REPEAT PRESCRIBING LES 2015/16 APPENDICES – Appendix 1.1
Systems and Process Review Selection
Selection Form for Practices
Practice Number
Practice Stamp or Address
(As shown on quarterly finance statement)
Please complete and return this form
by midday Friday 27th March 2015
TO:
Richard Hassett
NHS Greater Glasgow & Clyde
PPSU
Queens Park House
Victoria Infirmary
Langside Road
Glasgow G42 9TT
Fax to: 0141 201 5217
Email to: [email protected]
Selection of Systems and Process Review Activity 2015/16
Local Enhanced Service – Repeat Prescribing 09/03/2015 to 31/03/2016
Please tick one of the following:
I confirm that the above practice is choosing to complete the Repeat
Significant Events Review (appendix 1.2) as part of the systems and process
review for the Repeat Prescribing LES 2015/16
I confirm that the above practice is choosing to complete the Review of Acute
Prescribing Systems and Processes (appendix 1.3) as part of the systems and
process review for the Repeat Prescribing LES 2015/16
I confirm that the above practice is choosing to complete the Patient Medicines
Awareness Campaign (appendix 1.4) as part of the systems and process review
for the Repeat Prescribing LES 2015/16
TRAINING
Please tick all that apply:
The practice would be interested in attending a ‘drop in’ question and answer
style information session within the CH(C)P area
The practice would in interested in refresher / new staff training in-practice
Completed by ……………………………………………..............
Dated ………………………………………………………………..
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REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.2 - Significant Events Analysis (SEA) Guidance
Background
Significant event review is a recognised methodology for reflecting on important events within
a practice and is an accepted process as evidence for GMC revalidation.
Activity Outline

In March 2015
o Review the provided support materials (this appendix) and consider a process
for identification and recording of Repeat Prescribing Significant Events. If
process pre-exists, Practice to review and amend if necessary.

During the contract year
o Identify and record at least 3 significant events around repeat prescribing
o Hold a significant event meeting to discuss and action three significant events
in relation to repeat prescribing

By 17th March 2016
o Provide evidence of completion via local CH(C)P Lead Pharmacist using
proforma ‘Significant Events Analysis (SEA) – Evidence of Completion’
Further Support
Sample completed SEA:
http://www.staffnet.ggc.scot.nhs.uk/Acute/Division%20Wide%20Services/Pharmacy%20an
d%20Prescribing%20Support%20Unit/Prescribing/Pages/MedicinesManagement.aspx
For further guidance and support please contact [email protected]
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REPEAT PRESCRIBING LES 2015/16 APPENDICES – Appendix 1.2 - Significant Events Analysis (SEA) Guidance
1. Consider process for identification and recording of significant events in
2. Identify three significant events in relation to repeat prescribing
relation to Repeat Prescribing. Think about:






Communication: who is to be involved in the process of recording SEAs,
why is it important, how are staff to be told, when does it ‘go live’?
What needs done? How best to record the event initially?
e.g. simple log book in reception, part fill SEA template, discuss at
regular team meeting
It may be helpful to write your process down to help inform staff and
help explain the purpose and importance of Significant Event Analysis
Set up process in March 2015
3. Hold a significant event meeting to discuss and action three
events






Involve all relevant key staff
Extend invite to people linked to but not directly employed by the
practice where appropriate e.g. Community Pharmacist if SEA is related,
Local Prescribing Team Pharmacist or Technician to provide advice, D/N
Analyse events and fill out three SEA templates, following the guidance
notes at each question
Where a SEA involves linked staff e.g. Community Pharmacist, but they
are unable to attend the meeting, the Practice are strongly encouraged
to develop a feedback mechanism to encourage participation in the
review process
Any changes discussed and agreed at SEA meeting should then be fed
back to all relevant staff (including external linked staff)
Consider if future meeting is required to review effectiveness of changes
and impact upon Significant Events

