Guidelines for Developing or Updating a Repeat Prescribing Protocol

Guidelines for Developing or Updating a Repeat Prescribing Protocol Version: 3 Ratified by: GMS/PMS Committee Date ratified: 26 th April 2012 Name of originator/author: Anne Kingham, Senior Pharmaceutical Adviser Date issued: 3 rd May 2012 Review date: May 2014 Target audience: GP practices in Worcestershire WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 1 of 13

CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Mary Shaw Pharmaceutical Adviser Reehana Moetteli Practice support pharmacist Lesley Sheik Practice support pharmacist Circulated to the following individuals for comments Name Designation Jane Freeguard Head of Medicines Management Julie McCann Pharmacy & Dispensing Practices Professional Adviser Practice support pharmacists NHS Worcestershire Isabelle Hipkiss Pharmaceutical Adviser GMS/PMS committee NHS Worcestershire Worcestershire LMC WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 2 of 13

CONTENTS 1.0 INTRODUCTION 4 2.0 PURPOSE 4 3.0 GENERAL 4 4.0 AUTHORISING REPEAT PRESCRIPTIONS 5 4.1 Authorisation to repeat 5 4.2 Items not suitable for repeat 5 4.3 Prescription information 6 5.0 HANDLING REPEAT PRESCRIPTIONS 7 5.1 Ordering 7 5.2 Processing 8 5.3 Issuing 9 6.0 MEDICATION REVIEW 9 7.0 AUDIT 10 8.0 REFERENCES 11 APPENDIX ONE Suggested acceptable prescriptions for as directed APPENDIX TWO Patients failing to attend for review of repeat medication 12 13 WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 3 of 13

Developing or Updating a Repeat Prescribing Protocol 1.0 INTRODUCTION Repeat prescribing involves the setting up of prescriptions, ordering and producing the prescriptions and the review of medication. Repeat prescribing plays a significant part in the supply of medicines to patients in primary care. Two thirds of prescriptions generated in primary care are for patients needing repeat supplies of regular medicines and these account for nearly 80% of medicines costs in primary care. 1 A well organised and managed repeat prescribing system will save time and energy for prescribers, staff and patients. Other benefits include improved quality of prescribing, improved patient safety and better use of NHS resources. The General Medical Council (GMC) Good Practice in Prescribing Medicines 2 states that any system for issuing repeat prescriptions should take full account of the obligation to prescribe responsibly and safely. Therefore before signing a repeat prescription the prescriber must be satisfied that it is safe and appropriate to do so and that secure procedures are in place to ensure patients are issued with the correct medication, each prescription is regularly reviewed and not issued if no longer required and the correct dose is prescribed. 2.0 PURPOSE As all practices are different it would be impossible to produce a universal repeat prescribing policy that would describe this process. This document is therefore a guide to practices to help them develop and update their own protocol. This guide includes the essential elements of a good repeat prescribing system taking into account any obligations for responsibility and safety and each stage of the repeat prescription being dealt with in turn. This guide should be read in conjunction with other NHS Worcestershire policies including Prescribing policy and the Policy for Managing Inappropriate or Excessive Prescribing. 3.0 GENERAL Practices must have clear, written procedures for the repeat prescribing process, describing the roles of each person involved in the production of prescriptions. They should be written by the practice and reviewed every 2 years. A system should be in place to record that all staff have read the procedures and that it is included in the induction programme for new staff. Patients should have access to written instructions on how to order repeat prescriptions. As with all policies consideration should be given to disability and access and communications. All staff involved in the prescribing system in general practice including GPs, practice nurses, district nurses, receptionists and practice managers and other non medical prescribers such as pharmacists should be involved in a review or update of the policy. WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 4 of 13

4.0 AUTHORISING REPEAT PRESCRIPTIONS 4.1 Authorisation to repeat To meet the GMC requirement to ensure the patient is issued with the correct prescription the protocol must detail: Who can authorise medications to be repeated and how those are added to the patient s repeat medication list. The person who sets up the repeat i.e. keys in the details, should be a doctor, nurse, pharmacy technician or pharmacist. This ensures that the correct item is chosen from the database and that there is clinical input to the process. How hospital letters are dealt with ie how and who is responsible for authorising these and adding new items to repeat records and ensuring discontinued items are deleted. Care must be taken to check the discharge form / hospital letter for dose changes, drugs stopped and started. How items are added following home visits. To meet the GMC requirement to prescribe safely the protocol must include details of: How to ensure a patient is reviewed. Setting an appropriate review date, taking account of the need for monitoring of therapeutic benefit and potential adverse effects is a mechanism that could be used. All items on repeat should be linked to an appropriate indication, READ code or if used off-license should be fully documented and the patient should be advised of the situation. General READ codes such as common illness or general symptoms should not be used. 4.2 Items not suitable for repeat To meet the GMC requirement to prescribe responsibly and safely the protocol must include a policy on the items that are prescribed for short courses and therefore generally not considered suitable for repeat. Practices may choose to use the repeat system to manage patients on these medicines but it is strongly advised that only limited numbers of repeats or short review dates are used. Examples of items generally not considered suitable for repeat include: Antibiotics for treating acute infections Anti-obesity drugs such as Orlistat Nicotine replacement therapy Bupropion Varenicline Analgesics for treating acute pain Hypnotics and anxiolytics Dressings Sip feeds WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 5 of 13

