The service user or patient as teacher is not a new phenomenon, and developing the concept into a more integral and active educator role has become a goal across care sectors and countries (Nursing and Midwifery Council (NMC), 2018; Health and Care Professions Council (HCPC), 2019). The paradigm shift from authoritarian approaches in the past also encompasses health policy, legislation and education provision across the western world (Scammell et al, 2015; Scottish Government, 2022). Amid this change, formalising and defining characteristics of service user populations has become more challenging as there are a range of non-professionals across society, including many diverse cultural, social and third-sector organisations (Kuti and Houghton, 2019).
This article will use the term ‘service user’, but it is recognised this may vary in other work and that authentic learning experiences value the contribution of this population. The National Co-ordinating Centre for Public Engagement (2023: 11) describes traditional ‘chalk and talk’ delivery as problematic and suggests that a lack of depth of application is aligned to ‘trying to teach someone to swim by showing them a video’. This relates to engaging with service users to enrich student experience using more embedded, person-centred, co-operative relationships, which are now embraced in the delivery of teaching supported by sound pedagogies.
Undergraduate health programmes, the regulatory bodies and aligned evidence available support the inclusion of service users across curricula, suggesting that this can lead to improved person-centred care and outcomes (General Medical Council, 2015; NMC, 2018; HCPC, 2019; Moore et al, 2021). However, there appear to be inconsistencies in this inclusivity, with variation and barriers relating to organisational and cultural aspects highlighted, including academic staff perceptions and, more pragmatically, access to service user groups (Kuti and Houghton, 2019; Moore et al, 2021).
The commonalities relating to this model of education are that there are mandatory requirements now embedded that contribute to students across programmes of study that can better define their professional congruity, as well as implementing enhanced empathy into future clinical care delivery (NMC, 2018; HCPC, 2019). Validating this collaborative model and concluding these best practice points and impact on healthcare professionals would be enhanced with evaluative tools (Tobell et al, 2020).
In the delivery of post-qualifying independent and supplementary prescribing programmes, this governance is also required and similar challenges have been shared in the pragmatic implications of embedding this consistently. As this approach is now aligned to NMP-approved quality frameworks, including and demonstrating service user integration in an authentic and homogeneous pattern is an area that must be addressed specifically (NMC, 2018; HCPC, 2019; Royal Pharmaceutical Society, 2021).
Background
Collaboration between NHS stakeholders and higher education institutions is well established, with many innovative and beneficial links with clinical colleagues. Developing this to include service users in a more integrative process within educational delivery supports further embedding of best practice, policy drivers and enhanced patient outcomes (Tobell et al, 2020; NHS Tayside, 2023).
The Scottish Government response to the Health and Sport Committee inquiry into access to new medicines in 2013 set out several recommendations for NHS Scotland, which included encouraging and supporting patient and public involvement (Scottish Government, 2013). As a result, NHS Tayside developed an expert group of patient and public members, the Patient and Public Forum for Medicines (PPFM), as a sub-group of the Area Drug and Therapeutic Committee (ADTC) in 2014 and members attend monthly meetings. The vision of the group is to have proactive members with background knowledge of the local and national medicine processes who may contribute to discussions with transparency and openness, leading to a co-productive approach to medicines development across NHS Tayside (NHS Tayside, 2023). The co-author, chair of the group and lead clinical pharmacist have been instrumental in the implementation of a wide range of best practice initiatives, receiving the Tayside Pharmacy Award 2023 for Patient Experience.
The PPFM undertakes an educational programme, with presentations and discussions in the following key areas: licensing of medicines; the role of local formulary/ADTC; the role of Scottish Medicines Consortium; different roles of pharmacy: hospital, community and locality; the roles of pharmacy team; where the public can access reliable medicines information on the internet; and the role of non-medical prescribers.
The members of this forum have, in addition, worked with NHS Tayside Patient and Public Network and in a variety of local patient interest groups including Multiple Sclerosis Society; Rheumatoid Arthritis Society; Maggie’s Centre (Oncology); Respiratory Managed Clinical Network; Parkinson’s Disease UK; Dundee Carers Centre and Perth Carers Centre.
The role and remit of the group includes enhancing the quality of new medicines pathways through harnessing user feedback, identifying gaps in service provision and acting as advocates for service change. This approach has demonstrated positive changes in knowledge for group members and influencing clinical practice (Box 1). The members of PPFM are passionate about shared decision making and empowering patients to make decisions about their treatments (Scottish Government, 2016).
Box 1.Feedback from PPFM representatives‘I had to pause the TV the other day when the BBC news was describing a cancer drug that didn’t get through NICE and I could explain to my husband what a QALY (Quality Adjusted Life Year) is’‘I wouldn’t hesitate now to go to my local pharmacist for advice about my medicines prior to seeing my GP’‘From attending ADTC meetings, I feel safe and confident with the knowledge, expertise and professionalism of healthcare staff who are discussing medication related decisions at these meetings’‘ADTC meetings have given me confidence that medication decisions are made based on the effectiveness of the medicines and not about cost. Where there were discussions about cost, patient outcomes were never compromised by any decisions’‘With the knowledge I have now I understand why some medicines are not available to me as a patient with MS’‘Being an active person on the PPFM during the last 4 years has been an amazing journey. Constantly learning, being involved in local medicines campaigns and medicines safety national conferences, feeling valued, listened to and fully appreciated. It has completely altered the way I see just how the NHS works, and has highlighted to me the key difficulties and obstacles that lie ahead in the future of the NHS. This is where I know I can help, as I have found my voice as a realistic and natural communicator between the public and the NHS’ Fran Benison, PPFM representative
There have been a number of achievements resulting in co-production of medicines initiatives to promote patient empowerment, shared decision making and self-management. These include development of medicines cards called ‘Not Sure? Just Ask!’ (Figure 1). These were used for a local campaign aimed at enabling patients to ask questions about their medicines to any health professional. NHS Scotland subsequently adopted the cards as a medicines tool for patients and the public (HIS, 2023). These have since been updated to ‘My Body, My Medicines, My Choice’ (Figure 2), with further shared decision making questions including lifestyle and support to help make informed choices (NHS Tayside, 2023).
