BULK PRESCRIBING AND HOMELY REMEDY GUIDANCE FOR SERVICE USER S IN CARE SETTINGS Good Practice Guidance recommendations for care home staff, prescribers and pharmacists working with care homes This good practice guidance has been developed by: The Medicines Optimisation Team at: The Isle of Wight Clinical Commissioning Group November 2017 1
Contents Table of Contents (1) Background... 2 1.1 Bulk Prescribing... 2 1.2 Why Bulk Prescribing... 2 1.3 Recommendations and Implementation tips... 3 (2) Guidance for Prescribers and GP Practice Staff... 4 2.1 What can be prescribed on a bulk prescription?... 4 2.2 What products are suitable to be prescribed?... 4 2.3 ONS and topicals... 4 2.4 How to record a patient using bulk prescribing... 5 2.5 Wording on the bulk prescription... 5 (3) Support for Care Home Staff... 6 3.1 Background... 6 3.2 Receiving bulk medicines from community pharmacies... 6 3.3 Administration of bulk medicines... 6 3.4 Monthly reordering of bulk medicines... 7 3.5 Bulk medicines waste management... 7 (4) Homely Remedies... 7 4.1 Background... 7 4.2 Definition... 7 4.3 Residents own homely remedies... 7 4.4 Medicines recommended for use as homely remedies... 8 (5) Contact Details... 8 1. Background This guidance provides support to care home staff, prescribers and pharmacists working with care homes on bulk prescribing and homely remedies. 1.1 Bulk Prescribing 1.2 Why bulk prescribing? Issuing a bulk prescription allows care home staff to use one supply of medication or product for all residents identified as clinically appropriate for that prescribed product, rather than the usual route of supply which is a named prescription for each patient. 1 There are many patients in care homes taking medicines when required (prn) and this can present problems for the prescriber in terms of determining the quantity to prescribe. It is onerous for GP practices to vary quantities on lots of individual prescriptions every month, and this is also the case for care homes. Care homes are often supplied prn medicines in blister packs, which leads to wastage or even if a medicine is given when it is not needed. 1 Legally a "Bulk" prescription is an order for two or more patients, bearing the name of a school or institution in which at least 20 persons normally reside, for the treatment of at least 10 of whom a particular doctor is responsible. It will not be a prescription only medicine. Such a prescription must be an order for a drug which is prescribable under the NHS and which is not designated a "Prescription Only Medicine" (POM) under Section 58(1) of the Medicines Act 1968, or for a prescribable dressing which does not contain a product which is designated POM. 2
Bulk prescribing confers the following benefits: Potential to reduce GP practice time Potential to reduce waste Reduction of space required in the drug trolley Reduction of drug round time/dispensing time Reduction of potential administration errors Save time when treating an outbreak such as of scabies when all the residents require the same treatment 1.3 Recommendations and implementation tips Table 1: recommendations and implementation Recommendations and implementation tips 1. Bulk prescriptions should only be written for patients taking regular medication and not for the acute requirements for medicine. 2. Homely remedies are more appropriate for treating common minor ailments. 3. The GP must have at least ten patients under their care within the care home to be able to bulk prescribe, and a signed agreement to administer to those ten or more patients by the G.P must be in place. 4. Patients not registered under a particular GP who is bulk prescribing for a care home should continue to receive named patient supplies from their own GP (unless their GP is also bulk prescribing for that care home). 5. Please note a multiple GP bulk prescribing for a care home system will be difficult to monitor and implement and may cause confusion. 6. The care home, GP surgery and pharmacy must work together to ensure successful implementation of a bulk prescribing procedure. However it is worth noting that the G.P practice is under no obligation to agree to bulk prescribing. 7. The pharmacy should be informed in writing by the GP practice that they wish to prescribe in bulk for the patients under their care in a care home. 8. The agreed list of items that can be bulk prescribed must be provided to the pharmacy so that they can label the medication as bulk stock rather than for named patients unless specifically instructed to by the GP. Where provided as a service, the pharmacy can also ensure that the medicines administration record (MAR) chart is annotated correctly or provide labels for the care home to put on the MAR chart as up to date instructions. 9. The care home staff must keep a record of their bulk stock, to calculate a resident s monthly usage, and be able to order sufficient quantity to last for the 28 day cycle from the surgery, taking into account any new patients that start bulk prescribing and any that stop. It is recommended that they also carry out stock audits every month. 10. The G.P Practice must be kept informed by the care home of any changes to a patient s condition where the G.P may need to review if the bulk prescribed medication is no longer suitable or if a dose change is required. 11. The G.P Practice should ensure that they are able to record on their clinical system when a patient has an item from bulk stock instead of producing a named patient prescription for it. 12. It would be good practice to have regular meetings between the care home, GP Practice and pharmacy to discuss any problems with the process or problems for individual patients. 3
