The best repeat prescribing decisions are based on patient’s need and a full evaluation of the available clinical evidence.
It would not be right to either stop or deny patients the medications they need, but it would be justifiable to change them to more cost effective drugs if it could offer the same benefit, has a similar safety profile and no known drug interactions.
The office for National Statistics has estimated that by 2035, 23% of the population will be over 65 compared to 16.5% in 2010. Many will have long-term conditions that will need active management with drugs. Money is tight and will get tighter. Managing spending on drugs will be essential.
According to a report commissioned by the DH, primary care in England wastes £300 million every year on unwanted medications. About one in five people admit to having a waste medication in their possession.
Repeat medicines account for around 80% of all prescriptions on the NHS. In NHS Oldham last year there were 4.75 million scrips dispensed at a cost of £42.3 million. If 80% of these were repeats, significant sums could be saved by a systematic handling of repeats.
Oldham CCG medicine management bears in mind three Cs when it comes to issuing a repeat prescription:
- care quality
This can only be achieved by working together with primary care clinicians and practices.
In my practice I undertook an audit of repeat prescribing. The purpose was to examine how community pharmacists ordered repeat medications on behalf of patients and what, if any, communication took place between the pharmacist and the patient.
Although this can be an efficient way of managing the supply of medicines to patients it can lead to wastage as medicines prescribed are often no longer needed. There are also safety concerns as patients accumulate large quantities of medicines that they no longer require.
Our two-month audit of repeat prescribing found the following:
- 52% of cases had received items that they had not requested or did not require.
- Of this 52%, 98% of patients reported that this happened frequently and 2% reported that this happened occasionally.
- 45 % were not taking their medications as prescribed because of either side effects, believing that they were taking too many, or not feeling that the medication was really necessary.
- 3% of patients were in the hospital, but depsite this the pharmacist had ordered the whole scrip.
What we did
Following a meeting with the patient participation group, the practice decided to take steps to reduce the inappropriate or excessive ordering of prescriptions.
We aimed to restrict the impact of community pharmacies in ordering repeat prescriptions for our registered patients. We also decided that GPs would conduct six-monthly review of all prescribed medications to ensure they were still needed.
We did this in the following ways:
- Posters were displayed in the waiting room to raise awareness of medicine waste among patients and carers.
- At the time of registration new patients, the patient or carer were given an information leaflet describing the method for ordering repeat medications.
- A message was printed on the prescription return slip: ‘Think, Order what is needed and Inform the staff/doctor if the medication is stopped’.
- We assigned a dedicated member of the staff to handle repeat requests
- We also dedicated a phone line to be manned for two hours per day taking requests.
- We decided that no orders of repeat prescriptions from the pharmacists would be accepted
We took complete control of repeat prescribing for our patients in November 2012 and continue to do so.
The main savings have been in the following areas:
- Inhalers for asthma and COPD
- Nasal sprays
- Analgesics including opioids for musculoskeletal pain
- Drugs for erectile dysfunction
- Diabetes testing strips
- HRT preparations
- Switching to generics (only in those where there were significant cost efficiencies without compromising patient care).
The total saving from November 2012-February 2013 is approximately £5,210.
This was at the expense of making our local pharmacists rather unhappy. They claimed the previous service was more convenient for patients. However, in my view the system we have established is a prescription for healthier prescribing, improved patient care and reduced medicines wastage.
- Dr Sharma is a GP in Oldham, Greater Manchester and clinical director for vascular and medicine management at Oldham CCG