Newly prescribed treatments and those with frequent alterations would be better set up as an acute prescription. It would be prudent to prescribe smaller quantities in these situations. 4.3 Prescription Information 4.3.1 Number of days supply The cost of medicines waste is at least 100 million per year and is a significant cost to the NHS. 3 There is evidence that in some circumstances limiting the prescription to 28 days reduces wastage, but this can cause inconvenience to medicine takers and drive up supply costs. 4 When determining how much of a medicine to prescribe, prescribers should first ensure that the prescription meets the clinical needs of the patient and that the circumstances of the patient are considered when decisions are taken about their clinical management. 5 Factors that should be taken into account when considering prescription duration for individual patients as exceptions to the usual policy include: 5 Stability of the patient s condition and how often their clinical management is reviewed The risk of side effects and hence the need for more frequent monitoring How likely it is the patient will take the medicine as intended Safety considerations associated with storing the particular medicine in the home Patient convenience including, where relevant, cost in prescription charges. Practices should have an agreed policy on the number of days treatment but this policy should be flexible to ensure the patient perspective is not ignored. This could be done by allowing exceptions. Controlled drugs Department of Health guidance as documented in the BNF states prescriptions for Controlled Drugs in schedules 2,3 and 4 should be limited to a supply of up to 30 days treatment; exceptionally, to cover a justifiable clinical need and after consideration of any risk, a prescription can be issued for a longer period but the reasons for the decision should be recorded on the patient s notes It is very strongly recommended that prescribers limit supply of all controlled drugs to 28 days. NB this includes temazepam schedule 3 and benzodiazepines schedule 4. As a guide, 28 day prescribing is advised in the following: Newly initiated medicines (use smaller quantities where possible ie maximum 28 day prescribing and set up as an acute initially) Care homes Patients requiring compliance aids such as monitored dosage systems or dosette boxes. In some cases, quantities less than 28 days may be appropriate refer to guidance on the Equality Act 2010 for further information. Drugs that require frequent monitoring (such as DMARDS) Expensive items (prescribers should be aware of costs) WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 6 of 13

Medicines liable to abuse Terminally ill patients Patients who may not be taking medicines appropriately or who may struggle to manage more than 28 days stock of medicines. Repeat dispensing can be used to save time for the practice and improve choice and convenience for patients. 6 See section 5.2.1 For items taken daily, quantities prescribed should be in multiples of 28 and quantities for individual patients should be synchronised so they all run out at the same time. This will help reduce medicines being stockpiled or wasted and potentially reduce the number of times the patient has to visit the surgery and the number of times a prescription has to be issued for the same patient thus saving clinical and administration time. 1 The use of seven day prescriptions is not recommended unless the patient is unable to manage larger quantities or is at risk of incorrect use. In these circumstances it would be appropriate to prescribe seven days at a time. This could be done using repeat dispensing. 4.3.2 Dosage instructions To meet the GMC requirement to prescribe safely the protocol must detail that all new drugs added to the computer system have clear dosage instructions, which includes liquid feeds, creams, nasal sprays and other external products. 'As directed' is not sufficient information to ensure the patient uses their medicines appropriately. Exceptions to specific directions may include dressings, test strips, appliances and gluten free products. See Appendix One. 4.3.3 Generic prescribing To meet the GMC requirement to prescribe safely the protocol must include a policy on generic prescribing and all drugs should be prescribed generically with the exception of the drugs listed below (not exhaustive): Slow release theophylline Slow release calcium channel blockers e.g nifedipine MR as Coracten XL Slow release morphine sulphate Carbamazepine when used as an anticonvulsant Lithium (use Priadel ) Oral contraceptives Hormone replacement therapy Mixed preparations e.g. alginates and antacids, some emollients please follow formulary recommendations. Wound management products - please follow County guidance Combination products where there is no internationally recognised nonproprietary name including Insulin preparations Combined Parkinson s disease medication Enteric coated mesalazine e.g. Asacol Tacrolimus and ciclosporin WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 7 of 13