All staff should be on the lookout
Importance of good recording e.g. record enough detail to provide a sound
description of the event which can then be reviewed at a later stage
This stage is not necessarily about analysing the event, it is about recording enough
information to enable the analysis
Examples:
 A degree of system failure - An area where the repeat prescribing system has failed
or deviated from normal or ‘ideal’ e.g. allowing patient to persistently over-order
medication
 Human error e.g. Giving a prescription out to the wrong patient
 Medication errors specific to repeat prescribing e.g. wrong drug prescribed
 Complaints e.g. A patient complaint around repeat prescribing
 Communication issues e.g. Failure to inform Community Pharmacist of a change to
an MDS patient, repeated issues with ‘lost’ prescriptions
 Drug monitoring / review issues e.g. failure to monitor a repeat drug prescribed
(where regular monitoring is key)
Timeline
Suggest start recording April 2015 once all relevant staff have been briefed
4. Provide evidence of completion


Three completed SEA proformas to be returned to the CH(C)P / Sector Lead Clinical
Pharmacist who will collate the information and forward to the Central Prescribing
Team
Complete by 17.03.2016
Further Information
http://www.rcgp.org.uk/clinical-and-research/clinical-resources/clinical-audit/significant-event-audit.aspx
Repeat Prescribing LES Appendices 2015/16 (20150204)
http://www.npsa.nhs.uk/nrls/improvingpatientsafety/primarycare/significant-event-audit/
REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.2 - Significant Events Analysis (SEA) Guidance
Significant event audit or analysis (SEA) is a technique to reflect on and learn from individual
cases to improve quality of care overall.
A significant event can be thought of as ‘any event thought by anyone in the team to be
significant in the care of patients or the conduct of the practice’.
Significant Event Analysis is the discussion of cases and events and the learning obtained
through reflection and is an extension of audit activity. Discussion of specific events can
provoke emotions that can be harnessed to achieve change. For it to be effective, it needs to
be practised in a culture that avoids allocating blame and involves all disciplines within the
practice.
The seven stages of Significant Event Audits
Stage 1 – Awareness and prioritisation of a significant event
Staff should be confident in their ability to identify and prioritise a significant event when it happens. The
practice should be fully committed to the routine and regular audit of significant events.
Stage 2 – Information gathering
Collect and collate as much factual information on the event as possible from personal testimonies,
written records and other healthcare documentation. In-depth analysis may be required to fully
understand causes.
Stage 3 – The facilitated team-based meeting
The team should appoint a facilitator who will structure the meeting, maintain basic ground rules and
help with the analysis of each event.
The team should meet regularly to discuss, investigate and analyse events. These meetings are often
the key function in co-ordinating the SEA process and they should be held in a fair, open, honest and
non-threatening atmosphere. Agree any ground rules before the meeting starts to reinforce the
educational spirit of the SEA and ensure opinions are respected and individuals are not ‘blamed’.
Minutes of the meeting should be taken and action points noted. These should be sent to all relevant
staff. An effective SEA should involve detailed discussion of each event, demonstration of insightful
analysis, the identification of learning needs and agreement on any action to be taken.
Stage 4 – Analysis of the significant event
Use the Significant Event Analysis proforma on the next page to help guide the meeting.
Stage 5 – Agree, implement and monitor change
Any agreed action should be implemented by staff designated to co-ordinate and monitor change in the
same way the practice would act on the results of ‘traditional’ audits.
Progress with the implementation of necessary change should always be monitored by placing it on the
agenda for future team or significant event meetings.
Where appropriate, the effective implementation and review of change is vital to the SEA process. To
test how well the SEA process has gone, practices should ask themselves ‘What is the chance of this
event happening again?’.
Stage 6 – Write it up
Write up and keep the completed SEA proforma as evidence that the SEA was undertaken to a
satisfactory standard.
Stage 7 – Report, share and review
Reporting when things go wrong is essential in general practice. The practice should formally report at
least one SEA to evidence completion of that part of the Repeat Prescribing LES (submission details
are on the proforma).
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REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.2 - Significant Events Analysis (SEA) – Evidence of Completion
Practice Number:
Title of significant event:
Date of significant event:
Date of significant event meeting:
Date report compiled:
Report compiled by:
What happened?
Describe what actually happened in detail. Consider, for instance, how it happened, where it happened, who was involved
and what the impact or potential impact was on yourself, the patient, the team, organisation and/or others.
Why did it happen?
Describe the main and underlying reasons – both positive and negative – contributing to why the event happened.
Consider, for instance, the professionalism of the team, the lack of a system or failing in a system, lack of knowledge or
the complexity and uncertainty associated with the event.
Who was involved in the discussion of the event?
The meeting should include key Practice staff as a minimum. The Practice are strongly encouraged to involve additional
staff not directly employed by the Practice (where appropriate) e.g. local Practice Prescribing Support Pharmacist or
Technician for advice, Community Pharmacist where event relates to managed repeats or other issues.
What have you learned?
Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members
have been involved in the analysis of the event. Consider, for instance: a lack of education and training; the need to follow
systems or procedures; the vital importance of team working or effective communication.
What have you changed in the Practice as a result of the review or why have no changes
taken place?
Outline the action(s) agreed and implemented, where this is relevant or feasible. Consider, for instance: if a protocol has
been amended, updated or introduced; how it was done and who was involved; how will this change be monitored. It is
also good practice to attach any documentary evidence e.g. a letter of apology to a patient or a new protocol.

