Fionnuala Plumart, Jade Tomes, Nick Rutherford Medicines Management Team, Brighton and Hove CCG
Why have we created this role?
Processing 100 + repeat requests a day Constant phone ringing Many different screens being opened on same computer Being asked by patients for medications not on repeat list Patient has gone past review date without a medication review Urgent requests for medication Following up queries Day to day office duties
Being the first point of contact for non-clinical prescribing queries Responsible for sharing information provided by the Medicines Management team(us) to all relevant practice staff Overseeing that the repeat prescribing process is followed and improving prescribing efficiencies Ensuring policies and procedures regarding prescribing are up to date Undertaking a small snapshot review(s) during the year Attending further training sessions
Understand the important role you play as the gatekeeper to prescriptions as a repeat prescribing co-ordinator. To have a greater knowledge of what Controlled drugs and High-Risk drugs are, and how this affects you in your role. To recognise what drugs are and are NOT suitable to be prescribed on repeat. To be aware of synchronisation and repeat dispensing and how implementing these can reduce your work load. To identify three learning points to take back to your practice in relation to its current repeat prescribing system. To be confident in incorporating these ideas into your day to day work.
Some medicines are CONTROLLED under the law (Misuse of Drugs legislation). Stricter LEGAL controls apply to controlled medicines to prevent them: being misused being obtained illegally causing harm Schedule 1 (highest level of control) Schedule 5 (lowest) Examples of controlled drugs include Methylphenidate (Schedule 2 for ADHD) Morphine (Schedule 2 for pain) Tramadol (Schedule 3 for pain) Diazepam (Schedule 4 for anxiety and spasms) Codeine (Schedule 5 for pain) These legal controls govern how controlled medicines may be: stored produced supplied prescribed
Prescriptions (in Sch 2, 3 and 4 ) valid for only 28 days from date of issue. The Law strongly recommends that the MAX quantity on a prescription should be limited to 30 days Prescriptions for Sch 2 and 3 CDs must include specific details : The pts full name, address & DOB Name and form of the drug (capsules, tablets etc.) Strength and dose Total quantity of preparation or number of doses, in both words and figures e.g. please supply 20 (twenty) tablets Prescriptions for temazepam and Sch 4 and 5 CDs are exempt from these requirements. Before supplying the medicine, pharmacists must check that the prescription is written correctly. If it s not, it must be corrected by the prescriber.
Although any medication taken incorrectly has a potential to cause harmsome medication have higher risks and require specific additional monitoring. These include Warfarin Methotrexate Immunosuppressant's such as Tacrolimus or Azathioprine Insulin therapy Opioid therapy Lithium People taking these medicines may require regular blood tests to make sure they are receiving an appropriate and safe dose to treat their condition. If these tests are NOT done, and the patient carries on taking their medication- they could come to serious harm.
A way of issuing regular medication without contact between doctor and patient. Because there is no contact, it is a potentially risky process, with possible pitfalls at every stage. A major part of the work of general practice accounting for 75% of all prescriptions and 80% of costs. The Quality and Safety of repeat prescribing are well recognised concerns
When deciding if a medication is suitable to be put on repeat, the prescriber must be satisfied that: The medication is at a stable dose It is achieving the desired effect The patient is experiencing no (or acceptable) side effects The patient understands the purpose of the medication The patient is not going to abuse their medication and repeat status The patient wishes and is able to take the medication An appropriate review date has been set.
Practices should agree their own list of drugs which they consider are NOT suitable to be on repeat. This may vary according to practice preference and systems. The following is an example list : Antibiotics* When required ( PRN ) medications Weight loss drugs e.g. Orlistat (Xenical) Smoking cessation therapies such as Champix and Nicotine Replacement Therapy Thrush treatments Benzodiazepines Hypnotics e.g. Zopiclone, Zolpidem etc
Patients with a number of repeat items will often run out at different times. When this happens, they will either: Request the item they have run out of when needed. More frequent requests. Increased practice workload. Inconvenient for patient. Order everything regardless of whether it is all needed. Over ordering / stockpiling. Waste of NHS resources. Increased risk to patient.
Synchronisation means organising the repeat medications so that all items will run out at the same time if taken as prescribed. To synchronise prescriptions you must ensure that: Quantities are correct for prescription duration (e.g. 28 days) All items have the same duration All items have a synchronised number of issues before re-authorisation (easier for medication review) Synchronisation involves everyone! GPs to consider when initiating Educate patients on benefits, highlighting problems Involve community pharmacies Regular medication review Synchronisation can greatly reduce your workload and prevent waste.
Based on patients with 4 items prescribed two-monthly over 1 year. Number of patients Potential prescription requests before synchronisation Prescription requests after synchronisation 1 24 6 20 480 120 100 2,400 600 2,000 48,000 12,000 4,000 96,000 24,000
Where to start?! Four Steps to Synchronisation: 1. Target patients most likely to have problems: Frequently ordering individual items Different quantities 5 or more items on repeat 2. Review/align repeat script items duration, quantity, no. of repeats 3. Use a Synchronisation Form Once completed form received, issue one-off script to bring medicine quantities/durations into line. 4. Review and maintain may need to re-synchronise in future Patient not taking as directed New items initiated out of sync When required medicines Special containers Lost prescriptions
Each group will have a case study featuring a repeat prescription scenario. Consider the areas we have covered today and evaluate the case study: Controlled drugs and High Risk drugs Drugs not suitable for repeat prescribing Synchronisation Discuss and note down any issues you would flag up and how you might expect them to be addressed.