5.0 Handling Repeat Prescriptions 5.1 Ordering To meet the GMC requirement that the patient is issued with the correct prescription the protocol must have a clear policy on ordering prescriptions to include: How patients can request their repeat prescription. Written methods are preferred because they are likely to be accurate and less likely to cause errors or misunderstandings. 1 Which staff members will deal with repeat requests. It is recommended that it is done by dedicated individuals who become familiar with the system, patients, care homes and pharmacists, rather than many different members of staff. Who can request prescriptions. There needs to be agreement about who is allowed to request repeat prescriptions eg patient, carer, pharmacist, care home staff and this should be included in the protocol. If third party requests are to be allowed then additional issues should be considered 1 : Assuring patient confidentiality Guaranteeing probity if repeat prescriptions are generated by community pharmacists Ensuring the correct information is exchanged when those making the request are not fully aware of medications, dose and frequency. Requests directly from a supplier other than a dispensing pharmacy are not recommended in NHS Worcestershire Details of how any urgent requests are processed. It is recommended that the practice includes details of their repeat prescribing process in their patient information leaflet which includes how long the requests will take to process. 1 5.2 Processing To meet the GMC requirement to prescribe safely and the requirement to ensure patients who need a further examination or assessment do not receive repeat prescriptions without being seen by a doctor the protocol must include a clear policy on processing to include: Details of the number of repeats allowed before review OR a review date, the latter being the preferred option. Ideally this should be aligned to any monitoring arrangements. Details of what happens when the number of repeats has expired or the review date has passed without the patient being formally reviewed. Practices should have an agreed mechanism for dealing with repeat requests for patients who have not attended for review. See Appendix Two. Details of what happens if the item requested is not currently on repeat. Non clinical members of staff should not under any circumstances add or change items on the repeat system. Details of who can sign the repeat prescription. Ideally this should be a prescriber who knows the patient or at least has access to their full medical records. 1 Any alterations made by hand to the printed prescription should be WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 8 of 13

added to the computer record by the clinician (Written amendments are not permitted if using the repeatable prescription system). It is recommended that the protocol includes how compliance is checked ie what constitutes an early/late request and when this needs to be highlighted to the GP eg early/late requests. 5.2.1 Repeatable Prescriptions 6 Repeat dispensing is the process by which patients can obtain supplies of their repeat medicines over a defined period of time without the need to contact their GP each time a new supply is required. The prescriber produces a master repeatable prescription on a standard FP10 form which is annotated to distinguish it from a standard prescription form and gives details of how many instalments the prescription contains. A series of accompanying batch issues, one for each time the prescription is to be dispensed is supplied at the same time (also printed on FP10 forms). The duration of the original repeatable prescription can be up to 12 months. The practice protocol should include how repeatable prescriptions are processed and staff must have had appropriate training. Procedures must be in place to allow communication to the dispensing pharmacy if there are changes to the medication. 5.3 Issuing Prescriptions 1 The practice protocol should detail: Where completed prescriptions should be stored; this should be where patients cannot reach them. How the practice will verify that the person collecting the prescription is authorised to do so. Eg. The person collecting confirms the address or date of birth of the patient. The procedure for dealing with a missing repeat prescription. All reasonable efforts should be made to locate the missing prescription and a thorough investigation should be carried out. If necessary the loss should be reported to the PCT security manager and/or the police particularly if it is suspected that the prescription items are of high street value or may be misused. Where appropriate, a duplicate prescription should be provided in a timely fashion. Although there is no legal requirement, it is good practice for controlled drug prescriptions to be signed for when collected. This will facilitate any investigation of controlled drugs prescriptions should a problem or dispute arise. The prescription box should be regularly cleared of uncollected prescriptions and occasional audits performed to determine the reason for non-collection. The issue should be cancelled on the patient s notes. WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 9 of 13

6.0 MEDICATION REVIEW Patient medication review differs from clinical review of a clinical condition in that it allows all medication related issues to be addressed. Best practice suggests that all patients aged over 75 years should have a review at least annually and those on four or more medicines should have a review six-monthly. 1 The review need not necessarily be face to face, it could be conducted by phone or by review of the clinical records but a face to face review provides an important opportunity for discussion. 1 Medication review can be used to meet the GMC requirements to ensure that before signing a repeat prescription the prescriber must be satisfied that it is safe and appropriate to do so and to ensure patients who need further examination or assessment do not receive a repeat prescription without being seen by a doctor. The protocol must detail the mechanism for achieving this either using medication review or an alternative mechanism. Medication review is also a requirement for QOF. A medication review should be recorded in the notes in the preceding 15 months for all patients: prescribed four or more repeat medicines (Medicines 11) prescribed repeat medicines (Medicines 12) The practice should agree and include in the protocol, what level of medication review they wish to achieve. 1 Medication review should cover all drugs available as repeats and account should be taken of the various clinicians involved e.g. a medication review by an asthma nurse may not cover all drugs prescribed. On initiation of repeat medication the patient should be given either a date for review or a certain number of repeats before review. The date is the preferred option. The reason for the review should be explained to the patient. When reviewing each repeat prescription, consideration should be given to the following: o the continued effectiveness and need for the drug o the appropriateness of the dose and presentation o patient s understanding of the treatment o monitoring, tests, examinations and follow-up o a check for side-effects, drug interactions and contra-indications o discontinuing items not needed o appropriate frequency of requests o all prescriptions being for the same length of time o use of over-the-counter medications Further information on medication review can be found on the National Prescribing Centre website-www.npc.co.uk. 7.0 AUDIT The quality and robustness of a practice repeat prescribing system should be audited/ self assessed on a regular basis. 1 Points to consider include 1 : Does the practice have a written repeat prescribing policy? Does the policy describe the functions of the staff involved? Are all staff, involved in the repeat process, consulted during policy production? WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 10 of 13

