A repeat prescription is one which contains medication items which are already on a patient’s repeats medication list section of their medical record.   This prescription can be obtained repeatedly when they run out without having to see a doctor.   These items should be limited to medicines which are prescribed for long term therapy to patients who are stable.  A repeat prescribing system is a system to issue such prescriptions but also includes measures to review the patient and their medication periodically, check concordance, remove any unnecessary medication and make fine adjustments based on good clinical practice.

Repeat prescriptions should be issued to

• patients who have an illness for which long term regular medication is appropriate
• patients who are likely to need a medication repeatedly but not regularly (e.g. gaviscon, lactulose)

Doctors are responsible for initiating repeat prescriptions. The patient must be stable on the medication.

1. Authorisation –  where the doctor initially puts a medication on repeat
2. Medication request– the patient requests he repeat medication via the repeat script (preferred) or electronically. Only in exceptional circumstances will we accept telephone requests.
3. Admin check medical records for compliance and review dates
4. Admin print the prescription. If all is okay, admin staff print of the prescription and hand over to doctor; if all is NOT okay, admin staff highlight any prescriptions of concern, keep these in a separate pile and then hand these over to the doctor.
5. Doctor does a medication review (and read codes it)
6. Doctor re-authorises and updates review date (as necessary) on SystmOne.
7. Doctor signs the prescription and hands it back to admin staff.
8. Prescription storage – admin staff place the prescription in a secure holding area until patient arrives to pick it up.

Authorisation is the decision by the prescriber that a particular medication is okay to have on a repeat prescription for that particular patient.  Only prescriptions which have been “authorised” may be issued by non-clinical members of staff.  An authorised prescription only includes those medicines on “repeat templates” on SystmOne. It does not include medication that appears in the acute, current of past history sections of the patient medication record.  Items on a patient’s repeats should be limited to medicines which are prescribed for long term therapy to patients who are stable.  Non-clinical staff can only be allowed to view or issue items already on a repeat list.  ONLY members of staff with relevant clinical qualifications are allowed to add medication to records.

Who can authorise medication?

• Doctors, Nurses with a prescribing number, an in-house pharmacist.

To authorise, the doctor, nurse, pharmacist or prescriber must check that

• the patient is stable on the medication,
• the medicine is well tolerated and
• it is still needed.

Medicines that are subject to monitoring and dose titration must not be added to the repeat until

1. they are deemed to be safe for that patient
2. a stable therapeutic dose has been achieved
3. if appropriate – bloods/investigations have been reviewed to check that the drug is okay to give at that dose
4. there is a clear protocol for issuing them as repeats.

When prescribing a new repeat, try and syncronise – match up all repeat medications in terms of quantities (that it runs out when other medication runs out) and review dates.

Repeat requests should ideally be received in writing on the repeat slip/ counterfoil, as they are more likely to be processed accurately.  In some circumstances it may be impracticable for practices to only receive written requests.  In these circumstances admin staff must ensure they ask sufficient questions to process the repeat request accurately (see under telephone header below for more information). Patients should be advised at the time of request that the doctor may wish to see them before the item is issued.

Written Requests

There is evidence to suggest that written requests are more accurate than telephone requests.  The patient should tick the items they want on the repeat side of the prescription foil and hand or post it to the surgery.  This will be processed within 2 working days.   This is the ideal because it (i) minimises transcription errors, (ii) minimises confusion with brand and proprietary name pronunciation, (iii) avoids mismatching the request to the patient’s record, (iv) allows prescriptions to be processed with no interruption from further calls and (v)  allows requests to be deposited in a post box in the reception area to avoid disturbing staff unnecessarily.  If the patient forgets/ loses the repeat slip then a repeat slip can be printed from the patient’s medication record or alternatively a request slip could be completed by the patient.

Electronic Requests

Staff need to be very careful with requests for repeat medication via e-mail or the internet. Especially check to make sure the item requested matches what is on the patient’s repeat list on SystmOne.  Don’t only check the name of the medication, but the strength, the form and the dosage instructions.  Also double check name, date of birth, address.   And finally, check to ensure that patients are not over or under ordering – SystmOne will tell you.  If there is ANY descrepancy, please ring the patient and check it out with them.

Telephone Requests

Remember that telephone requests for medication can  (i) block more urgent calls, (ii) block patients trying to make appointments, (iii) distract receptionists whilst processing requests, and  (iv) lead to one request not being processed before the next telephone call is answered. Alternatively, if the number of telephone calls are low the receptionist allocated to that role does not have a constant work flow.  Where a practice chooses to use telephone requests,
dedicated times should be encouraged to concentrate calls to a specific time releasing the receptionists at other times in the day. This does not mean that patients telephoning outside these hours should be refused medication, instead the request should be accepted and the patient reminded of the designated times when requests should be made.