Mr M. Mouse, The Castle, Disneyland Aspirin 75mg tablets Take 1 daily 28 tablets Simvastatin 20mg tablets Take 1 ON 56 tablets Isosorbide Mononitrate Take 1 BD 56 tablets 10mg tablets Morphine Sulphate 60mg Take as directed 200 capsules MR capsules Viagra 50mg tablets (SLS) 1 when required 28 tablets Atenolol 50mg tablets Take 1 daily 56 tablets
Synchronise quantities of regular meds If 28 day Reduce simvastatin and atenolol to 28 If 56 day Increase aspirin to 56 and ISMN to 112 Morphine sulphate Controlled drug. Ambiguous directions get GP to confirm. PRN or regular? Long term? Suitable for repeat? Risk of abuse/diversion Quantity likely too high Viagra Quantity too high Usually 4 per month considered appropriate Possible risk of diversion? Suitable for repeat?
Miss A. Piggy, 32 Sesame Street Metformin 500mg Take 1 three times a day 84 tablets tablets Gliclazide 80mg Take 1 twice a day 28 tablets tablets Pioglitazone 30mg Take 1 OD 60 tablets tablets Temazepam 10mg Take 1 at night PRN 56 tablets tablets Amoxicillin 250mg 1 TDS for 5 days 21 capsules capsules Aviva blood glucose Test three times a day 200 strips testing strips
Synchronise quantities of regular meds If 28 day Increase gliclazide to 56, reduce pioglitazone to 28 If 56 day Increase metformin to 168 and gliclazide to 56. Maybe change pioglitazone from 60 to 56. Temazepam Controlled drug PRN Suitable for repeat? Long term or short term? Risk of abuse/diversion If scripts should be 28 day (and treatment is regular long term), need to reduce quantity to 28. Amoxicillin antibiotic 5 day course not suitable for repeat prescribing Risk of taking too much, waste, antibiotic resistance Even if prescribed acutely, quantity should be 15 caps based on directions
Mr W. Pooh, 100 Acre Wood Methotrexate 10mg Take 1 every week 28 tablets tablets Accrete D3 tablets Take 1 twice a day 28 tablets Oxycodone 20mg MR Take 2 twice a day 56 tablets tablets Nicotine 4mg lozenges Suck 1 up to QDS 200 lozenges Citalopram 10mg Take 1 OM 28 tablets tablets Ibuprofen 5% gel Apply three times a day PRN 100g tube
Methotrexate High risk drug 10mg tablets should not be used in primary care change to 2.5mg tablets Change quantity to 16 x 2.5mg Synchronise quantities of regular meds If 28 day Increase Accrete D3 to 56, oxycodone to 112 If 56 day Increase Accrete D3 to 112, oxycodone to 224, methotrexate to 32 x 2.5mg, citalopram to 56. Oxycodone Controlled drug long term? Taken regularly or prn? Suitable quantity? Nicotine lozenges quantity high? Risk of diversion? Suitable for repeat?
VIDEO Public health Repeat Dispensing for General Practice (https://vimeo.com/67715690) Procedures should be agreed at a practice level but may include: READ code 8BM1. On Repeat Dispensing System in patient s computerised records (NB: ensure this READ code is removed if the repeat dispensing arrangement is stopped for an individual patient.) Annotation On Repeat Dispensing System on practice system notes page Practice list of patients participating in the scheme displayed at prescription issue desk
Based on patients with 4 items prescribed two-monthly over 1 year. Number of patients Potential prescription requests before synchronisation Prescription requests after synchronisation Prescription requests after 12 monthly repeat dispensing 1 24 6 1 20 480 120 20 100 2,400 600 100 2,000 48,000 12,000 2,000 4,000 96,000 24,000 4,000
Discuss repeat dispensing in the practice if it is not already established Highlight patients who may be suitable for repeat dispensing Educate patients regarding the repeat dispensing programme Ensure appropriate recording and communication Be a link person with the pharmacies to ensure smooth running of the system where this is appropriate
Controlled medication have stricter legal requirements when it comes to prescribing. Certain drugs are considered High Risk and require extra monitoring. Not all drugs are suitable to be on repeat e.g. Canesten cream Synchronisation means organising repeat medications so that all items will run out at the same time if taken as prescribed Synchronisation can greatly reduce your workload and prevent waste. Repeat dispensing is more convenient for the patient and further reduces the practices workload.
Hopefully your knowledge has increased & you feel empowered. Find out if your practice have safety nets in place to recognise if high risk drugs are not being monitored or if CDs are being over-ordered. Find out if your practice have a list of drugs that should NOT be on repeat. Find out who has the authority to synchronise prescriptions and are you confident to get involved? Do you have patients already on Repeat Dispensing and could you roll this out further?
As part of this years Prescribing Incentive Scheme, we have asked practices to review their Repeat Prescribing Policy and discuss any shortcomings they might identify. When you return to your practice, we would like you to get involved!!!
Any questions?