of the registered pharmacy technician. Requiring a qualification of a minimum Level 3 (broadly equating to the UK subject advanced level qualifications—A level), Figures 1 and 2 illustrate the comparison of activities from the previous qualification to the new IETS and measures these along a continuum of pharmacy skills.

Figure 1 illustrates the mandatory skills required for the 2010 GB qualification at day one of practice and extended skills along a continuum of skill complexity and autonomy. It shows inclusion of the traditional skills of dispensing, receiving prescriptions, and managing the stock of the pharmacy. Another inclusion is extemporaneous dispensing skills, sometimes referred to as compounding. In the UK, this skill has become all but non-existent with community pharmacies in particular due to the high risk involved in the preparation, with pharmacies opting to outsource these requests to organisations specifically set up for this type of production. The communication skills required for these standards are at a basic or routine level for handing out prescriptions, giving mainly noncomplex instructions and dealing with routine queries and customer service issues. Figure 1 also illustrates the addition of final accuracy checking. This was the first extended skill to be undertaken by pharmacy technicians approximately 20 years ago, originally in hospital pharmacy but now also widely practiced in community pharmacy. Medicines reconciliation (an activity that is integral to medicines optimisation\*) was the second extended role introduced in acute hospitals following the publication of guidance by the National Institute for Health and Care Excellence in 2007 [30] (then called the National Institute for Clinical Excellence). Originally a role for pharmacists, this became a delegated activity and pharmacy technicians have been training to undertake medicines reconciliation over the last 10 years. This activity has increased and is now accepted as part of the pharmacy technicians' progression and practiced across all settings where there is patients' transfer of care.

**Figure 1.** Great Britain (GB)-registered pharmacy technician role and skills—2010 General Pharmaceutical Council (GPhC) education standards.

In comparison, the first three levels of Figure 2 show that the core skill of dispensing—in its broadest definition of receiving prescriptions, validating, assembling medicines, and issuing medicine to a named person—remains. The next four levels then illustrate the mandatory activities newly introduced in the 2017 IETs, with extemporaneous dispensing removed from the standards completely as it was considered an obsolete activity. In addition to Medicines Optimisation\* and Accuracy Checking, previously widely recognised as extended, advanced communication and leadership skills have been introduced. These changes and additions reflect the expectations of pharmacy technician practice by the GB regulator as well as working within the regulatory Standards for Pharmacy Professionals [1]. The mandatory inclusion of medicines optimisation\* and accuracy checking activities which are delivered through person-centred care, commands taking responsibility for the legal, safe, and efficient supply of medicines together with using professional judgement and strategies for continuous quality improvement. The additional skills required to support this competence are now intrinsically embedded within new IETS [26] learning outcomes along with the required leadership and advanced communication skills. Although skills such as procurement and stock managemen<sup>t</sup> have been removed from the IETS at the 'does' level, they have not been removed entirely and PTPTs will need to learn and be assessed at the 'knows how' level of the Miller's pyramid.

**Figure 2.** GB-registered pharmacy technician role and skills—2017 GPhC standards.

Recognising that the regulatory purpose of the IETS [28] is to ensure that newly registered pharmacy technicians are competent to practise safely and effectively, it is important to acknowledge that competence is much broader than skills alone. Whereas skills are specific to a task or activity, to perform these competently to an acceptable level of ability requires the appropriate depth and breadth of underpinning knowledge and understanding. Thus, professional pharmacy technicians need to be able to identify the required knowledge that underpins their job role and must be able to apply it in practice.

Given that competence is said to build on a foundation of clinical skills, scientific knowledge, and professional development, it also begs the question as to what extent of knowledge is required to combine both the knowledge and competency elements of the evolving job role.

Accepting that Miller's Pyramid requires achieving and exceeding the preceding level [29], and the regulators expectation that the newly registered pharmacy technician will be acting autonomously and consistently in complex situations [27], albeit defined situations, it can be argued that the level of knowledge required is considerable.

As the GB pharmacy regulatory Professional Standards [1] are very much reflected in the new IETs [28] and these include the complexity of ethical and e ffective decision making, identifying and responding to errors, and raising concerns, this arguably raises the level and expectations from day 1 of practice and that of a qualification fit for purpose.