Complete three SEAs by 17.03.2016 and return to local CH(C)P Lead Clinical Pharmacist
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REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.3 – Review of Acute Prescribing Systems and Processes
Background
A 2013/14 repeat prescribing audit within NHSGGC highlighted a variety of acute prescribing
issues, potentially increasing the risk of patient harm and leading to excess prescribing waste.
These included issues with ordering, processing, authorisation and collection. A review of
acute prescribing systems and processes may be helpful to address Practice specific issues.
Some of the common issues flagged by Practices in the audit:
Patient attends Practice to pick up acute but it is not there:
 GP has decided it is not appropriate to issue but there is not a note to that effect
 Acute request not yet done but unclear which GP is dealing with request
 Acute has been issued but dose is incorrect
 Acute prescription queries not put in correct place
 Acute prescription not 'married up' to repeat because it is still being processed
 Acute has mistakenly gone to the patient designated pharmacy (as per their repeats)
High demand for acutes

Frequently issuing acutely for no reason other than that they have not been reviewed and moved
to repeat
Patient expectations

Patient has attended for collection within normal timescale for repeats, not realising that acutes
usually take longer
A suggested method for reviewing the acute prescribing systems and processes can be found
on the following pages.
Activity Outline

In March 2015
o Review the provided support materials (this appendix) and consider a plan for
completion over the contract year

During the contract year
o Hold ‘Session 1’ meeting in Practice
o Undertake data collection
o Hold ‘Session 2’ meeting in Practice
o Implement Change

By 17th March 2016
o Provide evidence of completion via local CH(C)P Lead Pharmacist using
proforma ‘Review of Acute Prescribing Systems and Processes – Evidence of
Completion’
Further Support
For further guidance and support please contact [email protected]
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Appendix 1.3 – Review of Acute Prescribing Systems and Processes (Session 1) Guidance
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Appendix 1.3 – Review of Acute Prescribing Systems and Processes (Session 2) Guidance
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REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.3 – Review of Acute Prescribing Systems and Processes – Evidence
of Completion
Practice Number:
Date:
Report compiled by:
List up to three issues identified with acute prescribing processes as a result of review:
Describe the issue(s) in detail. Detail, for instance, what, how, why and where it was happening and what the impact was
on yourself, the patient, the team, organisation and/or others.
1)
2)
3)
Which of the above issue(s) did the Practice decide to address?
What have you changed in the Practice as a result of the review or why have no changes
taken place?
Outline the action(s) agreed and implemented, where this is relevant or feasible. Consider, for instance: if a protocol has
been amended, updated or introduced; how it was done and who was involved; how will this change be monitored. It is
also good practice to attach any documentary evidence e.g. process map prior to and post review, a new protocol.
What positive impact did the change(s) have on the Practice? (Note all)
e.g. data shows removal or lessening of the occurrences of the issue(s) identified, data shows a gain of three hours per
week ‘free up’ of staff time as a result of change

