Overcoming the Repeat Prescription Challenge

A few days ago, renowned pharmacist Shilpa Patel posed a challenge to her contacts on LinkedIn: Was there not a better way of managing repeats than the monthly request and authorisation cycle? Could the system not be simplified to allow a one-off annual authorisation, thus freeing up prescriber time to allow focus on monitoring and optimisation of treatment.

The responses from many pharmacists have centred on the fact that there is already a repeat dispensing alternative in place, which assumes that the medication is suitable for dispensing over a suitable period without need for review by a prescribing clinician. Thankfully, NHS England has a page dedicated to everything to do with electronic repeat dispensing; which also covers situations when repeat dispensing may not be appropriate.

When eRDs are suitable

The NHS guidance identifies the following patients as potentially suitable for eRDs

• on stable therapy
• with long-term conditions
• on multiple therapies, e.g. for hypertension, diabetes, asthma etc.
• that can appropriately self-manage seasonal conditions

When eRDs are not suitable

At the same time, it lists the following patients as potentially unsuitable:

• requiring frequent changes to drug therapy
• on complex medication regimes
• with an unstable medical condition and/or recent history of frequent admissions to hospital
• requiring regular review (3 monthly or more frequent)
• requiring terminal/palliative care
• in residential institutions, e.g. care homes
• who decline to consent or nominate a pharmacy
• who are drug misusers
• on the following medications:
  • controlled drugs (including temazepam, tramadol, gabapentin and pregabalin)
  • benzodiazepines
  • hypnotics
  • drugs which require close and careful monitoring, e.g. methotrexate
  • unlicensed medicines

My response covered an additional two situations when issuing a long-term repeat would be inappropriate:

• When patients show intentional or unintentional medicine nonadherence
• As part of targeted deprescribing objectives for patient benefit

Reviewing the chronic disease management journey

We need to review the desire to eliminate the tedium around repeat prescription management in the context of overall chronic disease management. As professionals and patients, we would love the chronic disease management to follow the following ideal pathway.

This would result in a clinician seeing a patient a couple of times during the diagnosis and initial prescription stages; but only once or twice a year thereafter. However, this model hides a lot of complexity and misses several processes. For instance, the diagnosis and review stages may involve many steps:

Diagnosis, showing the potential stages involved. Some or all of these may be involved. The result is that the clinician may see the patient several times before confirming the diagnosis.

While we would expect the medication and conditions review stages to be somewhat easier, they usually involve a lot of the elements of diagnosis, accompanied by additional questions related to the treatment and patient factors.

It is also true that between the initial and repeat prescriptions is a review process that incorporates the elements immediately identified above. This can result in the initial review becoming a series of cyclical steps until the optimum treatment goal is attained.

A (slightly) more realistic chronic disease management model

We therefore arrive at a somewhat less-fluid, but more realistic, model of the management of chronic conditions. It still does not fully capture reality, but does a better job than the streamlined process presented above.

On the left we see the various interests involved in patient care, covering general practice, the patient, community pharmacy and other primary care professionals. On the right we see a flow chart with various feedback loops and identification of some of the challenges associated with managing the condition. We can see that involving the patient is indispensable at every stage of care.

We also note that although, in theory, the clinician based in general practice remains involved in patient care (though authorisation of repeats where necessary), community pharmacy and other aspects of primary care that have ongoing contact assume greater importance as we move onto the “maintenance” stage of chronic disease management. Any strategy adopted by general practice or secondary/tertiary care that fails to incorporate community pharmacy, district nurses or other relevant primary care professionals in direct regular contact with the patient, is likely to fall sort of best outcomes.

This is recognised in the NHS guidance in the following statement:

Pharmacies often see patients on a more regular basis than their GP, so are well placed to identify patients who may be suitable for eRD.

Potential solutions

We therefore conclude that this is a problem that general practice, working on its own, cannot solve. A combination of approaches is required: 

• Working with community pharmacy to ensure the selection of the right cohort of patients to transfer to eRDs/ longer-batch prescriptions, based on their intimate local knowledge of individual patients.
• Following the NHS guidance for repeat dispensing
• Shared decision making with patients regarding repeat prescriptions at scheduled reviews.
• Making use of practice-based and ARRS staff to then conduct targeted SMRs with higher-risk patients or those deemed unsuitable for longer prescribing intervals.

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