2. Guidance for Prescribers and GP practice staff 2.1 What can be prescribed on a bulk prescription? Bulk prescribing is NOT a way of obtaining stock items of homely remedies. Anything being used as a homely remedy must be purchased by the home not ordered on a bulk prescription. The medication must be prescribed on the NHS and be either: A P pharmacy only medicine which can be bought in a pharmacy or A GSL product general sales list product that can be bought in a supermarket/petrol station etc for patients under my care at Perfect care home, Isle of Wight Senna Tablets 7.5mg x 100 to be given in accordance with GP instruction on the MAR chart. *BULK PRESCRIPTION* Dr A.Mazing 1/1/2015 2.2 Which products are suitable to be prescribed in bulk? 1. Lactulose syrup 2. Senna tablets or senna liquid for service users with swallowing difficulties. 3. Cosmocol sachets (first-line in the IOW CCG formulary) 4. Paracetamol tablets - up to 96 tablets only - quantity greater than this is a Prescription Only Medicine (POM). Service users taking regular paracetamol will not be suitable for bulk prescriptions. If larger quantities are required on bulk prescription multiple individual prescriptions for quantities of 96 tablets or more will be required. 5. Paracetamol suspension 250mg/5ml, for service users with swallowing difficulty/restricted fluid intake. 2.3 ONS and Topical s on bulk prescription Oral Nutritional Supplements (ONS) and Powdered supplements/ Complan if more than two residents require the same nutritional supplement, bulk prescribing may reduce waste and provide more choice of flavours for patients. However it is important to note that the CQC prefer individual patient prescribing, so care homes may be reluctant to accept bulk prescribing for these items Creams, Ointments and Topical Applications are NOT considered suitable for bulk prescribing as they cannot be shared between more than one resident due to cross contamination. 4
2.4 How to record when a patient is using a bulk prescribed item 1. On commencing treatment, the medication must be prescribed initially on a prescription bearing the service user s name. This will ensure the medicine and specific directions appear on that service user s subsequent medicines administration record (MAR) charts and health care records in the G.P practice. NB/ It is at the pharmacist s discretion whether a MAR chart is supplied as they are not contractually obliged to provide MAR charts. 2. This will also provide evidence that the service user has been clinically assessed and initially prescribed this medication. Subsequent prescriptions for each new service user can then be ordered using a bulk prescription. 3. A copy of the original prescription should be kept in the service users care plan (if this has been transmitted as an electronic prescription a copy of the token should be kept in the clients clinical notes). 4. A bulk prescription can be written or printed on an ordinary FP10 prescription. It is not possible to transmit bulk prescriptions electronically. Charges are not payable in respect of "bulk" prescriptions for schools or institutions supplied in accordance with the Regulations. 5. A copy of the original prescription should be kept in the service users care plan (if this has been transmitted as an electronic prescription a copy of the token should be kept in the clients clinical notes). 6. When a bulk prescribed medicine has been administered to a patient, records should be made on the MAR chart as well as in the patient s individual health care plan. 7. Bulk prescribed medicines should be reviewed regularly by the G.P/ Medicines Optimisation Pharmacist. 2.5 Wording on the Bulk Prescription Table 3: Writing requirements for bulk prescriptions Writing requirements for bulk prescriptions 1. Wording for patients under my care at {the name of the care home} (instead of the individual name of the patient) 2. Date prescribed 3. The words bulk prescription to identify the type of prescription 4. The medicine that is being bulk prescribed 5. The total quantity required for all service users on this medication 6. The directions may state to be given in accordance with GP instruction on the MAR chart. Due to variation in doses for each patient, the patients MAR chart will need to provide the dose to be administered. 5
3. Support for Care Home Staff 3.1 Background Check the list of medicines suitable for bulk prescription. Decide if service users fit the criteria for bulk prescribing. Care home manager and prescriber should discuss and agree on medicines that can be bulk prescribed in their care home and inform community pharmacy. The care home manager must ensure that staff responsible for ordering and administering medication understands the principles of bulk prescribing. It is not appropriate for service users who self-medicate to be included in bulk prescribing. In this situation, medicines are stored within a locked facility in the service user s own room. These must not be shared. The Royal Pharmaceutical Society for Great Britain recommends bulk prescribing is not a way of obtaining stock items of homely remedies. Please see section 5. Prior to requesting a bulk prescription assess current stock by checking the dose prescribed and administered on the MAR, calculate the amount required for each service user. Total the amount required and record. An example shown below: Checking stock to reorder (usually at week 2 in ordering cycle) For Lactulose Liquid Service user Name Dose Quantity prescribed for month supply per patient Service user a 10ml bd prn 560ml (prn check service users requirements) Service user b 15ml bd prn 840ml (prn check service users requirements) Service user c 10ml od 280ml Service user d 10ml bd 560ml Service user e 10ml bd prn 560ml (prn check service users requirements) Total required per month 2,800ml If maximum daily doses are required Please ensure all service users requirements are checked each month for any changes and adjust stock levels accordingly 3.2 Receiving bulk medication from community pharmacy Check that the quantity received was the quantity ordered NB: the label on the medicine will identify the care home not the individual service user e.g. Perfect View Care Home Check that the MAR charts have the medicine and the correct current dose of the bulk prescribed medicine for each service user. Report any discrepancy to the community pharmacy Store the bulk medicine in a lockable storage facility. 