Prescribing teaching delivery: A new era in service user co-production
When the Lead Clinical Pharmacist in NHS Tayside joined the NMP module team in 2018, the delivery of content was enhanced by the diversity and expertise of a clinical pharmacist and educator. As a practising prescriber, this role, in addition to the NHS lead role in realistic medicine, shared decision making and Chair of Patient and Public Forum for medicines, was the start of a new era in patient collaboration.
The NMP content was updated to include shared decision making activities with members of the PPFM, demonstrating a consistent theme throughout the learning, teaching and assessment including narrated personal stories integrated into discussion boards, case studies and face-to-face and online teaching. These narratives supported connecting students in more authentic discussions with deeper peer review in relation to their own practice, and was evaluated as a valuable learning experience (Covelli 2017; Kahn and Anderson, 2019). This confidence in using technology highlighted the value for both PPFM members and students, and following review of student feedback it was evident that the use of patient experiences had a powerful impact on the students’ understanding of the risks and benefits of prescribing on patients.
The programme further developed the online content to incorporate live sessions, involving patients telling their stories of good and bad experiences with medicines. This stimulated live discussions with patients and students, and a mutual understanding of the risks and benefits of medicines from patient stories (Scottish Government, 2020; Bell et al, 2022). Person-centredness was reviewed as being influenced by the voice of the patient and created a powerful message across the online delivery of teaching and learning (Rhodes, 2012; Scammell, 2015; Scottish Government, 2022). As a result of positive student and service users feedback following the deliveries of teaching, the participation has developed and is now a collaborative face-to-face session as well as the recorded audio narrations.
Following a shared decision-making session led by PPFM members, the NMP module team asked the students to reflect on the session and give feedback (Box 2). Co-authors and two members of PPFM, Sue Cole and David Barrowman, reflect on their roles within NHS Tayside and the University of Dundee (Box 3).
Box 2.Feedback from non-medical prescribing students following PPFM teaching sessions‘I really enjoyed the sessions, they raised some great points that we all need to consider in healthcare. It is important that patients are fully informed about any healthcare treatments for them to make an informed decision and give consent to treatment. I often feel that patients don’t necessarily take in everything that is discussed, so it is good to give them the opportunity to ask questions in their own time, which can be challenging given the time constraints on all services, but it is important to allow that open dialogue. Sue and David discussed many points which I will consider when discussing treatment options with patients and family members, and highlighted the value from a patient’s perspective of the importance of shared decision making. A very worthwhile session on the timetable’‘I found the session to be enlightening and enjoyable. They reminded us all as professionals the importance of explanation and collaboration when discussing treatment/care options. I liked the interactive session as it instigated meaningful and interesting discussions within our group and enriched our learning experience. Both were excellent ambassadors for the patient group perspective, and I thought this to be an excellent addition to our timetable’
Box 3.Feedback from PPFM members‘I I have been a public representative in NHS Tayside since 2006/7 and became a member of the PPFM in 2014. I have been involved in many medicines initiatives during this time including “Safer Prescribing Tayside” event where we developed the “Not Sure Just Ask” cards for patients. The objective is to give the patient confidence to ask questions about their medicines and to make lifestyle changes to enhance their personal health journey and be involved in shared decision making. I have been involved in three non medical prescribing modules, one session was virtual and two sessions face to face within the Dalhousie Building in Dundee. It was very good interaction with the students and good to see NHS staff upgrading their personal skills and their professional education and further development’ David Barrowman, member of PPFM‘I have been a member of the PPFM for 6 years. I have rheumatoid arthritis and am a patient representative for the National Rheumatoid Arthritis Association. I am also an active member of my community and enjoy helping people. I have a keen interest in making healthcare services easily available to all at the point of need, and the concept of shared decision making where patients feel worked with and not worked on. I am also interested in promoting the concept of the “Green NHS” particularly reducing medicines waste and saving resources, and non-pharmacological treatments such as social prescribing. I have been greatly encouraged to see so many NHS staff continuing their personal development and engaging in the non-medical prescribers programme. It was really interesting to hear the feedback from the students, all very informative to me. This can only benefit the NHS and the wider community. To develop shared decision making and help to encourage patients to be involved in their health journey’ Sue Cole, member of PPFM
Conclusion
Co-production of teaching delivery in the University of Dundee NMP Module has been enhanced with the continuing collaboration and support of our service user representatives. The representatives of PPFM have a vital role in developing medicines related services within the NHS and have extrapolated this expert knowledge to explore patient experiences to enrich the education of our student prescribers. Critical reflection on service user experiences is guiding educators to highlight areas not previously included in the content of programmes and enhance best practice (Kuti and Houghton, 2019).
Students, educators and service users have anecdotally, and within student discussion boards, benefited from this model in our programme. Continued evaluation and feedback will enable further development and integration of our service users in prescribing and other healthcare programmes.