Complete by 17.03.2016 and return to local CH(C)P Lead Clinical Pharmacist
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Appendix 1.4 – Patient Medicines Awareness Campaign
Background
An estimated 3-4% of prescribing cost is incurred through prescribing waste, a half of which is
thought to be cost effectively avoidablei. In NHSGGC this equates to approximately £4million
per annum.
It is suggested that between a third and a half of all medicines prescribed for long-term
conditions are not taken as recommendedii.
A medicines awareness campaign for patients could assist the Practice in working towards
reducing medicines waste and improving patient safety.
A suggested method can be found on the following pages.
Activity Outline

In March 2015
o Decide between a campaign around Medicines Waste or Medicines Adherence
and consider a plan for implementation

During the contract year
o Run an initial data collection in the form of a patient questionnaire (suggest
around 10 per day for an average working week)
o Review the results of the questionnaire to help inform the campaign
o Run a patient medicines awareness campaign (one simple message) around
chosen area for a minimum period of two weeks (see appendix 1.4 for resource
materials)
o Run an second data collection in the form of a patient questionnaire (suggest
around 10 per day for an average working week) and analyse to assess the
impact of the campaign

By 17th March 2016
o Provide evidence of completion via local CH(C)P Lead Pharmacist using
proforma ‘Patient Medicines Awareness Campaign – Evidence of Completion’
Further Support
For further guidance and support please contact [email protected]
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Appendix 1.4 – Patient Medicines Awareness Campaign Guidance
1. Consider a campaign around either Medicines Waste or Medicines Adherence. Think
about:








What one simple message would you like to promote from the Practice point of
view? (Be prepared to adjust in light of your patient questionnaires)
What are the risks and benefits of running such an event? - can you learn from
evaluations/outcomes of previous events?
What is it that you hope to achieve? - what is the current situation and what change
do you want to happen?
How will you measure the impact / success of the event? - what are your desired
outcomes, what (if any) will be the legacy of the event
Set up a small medicines awareness campaign group in Practice to take forwards
Communication: who is going to lead and who is going to be involved, why is it
important? How are staff to be told?
When is the best time of year to do it? How long will you run it for (suggested
minimum 2 weeks)? How will you do it? Set out timescales for completion.
Complete this part in March 2015
3. Run patient awareness campaign
What?
 What needs done before the campaign starts?
How?
 Provide the right balance of information
 Alert them to the issue / message in a way they can understand
 Familiarity drip fed via a number of means has more of an impact, as it acts
as a constant reminder
Who?
 Involve all relevant staff
 Interact with your patients – is it worth having a ‘manned’ station to create
interaction?
Where?
 Make your campaign visible – catch your audiences attention
2. Gather data, decide campaign theme and gather materials
4. Second run patient survey and analysis of results



Print questionnaires
Target patients who have at least one drug on repeat prescription
Aim to have at least 10 questionnaires completed each day on an average week



Repeat patient questionnaire post campaign
Target patients who have at least one drug on repeat prescription
10 questionnaires completed each day on an average week



Analyse results – enter data into Excel sheet available on MM website on Staffnet.
Review results – review graphs from Excel sheet.
Discuss results – discuss with Medicines Awareness Campaign group
o Do they tie in with the proposed campaign discussed earlier?
o Decide on campaign theme – make your message simple





Firm up timescales for running campaign
Repeat Prescribing LES Appendices 2015/16 (20150204)
Gather materials e.g. from the RPLES appendices or MM website on staffnet or11
originate your own materials (think about posters, patient leaflet, Rx message, etc)
Analyse – enter data into Excel sheet available on staffnet MM website.
Review – review graphs from Excel sheet.
Discuss – discuss with Medicines Awareness Campaign group
o Has there been an improvement?
o What went right / wrong?
o What now?