Compliance – under or over using

• Did you know that you can check compliance through the computer – SystmOne will tell you how often the patient is ordering the medication – and whether they are underusing, overusing or are just right.  Repeat prescribing admin staff need to  have been trained to look at the compliance section of SystmOne and to tell you if a patient is significantly under or over using a medication.  whether the patient is taking the medication as prescribed (i.e. is concordant) and not underusing or abusing it.  Check under ‘history’ in SystmOne to ensure the patient is not ‘under using’ for ‘over using’ the drug.
• The Practice Manager will check that the computer is set so that compliance issues are flagged and a message over ridden before the receptionist can continue. There is evidence to suggest that on screen reminders are more effective than feedback in modifying behaviour related to medicines management.
• Early requests for items can be permitted in certain circumstances i.e. if a patient is due to go on holiday, even though the computer will identify this as overuse.
• Medicines which can be taken on a ‘when required’ basis may be flagged by the computer as being underused e.g. pain-relief, indigestion remedies etc. Staff who process repeat prescriptions should be aware that this is acceptable although should still be brought to the doctors attention. The practice should develop their own list of medicines which they feel are acceptable to be under-used.    

Review Period

• Check that the repeat item is within the authorised period – i.e. the review date has not been exceeded   OR   the number of authorised prescriptions has not been exceeded.   If it has, then do NOT issue the prescription and refer the case to the doctor or prescriber.
• If the review date is approaching, the item can be issued and the patient informed that a review appointment is due e.g. highlighter or stapled note attached to the prescription.  Where prescriptions go direct to the pharmacy, the pharmacy staff should indicate to the patient that a review appointment needs to be made.

• Repeat prescriptions need to be prepared with accuracy by a receptionist who is trained up in the role of repeat prescribing.
• In order to reduce the risk of mistakes, the receptionist who has the task of processing the repeat prescriptions should do so in a quiet area where they can concentrate and not be distracted.
• A computer system must be used to issue all prescriptions.
• Before you issue the prescription
  
  • Check SystmOne to see if the patient is underusing or overusing the medication significantly.  You should know how to do this, if not, ask a colleague.  If they are under or overusing, please write this on the right hand side of the printed prescription and highlight it with a highlight marker for the doctor to see.  Early requests for items can be permitted in certain circumstances i.e. if a patient is due to go on holiday, even though the computer will identify this as overuse.  Medicines which can be taken on a ‘when required’ basis may be flagged by the computer as being underused e.g. pain-relief, indigestion remedies etc. Staff who process repeat prescriptions should be aware that this is acceptable although should still be brought to the doctors attention. The practice should develop their own list of medicines which they feel are acceptable to be under-used.
  • Check that the repeat item is within the authorised period – i.e. the review date has not been exceeded   OR   the number of authorised prescriptions has not been exceeded.   If it has, then do NOT issue the prescription and refer the case to the doctor or prescriber.
  • If the review date is approaching, the item can be issued and the patient informed that a review appointment is due e.g. highlighter or stapled note attached to the prescription.  Where prescriptions go direct to the pharmacy, the pharmacy staff should indicate to the patient that a review appointment needs to be made.
• Prescriptions need to be printed and processed within 48 hours of recieving the request from the patient.  When accepting a request from a patient for a repeat prescription, please tell them that the turnaround time for a prescription will be 2 days and that they should not come to collect it before then.

It is important to ensure prescriptions are issued via SystmOne rather than hand-written because computers…

• Warn of possible interactions, contra-indications and side effects.
• Provide a record of the issue in the patients notes – so that others can see what has been given.
• Provide the patient with a copy of the items that have been authorised as a repeat prescription, which can be used to request a repeat.
• Can be used as a source of data and audit to improve prescribing quality and maximise cost effectiveness.
• Provide the doctor with a profile of their prescribing habits.

During a review patients should be considered individually, with respect to their illness and medication.   The person reviewing the patient should be satisfied that the patient still requires long term medication and will check the items listed below.  All queries and complex issues should be referred by the nurse to the doctor.  If a patient fails to attend for their Medication Review repeatedly, consider doing it opportunistically when they present acutely.  A medication review can be done by a doctor, an inhouse pharmacist or an appropriately qualified nurse (with prescriber status).  Not all medication reviews need to be done face-to-face either.  Many can be done over the phone – especially where the patient is on four or less medication repeats.   Medication Review and Re-authorisation of medication should be done at the same time.

