1.4.1 Definitions and extent of repeat prescribing
About 400 million prescriptions were issued in England in 1992-93 at a cost of £2.4 billions (National Audit Office, 1993). In 1996, the net ingredient cost of all prescriptions was £4.0 billion in England (Government Statistical Service, 1997). Repeat prescriptions have been found to comprise at least two-thirds of all general practice prescriptions and represent four-fifths of the total prescribing costs (Zermansky, 1996). Regular review of these prescriptions therefore becomes an important quality issue for the prescribing of medicines to the general public. Harris and Dajda (1996) estimate that repeat prescriptions accounted for 75% of all prescribed items and 81% of prescribing costs and that 48.4% of all patients were receiving repeat prescriptions. A common understanding of repeat prescribing is of prescriptions issued without a consultation to patients with chronic conditions. Since the definition of repeat prescribing is in some respects a bit vague, the statistics produced on
the overall costs connected to repeat prescribing varies depending on the definition chosen. Repeat prescription have been given several definitions as exemplified in Table 1.1.
Table 1.1. Definitions of repeat prescriptions
Definitions Source
The issue of a prescription to a patient who has a long-standing condition for which regular therapy is required, and where no direct face-to-face
consultation between the patients and the doctor takes place.
(Walker, 1971)
A prescription issued without a consultation. (National Audit Office, 1993) The subsequent issues of prescriptions with or
without a consultation.
(Reilly and Gilleghan, 1997)
[Prescriptions] issued without a consultation to patients on long-term treatment.
(Zermansky, 1996)
[Prescriptions] printed by a practice computer from its repeat prescribing programme in the course of one year.
(Harris and Dajda, 1996)
The National Audit Office estimate repeat prescriptions to be 57% (1998a) and 50% (1998b) of all prescriptions issued, each estimate being dependent of the definition chosen. They recognise the problem of each estimate varying with the definition chosen and encourage health authorities to carry out more research on the extent of repeat prescribing and improve the control and review of repeat prescribing. In this thesis, repeat prescribing was chosen as a focus point for GP-pharmacist cooperation and the latter definition was considered most appropriate (Harris and Dajda, 1996). Only items under the ‘repeat section’ were printed as request-forms for the patients and used for consecutive requests of repeat medication.
1.4.2 The process of issuing repeat prescriptions
Repeat prescribing constitutes a significant proportion of routine general practice work. Before the introduction of computers, a manual card system attached to the patients’ medical notes was recommended. The system was used both in general practice (Walker,
1971) and in hospitals (Livingston, 1984). Manasse (1974) studied the characteristics of patients who received repeat prescriptions in three group practices. Only a small proportion of patients had not been seen by the doctor within the last year (5.9%) and 72% of those requesting routine repeat prescriptions had been seen within three months. The author argues that time could be saved by prescribing enough drugs for that period to reduce the need for repeat prescriptions to be issued in the meantime. Anderson (1980) found that the number of people prescribed diuretics or drugs acting on the cardiovascular system as repeat prescriptions had trebled from 1969 to 1980. Fifty-eight per cent of people taking medicines reported that at least one of the items they were taking were originally prescribed one year or more previously.
1.4.3 Lack of regular review and quality assurance of repeat prescribing
Zermansky ( 1996) examined repeat prescribing in 130 practises. By examining production of the prescriptions, management and clinical control, Zermansky found that most repeat prescriptions had no evidence of periodic review in a 15-month period. Many patient took tablets for years without any recorded clinical re-evaluation. The most disturbing shortcomings of repeat prescribing seemed to lie in the doctor’s domain and much of the repeat prescribing was not under adequate medical control. Further, repeat prescribing is wasteful, inefficient and potentially dangerous and has to be improved. However, a more strict control and regular medication review requires time and is expensive. With the proper training provided, alternative reviewers to doctors may be hospital clinical pharmacists and practice nurses. Involving a community pharmacist could possibly create difficulties in the attachment to a local practice. Even patients were suggested to be able to review their own medication as many patients with certain diseases are knowledgeable about their conditions and adjust their own treatment.
Most general practices have computers to issue repeat prescriptions. Repeat prescription records are reported to be complete and accurate in some medical areas. Inter-practice variation is also reported, though generally computer accuracy was reported to be high (Whitelaw et al, 1996). Using computer software to organise and print repeat prescriptions makes the process more efficient. However, it becomes less likely that the doctor will
spend time thinking critically about each prescription. How well this process is managed has added a new element to the quality of repeat prescribing (Harris and Dajda, 1996). The medical profession has discussed the problem of repeat prescriptions, stating that the actual signing of the repeat prescriptions tends to be completed between finishing morning surgery and going on domiciliary visits. This is the time when the doctor is naturally ready for a break, and the GP often loses the opportunity to review the patients’ prescriptions and needs. This increases possibility of over prescribing, there may be increased costs following this and finally there are more likely to be errors in the prescribing (Drury, 1990).
Repeat prescriptions are intended for patients under long-term medical treatment. Parker and Schriber (1980) found that the most likely group of medicines to be prescribed as a repeat prescriptions were ‘night sedation’ (40%) whereas medicines for infections and ‘one-off medicines’ were hardly prescribed as repeat prescriptions. Drury (1982) reviewed the literature published on repeat prescribing, and pointed out that although the repeat prescription system is criticised for increasing the likelihood of errors to occur with the prescription and lessen the doctors chance of identifying adverse reactions or interactions, there is no evidence that repeat prescribing is providing better or worse cafe for the patient. Other studies have pinpointed problems such as duplication of supply (Anonymous, 1973) and no review of long term psychotropic drugs (Dennis, 1979) on repeat prescriptions.
Reviewing prescriptions involves an extra effort, in particular if the patients have used the medication for a long time and the patients do not feel that there is any reason to change. Certainly, this may be true if patients change doctors, but continue to insist on medicines prescribed by the previous doctor. Britten et al (1995) studied this group of patients. Some patients reported that they would consider alternatives to the present medication, and that they would switch to another drug. Others were concerned that the new drug had to have the same effect as the old drug. The authors think this is reflecting that the patients would not change as patients reported to feel attached to the drugs they were familiar and relied on. Interestingly, their insistence to continue on “improper” medication (that is medication considered by their new GP not to be needed or with better alternatives now available) was reported to be as important as the properties of the medicine itself, and the patient continuing to take these improper medicines reflect that the relationship with the original
prescriber was successful. The conclusions of the study highlight the importance of reviewing long-term mediation in a systematic way even if patients are resistant to change. It is suggested that community pharmacists are well placed to help with this process. In any case, the patient’s perspective needs to be included for an intervention on prescribed medication to be successful.
Based on the literature, there is a clear need for review of patients on long-term treatment. However, the studies seem to focus on the logistics of the review and issue process, and proper models for how to review the repeat prescriptions as a long term quality assurance has not been suggested. Both Britten (1995) and Zermansky (1996) suggest that pharmacists should get more involved in prescribing review. Traditionally, pharmacists have not been involved in reviewing medication, but repeat prescribing has become more common and patients are increasingly taking more medicines and more potent medication. Pharmacists’ pharmaceutical knowledge is needed both to comment on the quality of the prescribing and to contributing to better compliance. The next section in this introduction will take a step back and look at why and how new responsibilities have been introduced to pharmacy in primary health care.