Complete and return evidence of completion by 17.03.2016
REPEAT PRESCRIBING LES 2015/16 APPENDICES
Appendix 1.4 – Patient Medicines Awareness Campaign
Selecting a message
Promote one simple message to patients. Select one from below or choose your own.
Waste
Only order what you need
If you don’t use it we can’t reuse it
What’s in your cupboard?
Adherence
Let’s talk medicines
Take them if you can, tell us if you can’t
Ask your Doctor or Pharmacist
Promoting the message
Where to promote?
Practice
 Practice leaflet / specific patient leaflet / newsletter
 Notice boards
 Rx message
 Website
 Prescription line answer machine
 Verbally
Community Pharmacy
Suggested minimum 2 weeks
Engaging Patients
Once questionnaire results are in use them to tailor your campaign to an area you feel will
benefit both patients and the Practice
Ensure everyone in Practice knows about the campaign and encourage them to engage with
patients
Think about what will create an impact and create interaction e.g.
- have a ‘manned’ station in the Practice during running your campaign to talk to patients and
raise awareness rather than simply putting up posters
- encourage patients to look at your campaign materials by signposting them when they collect a
prescription
- attach a leaflet onto repeat prescriptions
- ask Community Pharmacy to display your campaign materials and engage with patients
around the same theme (encourage feedback on any pertinent issues flagged by patients)
Campaign Materials
Available from the MM website on staffnet:
http://www.staffnet.ggc.scot.nhs.uk/Acute/Division%20Wide%20Services/Pharmacy%20and%2
0Prescribing%20Support%20Unit/Prescribing/Pages/MMSupportMaterial.aspx
S
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Appendix 1.4 – Patient Questionnaire
Medicines Waste / Adherence Campaign
- Patient Questionnaire
Personal Information
1. What is your sex and age?
Under 17
17 -24
25 -34
Male
Female
35-44
45-54
55- 64
65- 79
80+
Repeat Prescriptions
2. How many items are on your repeat prescription?
Less than 4
4-9
10+
3. How many of those do you regularly use?
4. How many items have you ordered today?
Your medicines
5. Do you ever forget to take your medicines? Yes
No
Sometimes
6. Do you ever find it difficult to take your medicines e.g. Swallowing tablets, using
inhalers?
Yes
No
Sometimes
7. Do you believe that the medicines prescribed for you are the best ones for you?
(If Yes, please go to Q10)
Yes
No
8. Have you discussed this with your Doctor or Pharmacist? Yes
No
9. Were you aware that by ‘only ordering what you need’ you could help other NHS
services?
Yes
No
Unsure
Unwanted and unused medicines
10. Do you ever have medicines left over? Yes
11. How do you dispose of medicines that are left over?
Yes
Pharmacist
Throw in bin
Flush down toilet
No
None left
Other
Leave in cupboard
12. Did you know that unused medicines cannot be reused, whether opened or not?
Yes
No
13. Do you ever stock up on medicines just in case you need them?
No
Occasionally
Often
Thank you for taking the time to fill out this questionnaire
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Appendix 1.4 – Patient Medicines Awareness Campaign – Evidence of Completion
Practice Number:
Date:
Report compiled by:
Was the Practice topic for the Patient Medicine Awareness Campaign 1) Medicine
Adherence or 2) Medicine Waste?
What was the theme for the campaign?
e.g. Only order what you need
What did the questionnaire results show before the campaign?
e.g. lack of patient awareness and understanding, apathy around taking responsibility for medicines
How did the Practice run the Patient Medicine Awareness Campaign?
Describe the campaign in detail. Detail, for instance, what, how, why and where you did it.
What did the questionnaire results show after the campaign?
e.g. data shows greater awareness and understanding, less apathy around taking responsibility for medicines
What have you learned and how will this affect how the Practice interact with patients
around the chosen theme?
e.g. a large portion of our patients did not know that unused medicines cannot be reused – we will periodically promote
this fact to patients to encourage them to only order what they need

