Jun 19, 2006 - D.o.B. Title, Forename, Surname & Address. Please don't stamp over age box. Pharmacy Stamp. Signature of Prescriber. Date. For dispenser.
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Repeat dispensing: the benefits for GPs, pharmacists and patients Rebecca Elvey MA (Econ), Darren Ashcroft PhD, MRPharmS and Peter Noyce PhD, FRPharmS All community pharmacies Pharmacy Stamp
Age
Title, Forename, Surname & Address
must now offer repeat dis-
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pensing. Here the authors explain the process and its
Please don’t stamp over age box
Number of daysʼ treatment N.B. Ensure dose is stated
benefits and explore some of
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GP REPEAT DISPENSING Authorising no. of issues = 12
the reasons for its slow uptake by GPs.
PARACETAMOL tabs. 500mg. Mitte (100) tablet (s).
GP REPEAT DISPENSING Authorising no. of issues = 12 LACTULOSE soln. 3.35g/5ml. Mitte (500) mls. 10 OR 15ML TWICE A DAY AS REQUIRED - - - - - - - - - - - - - Two prescriptions on form
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For dispenser No. of Prescns. on form
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Figure 1. A repeatable prescription. Despite the benefits of repeat prescribing and dispensing, GPs have been slow to implement the scheme
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efore the NHS regulations were amended to allow repeat dispensing, the UK was the only developed countr y without a routine system allowing patients to collect repeat medications without visiting the surgery. However, local arrangements have existed in many areas. Supplying prescriptions for repeat medications without patients seeing a doctor each time is an important part of everyday general practice activity: 75 per cent of pre12
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scribed items are repeats.1 Despite such common use, repeat prescribing systems have been criticised for lacking adequate clinical or management controls.2 Pharmacy-based pilot schemes aimed at improving these processes were trialled in the 1990s, and evaluations of these schemes confirmed that they were feasible and popular with GPs, community pharmacists and patients.3 The Repeat Dispensing (RD) pathfinder scheme started in 2003
in 89 PCTs in England. More recently, this was superseded by the implementation of the new community pharmacy contract in 2005. RD is now an ‘essential service’ in the new community pharmacy contract, which means that all community pharmacies must offer the service. However, the service is still bedding down: as of December 2005 prescribers in only 220 out of a possible 303 PCTs in England had issued repeatable prescriptions.4 www.escriber.com
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How repeat dispensing works
The key differences between RD and traditional repeat prescribing systems are that the GP does not have to sign a prescription each time the medicine is repeated, and the patient can collect their medicines direct from the community pharmacy without having to visit the general practice. Figure 2 outlines the process.
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The national pathfinder scheme found that RD was commonly being used for patients aged 60 and over, medicines for chronic conditions such as hypertension and diabetes, and stable regimens of long-term medications. Benefits
RD represents little change from the tasks involved in routine prescribing and dispensing and,
unsurprisingly, has been generally well received by those GPs and pharmacists running it as a means of streamlining the familiar but often cumbersome process of supplying repeats. GPs have welcomed the opportunity to ‘tighten up’ repeat prescribing practices and many have found their prescription-signing workload reduced. Pharmacists are expected to check with the patient each time
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Analysis
they collect a prescription that all items are required, and GPs and pharmacists agree that the increased monitoring patients receive at the pharmacy is likely to improve quality of care. The impact on community pharmacy working practices has been minimal. The RD dispensing process is essentially the same as standard dispensing, and sometimes more efficient because pre-
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scriptions are held at the pharmacy, so dispensing can be a planned process. Dispensing RD prescriptions also takes slightly less time than normal prescriptions. The research highlighted examples of successful working relationships between GPs and community pharmacists. RD seems to encourage interprofessional working and increase recognition of one another’s skills. Patients benefit
from the convenience of making fewer trips to the surger y. Medicines can be collected direct from the pharmacy and the patient only has to visit the practice after all repeats have been dispensed. Problems
Despite the generally positive reception, uptake of RD has progressed at a modest rate. In December 2005 RD made up only
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Patient on a stable prescription agrees to accept a repeatable prescription. GP provides the repeatable prescription consisting of a master copy, which is signed, and a series of duplicate repeats (unsigned). GP and patient agree the number of repeats, the duration of the repeats (maximum 12 months) and the nominated pharmacy that will manage the prescription.
Repeatable prescription taken to the pharmacy by the patient and first instalment is dispensed. Pharmacy retains the remaining prescriptions.
Where the patient’s medication is changed midrepeat, a new repeatable prescription is issued and taken to the pharmacy to replace the original one.
Patient visits pharmacy, ideally a few days before running out of medicines. Pharmacist dispenses medication from the repeatable prescription, checking which medications are required and whether side-effects are being experienced. If required, patient pays prescription charge as per normal prescription. Pharmacist sends one of the duplicates to the Prescription Pricing Authority for reimbursement.