Are the views of patients/representatives sought and incorporated? Has a risk assessment of the process been undertaken, and any necessary interventions made? Is the policy reviewed regularly? Does the practice monitor, and share learning from near misses and critical incidents to reduce errors? Are regular audits performed to assess the quality of the process? Are there systems in place to guarantee both the quality and security of the information held? Is staff training provided and regularly updated on the process and use of the systems? Is information readily available for patients/representatives on how the process works? Are people whose first language isn t English catered for? Is discrimination avoided against people who have impairment to either their physical or psychological functioning? 8.0 REFERENCES 1. National Prescribing Centre. Saving time, helping patients. A good practice guide to quality repeat prescribing. January 2004 2. GMC Good Practice in Prescribing Medicines September 2008. Accessed at: http://www.gmc-uk.org/guidance/ethical_guidance/prescriptions_faqs.asp 3. National Audit Office. Prescribing costs in primary care, May 2007. Accessed at: http://www.nao.org.uk/publications/0607/prescribing_costs_in_primary_c.aspx?alreadysear chfor=yes 4. York Health economics consortium. Evaluation of the scale, causes and costs of medicines waste medicines. November 2010. Accessed at: http://www.pharmacy.ac.uk/fileadmin/documents/news/evaluation_of_nhs_medicines_wa ste web_publication_version.pdf 5. National Prescribing Centre. Connect- a quarterly newsletter for primary care prescribing advisers, issue 55 December 2008 6. National Prescribing Centre. Dispensing with repeats a practical guide to repeat dispensing. September 2008 WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 11 of 13

APPENDIX ONE Suggested acceptable prescriptions for 'as directed' Dressings Appliances including stoma, hosiery, trusses, catheters etc Blood and urine testing strips Lancets, syringes etc Gluten free products Difficult Items for Instructions Examples; Aqueous Cream - apply regularly to dry skin Steroid creams - apply sparingly once or twice a day Warfarin - take as directed in yellow book Epoetin - state exact dose as quoted on the consultants' letters Viagra - do not take more than one dose in 24 hours Drops for ear, eyes and nose - instil 2-3 drops 3-4 times a day to the.state right/left/both eye, ear or nose. Always add the dose given in the ophthalmologists letter for eye drops. Sorbaderm use a pea sized amount every three washes WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 12 of 13

APPENDIX TWO Patients Failing to Attend for Review of Repeat Medication The General Medical Council (GMC) in its publication Good Medical Practice 1 states that a clinician must only prescribe drugs or treatment including repeat prescriptions when you have adequate knowledge of the patient s health and are satisfied that the drugs or treatment serve the patients needs. Without having contact with the patient the clinician cannot be assured of this and therefore attempts should be made to contact the patient or carer for e.g. children. 1. For patients who fail to attend, a number of different means of contacting the patient should be tried. It is not possible to suggest one strategy as this will vary depending on the patient but possible ideas include: o Letter explaining the GPs obligation to ensure the welfare of the patient. o Phone call o Visit to home o Reducing the quantity of repeat medication issued (harder for inhalers)* o Text message o Using practice extended hours to offer appointments o Email alerts *It would be difficult to stop a patients medication altogether because this would effectively be withholding medication knowing that the patient may suffer harm as a result. 2. Check whether the patient has recently been reviewed by another health professional/organisation e.g. secondary care / mental health team etc. 3. Check that it is appropriate to contact the patient using one of the methods above. It may be that the patient s carer should be contacted. 4. Check that the patient is still resident at the registered address; it may be that the patient has moved and the practice has not been notified, for example, students and patients living abroad for the winter months. 5. For patients that have co-morbidities, try to co-ordinate reviews so that the attendances at the practice are reduced. 6. All attempts to contact the patient or carer must be documented in the notes. References: 1. http://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care/index.asp WPCT Guidelines for Repeat Prescribing by GPs- version 3 May 12 Page 13 of 13