Complete by 17.03.2016 and return to local CH(C)P Lead Clinical Pharmacist
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APPENDIX 2 - Level 1 Medication Review Guidance
The Repeat Prescribing LES asks Practices to:
-
Perform a Level 1 medication review in 85% of all regular repeat prescribing records
between 10.03.2014 and 31.03.2016 as defined within appendix 2. Practices are strongly
encouraged to include care home / MDS patients, and those patients who have never had a
level 1 medication review.
Level 1 medication review to consist of:
o
Inactivation of duplicate repeat drugs – review of repeat prescribing and removal
of identical duplicate repeat drugs. Non-identical duplicates i.e. same drug, strength,
form but differing doses are referred to a clinician.
o
Inactivation of obsolete repeat drugs – review of repeat prescribing and removal
of repeat medication which has not been ordered for a Practice specified time period
e.g. one year. Clinicians to identify drugs which are not appropriate for removal
without clinician review.
o
Alignment – review of repeat prescribing and aligning repeat medication quantities
to a supply period on an individual patient basis e.g. ensuring all medication is 28
day supply for each monitored dosage system (MDS) / dosette and care home
patient. Clinicians to identify drugs where alignment is not necessary or not
appropriate e.g. oral contraceptives remain as a three month supply.
CMS patients should have their prescription aligned to the GP set period (usually 24
or 48 weeks) – and should not be aligned to 28 or 56 day supply.
o
Compliance check – review of repeat prescribing and check if medication is issued
as expected e.g. one issue every two months for a patient receiving 56 days supply
of medication. Practices are expected to work to improve compliance where poor
compliance is identified.
o
Identification / correction of drugs with missing or ambiguous directions –
review of repeat prescribing and correction of drugs with missing or ambiguous
directions e.g. ‘take as directed’. Clinicians to identify standard directions for selected
drugs where appropriate or review directions on individual patient basis and correct.
A ‘Level 1 Medication Review Checklist’ is on the next page to help support the level 1
medication review process if required.
Once complete readcode: 66RZ ‘Rep. Presc. Monitoring NOS’
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Appendix 3 - Improving Compliance and Reducing Prescribing Waste – Installation of
the Scottish Therapeutics Utility (STU) and Review of Patients ordering all medication on
one date every time they order for the most recent three issues
Background
The Scottish Therapeutics Utility (STU) is an IT solution to help improve general practice repeat
prescribing. Working within the clinical systems EMIS and InPS Vision, STU can identify and
target potential problems with a patient’s list of repeat medicines. More information on STU is
available from the MM website on staffnet.
Some patients may be ordering all repeat medication as one order (e.g. ticking all boxes on their
repeat reorder slip) every time they order regardless of need or stock levels, particularly PRN
medicines, dressings, appliances.
A suggested method can be found on the following pages.
Activity Outline