3.3 Administration of bulk medicine Check the service user s MAR chart and the dose prescribed. Bulk medicine should only be used when stated on a MAR chart Select the bulk prescribed medicine NB/ this will be labelled with the Care Home s name not the individual service user s name. To avoid unnecessary medication waste, ensure service users initial supplies of this medicine (labelled with their own names) are used first before administering from bulk stock. Medication labelled with an individual s name must only be administered to that service user. Follow the normal care home administration procedure. 6
3.4 Monthly re-ordering of bulk medicines Each month, the staff member responsible for the ordering must check the quantities being administered, estimate the amount remaining by the end of the month and adjust the total quantity to be ordered, to prevent excess stock accumulating or being wasted. Take into account: The variable dose prescribed: if applicable. The quantity being administered to the service users The quantity currently in stock Any service user who has stopped this medication or where the medicine has been stopped by the prescriber. Ensure the service user s MAR chart is endorsed appropriately and inform the community pharmacist that this person has stopped using the bulk prescription order form. This will ensure the medicine does not appear on the new MAR. NB. There must be at least 2 services-users who are still prescribed the particular bulk medicine when it is reordered. A new prescription must be requested for the individual service user if there is any change to the dose of the bulk prescribed medication. Subsequent prescriptions can be requested on bulk prescription. 3.5 Bulk Medicine Waste Management To avoid unnecessary medication waste, service user s initial supplies that are labelled with their own names should be used first before administering from bulk stock. Medication labelled with an individual s name must only be administered to that service user. Regular audit of medication returns book will highlight any avoidable bulk medication returns. 4. Homely Remedies 4.1 Background The Care Quality Commission agrees that care homes may stock a small range of homely remedies for the treatment of minor ailments. Homes will need a robust policy for the use of homely remedies and agreement from the G.P to allow the use of these products on the residents. 4.2 Definition A homely remedy is a product that can be purchased (e.g. from a pharmacy or supermarket) for the relief of a minor, self-limiting ailment without the need for a prescription. Homely remedies should be made available in care homes to allow access to medicines that would commonly be available in any household. Discussion and agreement on the consent for use of homely remedies in the care home should be held with residents and their families. The resident s GP should also agree to the use of homely remedies for the treatment of minor ailments, and there should be a policy in place for how these products are going to be managed in the home. 4.3 Residents own homely remedies Any resident who brings in their own homely remedy to the care home that has been approved by their own GP should have the medicine stored, recorded, and administered as per any other medicine. The remedy must be used by that resident only. 7
4.4 Medicines recommended for use as homely remedy Table 1: examples of medicines that can be included in a homely remedy Name of medicine Indication for the medicine to be used as a homely remedy Paracetamol 500mg tablets For the relief of mild/moderate pain, or to reduce temperature Paracetamol 250mg/5ml susp For the relief of mild/moderate pain, or to reduce temperature Peptac liquid For the occasional relief of indigestion/heartburn Senna 7.5mg tablets For the relief of mild constipation Senna 7.5mg/5ml liquid For the relief of mild constipation Oral rehydration sachets To replace electrolytes after vomiting/diarrhoea Simple linctus sugar free Relief from a dry irritating cough (sugar free recommended to allow use in diabetic residents) Cetirizine 10mg tablets For allergy relief Cetirizine 5mg/5ml liquid For allergy relief This is just an example list of products that could be included in a homely remedy policy 5. Contact Details The Isle of Wight Clinical Commissioning group has produced guidance on Reducing Medicines Waste in Care Settings which you can access via this link. If you have any questions relating to Bulk Prescribing please contact: Medicines Optimisation Team Isle of Wight Clinical Commissioning Group, Building A, The Apex, St Cross Business Park, Newport, Isle of Wight PO30 5XW 01983 534769 Or E-mail Hayley.jeneson@iow.nhs.uk Useful references: Drug tariff Nov 2017: https://cms.nhsbsa.nhs.uk/sites/default/files/2017-05/may%202017.pdf PSNC website: http://psnc.org.uk/dispensing-supply/receiving-a-prescription/is-this-prescription-form-valid/http://psnc.org.uk/sheffield-lpc/wpcontent/uploads/sites/79/2013/06/bulk-prescribing-oct-2013.pdf 8