For each individual medicine…

• Does the patient understands the purpose of the medication
• Are the dosage instructions are clearly written on the prescription. If the prescription states ‘when required’ then a maximum dose needs to be stated.   MDU or ‘as directed’ are not acceptable.
• Is the patient taking the medication as prescribed (i.e. is concordant) and not underusing or abusing it.  Check under ‘history’ in SystmOne to ensure the patient is not ‘under using’ for ‘over using’ the drug.
• Does the drug continue to be effective – is it having the desired effect, are they on the right dose?  Is there a better and more suitable alternative?
• If the medication is no longer necessary remove it.
• Is the patient is experiencing any intolerable side effects?  (Side-effects/ ADRs/ allergies should be recorded in the patient’s notes.)
• Change the medication to generic form if appropriate (exceptions listed below). If you do this, inform the patient that you have changed the name of his/her medication, but that it is chemically the same. Alert the patient to any change in appearance of the drug. (Nurses – If in any doubt, consult the doctor)
• Review any bloods (e.g. TFTs for thyroxine, TFTs and Li levels for Lithium, CVD bloods, Renal Bloods, Rheumatology bloods and so on)
• Have appropriate measurements and examination been done? – eg BP, HR, ECG
• Reauthorise to allow 12 months (6 months in over 75’s) of repeat medications.
• Code Medication Review Done on the computer (this is part of the template).
• Document any changes in the patient’s notes.   Any change should be monitored, and be reviewed again at reauthorisation or when medication review is due in line with QoF.

For the repeat prescrbing list as a whole…

• Determining which medicines are being taken and deleting any medicines which are not being ordered and duplicate medicines.  It is good practice to periodically run searches to determine which medications are not being ordered.
• that all medication is prescribed in equivalent quantities (so, for instance, they all run out at the same time, enabling the patient to re-order everything in one go where possible). The quantities must be sufficient and not excessive.
• that prescribing is generic where appropriate
• other medications prescribed from other organisations and over the counter medicines are identified and listed.
• that the patient has been informed of the next review date

Other considerations for the doctor’s medication review

• Check that each prescription has a relevant ‘indication’ item on the computer.
• Check that the prescription is appropriate within the prescribing incentive scheme markers
• Stop any medications that are not being ordered regularly
• Consider dossett boxes in elderly patients or those on complex polypharmacy
• Consider referral to case manager in patients with complex polypharmacy (more than 8 medications on repeat)
• Consider review by pharmacist in complex polypharmacy

Drugs that should NOT be prescribed generically…

• Diltiazem
• Nifedipine
• Isosorbide mononitrate
• Theophylline slow release preparations
• Anticonvulsants
• Mesalazine
• Insulin

Reauthorisation

All repeat medications must be commenced on the computerised patient repeats prescription list by a GP and authorised for a set number of issues. Once this number has been achieved it has to be re-authorised by the GP.  The GP should try to synchronise the list of repeat medications to need re-authorising at the same time and at this re-authorisation carry out a formal medication review.  It’s also good practice (and it saves a lot of work) if one can do medication reviews and reauthorisations at opportunistic times like at the chronic disease review clinics.  If you are doing a reauthorisation, also try and do a medication review.

Remember: reviews don’t necessarily have to be done face-to-face. There is the option of the telephone! Give message to the reception staff to ask patient to make appointment for Medication Review. If any blood tests are required give clear message to the receptionist to book these prior to the review and note in consultation record which bloods are required. The medication review can still be booked as a telephone consultation if appropriate.

The Review Date

• Normally the review date for stable medicines is set at 12 months but it should be set earlier for patients who should be seen more often (e.g. older people on polypharmacy set for 6 months).
• Review dates are the key to managing long term medicines.
• The review date acts as a safety mechanism to ensure that medicines are flagged back to the prescriber for review.
• When you are asked to review a medication, try and review ALL the medication on repeats and set the review date for ALL those medication.   Read code that a medication review has been done (their is a tick box for this in SystmOne when you reauthorise medication – left hand side at the top of the page).
• It is preferable to have a review date rather than a maximum number of issues.
• The review date should be the same for all the medicines (except those where a particular medicine may need an earlier review). This ensures the patient’s medicines are reviewed holistically.
• Only a clinician or an in-house pharmacist should update the review date.
• The review date must be updated each time a medicine is added or changed.
• An entry needs to be made in the medical records at the time of medication review to indicate that it has occurred, noting any changes.

• The prescriber should have access to the patients’ medical notes when signing/ re-authorising repeat prescriptions.

• Once prescriptions are signed, they should be stored in a secure area away from public access.  In Ashcroft Surgery, there is a prescription filing cabinet in the receptionists area (which is partitioned off from the patient waiting area).