During the contract year
o Using STU and the RPLES MS Access Database tool for EMIS and Vision,
Practices to review patients who order all repeat medication as a single order
every time they order (excluding MDS and Care Home patients) for the most
recent three issues and take appropriate action.
o We would recommend that Practices retain details of the prescription records
reviewed to assist in event of verification.
Further Support
Available from the MM website on staffnet:
http://www.staffnet.ggc.scot.nhs.uk/Acute/Division%20Wide%20Services/Pharmacy%20and%2
0Prescribing%20Support%20Unit/Prescribing/Pages/MMSupportMaterial.aspx
Or
Manually access the website:
Go to www.staffnet.ggc.scot.nhs.uk then:
 Acute > Division Wide Functions > Pharmacy and Prescribing Support Unit > Prescribing
 Look at the menu down the left hand side and click on either ‘MM – Support Material EMIS’
or ‘MM – Support Material Vision’.
 The database is available to download from this page, along with instructions.
Or
Contact [email protected]
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Appendix 3 - Improving Compliance and Reducing Prescribing Waste – Installation of
the Scottish Therapeutics Utility (STU) and Review of Patients ordering all medication on
one date every time they order for the most recent three issues
Why are we being asked to do this activity?
The idea behind including this in the LES is to identify patients (either self ordering or via
pharmacy) who simply may order everything without thinking about it. These patients may be
stockpiling medication and this represents a potential risk. The risks could include:
 using expired medication
 getting confused and taking medication which is no longer supplied on repeat
 providing excess medication to another person to self-medicate similar symptoms
 disposing of medication inappropriately (potentially harming the environment) due to
inability to store large amounts of excess e.g. flushing down the toilet or throwing in a bin
Identifying and reviewing this type of ordering can help the Practice to reduce these risks to
patients and reduce wasted medicines.
What should we be looking for?
The Scottish Therapeutics Utility (STU) and the MS Access RPLES Database Tool (available
from the MM Website on Staffnet) will assist the Practice in identifying these patients. STU
provides a snapshot of the numbers of patients ordering all medication at the most recent issue;
the RPLES database tool provides a patient list report of those patients who ordered all of their
repeat medication on one date every time they ordered for the most recent three issues.
Prescribing varies from patient to patient but there may be items prescribed on repeat which you
may not expect a patient to order every time:
 Items prescribed in larger quantity than the order frequency e.g. patient has 56 day supply of
tablets on repeat but has ordered everything for each of the preceding 3 months (rather than
ordering over the expected 6 months)
 Items prescribed with the direction ‘when required’ – Drugs prescribed in this manner are
ordinarily taken when required to resolve symptoms and may not necessarily need to be
used on an ongoing basis. There may be circumstances where a patient does actually need
to take the item regularly to control symptoms but there are some medicines which may
benefit from review if the patient is genuinely using all ‘when required’ supplied. These areas
could include (but not limited to):
o Laxatives e.g. senna tablets, fybogel sachets,
o Indigestion remedies e.g. peptic liquid,
o Anti-diarrhoeals e.g. loperamide capsules
o Strong painkillers e.g. co-codamol 30/500
 Cream and ointments – large volumes of creams and ointments that seem at odds with the
dose directions e.g. 500g of E45 ordered monthly with dose direction ‘apply to hands daily’.
 Glyceryl trinitrate spray – a typical GTN spray contains 200 sprays and should last a patient
for an average of 33 separate angina attacks (at maximum dose). A potential need for
review is indicated where a patient appears to be using a lot of GTN.
 Sundries – large volumes of catheters, stoma and leg bags or associated items
Where the above has been identified then it may be worth reviewing further.
It is important to note that a patient ordering all medication each time they order is not
necessarily indicative of stockpiling, it could simply be that their medication has been
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synchronised and they have no medication with variable dose directions e.g. ‘when required’
drugs. For the type of patient noted above, no further action would be necessary.
What should we do when we identify an issue?
The RPLES Contract asks the Practice to take appropriate action as decided in-house.
In the past and dependant on individuals, Practices have:
 Invited patient in for review with GP, Nurse or Pharmacist
 Telephoned patient to query and work to resolve
 Added a flag in the patient record to discuss at next appointment
 Moved selected drugs to acute prescribing to ensure GP reviews as a ‘special’ prior to
reissue
 Initiated tighter controls on the monitoring and processing of repeat ordering e.g. review
and restrict if a patient is ordering too early without a valid reason, printing last order
date on prescription
 Worked more closely with Community Pharmacy around ordering e.g. working together
to improve ordering systems, increasing Chronic Medication Service prescribing (where
medication is supplied to a patient by Community Pharmacy at regular Practice set
intervals based on one ‘master’ prescription issued)
We would recommend that Practices retain details of the prescription records reviewed to assist
in event of verification.
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References
i
Trueman, P., Taylor, D.G., Lowson, K., Bligh, A., Meszaros, A., Wright, D., Glanville, J., Newbould, J., Bury,
M., Barber, N. and Jani, Y.H. (2010) Evaluation of the scale, causes and costs of waste medicines. Report of DH
funded national project. ISBN: 978 090 293 620 1. Technical Report. York Health Economics Consortium and The
School of Pharmacy, University of London. , York and London.
ii
Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence,
National Institute for Clinical Excellence, January 2009
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