When the number of repeats is finished patient visits GP for new repeatable prescription.
Figure 2. The typical repeat dispensing pathway
0.3 per cent of all prescriptions issued in England, although estimates put the potential figure at around 50 per cent. Implementation of the scheme has been hampered by a number of practical issues. Some GPs have struggled with software systems that are less than ideal. These make data management time consuming, especially when recording medication changes. The initiation process for signing patients up to the scheme can also be tedious. ‘As required’ medicines on the same RD prescription as a regular dose can cause problems at the dispensing stage. If an item is not needed at the time the repeat is dispensed then it will not be available without using another repeat. As a result it is probably best to put 16
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‘as required’ items on a separate repeat. The prescription charge may be an issue when, as is the case in many PCTs, 28-day prescribing is encouraged. Charge-paying patients often receive prescriptions for three- or even six-month periods and may not want to pay a monthly prescription charge. Although there is no contractual requirement to limit prescribing to 28 days, many PCTs through implementing prudent medicines management guidance encourage this as good practice. Some GPs are wary about engaging in the system unless patients are using a pharmacist with an established working relationship with themselves. Pharmacies with high numbers of locums are of particu-
lar concern. Part-time and locum working are common in community pharmacy.5 However, under their terms of service pharmacists must make a number of checks before dispensing a repeatable prescription, including establishing the patient is taking, and is likely to continue taking, the medication appropriately and that they are not suffering from side-effects. Community pharmacists are now required to dispense RD prescriptions, but no equivalent requirement exists for GPs to produce them. Some practices have both RD active and nonactive GPs, which has implications for continuity. A patient may visit the practice, receive an RD prescription, but the next time see a nonactive GP and be unable to access the www.escriber.com
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ser vice. Without GPs producing the prescriptions there is no RD, therefore engagement needs to be increased so that more professionals and patients can benefit. Making the most of repeat dispensing
There are several issues that need to be addressed before the advantages of RD can be fully realised: • Raising awareness among GPs and facilitating interdisciplinary training to encourage uptake. • In the Quality and Outcomes Framework (QOF) general practices have to agree up to three actions related to prescribing, and some PCTs are encouraging GPs to be involved in RD schemes as one of these. Evidence suggests that offering financial incentives to GPs and pharmacists can increase RD activity.6 • Monitoring arrangements in the new pharmacy contract require evidence of meeting the ‘essential’ ser vice specifications, eg having standard operating procedures in the pharmacy. Promoting understanding of these requirements may help to reassure GPs concerned about patients using pharmacies where the pharmacist and GP do not have an established working relationship, or where locums are employed.
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Key benefits Repeat dispensing may: • reduce prescription signing workload for GPs • streamline the repeat medication supply process • shorten the patient journey, improving access to medicines • allow community pharmacists to plan their workload more effectively • encourage closer working between pharmacists and GPs
RD is one of a number of services like supplementary prescribing and minor ailments ser vices designed to address the wider policy of improving access to medicines. Close working with pharmacists and ensuring good practice in RD systems may help practices score points under the medicines management indicators in the QOF. In addition, the forthcoming implementation of electronic transfer of prescriptions should reinforce RD as the patient’s nominated pharmacy will be able to access prescriptions electronically. It is still early days for RD, and with all new schemes it takes time for practitioners to build up confidence and familiarity with new arrangements. Early experiences suggest that while there are still
some negatives to be overcome, once GPs are further engaged RD has the potential to streamline the repeat medicines supply process and play an important role in primary care modernisation. References
1. Harris C, Dajda R. The scale of repeat prescribing. Br J Gen Prac 1996; 46:649-53. 2. Zermansky AG. Who controls repeats? Br J Gen Prac 1996;46:643-7. 3. Morecroft CW, Ashcroft DM, Noyce P. Repeat dispensing of prescriptions in community pharmacies: a systematic review of the UK literature. International Journal of Pharmacy Practice 2006;14:11-9. 4. Prescription Pricing Authority. Update on growth in prescription volume and cost year to December 2005. www.ppa.org.uk/pdfs/publications/ volume_cost_year_dec05.pdf. 5. Hassell K, Shann P. The national workforce census: (3) The part-time pharmacy workforce in Britain. The Pharmaceutical Journal 2003;271:58-9. 6. Wang L. Bristol North leads repeat dispensing. The Pharmaceutical Journal 2006;276: 294-5.
Rebecca Elvey is a research associate, Darren Ashcroft is a clinical senior lecturer and Peter Noyce is professor of pharmacy practice at the Centre for Innovation in Practice, School of Pharmacy and Pharmaceutical Sciences, University of Manchester
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